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Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Tuesday, November 5, 2013

More Discussion About Conversion Therapy, An Alternative Psychotherapy

The Philadelphia Inquirer this morning headlines a story “Parents challenge state ban on gay conversion therapy” (Nov. 5, 2013; B1, B8). As many readers will know, in recent months New Jersey and California both passed  legislation prohibiting the use with minors of conversion therapy, an intervention that purports to alter same-sex attraction so that the treated person experiences heterosexual attraction and behaves accordingly. Conversion therapy has been practiced both by a small number of mental health professionals and by members of the clergy; the New Jersey legislation applies only to licensed therapists.
The California law has been upheld in a federal appeals court. There are presently two challenges to the New Jersey law, both in federal courts. According to the Inquirer article, one case has two licensed therapists among the plaintiffs. The second involves parents who claim a violation of their constitutional rights by the law that prevents them from seeking conversion therapy for their 15-year-old son (by the way, it does not prevent them from “seeking treatment”, as the Inquirer says; they are free to seek treatment that will help the son resist inappropriate impulses or will help him come to terms with his developing sexuality). The parents argue that the law violates their rights to free speech, freedom of religion, and equal protection of the laws.

One of the lawyers representing these plaintiffs, Demetrios Stratis, also argued that the law was based on faulty and incomplete research, and pointed out that even the American Psychological Association report, which opposed conversion therapy, agreed that the scientific basis was weak. Stratis also stated his belief that reports of harm from the treatment are inaccurate.

Is this correct? Was this law enacted without sufficient scientific evidence to support it? As one who testified in favor of the New Jersey law, I must say that the answer is probably “yes”--  but that the question is not nearly as simple as it appears to be.

Much of the evidence I heard given was personal in nature. Members of the LGBT community spoke of their terrible difficulties in growing up as part of a rejected minority. A few spoke of undergoing conversion therapy and of the distress they experienced. Members of fundamentalist Christian groups spoke deploring the troubles and dangers of a life of same-sex attraction, and argued that although the clergy might be able to do the treatment, they needed real mental health professionals to handle tough cases. A very small number of us addressed the nature and foundational beliefs of conversion therapy. It would be quite inaccurate to say that the information witnesses provided to the Assembly committee emphasized scientific evidence, either about the nature of sexual orientation or of the effectiveness and safety of conversion therapy. Although the committee presumably sought more information elsewhere, the effect of  testimony was probably to pit the strength of one political group’s power against that of another.

Although I strongly support the New Jersey law, I cannot claim that it is based on scientific evidence rather than political positions. There is little scientific work examining the safety and effectiveness of conversion therapy, and that fact raises one of the questions packed into the question about the evidence for the law. Why is this the case? Why are we lacking an evidence basis that would support arguments for or against conversion therapy?

A possible answer to this question--  and the answer that I think the plaintiffs in these appeals want to imply--  is that conversion therapy is an emerging psychotherapy. This would mean that it is a treatment so new and so underutilized that it has not yet been possible to collect the data that would allow us to evaluate it. There are such therapies, and it would be quite inappropriate to claim that laws should prohibit their use simply because of lack of evidence.

A second possible answer is that there is little evidence about conversion therapy for two reasons. One is that practitioners of the treatment do not believe such evidence is necessary and therefore have not systematically collected outcome data. The other is that practitioners of conventional treatments have regarded conversion therapy as not worth their while to study. They have thought of it with a range of rejecting terms like unconventional, complementary-and-alternative, fringe, New Age, or snake oil--  although they might not have spent much time considering how or why conversion therapy should be classified in one of these ways.

In my opinion, conversion therapy is best classified as an alternative psychotherapy. I offer this term to describe a treatment that has three characteristics: first, it lacks a clear evidence basis; second, it has been demonstrated to do harm, in which I would include unnecessary emotional pain or burdens for the client; and third, it is implausible, or incongruent with established information about personality, development, or mechanisms of emotional change. Unlike emerging therapies, there may be very good reasons for prohibition of alternative psychotherapies, especially prohibition of their use with minors.

Let’s look at conversion therapy and see how it fits into the category of alternative psychotherapy. We have already established the lack of a clear evidence basis supporting the effectiveness of the treatment--  this in fact forms part of the foundation of the legal appeals. In addition, testimony has established harm to clients in the form of distress and emotional burdens which appear to me to be beyond the level to be expected from a psychotherapy.

Our remaining question is about plausibility—the extent to which a treatment agrees with or contradicts established information. We can look at conversion therapy’s plausibility both in terms of its assumptions about the causes of homosexual attraction and about the methods for changing such attraction.

All the present evidence states that same-sex orientation as part of personality (rather than as a situational factor, such as a long prison term, or as culturally determined) is dependent on the individual’s genetic make-up.  This means that the primary factor causing same-sex attraction is in every cell of the body throughout life. This does not mean that the individual must act on the attraction—obviously neither heterosexuals nor homosexuals act on every attraction they feel! But it does mean that the orientation is an intrinsic part of that person’s constitution.

Conversion therapy, incongruently, attributes same-sex orientation of males to a failure of a loving attachment relationship with a father. Such an assumption is implausible in the light of what is known about causes of sexual orientation. Heterosexuals do not prefer the opposite sex because they had good relationships with a same-sex parent, but because of much more basic factors. Some readers may remember the blundering work of John Money in the 1970s; he recommended that a baby boy whose penis had been badly damaged in a circumcision accident should be castrated and raised as a girl. In spite of hormone treatment and constant reinforcement by affectionate and concerned parents, the boy later abandoned the hormone treatment, returned to living as a male, fell in love with a woman, and married. The same considerations apply to same-sex attractions.

Conversion therapy is also incongruent with established knowledge about development in its use of the attachment concept. Rather than following conventional theory and research about the natural history of emotional attachment, conversion therapy has simply picked up the views of another alternative psychotherapy, so-called Attachment Therapy. Attachment Therapy, which is also potentially harmful and without supportive research evidence, which assumes that emotional attachment is caused by experiences of dependency and by prolonged eye contact, and which posits that where attachment has failed it can be produced in older persons by experiences of physical restraint and forced submission. Conversion therapy also uses methods that attempt to re-enact through physical restraint the experiences that are erroneously believed to be the causes of attachment--  at the same time that its practitioners erroneously assume that attachment is related to same-sex or opposite-sex attraction.  (Bizarrely, this produces a situation in which a young man lies in the arms of an older male therapist in order to be persuaded not to be attracted to males.)

Conversion therapy is thus clearly implausible, as well as being without an evidence basis and potentially harmful. It is an alternative psychotherapy, and that is why conventional mental health professionals do not study or practice it.

But should all alternative psychotherapies be prohibited by law? This is tempting, but would seem to be a Draconian measure that would violate the First and Fourteenth Amendments, if treatment of adults were included. Minors, however, need and deserve the full protection of the law against ineffective, unsafe treatments, whether medical or psychological. I hope the appeals court in New Jersey will act to provide that protection against conversion therapy.


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