On ethics and CAMFT's record of published statements about AAMFT

In their own words.                                                                                                                                                                                                                                                                                      All bold text is my emphasis added.

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"Marriage and family therapists, when acting as teachers, supervisors, and researchers, stay abreast of changes in the field, maintain relevant standards of scholarship, and present accurate information."
- CAMFT Code of Ethics, principle 3.5

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On AAMFT and AAMFT-CA's legislative interest

CAMFT statement: "The opposition [to the LPC bill] in California from AAMFT and AAMFT-CA never surfaced until 2007 and their legislative interest was limited to this single effort - this single piece of legislation."
- CAMFT Feature Article, The Therapist magazine, March/April 2008

Fact check 1: "Assembly bill 894, introduced last year, would create a professional counselor (LPC) license in the State of California. While AAMFT-CA has no objection to the licensure of mental health professions, we had major concerns with the content of this bill, and therefore took a position of opposition. [...] I spoke to the legislature’s Joint Committee on Boards, Commissions, and Consumer Protection in November [2005] to let them know our position and the reasoning behind it."
- AAMFT-CA newsletter, Legislative and Advocacy column, Spring 2006

Fact check 2: "Among our accomplishments in 2007, we have worked with the BBS to improve license portability into California. [...] We also helped to defeat the bill that would have created an LPC (licensed professional counselor) license in California [...] We are not opposed in principle to counselor licensure [...] We also have been very vocal with the BBS in helping shape the new educational requirements for MFT graduate programs, which are likely to be put into legislation next year."
- AAMFT-CA newsletter, Legislative and Advocacy column, Fall 2007

Fact check 3: "In 2007 the AAMFT experienced many successes on important advocacy initiatives. In particular, the AAMFT is pleased to announce that we were successful in obtaining participation for MFTs in the U.S. Substance Abuse and Mental Health Service Administration (SAMHSA) Minority Fellowship Program. [...] Also, for the first time, the US House of Representatives passed a bill including MFTs in Medicare."
- Membership renewal message from the AAMFT Executive Director, 2008

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On working collaboratively

CAMFT statement: "CAMFT has approached the [AAMFT-CA] division about legislative issues that CAMFT is sponsoring to involve them in joining our efforts -- efforts to work together to further the interests of the profession. There has been no willingness or interest in working with CAMFT on these legislative matters."
- CAMFT Feature Article, The Therapist magazine, March/April 2008

Fact check: "With the resources I have available [through] AAMFT, I think that a joint and collaborative effort would be valuable. If you let me know when and where the meeting is taking place, I would like to make arrangements to join you."
- Email regarding counselor legislation from AAMFT-CA Executive Director Olivia Loewy to CAMFT Executive Director Mary Riemersma, March 27, 2007

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On AAMFT's interest in federal legislative matters

CAMFT statement: "Historically, AAMFT, at the federal level, had no interest in legislative matters. It was actually Richard Leslie at CAMFT who pushed AAMFT, thereby turning the tide on their involvement in federal legislative matters to attempt to advance the MFT profession."
- CAMFT Feature Article, The Therapist magazine, March/April 2008

Fact check 1: "The association not only incorporated as a trade organization in Washington, but also began a long association when it hired Steven L. Engelberg as legal counsel for Washington (federal) affairs in 1974. [...] Failing to make progress in two months of negotiations with the Department of Defense [after CHAMPUS reimbursement for MFTs had been eliminated], the AAMFT sued the DoD for reinstatement on April 26 [1975]."
- William C. Nichols, The AAMFT: Fifty Years of Marital and Family Therapy, pp. 41, 63.

Fact check 2: "CAMFT contracted with Richard S. Leslie, Attorney, in 1976."
- CAMFT Executive Director Mary Riemersma, "The building of a profession"

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On correcting false information, Part I

My correction request: "At the article’s conclusion, Ms. Riemersma writes, “No one gains by steadfastness, an unwillingness to negotiate, and casting barbs at the perceived opposition.” With this, I would agree wholeheartedly. Unfortunately, much of the Feature Article appears to be an attempt to cast barbs at AAMFT – an organization that, like CAMFT, has the best interests of the profession at heart. Even when the organizations disagree, it serves us best to present information that is clear and accurate."
- My May 7, 2008 Letter to the Editor requesting CAMFT correct the provable factual errors detailed above

CAMFT response: "Your letter will not be printed in an upcoming issue of The Therapist due to the fact that members are troubled by the debate and do not benefit from it."
- CAMFT response to my request

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On CAMFT informing the legislature (and its members) about a one-license future

CAMFT magazine: "I attended the AAMFT Long Beach Conference where their president Mike Bowers made a pronouncement at a conference forum of about 500 people that Mary Riemersma of CAMFT informed the California legislature that all therapists will hold the same license in the near future! I became alarmed. [...] I knew Mary. This could not have been accurate. I called Mary and she quickly informed me of this misinformation."
- Letter to the Editor, CAMFT's The Therapist magazine, Jan/Feb 2011, p. 5

Fact check: "CAMFT states, “At some time in the future, we project that there will only be one masters level profession in California, with individuals specializing within that license. Thus, those who wish to specialize in systems work will do so; those who wish to specialize in art therapy will do so, etc. The current system with a variety of acronyms is confusing for consumers who just want to be helped and do not perceive greater value from one professional compared to the next.”"
- California Senate Committee Analysis of AB1486, July 2007
- Same text appears in a CAMFT email to members, May 24, 2007

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On correcting false information, Part II

My request for correction: "Michael Bowers [is] AAMFT’s Executive Director, not its president [...] It is true that Riemersma’s letter refers to “some time in the future,” and not the “near future” as the letter writer wrote – but this minor difference is an error on the part of the letter writer, not Bowers. Bowers quoted, in his speech and in his presentation slides, the exact text the legislative report quoted."
- My Letter to the Editor again requesting CAMFT correct provable errors of fact

CAMFT response: "Your request to print the proposed correction was denied."
- CAMFT response email

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"Marriage and family therapists treat and communicate with and about colleagues in a respectful manner and with courtesy, fairness, and good faith, and cooperate with colleagues in order to promote the welfare and best interests of patients."
- CAMFT Code of Ethics, principle 5

How should religious therapists handle gay and lesbian clients?

Counselors and therapists with strong religious beliefs sometimes refuse to treat gay and lesbian clients. Some even refuse to offer referrals. Can they do that?                                                                                                               

So-called "conscience clauses" are common in health care. They allow professionals to refuse to provide a service within their scope when that service would conflict with the professional's moral or religious values. In reproductive health, for example, this allows gynecologists to refuse to perform abortions, and allows pharmacists to refuse to distribute birth control, if they find these objectionable.

Such provisions are controversial. The Obama administration has moved to (mostly) end them in federally-funded facilities, and there have been several instances where patients have been harmed -- and then filed lawsuits -- over treatment refusals based on conscience clauses.

The debate is now coming to mental health, as a result of religious therapists and students taking a stand against treating gay and lesbian clients. These cases point to an interesting contradiction in professional ethical codes:

• Mental health professionals do not discriminate based on sexual orientation.
• Mental health professionals do not treat clients outside of their scope of competence.

Though the specific wording varies, versions of those statements can be found in the ethical codes of every major mental health association. When a religious therapist, whose beliefs suggest that homosexuality is immoral[*], is asked to treat a gay or lesbian client (or couple), what should the therapist do?

Offering treatment would abide by the non-discrimination sections of professional ethical codes, but could lead to ineffective -- or even harmful -- treatment. Religious therapists who, perhaps by their own choosing, lack the training and experience to work effectively with gay and lesbian clients then should not ethically be treating those clients. On the other hand, refusing to treat a client based on the client's sexual orientation seems to be quite clearly discriminatory.

On issues like this where different parts of a code of ethics conflict, the ethical codes generally do not indicate which standards should take precedence over others. (They also do not allow exceptions based on the therapist's religious beliefs.) The NASW Code even includes a clear statement that it does not prescribe such an ethical hierarchy, as ethical decision-making is centered around process more than outcome. So no one really knows whether it is ethical for a therapist to refuse to treat clients in same-sex relationships.

Again, allowing a health care provider to refuse to treat clients based on the provider's religious beliefs is common in other fields (Pharmacy | Medicine), but it comes with an important caveat: The provider usually must give the patient a referral to another provider who would offer the treatment in question. In theory, that should resolve the issue; patients get the services they need while providers maintain their religious convictions. In practice, it only works if that other provider is close at hand. Patients refused services based on religious "conscience clauses" in rural areas, as well as those needing to be treated immediately for the treatment to be effective, are left without options when their provider refuses to treat them for religious reasons -- which is precisely why many states put exceptions in their "conscience referral" legislation or simply do not allow such referrals.

Some states already have "conscience clause" laws on the books that do not require any referral at all, which has drawn protest from professional associations who worry that they allow a health care provider's religious beliefs to "run roughshod over the profession’s code of ethics." In the Lincoln (Nebraska) Journal-Star, Rev. Christopher Kubat presented the case that religious therapists should be able to turn away same-sex couples without offering referrals:

Since the Catholic Church teaches that sexual relations are meant for one man and one woman in the context of marriage, if a same-sex couple requests therapy to support, validate or enhance their sexual relationship or something akin to marital therapy, it would be inappropriate to provide that specific, narrow service or make a referral for it, as referring for something considered inappropriate or immoral would itself be inappropriate and immoral because of the element of cooperation.

That strikes me as blatantly discriminatory and harmful to those in need of treatment. It also is theologically consistent.

This is the debate I wish had taken place in CAMFT's rightly-maligned (and eventually disowned) same-sex-marriage issue of The Therapist. I think there is a legitimate concern on both sides. Religious therapists have an ethical obligation not to refuse treatment based on a client's sexual orientation. But how can that treatment possibly in the client's best interests when the therapist's religion precludes them from in any way supporting the client's romantic relationship? It seems unlikely. Is there a workable middle ground?

Proposed legislation in California would attempt to at least partially resolve this issue by ensuring all mental health professionals receive training in working with LGBT populations. That may be helpful when it comes to establishing competence, but likely will not change anyone's religious beliefs.

I do not pretend to have the answer here, though I am optimistic such an answer exists. I wish all clients, regardless of sexuality, could receive competent and accepting treatment anywhere they seek it. I also do not want any of the talented religious therapists I know to feel like they need to betray their religious beliefs to work as mental health professionals. I just wish there were a place for honest, genuine, respectful debate on this issue that could land on some ethics code language on which both sides could agree. Is there a place for that?

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* - For clarity's sake, of course not all religious therapists believe that homosexuality is immoral, or would refuse to treat gay or lesbian clients. I personally know many strongly religious therapists who see no conflict at all in offering their professional services to clients regardless of sexual orientation.