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.

Media reports regarding the APA sexual orientation and therapy report

In addition to the separate posts on the topic, here is some additional coverage. If time permits, I may add a comment or two of opinion to them.

USA Today

Christianity Today

World Magazine

Mother Jones

AP Radio Network

Associated Press

Los Angeles Times

Southern Voice

The Advocate

Citizenlink, Day 1

Citizenlink, Day 2

Washington Times

CBN reports on APA report

The Christian Broadcasting Network reports this morning on the APA task force findings.

UPDATE: The video now does not reflect the news report linked above.

Wall Street Journal covers APA task force report and sexual identity therapy

The Wall Street Journal’s Stephanie Simon has captured well the application of the APA task force sexual orientation report in an article out this morning. Of course I would say that…

The men who seek help from evangelical counselor Warren Throckmorton often are deeply distressed. They have prayed, read Scripture, even married, but they haven’t been able to shake sexual attractions to other men — impulses they believe to be immoral.

Dr. Throckmorton is a psychology professor at a Christian college in Pennsylvania and past president of the American Mental Health Counselors Association. He specializes in working with clients conflicted about their sexual identity.

The first thing he tells them is this: Your attractions aren’t a sign of mental illness or a punishment for insufficient faith. He tells them that he cannot turn them straight.

But he also tells them they don’t have to be gay.

For many years, Dr. Throckmorton felt he was breaking a professional taboo by telling his clients they could construct satisfying lives by, in effect, shunting their sexuality to the side, even if that meant living celibately. That ran against the trend in counseling toward “gay affirming” therapy — encouraging clients to embrace their sexuality.

But in a striking departure, the American Psychological Association said Wednesday that it is ethical — and can be beneficial — for counselors to help some clients reject gay or lesbian attractions.

The APA is the largest association of psychologists world-wide, with 150,000 members. The association plans to promote the new approach to sexuality with YouTube videos, speeches to schools and churches, and presentations to Christian counselors.

According to new APA guidelines, the therapist must make clear that homosexuality doesn’t signal a mental or emotional disorder. The counselor must advise clients that gay men and women can lead happy and healthy lives, and emphasize that there is no evidence therapy can change sexual orientation.

But if the client still believes that affirming his same-sex attractions would be sinful or destructive to his faith, psychologists can help him construct an identity that rejects the power of those attractions, the APA says. That might require living celibately, learning to deflect sexual impulses or framing a life of struggle as an opportunity to grow closer to God.

While the report doesn’t use my exact words (e.g., I don’t say ‘you don’t have to be gay’), she does catch important aspects of the APA report and the stance I use within the sexual identity therapy framework. Furthermore, I don’t show the video at the same time in the same order of things to clients and then they make a decision about their direction. I do however, do extensive informed consent and answer lots of questions which involves videos and slides to answer. Thanks for Michael Bailey for those vids.

This report captures the essence of the novel findings in the APA report in contrast to the AP report which continues to present a polarized picture. For sure, as long as the dialogue around change is important to people, we keep talking past each other. However, when you look at what both sides actually claim, they are not that far apart. According to the AP report, Jones and Yarhouse are going to report over half of 61 subjects either changed or are celibate. Whatever the percentage, it is clear that change cannot be promised to clients as a predictable function of therapy or ministry. We should be able to agree about that and then place emphasis on belief and value congruence. From there, see what happens.

I will have other posts on the media reaction and additional analysis…

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.

Press release: APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation Report

The APA released the report from the Task Force on Appropriate Therapeutic Responses to Sexual Orientation today. This post is the APA press release, I also have an analysis of the report and another post coming with press reports.

APA PRESS RELEASE

August 5, 2009

Contact: Kim Mills

(202) 336-6048 until Aug. 5

(416) 585-3800 – Aug. 5-9

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INSUFFICIENT EVIDENCE THAT SEXUAL ORIENTATION CHANGE EFFORTS WORK, SAYS APA

Practitioners Should Avoid Telling Clients They Can Change from Gay to Straight

——————————————————————————–

TORONTO—The American Psychological Association adopted a resolution Wednesday stating that mental health professionals should avoid telling clients that they can change their sexual orientation through therapy or other treatments.

The “Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts” also advises that parents, guardians, young people and their families avoid sexual orientation treatments that portray homosexuality as a mental illness or developmental disorder and instead seek psychotherapy, social support and educational services “that provide accurate information on sexual orientation and sexuality, increase family and school support and reduce rejection of sexual minority youth.”

The approval, by APA’s governing Council of Representatives, came at APA’s annual convention, during which a task force presented a report that in part examined the efficacy of so-called “reparative therapy,” or sexual orientation change efforts (SOCE).

“Contrary to claims of sexual orientation change advocates and practitioners, there is insufficient evidence to support the use of psychological interventions to change sexual orientation,” said Judith M. Glassgold, PsyD, chair of the task force. “Scientifically rigorous older studies in this area found that sexual orientation was unlikely to change due to efforts designed for this purpose. Contrary to the claims of SOCE practitioners and advocates, recent research studies do not provide evidence of sexual orientation change as the research methods are inadequate to determine the effectiveness of these interventions.” Glassgold added: “At most, certain studies suggested that some individuals learned how to ignore or not act on their homosexual attractions. Yet, these studies did not indicate for whom this was possible, how long it lasted or its long-term mental health effects. Also, this result was much less likely to be true for people who started out only attracted to people of the same sex.”

Based on this review, the task force recommended that mental health professionals avoid misrepresenting the efficacy of sexual orientation change efforts when providing assistance to people distressed about their own or others’ sexual orientation.

APA appointed the six-member Task Force on Appropriate Therapeutic Responses to Sexual Orientation in 2007 to review and update APA’s 1997 resolution, “Appropriate Therapeutic Responses to Sexual Orientation,” and to generate a report. APA was concerned about ongoing efforts to promote the notion that sexual orientation can be changed through psychotherapy or approaches that mischaracterize homosexuality as a mental disorder.

The task force examined the peer-reviewed journal articles in English from 1960 to 2007, which included 83 studies. Most of the studies were conducted before 1978, and only a few had been conducted in the last 10 years. The group also reviewed the recent literature on the psychology of sexual orientation.

“Unfortunately, much of the research in the area of sexual orientation change contains serious design flaws,” Glassgold said. “Few studies could be considered methodologically sound and none systematically evaluated potential harms.”

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.

“Without such information, psychologists cannot predict the impact of these treatments and need to be very cautious, given that some qualitative research suggests the potential for harm,” Glassgold said. “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.”

As part of its report, the task force identified that some clients seeking to change their sexual orientation may be in distress because of a conflict between their sexual orientation and religious beliefs. The task force recommended that licensed mental health care providers treating such clients help them “explore possible life paths that address the reality of their sexual orientation, reduce the stigma associated with homosexuality, respect the client’s religious beliefs, and consider possibilities for a religiously and spiritually meaningful and rewarding life.”

“In other words,” Glassgold said, “we recommend that psychologists be completely honest about the likelihood of sexual orientation change, and that they help clients explore their assumptions and goals with respect to both religion and sexuality.”

A copy of the task force report may be obtained from APA’s Public Affairs Office or at http://www.apa.org/pi/lgbc/publications/therapeutic-response.pdf.

Members of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation:

Judith M. Glassgold, PsyD, Rutgers University – Chair

Lee Beckstead, PhD

Jack Drescher, MD

Beverly Greene, PhD, St. John’s University

Robin Lin Miller, PhD, Michigan State University

Roger L. Worthington, PhD, University of Missouri

The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world’s largest association of psychologists. APA’s membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting health, education and human welfare.

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Cutting Medicare Advantage is not the change we need

I have a family member with a Medicare Advantage plan and am very well aware of how it works. Compared to what I know about basic Medicare, I think advantage is an accurate description. When I read that President Obama believes these plans are helpful only to the insurance companies, I have to disagree.

Disagreed so much I wrote an article about it which has been published several places, including here.

Anti-Christian atrocities in Pakistan

Horrible. Just horrible. Let’s stand with our brothers and sisters and lift them up.

A spasm of religious violence came to this rural town in the shape of an angry Muslim mob Saturday morning. The Muslims marched to avenge what they believed was the desecration of a Koran one week earlier. When it was over, dozens of houses were torched and Faith Bible Pentecostal Church lay in ruins. Two villagers were shot dead, residents said. Five others, including two children, burned alive.

Killing has become commonplace in Pakistan. But this attack startled the country both for its ferocity and for its stark message to religious minorities. Many saw the violence as further evidence of the growing power of the Taliban and allied Islamist militant groups in Punjab province, home to about half of Pakistan’s population.

“They have made up their minds to crush Christianity. They always call us dogs of America, agents of America,” said Romar Sardar, an English teacher from the area. “There has been no protection by the police. Nothing.”

More detail is provided on Crosswalk.com.