Discover article on sexual orientation change and the APA report

Discover magazine has an online article out today which covers the APA report, NARTH and the Jones and Yarhouse study.

Here are some excerpts:

Joseph Nicolosi, a psychologist in Encino, Calif., says he can rid adults, teens, and even children of homosexuality. For nearly 30 years, he has offered a “psychodynamic” form of reparative therapy for people—mostly men—seeking to change their sexual orientation.

“If [a patient] can accept his bodily homoerotic experience while staying connected to the therapist,” he wrote in “The Paradox of Self-Acceptance,” “the sexual feeling soon transforms into something else: the recognition of deeper, pain-generated emotional needs which have nothing to do with sexuality.”

He cites the following case: A 43-year-old married accountant was recalling another man that he had seen at the airport while on a business trip. “This had awakened his sexual fantasies and dreams. I asked him to hold onto that image and observe his bodily sensations while staying connected to me. As he did, he felt an intense sexual longing. But as he followed that fantasy through an imaginary sexual scenario, quite unexpectedly, he then experienced an embodied shift to sadness, longing, and emptiness. In tears, he spoke of his sense of deep unworthiness. ‘I would just love him to be my friend! He’s the kind of guy that I always wanted to be close to. How much I just want to be friends with a guy like him.'”

This describes an aspect of the approach advocated in Nicolosi’s new book, Shame and Attachment Loss. People I have seen who have been through this approach describe it as being a chase for making sense of what they eventually come to see as an automatic reaction in search of a justification. Having said that, perhaps this gives some men a greater sense of control over their automatic impulses.

The center of this so-called “reparative therapy” is the National Association for Research and Therapy of Homosexuality (NARTH). Its membership—around 1,100 people, according to current NARTH president Julie Harren Hamilton—is dwarfed by the APA’s 150,000 members.

Treatments follow from the assertion that homosexuality is not an innate trait, but rather a result of childhood trauma and lack of attachment to members of the same sex.

“The treatment is different for men and women,” Nicolosi, one of NARTH’s former presidents, told DISCOVER. “The principles are the same—we find that for the lesbian, there is a traumatic attachment loss with the mother, and for the males it’s a traumatic attachment loss with the fathers. We believe the male homosexual should work with a male therapist, and the lesbian should work with a woman.”

It is always difficult to know who Nicolosi is referring to when he says, “we.” Is he referring to NARTH or those who are reparative therapists, or the royal we, referring to himself? However, Hamilton seems to distance NARTH from the singular approach used by Nicolosi when she says:

These treatments take on several approaches. “Psychological care for individuals with unwanted homosexual attractions includes a variety of approaches. There are many paths that lead into and out of homosexuality,” NARTH president Julie Harren Hamilton wrote DISCOVER in an email. “Therapists who assist clients with unwanted homosexual attractions vary in their…methods, [which include] object relations, interpersonal therapy, cognitive-behavioral therapy, family therapy, and many others.”

This would be a welcome departure for NARTH and Hamilton. On her video Homosexuality 101, she lays out the typical reparative drive explanation as the most common pathway. If NARTH truly wants to move away from the singular cause, it should make it clear what other pathways they view as possible.

Then the article turns to the Jones and Yarhouse study.

SOCE advocates have done studies in recent years to try and show that their efforts are working. One of the more influential among sexuality-change advocates was a study by two professors at Christian colleges: Mark Yarhouse, a psychology professor at Regent University, and Stanton Jones, provost and professor of psychology at Wheaton College.

The six-year study started with 98 subjects, most of whom were white, male, and religious—92 percent identified themselves as “born again.” All of the treatments were provided by Exodus International. Of the 61 who provided data in all six years, 14 of them—23 percent—reported that they had successfully converted to heterosexuality “in some form or another,” according to Jones. Meanwhile, 18 subjects—30 percent—reported that they had dis-identified as homosexuals and were now “chaste,” meaning no overt sexual activity at all. The results were based entirely on self-reported surveys.

I think Judith Glassgold’s assessment of the study was too harsh when she said:

The study was dismissed by the APA task force on multiple grounds, and held as an example of the systematic scientific problems of SOCE today. “Everything was wrong with that study,” Glassgold says. “[Yarhouse and Stanton] chose the wrong statistics to evaluate, they violated statistical laws, and they didn’t have a control group—just a small sample of people recruited from religious groups. They followed the individuals over a couple of years, but didn’t specify that the subjects should only try one intervention at a time, so they tried many at the same time. So we aren’t sure which, if any, intervention was causal.”

The reporter is a little sloppy here referring to Yarhouse and Stanton (Jones, I assume; a little later someone named Miller is named without a first name or introduction) and does not interview another person to provide another perspective. I think if anything the Jones and Yarhouse study is not very positive for sexual reorientation. Flaws aside, it does not help those who want to promote change as the proper focus of therapy or ministry.

There is a historical review of some of the behavioral sexual reorientation methods that might be new to some readers. The article notes that the polarization continues between NARTH and the APA. However, the article failed to really grasp the important news from the APA report, i.e., the respectful and appropriate treatment of religion as a diversity variable and the interface with client self-determination.

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.