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).

The scenario
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.”

Interpretation

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: ct@counseling.org

Recognizing the importance of disaster behavioral health preparedness, the Substance Abuse and Mental Health Services Administration convened a national summit in New Orleans on May 22-24 to help states and territories assess the progress being made on disaster behavioral health plans and address existing barriers in the planning process. Fifty-four states and U.S. territories sent governor-appointed teams of mental health, substance abuse and related health and human services professionals to participate in the Spirit of Recovery National Summit: Lessons Learned After the Hurricane. As part of the summit, the teams collaborated with national mental health organizations, including the American Counseling Association.

At the summit, ACA was recognized for sending 20 percent of the total number of deployed mental heath counselors to the Gulf Coast after the devastating hurricanes of 2005, demonstrating that ACA members heard the call for help and took action.

“The response from ACA was simply overwhelming, and not only did your organization respond during the early stages but also (continues to) provide ongoing support,” said Edna Davis-Brown, manager of the SAMHSA Katrina Assistance Project with Westover Consultants. “ACA has helped us so much. We are quite thankful for all that ACA has done.” Davis-Brown noted that as of last month, ACA had helped increase SAMHSA’s mental health crisis responder database by more than 1,000 counselors.

“We were really honored to be able to participate in the (crisis response),” said ACA Executive Director Richard Yep. “When we were informed about providing professional counselors, we were more than willing to assist, given our members’ past history and their willingness to volunteer in times of great need. We were asked to find 100 professional counselors who could serve in the Gulf region. We dropped everything and moved this to the top of our priority list. We activated our listserv, posted an alert with information on our website and within 72 hours identified, screened and submitted the names of 178 professional counselors who were willing to serve.”

Over the course of the weekend, summit attendees interacted in a peer-to-peer environment to review lessons learned from hurricanes Katrina, Rita and Wilma. Participants identified opportunities for consolidating the ongoing response to behavioral health issues and strategized all-hazards preparedness efforts for future disasters. Presentations and workshops structured to promote intensive analysis and knowledge-sharing focused on topics such as substance abuse and mental health treatment, pandemic influenza and other public health emergencies, the needs of high-risk populations, evacuation and displacement, emergency response centers, partnerships and coalition-building, public safety workers, disaster-related suicide, access to opiod treatment, psychotropic medications, methadone treatment and regional collaboration.

Also attending the summit were more than 100 of the first responders to the disaster, as well as several survivors. Many of the first responders and survivors gave personal accounts of the events following the hurricane crisis.

Yep participated in a panel discussion with other national association representatives to address what went well in preparing for and responding to the hurricanes and what needs to be improved. Yep shared several points with the panelists pertaining to ACA’s hurricane-response efforts. He also shared feedback that ACA received from its members on what could have worked better as well as recommendations for addressing those issues. Among the important points:

• Success: ACA was able to work quickly to locate counselors willing to deploy.
• Success: SAMHSA recognized the need for professional counselors in a disaster situation.
• Success: ACA proved that it could be relied on in a time of national need to provide qualified mental health professionals.
• Issue: Not all mental health workers were adequately trained in disaster mental health relief and were lacking skills in trauma/crisis counseling.
• Issue: Many counselors assumed their only role would be providing mental health services.
• Recommendation: Establish a national alert system with trained disaster crisis professionals “in the pipeline” who are ready to respond at a moment’s notice, similar to a volunteer fire department.
• Recommendation: Provide more disaster mental health training to orient professionals and provide clear expectations.
• Recommendation: Make an online learning/discussion community available to those who have been deployed.
• Recommendation: Improve cultural sensitivity of the counselors and others who are deployed.

“In a crisis situation, you really have to be flexible and open to what you are assigned to do,” Yep said. “For example, the most important thing might not be sitting there and doing some kind of crisis intervention. It may be that they need someone to go to Wal-Mart and get more water. In many cases, it’s not a traditional counseling session given everything that is going on.”

SAMHSA also presented recognition awards at the Spirit of Recovery summit to local and national companies, organizations and individuals who served valiantly and faithfully to assist those affected by the 2005 hurricanes. Among those honored was ACA member Irene McIntosh, an associate professor in the College of Education at the University of South Alabama. She was recognized for serving as a team leader in assisting D’Iberville, Miss., with its hurricane response and recovery efforts following Hurricane Katrina. McIntosh, along with the recovery team of the D’Iberville Volunteer Foundation, has worked many hours to help rebuild the city in the aftermath of Katrina.

McIntosh has used her counseling skills to help hurricane victims get their lives back in order and to help volunteers deal with the pain they witness as they assist with the rehabilitation and recovery efforts. McIntosh also helped establish a soup kitchen for first responders, citizens and volunteers in a concession stand at the D’Iberville Recreation Complex and a free medical clinic in a nearby grocery story. She has continued to work on the disaster recovery project while teaching a full load at South Alabama and conducting research for the Monroe County Public School System.

Cirecie Olatunji, president-elect of the Association for Multicultural Counseling and Development, was invited to present at the summit on her personal experiences as a deployed mental health provider to the Gulf Coast region. She spent her winter holiday in New Orleans counseling first responders and municipal employees as well as their spouses and children. In her presentation, she pointed out two areas in which efforts must be improved for disaster mental health preparedness and response efforts to truly move forward: increased collaboration among mental health professionals in interdisciplinary groups and increased cultural sensitivity among crisis intervention workers.

“AMCD is putting together a structured initiative so we can help SAMHSA and other agencies to deal with issues of cultural competency and disaster response,” she said. “It will be how to prepare, train and support mental health professionals who are responding to disasters.” She added that AMCD plans to present the training in August at the American Psychological Association Convention in New Orleans and at the ACA Annual Convention in Detroit next year.

“I’m really proud of our licensed professional counselors who agreed to be deployed through ACA’s call to action,” Yep said. “What we heard overwhelmingly was a very positive response from those they served and from the counselors themselves. We appreciate Westover and SAMHSA for including us and acknowledging the fact that professional counselors can play such an important role in dealing with disaster response.”

Several of the PowerPoint presentations from the Spirit of Recovery National Summit are currently available for download at www.spiritofrecoverysummit.com/presentations.htm.

The trustees of the American Counseling Association Foundation recently honored Angie Reese Hawkins, Ervin Bernard Reid and ACAF Past Chair Clemmie Solomon with 2006 Bridgebuilder Awards. The three were selected for their support and service to ACAF’s signature project Growing Happy and Confident Kids. The special initiative utilizes literature as a counseling tool and strives to increase self-esteem, self-efficacy, understanding of emotions and coping strategies among young students.

“The world in which our kids grow and develop has been made fragile by threats both near and far,” said ACAF Chair Jane Goodman. “In schools, competition to succeed, peer pressure and aggressive behavior by bullies are representative of the myriad threats to individual success and self-esteem. At home, relationships can become tenuous or broken. In neighborhoods and communities, violence, gangs, substance abuse and other problems are more prevalent than ever before. Finally, in the larger world, no child can turn on a television set and not witness crime, war, terrorism and global unrest.

“Using the love and promotion of reading among elementary school-age children, the GHCK initiative will identify and use approximately 30 works of children’s literature as the launching point for individual and group interaction that will allow participating children to become more aware, expressive and confident — qualities ACAF believes will add to their potential to succeed in school and society.”

Hawkins, president and chief executive officer of the YMCA of Metropolitan Washington, has embraced the spirit of the Growing Happy and Confident Kids project and has welcomed use of the donated literature in many of the YMCA’s school programs in the Washington area. Solomon presented the award to Hawkins for her dedication to and cooperation with the project.

Reid, a business developer and political consultant, was part of the ACA Foundation Steering Committee and has donated much of his own time and money to the cause of Growing Happy and Confident Kids. “Ervin was the first to step up and ask ’What can I do?’” said Solomon. He pointed out that Reid initially suggested the collaboration between ACAF and the YMCA and was instrumental in forging that partnership.

In a slight surprise, Goodman turned the tables and presented Solomon with a Bridgebuilder Award for his vision for Growing Happy and Confident Kids, the ACA Foundation’s inaugural signature project. Solomon initiated and planned the project last year during his tenure as chair of the foundation.

So far counselors in more than 20 schools and community agencies have implemented the emotional education literature venture. Each of the books being used in the Growing Happy and Confident Kids project (see sidebar below) was selected for its relevance to growth and development matters faced by today’s children. Many of the authors of the selected books have been recognized for their works and their contributions to helping kids understand personal, family and societal issues. The ACA Foundation’s goal is to reach 1,000 elementary schools during the next five years.

The ACA Foundation continues to review applications and select elementary school counselors and their schools to participate in the Growing Happy and Confident Kids project. To be eligible for participation in the project, interested counselors and schools must:

• Possess a commitment to using children’s literature as a vehicle for promoting self-esteem, self-efficacy, understanding of emotions, coping strategies or an appreciation of diversity
• Submit an application signed by both the counselor and the principal
• Follow ACAF-developed activities and literature user guides in counseling activities for a period of one school year
• Evaluate the impact of the Growing Happy and Confident Kids initiative in the school and submit a final report to the ACA Foundation at the end of the project

The ACA Foundation reserves the right to select qualifying schools for participation on a first-come, first-served basis and to ensure broad geographic distribution. In addition, preference will be given to credentialed school counselors and counselors who are members of ACA, and to schools that serve children who are disadvantaged economically or in other measurable ways.

Each school selected for participation by ACAF will receive, at no cost, 10 books of its choice from among the 30 being offered by the Growing Happy and Confident Kids project, along with an activity and discussion guide. Each book will address one or more of the issues identified by the Growing Happy and Confident Kids project, and the guide will provide information regarding how that book might be used in the counseling environment.

Using the discussion guide, counselors will integrate the project’s activities into their ongoing counseling activities while also encouraging students to read the provided literature on their own. “We hope that the books and accompanying discussion guides will allow children to become more aware, expressive and confident,” Goodman said.

For additional information about the Growing Happy and Confident Kids project, contact the ACA Foundation via e-mail at GHCKproject@counseling.org or by calling 800.347.6647 ext. 350.