Tag: reorientation therapy

New Sexual Reorientation Study Off to a Shaky Start; Michael Bailey's Brain Scan Offer is Still Good

After the closing of Exodus International, the wind went out of the sexual reorientation sails. In June of last year, former ex-gay organization Exodus International leader Alan Chambers said the movement was “gasping for air.”
However, a quiet breeze may be blowing still as demonstrated by a study being conducted by one of the luminaries of reparative therapy, Joseph Nicolosi and relative newcomer Carolyn Pela.  Nicolosi and Pela summarized their preliminary findings at a meeting of the Christian Association for Psychological Studies a year ago. Nicolosi described the study on his website:

Dr. Pela described the study as being longitudinal with a within-group repeated-measures design.  Their dependent variable was psychotherapy as conducted at Dr. Nicolosi’s Thomas Aquinas Psychological Clinic.  The independent variables were (1) well-being as operationalized by the Outcome Questionnaire 45 (OQ-45.2), a highly respected measure of psychotherapy process and outcome, and (2) separately assessed dimensions of sexual orientation, namely, thoughts, desires, behavior, and identity.  Data collected to date involved 102 male psychotherapy clients who presented with ambivalence, discomfort, or distress regarding their SSA.  Eighty-one participants had been involved in the study long enough to have well-being assessed and data on change were available from 56 participants at the time of the CAPS presentation.

I am pretty sure the dependent and independent variables are reversed in his description. The independent variable is what is manipulated in an experiment and the dependent variable is a measure of results (see this brief explanation). That problem aside, what did they find?

Findings from preliminary data collected over a 12 month period indicated statistically significant reductions in distress and improvements in well-being, significant movement toward heterosexual identity, and significant increases in heterosexual thoughts and desires with accompanying significant decreases in homosexual thoughts and desires.  Effect sizes for these changes were generally in the moderate range, which suggests they are robust and not likely to be statistical artifacts.  The findings did not discover significant change in heterosexual or homosexual kissing or sexual activity.  These findings appear to have been the result of very low base rates in these behaviors among study participants leading to floor effects and a subsequent lack of change, as it is not possible to change a behavior in which participants are not engaging.

To summarize, the participants were thinking straighter but not doing anything about it.
To me, this result is understandable. If one is in treatment with the stated goal to think more about heterosexual outcomes, then there would be strong motivation to produce those experiences when asked. However, the test for any actual change will be when therapy is over and the regular rehearsal of such ideas isn’t happening. The difference between process changes (how a client feels during therapy) and outcome changes (what remains after therapy is over) is often great. Reorientation therapy studies are filled with people who said they had changed during the study but then felt differently months or years later. Thus, follow up must be a key component of any therapy study.
It should be pointed out that this study isn’t a true experiment since there is no control group. There isn’t a way to test for the effect of the passing of time. Spontaneous fluidity has been reported and it isn’t clear without a control group that psychotherapy is responsible for any change that is reported (or to what degree the therapy is responsible). Without a long term follow up and a control group, this study won’t provide much more information than we already have.
Finally, if Nicoloso and Pela truly want a potent and believable pre and post measurement, they should take Northwestern University professor Michael Bailey’s offer to conduct brain scans of the participants. Some years ago, Bailey informed Nicolosi that he could bring his patients to the lab to test their automatic responses to erotic cues. Nicolosi never took him up on the offer. I recently asked Bailey if the offer was still good. He answered in the affirmative. Pre (or even mid) treatment scans compared with post-treatment scans would help to offset the lack of a control group.
 

Nick Cummings USA Today Article on Reorientation Therapy

A couple of readers asked me to comment on Nick Cummings USA Today column on reorientation therapy. With some caution, I think it would be good to do so.
First I want to say that I have always liked and admired Nick. His work in managed behavioral health care was pioneering. In the 1980s, Nick promoted the idea that excellent clinical services could save businesses a lot of money and actually expand access to therapy. He was correct and helped create modern managed behavioral healthcare, which is essentially the dominant system today. In addition to the new business strategies that Nick’s company (American Biodyne) innovated, Nick was/is a gifted clinician and trainer. I learned a lot from Nick about therapy as a Biodyne clinician in the mid-1980s. I will always be grateful for his influence on me at that time.
Nick is an admirable gentleman in many ways. He seems to be indestructible and maintains an ambitious and rigorous schedule into his older age. He also reads and studies Greek (another area of common interest) and has developed a cooperative program with China that is helping to shape their behavioral health system.
Having declared a sincere admiration for Nick, I have to add that we disagree about his recent push to defend reorientation therapy as a modality. Nick is an endorser of the Sexual Identity Therapy Framework and I have heard him promote the ideals we support.  Thus, I know that any person who sought change therapy from him would not get the usual reparative therapy explanations for homosexuality, nor would religion be used as a coercive tool. In other words, I don’t believe Nick wishes to defend any and all approaches to change therapy; I think he wishes to defend the right of clients to arrange their lives and seek help to do it. However, it is dismaying that his defense comes in the context of  the JONAH’s court case. Much of what is done in the name of reorientation cannot be defended.
One area Nick and I disagree about is how much to emphasize the role and importance of bisexuality. Nick once told me that clients who had no prior heterosexual experience were not successful in changing orientation and so over time, the Kaiser-Permanente therapists discouraged orientation change for those clients. To me, this suggests that many of those “changed” clients were bisexuals who found ways to live with or minimize their same-sex attractions. Furthermore, to my knowledge, no one was discussing “spousosexuals” from 1959-1979. Some men and women are generally attracted to the same sex but spontaneously fall in love with one person of the opposite sex. Some of those successes could easily have been people who had the potential for that kind of fluidity. Another problem with relying on Nick’s data is that follow up was lacking for many of the clients. Nick is aware that some of his clients remained changed, but he does not have systematic data on the population.
If all reorientation therapists were like Nick, I doubt we would have the conflict and polarization we have seen over the past decade or so. I also doubt there is anybody currently vocally defending reorientation who practices as Nick did. Current reorientation therapists blame parenting and masculinity deficits for same-sex attraction, some of them put people through emotionally taxing and empirically questionable human potential exercises, still others attempt to coerce people with religion. My impression is that Nick and his crew did none of that. Certainly, in all of my dealings with American Biodyne, no one ever suggested any of that. The emphasis was always on helping the client find strategies to enhance mental health and live in accord with their aspirations.
Nick’s closing paragraph makes me think that he believes that there are some, perhaps many, therapists who work empirically and ethically with “fully informed persons.” This is where we disagree. The way reorientation is practiced as I have seen it and heard it described at various conferences and by various therapists in my travels during the last decade or so gives me no confidence that he is right this time.
Given those concerns, I continue to support the APA’s distinction between sexual orientation and sexual orientation identity; the former being durable once established and the latter being more subject to modification. I am skeptical there are many current reorientation therapists fully inform their clients about that distinction.

APA Monitor on the APA sexual orientation and therapy report

The current American Psychological Association Monitor briefly reports on the August report from the Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Not much new here for regular readers of the blog. The big news in my view was the treatment of religion which did not get as much coverage as the discouragement of change therapies.

The article ends with quotes from NARTH’s Julie Hamilton and me.

Warren Throckmorton, PhD, an associate professor of psychology and fellow at the Center for Vision and Values at Grove City College in Grove City, Pa., described the task force’s work as a “well-done effort.”  

“I felt the treatment of religion was very respectful, and in doing so, it created space for clients of conservative religious faith to explore the reality of their sexual orientation, while maintaining their faith commitments,” said Throckmorton, who researches sexual orientation and homosexuality and writes about such issues from a Christian perspective.

Julie Harren Hamilton, PhD, president of the National Association for Research and Therapy of Homosexuality (NARTH), said she appreciated what she described as the task force’s recognition that clients have a right to self-determination, and its respect for religious diversity. But she disagreed with the task force’s main conclusions, and charged that the task force was composed only of members opposed to sexual orientation change efforts. 

“We believe that if the task force had been more neutral in their approach, they could have arrived at only one conclusion, that homosexuality is not invariably fixed in all people, that some people can and do change,” she said.

 Some people may change something but there is little evidence which would allow more than guesses about what the potent elements in any such change might be. The NARTH review found that all kinds of approaches reported some degree of change. Can they all be right? In such a situation, a more plausible guess might be that there was some common element of the clients and/or the therapy that could be involved. And as Jones and Yarhouse suggested in the discussion section of their APA report, perhaps sexual identity is a better concept to consider when discussing categorical change. If someone shifts a Kinsey point or two, one might feel satisfied with this and justified in considering themselves to have changed.

As I have noted, the distance between opposing views may be narrowing significantly.

Jones and Yarhouse Exodus study follow up

This morning at the American Psychological Association annual convention, Stanton Jones and Mark Yarhouse are presenting their Time 6 and final follow up to the study of Exodus participants seeking change of orientation. The paper is titled, Ex Gays? An Extended Longitudinal Study of Attempted Religiously Mediated Change in Sexual Orientation. They are presenting these data as a part of a APA symposium titled Sexual Orientation and Faith Tradition Symposium chaired by Dean Byrd.

You can review the paper in full so I will only highlight a few points in the post.

The paper begins by recounting the skepticism toward change evinced by the professional mental health associations. Then, they note an important limit and hypotheses of the study:

Our study addresses the generic questions of whether sexual orientation is changeable, and whether the attempt is intrinsically harmful, by focusing only on the religiously mediated approaches to change; this is not a study of professional psychotherapy. Our hypotheses for this study were taken directly from the prevailing professional wisdom: We hypothesized 1) sexual orientation is not changeable, and 2) the attempt to change is likely harmful. We already cited the American Psychological Association’s (2005) claim that sexual orientation “is not changeable.” Regarding harm, our study was framed in light of the American Psychiatric Association’s (1998) claim that the “potential risks of ‘reparative therapy’ are great, including depression, anxiety and self-destructive behavior.” The tools of scientific study are ideally suited to investigate empirically such strong, even absolute claims.

I bolded the statement about the study not being an examination of psychotherapy because I predict that NARTH affiliated therapists and various religious conservative groups will not clearly communicate this point when messaging the results of this study. Despite the fact that Christian self-help groups are different than therapy as practiced by many psychodynamic therapists, I suspect some therapists will hope the public does not catch the distinction.

Now for some results. Retention is sure to be an issue as this study is discussed:

Retention. We began with 98 subjects at T1. Our sample eroded to 73 at T3, a retention rate of 74.5%. This retention rate compares favorably to that of respected longitudinal studies. 63 subjects were interviewed or categorized at T6, for a T1 to T6 6 to 7 year retention of 64%.

Kinsey scale changes:

Table 1

This table shows the shifts in Kinsey scale scores (7 is exclusively homosexual with 1 being exclusively heterosexual). You can see that the shifts on average were about a point on the scale – less than one for the entire group and more than one for the group which were deemed more gay identified at the beginning. Although statistically significant, this would not on average take the group to the straight side of the continuum but rather by considered bisexual by most observers.

They also used the Shively-DeCecco scale which asks participants to rand both same-sex attraction and opposite-sex attraction. As you can see below, the change reflected in the Kinsey moves was due to reductions in SSA and not increases in OSA.

Table 2

Regarding categorical self-assessments, Jones and Yarhouse report modest shifts.

Table 5

Regarding these changes, Jones and Yarhouse say:

Several results are particularly notable. Despite a smaller N for the T6 sample than at T3, we found growth in absolute size in the two Exodus “success” outcome groups moving from row 1 to row 3: Conversion cases grew from 11 to 14 and Chastity cases from 17 to 18. But the group that grew the most in absolute and proportional terms was Failure: Gay Identity which doubled in absolute size from 6 to 12. The percentage of those showing stability of outcome T3 to T6 (row 4) is greatest in columns 1 and 6: the Success: Conversion (73%) and Failure: Gay Identity (67%) categories, with slightly less in the Success: Chastity category (53%). Of the one subject each that shifted from the Success: Conversion and Failure: Gay Identity categories from T3 to T6, each moved to the Continuing category at T6. The largest absolute shift from T3 to T6 of those who participated in the T6 interview was a T3 Success: Chastity case that became a Failure: Gay Identity case; next largest was a Non-Response case at T3 that became a Success: Conversion case.

Most germane to our principal hypothesis that change of sexual orientation is not possible, 53% of the T6 sample of 61 cases that self-categorized (row 3) did so as some version of success, either as Success: Conversion (23%) or Success: Chastity (30%). At T6, 25% of the sample self-categorized as an Exodus failure (Confused or Gay Identity).

In my view, this means of description confuses success with change. Over half did describe some version of success but that is not the same as over half describing sexual orientation change. I will be interested to see how this is reported in the press.

The changes reported here are significant and no doubt welcomed by the people involved. However, they are not the types of changes which I suspect the various mental health groups mean by “sexual orientation change.” Whatever happened to the participants in this study, they do not appear to have gone from gay to straight — in the sense that people who have always been straight are straight. They have gone from gay to less gay and a bit more straight. I do not mean to suggest that this is not important information; it is. But I am wondering if anyone at APA would dispute the within category changes reported here. I am going to ask and will report what I learn.

Jones and Yarhouse seem to be aware that the results can be understood as a change in identity and not orientation. They write:

There is also the question of sexual identity change versus sexual orientation change (see Worthington & Reynolds, 2009). Recent theoretical (e.g., Yarhouse, 2001) and empirical (e.g., Beckstead & Morrow, 2004; Yarhouse & Tan, 2004; Yarhouse, Tan & Pawlowski, 2005; Wolkomir, 2006) work on sexual identity among religious sexual minorities suggests that attributions and meaning are critical in the decision to integrate same-sex attractions into a gay identity or the decision to dis-identify with a gay identity and the persons and institutions that support a gay identity. In light of the role of attributions and meaning in sexual identity labeling, is it possible that some of what is reported in this study as change of orientation is more accurately understood as change in sexual identity?

The entire section on identity and orientation in the discussion section of the paper is good reading. Finally, in light of the APA task force report, I wonder if the discussion section of the Jones and Yarhouse paper could be revisited. The APA report, while skeptical of categorical change, did not take a strong stance regarding harm. Actually, the APA report and the Jones and Yarhouse paper agree on the inconclusive nature of the evidence on that question.

APA sexual orientation task force report: Analysis

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.