Several years back I worked as a legislative analyst where I reviewed and drafted bills

on a range of topics. In doing this work it became obvious that human error and errors

of political judgment would occur. Sometimes laws were passed that created

unintended problems, in other cases that the piece of legislation had no discernible

impact. This brings me to a bill that has passed in the Tennessee legislature and is

going to the Governor for signature, HB 1840. As you may have heard, this bill is

another proposed “religious freedom” law that would specifically impact gay, lesbian,

bisexual, and transgender citizens. HB 1840 explicitly impacts lgbt clients accessing

mental health services in that the provider of such services may decline to treat the lgbt

consumer based upon the therapist’s religious beliefs. In the current legislation it is

proposed that:

“No counselor or therapist providing counseling or therapy services shall be required to

counsel or serve a client as to goals, outcomes, or behaviors that conflict with a

sincerely held religious belief of the counselor or therapist; provided, that the counselor

or therapist coordinates a referral of the client to another counselor or therapist who will

provide the counseling or therapy.”

On its face this is a clear statement of supporting the rights of a professional therapist to

choose not to treat lgbt clients, based upon sincere religious beliefs. Having written

legislation on special education, nuclear power, and honoring the music of Willie

Nelson, I know legislation relies upon terms having precise meaning. I sincerely doubt

the Tennessee codified statues defines the legislative intent of “sincere.” I think that

HB1840 therefore is highly symbolic – e.g. yet another anti-lgbt piece of legislation. At

the same time I feel it is highly irrelevant in light of a variety of commonly encountered

realities of mental health practice. These factors are only in part due to ideological –

read as religious – issues. Three specific reasons I think this piece of legislation is in

essence useless are briefly laid out below:

1. Deciding to treat is often elective. In my clinical practice I frequently decline to take on

psychotherapy patients for a variety of reasons, scheduling, being one, another being

persons who seek areas of specialization I do not work in – such as eating disorders,

marital therapy, or substance abuse. Many therapists do not take on clients due to

issues such as age “I don’t work with pre-teenagers” is not an unusual comment one

might hear. Many therapists with little training and experience with substance

dependence, for example, are reluctant to work with alcoholics, with the feeling being

this is an area of expertise that needs to be considered. This reason to not treat is

closely linked to the second major concern, that of the therapists clinical competence.

2. Competence is always an issue in service delivery. It is widely recognized in

psychotherapy practice and often articulated in psychotherapy ethics that the treating

therapist should not provide services outside of their area of competence.

As the 2011 American Psychological Association (APA) Guidelines on delivering

psychological services to lgbt clients

(http://www.apa.org/pi/lgbt/resources/guidelines.aspx) notes “Despite the rising

emphasis on diversity training during graduate education and internship, studies have

shown that graduate students in psychology and early career psychologists report

inadequate education and training in lesbian, gay, and bisexual issues (Mathews,

Selvidge, & Fisher, 2005; Pilkington & Cantor, 1996) and feel unprepared to work with

these groups (Allison, Crawford, Echemendia, Robinson, & Knepp, 1994; Phillips &

Fischer, 1998).” This is important for two reasons. Firstly, professionals develop

competencies in areas largely of their choosing. Psychotherapists may learn how to

treat anxiety using cognitive behavioral therapy, or they may seek to learn skills in

couples counseling, group therapy, or use techniques for stress management. It is hard

to imagine a professional psychotherapist seeking specialized knowledge to treat a

client group that they find objectionable due to their “sincere” religious principles. A

professional counselor or therapist does specialize in treating a client group that their

personal belief systems finds problematic. Additionally, and importantly, research shows

that training individuals about topics of diversity and culture may strengthen opposition

to culturally diverse groups when the learner feels such training is forced upon them. In

such cases the learner will more strongly identify with the biases and prejudice they a

priori subscribe to. Professional counselors who are mandated to learn about social

groups that they hold hostile or ambivalent feelings towards may therefore strengthen

the underlying rejection of persons of a specific social outgroup. This brings me to a

final critical point, the emotional status of the profession counselor who faces the

prospect of treating someone they view as undesirable, unworthy, or invalid, particularly

when due to a core belief system such as one’s own religious worldview.

3. Recognition of emotional and ideological reasons not to treat is already assumed.

Largely independent of any theoretical approach, it is agreed that the practitioner needs

to be open to and interested in the individual they treat. Further, the practitioner is

expected to evidence a genuine empathy and appreciation for the client. When this is

adequately realized a therapeutic bond is established, frequently within the first half-

dozen sessions. If the psychotherapist’s beliefs preclude this from happening, the

practitioner from an ethnical standpoint ought not to treat the client. The 2011 APA

guidelines on delivering psychological services to lgbt clients note that “The

psychological assessment and treatment of lesbian, gay, and bisexual clients can be

adversely affected by their therapists’ explicit or implicit negative attitudes.” As such, the

attitudes held by the treating therapist always need to be considered in the ethnical

treatment of lgbt clients. It therefore is clear that a psychotherapist who is conscious of

their rejection of an lgbt lifestyle due to their personal religious beliefs is unable to

ethically treat such a client. This, of course, is not only true for issues about religion and

sexual orientation. Many treating therapists might be unable to effectively treat

pedophiles, spousal batterers, or violent offenders, due to personally-held adverse

attitudes towards these individuals. Put simply the therapist needs to decide when they

can and cannot effectively treat a patient given specific characteristics of the individual.

This notion of psychotherapist counter-transference – an idea that goes back to

classical psychoanalysis – is recognized as a barrier to effective mental health service

delivery.

So we must remember it is not uncommon for practicing psychotherapists to decline to

treat potential clients for a range of reasons, including problems outside the

practitioner’s clinical specialization, issues of client age, an absence of their cultural

competence, or an awareness of one’s own biases and beliefs.

Experienced psychotherapists know the limits of their expertise, treating any person that

is outside of the scope of their competence poses ethical and practical problems.

What is important however is the symbolic nature of the HB1840. Having spent a great

deal of time analyzing hate crimes – and having treated hate crime offenders – the risk

posed by the bill is the encouragement of lgbt hostility by individuals who are

psychologically compromised – e.g. ”at-risk.” The bill (unintentionally?) constitutes a

form of permission-giving to gay bash and discriminate against lgbt citizens. As a gay

basher once said to me “I know a lot of people agree with what I did.” We encourage

this attitude when we put forward symbolic legislation to curtail the rights of our citizens.

So what is the intent of HB1840? Simply to rally a base of conservative voters – as a run

up to the presidential election – who respond to anti-civil rights agenda. What does it

change in the realities of mental health service delivery? Not a thing. But we can’t

discount nor ignore the symbolism of this otherwise useless bill.

 

http://www.capitol.tn.gov/Bills/109/Bill/HB1840.pdf

http://www.apa.org/pi/oema/resources/policy/provider-guidelines.aspx