Month: June 2011

Sexual identity: Wall Street Journal reports on APA report and sexual identity therapy

(First posted on August 6, 2009)
The Wall Street Journal’s Stephanie Simon has captured well the application of the APA task force sexual orientation report in an article out this morning. Of course I would say that…

The men who seek help from evangelical counselor Warren Throckmorton often are deeply distressed. They have prayed, read Scripture, even married, but they haven’t been able to shake sexual attractions to other men — impulses they believe to be immoral.
Dr. Throckmorton is a psychology professor at a Christian college in Pennsylvania and past president of the American Mental Health Counselors Association. He specializes in working with clients conflicted about their sexual identity.
The first thing he tells them is this: Your attractions aren’t a sign of mental illness or a punishment for insufficient faith. He tells them that he cannot turn them straight.
But he also tells them they don’t have to be gay.
For many years, Dr. Throckmorton felt he was breaking a professional taboo by telling his clients they could construct satisfying lives by, in effect, shunting their sexuality to the side, even if that meant living celibately. That ran against the trend in counseling toward “gay affirming” therapy — encouraging clients to embrace their sexuality.
But in a striking departure, the American Psychological Association said Wednesday that it is ethical — and can be beneficial — for counselors to help some clients reject gay or lesbian attractions.
The APA is the largest association of psychologists world-wide, with 150,000 members. The association plans to promote the new approach to sexuality with YouTube videos, speeches to schools and churches, and presentations to Christian counselors.
According to new APA guidelines, the therapist must make clear that homosexuality doesn’t signal a mental or emotional disorder. The counselor must advise clients that gay men and women can lead happy and healthy lives, and emphasize that there is no evidence therapy can change sexual orientation.
But if the client still believes that affirming his same-sex attractions would be sinful or destructive to his faith, psychologists can help him construct an identity that rejects the power of those attractions, the APA says. That might require living celibately, learning to deflect sexual impulses or framing a life of struggle as an opportunity to grow closer to God.

While the report doesn’t use my exact words (e.g., I don’t say ‘you don’t have to be gay’), she does catch important aspects of the APA report and the stance I use within the sexual identity therapy framework. Furthermore, I don’t show the video at the same time in the same order of things to clients and then they make a decision about their direction. I do however, do extensive informed consent and answer lots of questions which involves videos and slides to answer. Thanks to Michael Bailey for those vids.
This report captures the essence of the novel findings in the APA report in contrast to the AP report which continues to present a polarized picture. For sure, as long as the dialogue around change is important to people, we keep talking past each other. However, when you look at what both sides actually claim, they are not that far apart. According to the AP report, Jones and Yarhouse are going to report over half of 61 subjects either changed or are celibate. Whatever the percentage, it is clear that change cannot be promised to clients as a predictable function of therapy or ministry. We should be able to agree about that and then place emphasis on belief and value congruence. From there, see what happens.

Sexual identity: APA sexual orientation task force report – Analysis

(First posted August 5, 2009)
Earlier today, the American Psychological Association governing board received the report of the Task Force on Appropriate Therapeutic Response to Sexual Orientation. The report and press release were embargoed until now. With this post, I want to comment on the paper and recommendations made by the Task Force.
Generally, I believe the paper to be a high quality report of the evidence regarding sexual orientation and therapy. The authors of the paper (see this post for the new release which contains authorship information) provide a very helpful discussion of the professional literature on sexual orientation change efforts (SOCE), potential benefits and harm and the role of religion and values in sexual orientation identity exploration. Before I get to a more detailed look at highlights, I want to note an important statement from the APA press release made by Task Force Chair, Judith Glassgold:

Practitioners can assist clients through therapies that do not attempt to change sexual orientation, but rather involve acceptance, support and identity exploration and development without imposing a specific identity outcome.

Dr. Glassgold here describes sexual identity therapy. In fact, as I will point out, the SIT framework is referred to positively throughout the paper. Whereas some evangelicals may be troubled by the negative view of sexual reorientation in this report, there is much here that clarifies important aspects of work in this field. The paper is long (130 pages) and so one post cannot capture all that is important. I want to start with what for me are the high spots, beginning with the abstract:

The American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation conducted a systematic review of the peer-reviewed journal literature on sexual orientation change efforts (SOCE) and concluded that efforts to change sexual orientation are unlikely to be successful and involve some risk of harm, contrary to the claims of SOCE practitioners and advocates. Even though the research and clinical literature demonstrate that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality, regardless of sexual orientation identity, the task force concluded that the population that undergoes SOCE tends to have strongly conservative religious views that lead them to seek to change their sexual orientation. Thus, the appropriate application of affirmative therapeutic interventions for those who seek SOCE involves therapist acceptance, support, and understanding of clients and the facilitation of clients’ active coping, social support, and identity exploration and development, without imposing a specific sexual orientation identity outcome. (p. v)

While the paper takes a dim view of change efforts, the authors indicate that attempts to change have been viewed as helpful by some and harmful by others. This is a fair reading of the research. Given these assessments of the research, the stance the APA recommends is to provide supportive psychotherapy without imposing an identity outcome on the client. To get to this view, the authors review change literature, literature on outcomes and research regarding religion and sexual orientation. I want to briefly recap each section.
Efficacy of change efforts
The Task Force reviewed 83 studies that met basic standards for inclusion. They were not impressed with the methodological rigor of the body of research. Their conclusion:

Thus, the results of scientifically valid research indicate that it is unlikely that individuals will be able to reduce same-sex attractions or increase other-sex sexual attractions through SOCE. (p. 3)

Safety of change efforts
The Task Force provided a cautious and nuanced response to the question of harm or benefit from SOCE. I believe they are on target here. Some people report harm and some report benefit but there are no studies which allow conclusions about likelihood of either outcome for any given person. About safety, the press release notes:

As to the issue of possible harm, the task force was unable to reach any conclusion regarding the efficacy or safety of any of the recent studies of SOCE: “There are no methodologically sound studies of recent SOCE that would enable the task force to make a definitive statement about whether or not recent SOCE is safe or harmful and for whom,” according to the report.

Religion and change efforts
One of the highlights of the report is the discussion of religion and sexual orientation. The authors are to be commended for their balanced and thoughtful approach. I especially like the discussion surrounding the concepts of “organismic congruence” and “telic congruence.” On page 18, the paper summarizes these concepts well:

The conflict between psychology and traditional faiths may have its roots in different philosophical viewpoints. Some religions give priority to telic congruence (i.e., living consistently within one’s valuative goals) (W. Hathaway, personal communication, June 30, 2008; cf. Richards & Bergin, 2005). Some authors propose that for adherents of these religions, religious perspectives and values should be integrated into the goals of psychotherapy (Richards & Bergin, 2005; Throckmorton & Yarhouse, 2006). Affirmative and multicultural models of LGB psychology give priority to organismic congruence (i.e., living with a sense of wholeness in one’s experiential self (W. Hathaway, personal communication, June 30, 2008; cf. Gonsiorek, 2004; Malyon, 1982). This perspective gives priority to the unfolding of developmental processes, including self-awareness and personal identity.
This difference in worldviews can impact psychotherapy. For instance, individuals who have strong religious beliefs can experience tensions and conflicts between their ideal self and beliefs and their sexual and affectional needs and desires (Beckstead & Morrow, 2004; D. F. Morrow, 2003). The different worldviews would approach psychotherapy for these individuals from dissimilar perspectives: The telic strategy would prioritize values (Rosik, 2003; Yarhouse & Burkett, 2002), whereas the organismic approach would give priority to the development of self-awareness and identity (Beckstead & Israel, 2007; Gonsiorek, 2004; Haldeman, 2004). It is important to note that the organismic worldview can be congruent with and respectful of religion (Beckstead & Israel, 2007; Glassgold, 2008; Gonsiorek, 2004; Haldeman, 2004; Mark, 2008), and the telic worldview can be aware of sexual stigma and respectful of sexual orientation (Throckmorton & Yarhouse, 2006; Tan, 2008; Yarhouse, 2008). Understanding this philosophical difference may improve the dialogue between these two perspectives represented in the literature, as it refocuses the debate not on one group’s perceived rejection of homosexuals or the other group’s perceived minimization of religious viewpoints but on philosophical differences that extend beyond this particular subject matter. However, some of the differences between these philosophical assumptions may be difficult to bridge.

On this blog, we have frequently grappled with these differences. Many such discussions have sides talking past each other because different views of congruence are assumed to be determinative. In this CNN clip about the Task Force, Psychiatrist McCommon and I came to about the same conclusion regarding congruence.
There are different assumptions about what best constitutes the answer to the question: ‘who am I?’ This paper nicely addresses these assumptions and acknowledges that people who are deeply committed to a non-gay-affirming religious position may stay same-sex attracted but not identify as gay. As the paper notes, this is an acceptable alternative.
Clinical approaches
The authors consider the role of therapy and ministries groups as aspects of SOCE. What they say about support groups is interesting.

These effects are similar to those provided by mutual support groups for a range of problems, and the positive benefits reported by participants in SOCE, such as reduction of isolation, alterations in how problems are viewed, and stress reduction, are consistent with the findings of the general mutual support group literature. The research literature indicates that the benefits of SOCE mutual support groups are not unique and can be provided within an affirmative and multiculturally competent framework, which can mitigate the harmful aspects of SOCE by addressing sexual stigma while understanding the importance of religion and social needs. (p. 3)

In a nutshell, support groups can have benefit when the singular focus is not change of orientation. Our conversations here regarding the change versus congruence model is relevant. I think the kind of changes that are most common are ideological and behavioral. And when I say behavioral, I mean both cessation of unwanted behavior and also less preoccupation with seeking harmful sexual behavior. I think some people feel they have moved on the Kinsey scale because they have better self-control regarding same-sex behavior. These are good and important telic changes but they don’t represent the kinds of changes which reflect dramatic organismic shifts. Orthodox Christianity does not require organismic changes in order to pursue spiritual development.
Moving from ministry to clinical worlds, the application seems obvious to me. And perhaps it seems obvious since I have been advocating for this stance for several years now. The client sets the value direction and the outcome is not imposed.

In our review of the research and clinical literature, we found that the appropriate application of affirmative therapeutic interventions for adults presenting with a desire to change their sexual orientation has been grounded in a client-centered approach (e.g., Astramovich, 2003; Bartoli & Gillem, 2008; Beckstead & Israel, 2007, Buchanan et al., 2001; Drescher, 1998a; Glassgold; 2008; Gonsiorek; 2004; Haldeman, 2004, Lasser & Gottlieb, 2004; Mark, 2008; Ritter & O’Neill, 1989, 1995; Tan, 2008; Throckmorton & Yarhouse, 2006; Yarhouse & Tan, 2005a; and Yarhouse, 2008). (P.55)

It is heartening to see the SIT framework referenced here (and elsewhere in the APA paper) as one “appropriate application of affirmative therapeutic interventions.” In general, I think the APA strategies and the SIT framework are quite compatible.
Bottom line: The APA report will likely be quite influential for years to come. They call for more research on SOCE and a cautious, and I think accurate, interpretation of the research on reorientation. I believe the therapeutic strategies called for are akin to the SIT framework and clarifies nicely the appropriate stance of therapists. The report also respects the place of religion in identity development and exploration. These issues were not clear prior to this report.
In additional posts, I will deal with various aspects of the paper as well as media coverage. The press release is here and here on the APA website.

Sexual identity: Our bodies tell us who we are

(First posted October 1, 2007)
Warning: Long post…
This post could be part three of the series on sexual identity therapy and neutrality but I chose this title because I want to focus on one specific issue, at least in my mind, with telling psychotherapy clients that “our bodies tell us who we are.” Saying something like this to a client is the expression of a natural law argument that is expressed by Dr. Joseph Nicolosi in his article “Why I Am Not a Neutral Therapist.”

Our Bodies Tell Us Who We Are
Philosophically, I am an essentialist — not a social constructionist: I believe that gender identity and sexual orientation are grounded in biological reality. The body tells us who we are, and we cannot “construct” — assemble or disassemble — a different reality in which gender and sexual identity are out of synchrony with biology.
The belief that humanity is designed for heterosexuality has been shaped by age-old religious and cultural forces, which must be respected as a welcome aspect of intellectual diversity. Our belief is not a “phobia” or pathological fear.
Natural-law philosophy says this view derives from mankind’s collective, intuitive knowledge; a sort of natural, instinctive conscience. This would explain why so many people — even the nonreligious — sense that a gay identity is a false construct.

Clients who already believe a natural law argument would most likely look for a therapist who believed as Dr. Nicolosi does. In that case, I do not see how he could be accused of imposing his values on the client; clients who are committed to this perspective (many conservatives, for example) might not work well with a therapist who did not articulate a similar view. On the worldview front, I suspect many people are directed by their spiritual advisors to look for counselors who are amenable to the teaching of their church. I also suspect, that feminists look for feminist therapists and so on. This will no doubt continue no matter what the professions pronounce.
What I want to raise now are some issues with the natural law argument. Specifically, I propose that if we know who we are via our bodies, then a fairly solid argument can be made against Dr. Nicolosi’s conclusions. He argues that genitalia and procreative capacity is the definer of correct identity. However, there is more to body than genitals and secondary sex characteristics. Brain is a part of body. As an organ of the body, the way the brain functions and is organized must be important as well. I am not here talking about psychological constructionism or the constructed opinion of a person that he/she is gay or straight, male or female. I am talking about the automatic response of the brain to triggers both sexual and otherwise that differentiate gay and straight people. In the research available, brain reactions differentiate people based on sexual preferences. In other words, if the body tells us who we are, and brain is body, then our brains tell us whether we like the same sex, the opposite one, or both. And our brains do this well before we have time to think about it.
I have written before about the pheromone studies conducted by a team led by Ivanka Savic from Sweden. Here is what I wrote about their study of lesbians:

This study shows that sexual orientation at the extreme (5-6 Kinsey scale) differentiates how the brain responds to a putative pheromone. The response from lesbians is not as clear cut as gay males. Lesbians process estrogen derived pheromones both in the normal olfactory fashion and via the hypothalamus (a link in the sexual response). The participants did not experience any sexual response so it is interesting that these lesbians’ brains registered the pheromones in a different way than did straight women. Lesbians were somewhat like straight men but not exactly like them. The reference is: Berglund, H., Lindstro”m, P., & Savic, I. (2006). Brain response to putative pheromones in lesbian women. Proceedings of the Natural Academy of Science, Early Edition (www.pnas.org).

I also reviewed their initial study of males:

• The study does show involuntary hypothalamic response associated with self-assessed sexual orientation
• The study shows that gay males do react to the estrogen condition but in a different manner than they react to the testosterone condition
• The study cannot shed light on the complicated question of whether sexual orientation of the participants is hard wired.
• The brains of these participants may have acquired a sexual response to these chemicals as the result of past sexual experience. In other word, the response described in this study could well have been learned.
• If these results hold up, this could explain why varying sexual attractions seem so “natural.” Also, such conditioning could give insight into why changing sexual attractions is often experienced by those changing sexual preferences as a process of unlearning responses to environmental triggers.

There are other lines of research that also find large involuntary differences in brain response or perceptual response associated with sexual attractions. I could add the brain imaging work of Michael Bailey which I referenced recently.
Continue reading “Sexual identity: Our bodies tell us who we are”

Reparative therapy information page

A reminder: I have a page dedicated to an examination of evidence for reparative therapy. More accurately, the page addresses the flaws of the theory and finds it inadequate as a general theory of same-sex attraction.
Here is a sampling:

Posts on the theory
Reparative therapy for females – Discounts Janelle Hallman’s thesis that lesbians do not have “selves.”
Father – Son estrangement – This brief post quotes research on father-son relationships in general and how that relates to the thesis that male homosexuals have poor relationships with their fathers. Straights have such poor relationships too.
Queer theories for the straight guise
Many people want to know why they experience same-sex attraction. Reparative drive theory provides a narrative but it may not be correct. In Why Do I Have These Feelings? I examine how this pressure for a narrative may be misleading.
Masculinity and reparative therapy
Mankind Project clarifies stance on reparative therapy – Reparative therapists often refer clients to activities and groups which promise to enhance masculinity as a means of reducing same-sex attractions. Macho Man group Mankind Project clarifies that the New Warriors Training Adventure is not a form of reparative therapy.

I have not included some of the recent posts or articles off the site, such as this one at Huffington Post on the use of the discredited research by George Rekers by Joseph Nicolosi, but will over the next several weeks. For now, I hope this is a useful resource.

Summer in the City – Lovin Spoonful

This short 1966 classic brought the heat.

Heads up: during the summer, I will be putting up some “best hits” from the past. I have some writing projects that I must get done and won’t be able to blog as consistently as usual. This week, I will put up some posts on reparative therapy with a couple of new posts about an article coming up in the New York Time weekend magazine on sexual identity therapy. I think it will post sometime on Wednesday. Stay tuned…