Do therapists need a “conscience clause”?

Culture wars in therapy

A friend texted me, “What is going on with the culture wars in the TWR group?”

Ugh, I thought. I don’t know. What does the term “culture wars” even mean? So I went to Wikipedia to see what it had to say. To my surprise, the word was a lot older than I realized. Wikipedia says it’s originally a German word, Kulturkampf ('culture struggle'), referencing a time in Germany in the late 1870’s when their was great divide over social issues. It’s become popular in the United States in the last decade or two with the divisions in the country surrounding abortion and LGBTQ rights. And here’s where we land for the Therapists who Rock FB group. There are over 4,000 people in the group. We each individually have personal beliefs and values about what it is right for us, but most of us understand as therapists, we don’t get to decide that for our clients or impose our beliefs onto them. This “culture war” has come to the forefront recently in Arkansas as our legislature has focused on legislation that are targeting LGBTQ+ people and the governor signed a “medical conscience objections bill into law’.

To say I was shocked by the divisions in the group over the treatment of LGBTQ people in our state would be an understatement. I’m not so naïve that I thought everyone in our state were supporters of the LGBTQ “rights movement” in Arkansas. Not at all, but as therapists who have masters degrees in a state where only 8% of people have advanced degrees, I consider therapists, social workers, psychologists, counselors and marriage and family therapists as the “educated class”. We have gone to college and been exposed to different people and varied ideas. Not only that, most of us through our graduate work in mental health, were exposed to a great number of people who were not like us at all. At least I was. I’m starting to see lots of practitioners who went to only online schools where I think the experience may be different. I know I hung out with classmates frequently in grad school. That would obviously be much more difficult when you are in an online only school. Could having limited interactions with others who are different than yourselves, like the mosaic of people who are drawn to social work also impact your work as a therapist? Yes, without a doubt. I believe a great number of the therapists supporting the conscience laws or the law restricting care to trans youth have never themselves met or interacted with a transgender person. We know that it’s often easy to label, judge and even hate and dehumanize people you’ve never met, but much more difficult when you have a personal relationship and when the person is up close to you. We all also know each of our codes of ethics, whether we are social workers, counselors, psychologists or marriage and family therapists, all talk about the dignity and worth of the person and being competent in our careers. Why would that stop when working with LGBTQ+ people?

The amount of anti LGBT sentiment espoused by therapists and graduate level practitioners was shocking. So many couched it behind religion or politics, which are deeply personal beliefs, instead of the perspective of what needs the client may have. I don’t want to mistakenly paint a picture that all Christians or conservatives are in support of the anti LGBTQ legislation, that’s not true. I know many people fit into both categories that categorically do not support any legislation that attempts to marginalize vulnerable people more. I’ve been doing what our human brains do, look for any type of pattern I can see in the therapists who are vocally in support of the “conscience law”.

I can’t say I ever gave much brain space to the idea that my clients and I need to share the same value system. My very first field instructor at my first social work internship 19 years ago was a very conservative, evangelical Christian. He and his wife home schooled their children, grew and canned their own food and were neat people. But his values were very different than my own and very different than those of many of the adolescents we served at the Juvenile Detention Center where our placement was. I can remember so many conversations with him about how not to impose our values on our clients. Forcing me over and over to acknowledge the differences in our experiences and what may be “right” for me, may not be for them and it wasn’t my job or business to press my beliefs about what was “right” or what they “should be” doing onto these clients-and to do it without judgement. It was a huge early lesson in social work for me and seems so basic now, but it was very profound in so many layered ways-clients have the right to decide what’s “right” for them, it’s not up to me to impose my values or beliefs on them, it was simply for me to show up with them right where they were at that moment in time and support them in the ways they needed.   So the notion that I need to somehow agree with my client’s values in order to help them is strange to me. But it’s a big mistake to confuse “values” with being LGBTQ+. Values are things like integrity, honesty, trustworthiness, intelligence, etc, not gender identity or sexuality. Can both therapist and client value living your truth? Of living an honest, genuine life? Of course. Again, another argument that doesn’t really hold water here.

I was at a therapist training this past week on bias and the presenter stated “if a person walks into your office and they have multiple partners but they don’t have a problem with it but you do, you need to seek therapy and do your own work around whatever bias might be coming up for you. If it’s an issue for you and not the client, it’s your issue to work on”. If you are a therapist and you disagree with this statement, I would like to know more about why. The arguments people go to are “well I wouldn’t want to have to provide treatment to a sex offender or someone like that and with this law, I can decline those people without fear of litigation”.
That doesn’t really hold weight. To be a therapist for people with sexual behavior issues, it’s a very specialized area. You wouldn’t be treating those individuals without first 1) an interest in that area, 2) Training and ongoing continuing education on the treatment of sexual behavior disorders and 3) Supervision and consultation from others who work with that population. (Also, BTW, people who have problematic sexual behaviors are also entitled to compassionate care). The same argument is made about abortions, that this law will allow doctors to refuse to provide abortions if it goes against their conscience. Again, another highly specialized area the physician would have to CHOOSE to work in. Yet another argument that comes up a lot is that the person does not have a “specialization” in LGBTQ+ issues so they can’t work with that population. Really? Is “gay depression” that much different than “straight depression”. Do gay couples have different reactions to overspending or infidelities by a spouse? Of course I realize there are differences and experiences that are unique to people in the LGBTQ community and to practice competently, additional trainings should be probably be undertaken. In my years of being a clinical social worker (17) the overwhelming majority of LGBTQ people I’ve treated weren’t coming to me about problems with their sexuality. They came to me with the generally the same problems my heterosexual, cis gendered clients had. That argument that somehow I don’t have the competency to treat people who may be LGBTQ for mental health issues seems a bit weak to me.

I’ve been having the the thought lately that some therapists have no interest in doing their own work. They have no interest in exploring their own biases, no interest in challenging their own beliefs or looking deeper for the WHY of their beliefs. The Harvard implicit bias quizzes are fascinating learning tools to me. They remind me that our biases (and we ALL have them) are something to grow from instead of being afraid of. Another concern I have about therapists who may be unwilling to challenge their own biases, is my fear that many of them have poor supervision or no supervision at all just getting out of school. If they went to an online school, plus poor quality or lack of supervision, that can’t lead to good clinical practices. While working towards my LCSW, I had several great supervisors who each helped me grow as a clinician. It wasn’t always pleasant or pretty, but it was much needed growth and I’m truly thankful for their nudges and putting up a mirror in front of me. Good supervision is invaluable. Can you have religious beliefs that are not biased? Of course. Religious beliefs are not synonymous with bias. People can have religious beliefs and be perfectly ethical counselors who treat a wide variety of people. Do you believe your religious beliefs insulate you from working with others who might believe differently? It’s very intriguing to me the role religion may be playing here. Could there be some spiritual bypassing going on?

As therapists, making referrals is something we do regularly. It’s really important that when emotionally fragile people reach out for help, that they don’t feel judged, shamed or rejected. Abandoning clients is something that is never ok and can lead to ethical breeches to your license. Good therapy does a great job with this article on outlining when to refer a client.  Arkansas is a rural state and there’s valid concerns that people who may be seeking care from therapists in rural areas, may not have a lot of options as far as looking for LGBTQ affirming care. If instead they face a therapist who invokes the “conscience clause” can you imagine the possible damage that could do to a client? If we can’t help people, we certainly don’t want to hurt them. We do not need a conscience clause; we need good training, ethical supervision, to do our “own work” and to continue to provide services in the most unbiased way possible.

Whether it’s attending online schools, poor quality supervision, lack of experience working with diverse populations, spiritual bypassing or just plain old religious intolerance, we have chosen a career that requires us to continue and grow. If you don’t want to do that, and instead want to only do continuing education around topics and issues that don’t challenge you, how do you help your clients grow? Change and being challenged and having to think deeply about our own beliefs and where they come from can be uncomfortable. How can you do that with client’s if you are unwilling to do it yourself? If you are unwilling to do look at your own “stuff”, then is a career field that expects that of you the right career? I certainly can’t answer that for anyone else, but it’s something to consider for further reflection.

What I do know is the TWR group will continue to operate from the values that LGBTQ+ people have immense value and worth and should have the resources and support to be successful. If you are a therapist and need more information on working with trans people, check out this paper from the APA