Tag: reparative therapy

Shame and attachment loss: Going from bad to worse

Trying to keep up on the new developments in reparative therapy, I purchased NARTH’s co-founder Joseph Nicolosi’s new book, Shame and Attachment Loss: The Practical Work of Reparative Therapy. This post is not a review but more of a prep for a review. I am going to provide some excerpts and comments which may form the basis for a more formal review at a later date.

You have to get past a couple of features of Nicolosi’s writing in order to proceed. He has an annoying (to me) habit of speaking of himself in the plural (“When a man finds masculinity mysterious and exotic, and seeks it outside himself, we believe he is living in a false self…). This form reappears throughout the book. You also have to grasp the jargon being used in order to understand what he proposes (“grey zone,” “double bind,” “double loop”). In some respects, reading this book is like reading material from object relations theorists such as Masterson and Volkan. It is inside baseball to most folks who are not conversant with attachment and object relations theory.

However, this book is published by Christian publisher Intervarsity Press and makes an effort to make some of the concepts accessible to a lay and non-psychodynamic audience. To be sure, Nicolosi doesn’t leave the reader unclear about his views. Regarding homosexuality, he begins by dismissing Daryl Bem’s empirically derived theory of same-sex attraction because it does not stigmatize same-sex attraction. He then, indicates what has remained the same since his earlier books and what has changed. First, what has remained the same:

The essential principle of reparative therapy remains the same – simply stated by one client as “When a real man sees me as a real man, then I become a real man.” (p. 31)

The real man is the therapist or some other model of masculinity and then to become a real man is apparently to become straight. Simple, right?

What has changed?

Recently, reparative therapy has expanded to conceptualize homosexual attraction as more than a striving to repair gender deficits. We now see it more broadly, as a striving to repair deep self-deficits. (p.31)

Translation: If you have SSA, you are worse off than Nicolosi first believed. You are not just deficient in your sense of gender identity, but your core sense of self is a wreck too. He continues:

My longtime clinical observation suggests one repeated trend in early childhood: specifically, an accumulation of early, core emotional hurts that have led to an attachment injury. I believe that homosexuality is not only a defense against gender inferiority, but a defense against a trauma to the core self.

Beyond the previously recognized needs of same-sex identification and affirmation, we now better understand the condition as an attempt to heal an abandonment-annihilation trauma. We see homosexuality as typically an attempt to “repair” shame-afflicted longing for gender-based individuation. As such, homosexuality can be seen as a pathologic form of grieving. Adopting concepts from bereavement and grief literature, we thus turn new attention to the contributions of attachment theory and the role of shame.(p. 31-32; all italics in the original)

I suspect those adopted concepts of bereavement and grief will want to return to their original family. According to Nicolosi, men (women, what women?) are drawn to sex with men because it somehow helps them grieve the loss of attachment to important figures in their childhood, most notably the father. However, these losses are not restricted to gender concerns.

This understanding that homosexuality is a symptom of a larger issue of self-identity is supported by the almost universal complaint of clients that they feel “insecure,” “inadequate,” “a little boy in an adult world,” “out of control” and lacking relational authority. For years I have heard clients express this interpersonal powerlessness: “She upsets me, they annoy me, he doesn’t take me seriously. (p. 33)

The trauma is broader than lack of attachment to the same sex parent. He notes:

Attachment is the foundation of our self-identity. It is through the mother-child attachment that we develop our sense of self and discover who we are. Shame felt during this process of attachment and individuation subverts development of both self-identity and gender identity.

Since our clients report a core experience of not having felt “seen” by their parents for who they are, they inevitably also felt that they were not loved – at least in the deepest and most genuine sense. There is a deep perception that the parents, even though they may have been truly well-meaning, have failed to fully see, know and accept them.

Because parents are not perceived as loving them for who they are, gay men develop a “false self” to defend against the abandonment of not being truly known. Kids start doing things they think will get their parents and other people to like them but those things are not really them. When they actually move toward what they want to do, they get depressed because they fear attachment loss. This is very nearly the same concept as the “false self” and “abandonment depression” of James Masterson. Masterson is nowhere referenced in the book which is a curious oversight. I wonder if it is because Masterson writes about the same dynamics with straight people being the primary clientele.

According to Nicolosi, reparative therapy helps clients give up the false self, a feature of which is same-sex attraction, in order to experience real attachment and affirmation from “real men.” As this occurs, the homosexuality will diminish and heterosexuality will emerge.

This should be reasonably easy to test. If all of this is true, homosexuals should be unable to hold jobs, or advance in careers, or do other things which require secure object relations and attachments. And of course, this is the practical problem for the practical work of reparative therapy. Many gay, ex-gay, post-gay, and SSA people do not have lives which correspond to the predictions in this book. Nor do their lives indicate the kind of deep self-deficits which are predicted here.

This is first in a series of occasional posts on this book. Stay tuned…

Christianity Today on evangelical divide over reparative therapy

Christianity Today has an article out online today which covers familiar ground to readers here.

Written by Bobby Ross, the article notes the divisions over reparative therapy which have been accentuated by the recent APA report on sexual orientation and therapy.

No surprise here: Evangelical leaders who advocate gay reparative therapy took umbrage at a highly publicized American Psychological Association (APA) resolution that criticized such efforts.

By a 125-4 vote, the 150,000-member association’s governing council adopted a task force report in August claiming a lack of evidence that efforts to change one’s sexual orientation work.

One aspect of the 138-page resolution, however, drew praise from some Christian psychologists—and exposed a divide in the evangelical therapy community.

As we discuss here often, modest change in orientation has been reported but, in my opinion, the change paradigm for therapy and ministry is old school.

Warren Throckmorton, a counselor who believes that the Bible prohibits homosexuality, commended the task force for “clarifying the value of helping clients sort out their beliefs and work out an identity and life that fit within the clients’ beliefs.”

A one-time proponent of sexual reorientation efforts, Throckmorton said he spoke up until 2004 at conventions of the National Association for Research and Therapy of Homosexuality (NARTH). But the Grove City College psychology professor has come to believe that changing a person’s sexual orientation is at best difficult.

Rather than focusing on reparative therapy, he has embraced “sexual identity therapy,” which focuses on helping a person live in a way that is consistent with his or her beliefs.

My issues with reparative therapy involve the lack of research support for the basic perspectives on the formation of same-sex attraction as well as the paucity of robust demonstrated outcomes.

“The reparative side sees the objective as healing the trauma [of family dysfunction] and thus curing the homosexuality,” said Throckmorton, former president of the American Mental Health Counselors Association. “The sexual identity side doesn’t see the efficacy of that approach and doesn’t think change is necessary in order to help people live in congruence with their faith.”

Ross then addresses the Jones and Yarhouse study and notes Mark Yarhouse’s views on change and therapy paradigms.

Yarhouse says more Christian psychologists are providing sexual identity therapy rather than reparative therapy. He recommends “a range of options” to help believers make sense of their sexual and religious identities.

“I don’t want to discourage people from making that attempt [to change orientation],” he said. “But for most of those people, success will not be a categorical shift from gay to straight. The gains will likely be modest, more along a continuum.”

As co-author of the Sexual Identity Therapy Framework, Mark offers a balanced view of the landscape. Most of the people who consider Exodus a success have a story of congruence with their faith than tell a story of some degree of change in their sexual arousal patterns.

Alan Chambers weighs in with more of the reparative therapy side of the divide.

Alan Chambers, president of Exodus International, said it is wrong to assert that sexual orientation cannot change as a result of therapy.

“That flies in the face of the testimonies of tens of thousands of people just like me,” said Chambers, a married father of two who credits God and counseling for helping him leave a homosexual lifestyle. “That’s not to say that you can flip a switch and go from gay to straight.”

Finally, NARTH’s David Pruden worries that the APA report will keep people from trying to change.

David Pruden, vice president of operations for NARTH, said the APA’s resolution likely will not affect how Christian psychologists counsel. He voiced concern, though, about its impact on potential clients.

“[This] could discourage individuals from even seeking assistance or entertaining the thought that growth or change is possible,” he said.

Well, if the proper information is disclosed to people, I doubt they will not seek assistance. However, if therapists practice in accord with the SIT Framework and recent APA guidance, they will not experience over promising or be directed to developmental theories which may not fit their lives.

Thoughts on the status of the Reorientation Wars

So now that the dust has started to settle from the APA convention in Toronto, let’s review the status of the Reorientation Wars.

Does therapy change orientation?

In anticipation of the APA’s report, NARTH fired an opening salvo with their paper (What Research Shows…). Perhaps sensing, incorrectly as it turns out, that the APA would advocate a ban on reorientation therapy, NARTH tossed every positive reference to change they could find into the paper. They noted problems in defining sexual orientation but did little to distinguish the various definitions and their meaning in the many studies they cited. They concluded, of course, that therapy can change orientation.

The APA on the other hand, differentiated sexual orientation and sexual orientation identity. Sexual orientation for them is the biological responsiveness to one gender or both. According to their literature review, the evidence that therapy can change orientation is not sufficient to permit therapists to inform clients that therapy can change their orientation. However, sexual orientation identity (i.e., self-labeling) may shift and be responsive to a variety of factors, including religious mediation.

It seems to me that what NARTH is calling sexual orientation includes the APA’s sexual orientation identity. While this statement risks taking us into the “all or nothing” dead end discussion about change, I do not mean that one must change completely for change to be important and psychologically relevant. I suggest instead that what many studies measure is how people see themselves, even if their sexual responsiveness (orientation) has only shifted by a degree (e.g., an average of less than a point on the Kinsey scale in the Jones and Yarhouse study). Jones and Yarhouse suggest as much in their recent paper when 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?

I believe the answer to their question is that it is not only possible but probable that change in sexual identity is what is being reported. The distinction between orientation and identity (or attraction and identity as we often describe it here) is key, in my view, in order for us to understand the experience of those who say they have changed while at the same time experiencing same-sex attraction. I also believe that men and women are different and their change may be different. Women seem to describe less exclusivity than men. Fluidity may be more likely with complete shifts described. I think we need to accommodate atypical experiences such as men and women who completely shift for a time and then shift back. Whatever the pattern, I hope we can agree that sexual attraction patterns may be one thing while meaning making aspects may lead two people with the same attraction pattern to identity in disparate ways.

Is sexual reorientation harmful or beneficial?

NARTH says reorientation might harm some people but that for the most part it is not harmful. The APA says existing studies are not good enough to allow conclusions. Point for the APA here. All we can say is that some people report harm and some people report benefit. The APA notes that the benefits can occur in programs which promote congruence with religious faith. This is clear and the Jones and Yarhouse study demonstrate that health status improves modestly for those who remained in the study. However, I would say we do not yet know much about what the potent or beneficial elements of those programs are. The APA report identified some of those elements.

Homosexuality and pathology

NARTH says homosexuals have more pathology than any other group of similar size. The APA says homosexuality is normal. By this they mean that homosexuality is not a developmental disorder or indicator of a mental disorder. The two recent reports go off in different directions but some observations can be made.

The NARTH report spends lots of time reporting on greater levels of mental health and health problems among homosexuals as compared to heterosexuals. The APA report does not do this. However, I believe the point regarding different levels of symptoms would be stipulated by the APA. However, the APA raises the minority stress model as responsible for many difficulties faced by non-heterosexual people. The NARTH report discounts the role of stigma.

I doubt the APA would dispute the health status data for another reason: greater group pathology does not mean inherent disorder. The APA’s position is not that gays have equal health outcomes but rather that the unequal health outcomes do not imply inherent pathology – that SSA is not inherently the result of pathological development. This is of course in great contrast to the reparative therapists. Joseph Nicolosi says that the only way you get SSA is to traumatize a child.

The reparative impulse to find trauma behind every gay person is misguided I believe, conceptually and for sure empirically. Women have greater levels of mental health problems than men but we would not consider women inherently disordered. NARTH has chosen some good studies to cite in the section of their paper which relates to health status (as well as some really bad and irrelevant ones). However, I don’t think it really gets them where they want to go.

And where do they want to go? This is clear from their press release complaining about the APA task force report. They state:

Further, if some clients are dissatisfied with the therapeutic outcome [of reorientation therapy], as in therapy for other issues, the possibility for dissatisfaction appears to be outweighed by the potential gains. The possibility of dissatisfaction also seems insignificant when compared to the substantial medical, emotional, and physical risks associated with homosexual behavior.

NARTH would suggest that these medical and emotional risks, along with the incongruity of homosexual behavior with the personal and religious values of many people will continue to be the motivation for some individuals to seek assistance for their unwanted homosexual attraction.

According to NARTH, gays ought to seek reorientation therapy because being gay is a risky life, full of health and mental health disadvantages. Their hypothesis is implied but hard to miss: reduce the SSA and reduce the health risks. The assumption appears to be that ex-gays will have better health outcomes than gays. One problem with this line of thinking is that there is no empirical evidence for it and some evidence against it.*

One researcher quoted in the NARTH paper regarding health risks was New Zealand’s David Fergusson. Dr. Fergusson has done significant work in this field. I asked him to look at the section of the NARTH paper in which his work was quoted. Here is a statement he provided about it:

While the NARTH statement provides a comprehensive and accurate analysis of the linkages between sexual orientation and mental health, the paper falls far short of demonstrating that homosexuality should be classified as a psychiatric disorder that may be resolved by appropriate therapy. To demonstrate this thesis requires an in depth understanding of the biological and social pathways that explain the linkages between homosexual orientation and mental health. At present we lack that understanding. Furthermore it is potentially misleading to treat what may be a correlate of mental disorder as though it were a disorder in its own right.

Fergusson also told me that one would need to develop studies to demonstrate that any changes in orientation associate with improvements in health status. The Jones and Yarhouse study provide some very general assessment but many potential confounds are uncontrolled. For instance, it is not possible to say that the modest shifts on the Kinsey scale were responsible for the shifts in health status. These folks were quite religious and religion is associated with enhanced health status. I suspect religious gays have a better health status than non-religious gays, on average. The point is we do not have evidence that sexual orientation status per se is what leads to the differences in health status.

While I am on the subject of health status, I need to mention that there are other factors which NARTH ignored. One, gender non-conformity is strongly correlated with adult homosexuality and is also associated with poorer mental health. Two, homosexuals report higher levels of sexual victimization which is also associated with higher levels of mental health problems. And, three, no one can discount the possibility that biological factors which associate with the development of homosexuality may also influence the development of emotional problems (i.e., in the same way women are more likely to report depression than men).

So where are we? I hope we have a larger middle and smaller numbers of people at the opinion extremes. People on both sides can agree that erotic responsiveness is extremely durable for men and perhaps less so for women, but behavior and self-identity reflection is alterable. People on both sides agree that conclusions about benefit and harm are not possible in any general sense. Also, I hope we can agree that full informed consent should be conducted prior to engaging in counseling. Regarding health status, both sides can agree that homosexuals have higher levels of problems but there is little agreement about what the differences mean.

Those on the far sides of the continuum will continue to argue that change is possible or change is impossible, and/or that reorientation is always harmful or never harmful and/or that health status difference mean something vital or irrelevant about inherent pathology.

The wars will continue but perhaps fewer people will be engaged in them; now is the time rather to reason together.

*Nottebaum, L. J., Schaeffer, K. W., Rood, J., & Leffler, D. (2000). Sexual orientation—A comparison study. Manuscript submitted for publication. (Available from Kim Schaeffer, Department of Psychology, Point Loma Nazarene University, 3900 Lomaland Drive, San Diego, CA 92106) – In this study, the authors found that mental health was better among the gay sample than the Exodus sample.

WorldNetDaily suddenly finds year old NARTH article newsworthy

A reader emailed me to say that the American Psychological Association had recently changed the official view on homosexuality causation to endorse an environmental set of causes. The prompt for the email was this article from WorldNetDaily: “‘Gay’ gene claim suddenly vanishes”
To arrive at this startling conclusion, the WND writer, Rob Unruh quotes an article published more than a year ago from NARTH titled, “APA’s New Pamphlet On Homosexuality De-emphasizes The Biological Argument, Supports A Client’s Right To Self-Determination.”
In the article, Dean Byrd notes that the APA document shifts emphasis on causes to a more nuanced and complex view. Byrd cites this quote:

“There is no consensus among scientists about the exact reasons that an individual develops a heterosexual, bisexual, gay or lesbian orientation. Although much research has examined the possible genetic, hormonal, developmental, social, and cultural influences on sexual orientation, no findings have emerged that permit scientists to conclude that sexual orientation is determined by any particular factor or factors. Many think that nature and nurture both play complex roles…”

However, oddly, Byrd leaves this last phrase from the APA website out of his quote:

…most people experience little or no sense of choice about their sexual orientation.

Also in the APA paper, reparative therapy is discussed. The APA says
What about therapy intended to change sexual orientation from gay to straight?

All major national mental health organizations have officially expressed concerns about therapies promoted to modify sexual orientation. To date, there has been no scientifically adequate research to show that therapy aimed at changing sexual orientation (sometimes called reparative or conversion therapy) is safe or effective. Furthermore, it seems likely that the promotion of change therapies reinforces stereotypes and contributes to a negative climate for lesbian, gay, and bisexual persons. This appears to be especially likely for lesbian, gay, and bisexual individuals who grow up in more conservative religious settings.
Helpful responses of a therapist treating an individual who is troubled about her or his same-sex attractions include helping that person actively cope with social prejudices against homosexuality, successfully resolve issues associated with and resulting from internal conflicts, and actively lead a happy and satisfying life. Mental health professional organizations call on their members to respect a person’s (client’s) right to self-determination; be sensitive to the client’s race, culture, ethnicity, age, gender, gender identity, sexual orientation, religion, socioeconomic status, language, and disability status when working with that client; and eliminate biases based on these factors.

From these paragraphs expressing concern, Byrd pulls out this sentence to portray a greater openness to change therapy than is warranted:

“Mental health organizations call on their members to respect a person’s [client’s] right to self-determination.”

I blogged about this article last year when it came out, commending the APA for their nuanced account of the research to that point. I think NARTH should do what the APA did a year ago and issue a statement about environmental causes. Then I wondered:

…when NARTH would make an APA-like statement about theorized environmental factors such as child abuse and same-sex parenting deficits. What if NARTH acknowledged “what most scientists have long known: that a bio-psycho-social model of causation best fits the data?” Wouldn’t there be a need for a statement cautioning readers of their materials that evidence for parenting playing a large or determining role is meager? Paralleling Dr. Byrd’s assessment of the APA pamphlet, shouldn’t NARTH say with italics, “There is no homogenic family. There is no simple familial pathway to homosexuality.”…
I wrote Dean and asked him about NARTH’s stance. He answered for himself by saying,

I think that the bio-psycho-social model of causation makes it clear that there is neither a simple biological or environmental pathway to homosexuality.

NARTH is widely known for championing a view of homosexuality that requires some kind of trauma as a causal factor. In point of fact, SSA can occur without bad parenting or abuse. Shouldn’t NARTH follow the APA’s lead and issue an official statement such as suggested above?
UPDATE: OneNewsNow and AFTAH have joined the echo chamber.
The ONN account begins:

The attempt to prove that homosexuality is determined biologically has been dealt a knockout punch. An American Psychological Association publication includes an admission that there’s no homosexual “gene” — meaning it’s not likely that homosexuals are born that way.

I wonder if NARTH will correct this misunderstanding of the APA’s publication. In fact, no knockout punch has been delivered to any theory, except perhaps for those dogmatic views that stress one pathway. Let’s see leaving aside extreme biological determinism, who else gets a knockout punch here? The APA statement cuts both ways but NARTH, and the people quoted in this report only want to see it go one way.
The APA (over a year ago) handled the research with integrity. When will NARTH and related groups do the same?