A Deeper Conversation: Conversion Therapy

The history of psychology, not unlike many other social and natural sciences, has gone through growing pains over the last hundred or so years. During this time, the theories of great men and women have been used both to define normal and abnormal and use those distinctions inappropriately.

For the purposes of this post, we start in 1952 and the release of the first Diagnostic and Statistical Manual of Mental Disorders (DSM-I) partially in response to the Sixth Edition of the International Statistical Classification of Disease (ICD-6) and also in response to a new understanding of the effects of social and personal distress on the internal concept of psyche following World War II. In fact, the structure of the DSM-I was structured in many similar ways to military classifications. Within the pages describing the 106 mental disorders was Sociopathic Personality Disturbance, a section describing individuals who are "ill primarily in terms of society and conformity with the prevailing cultural milieu, and not only in terms of personal discomfort and relations with other people" (DSM-I, p. 38, 1952). Among the handful of sociopathic disturbances was Sexual Deviation which included homosexuality, transvestism, pedophilia, fetishism, and sexual sadism (including rape, sexual assault, and mutilation).

It's important to note that, at the time, there need not be discomfort caused by any of the Sociopathic Disturbances (Antisocial Reaction, Dyssocial Reaction, Sexual Deviation, Addiction, and "Special Symptom Reactions") internally; instead, only the existence of the thought or behaviour would be enough for these diagnoses. It is also important to keep in mind that the majority scientific understanding revolved around a combination of competing and correlating systems, most predominantly psychodynamic and emerging neurobiological psychological theories. Overall, these were exceptionally useful ways of understanding mental illness at the time but were often in opposition to many day-to-day behaviours even in the 1950s and 60s. One aspect of that was the incongruence between homosexuality and psychodynamic principles. Sigmund Freud, largely considered the founder of this particular school of thought, and his contemporaries saw homosexuality as an immature sexuality founded in an inappropriate attachment or a psychosexual trauma in childhood which, additionally, went against the basic motivation of any species: reproduction.

The Diagnostic Manual also led to an explosion of treatment methodologies, as I'm sure you can imagine. Within the year there were hundreds of treatments being attempted at any given time and not enough work was being done to really dig in and study those methods. Unsurprisingly, this led to the beginning of a large (and ongoing) anti-psychiatry movement as dangerous treatments were being used largely without informed consent (not a requirement in research or medical practice until 1980), if at all voluntarily (using the concept of assumed consent: that an otherwise mentally competent person would consent to treatment).

One of the treatment approaches used to "help" those "suffering" from homosexuality was called Conversion (aka Reparative) Therapy. The early use of Conversion Therapy was messy because literally any idea was good as long as there was a plan and a theory to back it up. Some of these methods included using psychoactive drugs, electro-convulsive therapy, lobotomies, chemical castration, hormone treatments, spiritual counselling approaches, cognitive therapy, behavioural therapy (reconditioning or aversion treatments), or some combination of all or any of the above depending on the practitioner's skill (little or nothing to do with the clients' wants earlier on). To this day, almost none of the treatment methods used had any true effect; that is to say, a homosexual person who underwent aversive conditioning may not continue to want to follow through on his or her sexual attractions but this would be due to a phobic reaction from the aversive conditioning and not from a genuine desire for heterosexual sexual intimacy.

The good news: People revolted. By the 1960s, in conjunction with the anti-psychiatry movement, gay rights activists protested against the American Psychological Association with the help of published research authors to show that homosexuality is not, in fact, a mental illness. In 1974, in the Sixth Printing of the DSM-II (originally released in 1968), homosexuality was removed as a category of a disorder and replaced with the category of Sexual Orientation Disturbance. 

This may still seem like an attack on homosexuality but the difference here is that a person must now be under some kind of clinical distress or impairment because of an anxiety caused by opposition between their perceived sexual orientation and their ideal self (later called ego-dystonic in the DSM-III).

So where does that leave us in 2018 (and why is this April's blog post)?

Back in February, the California state assembly introduced Bill 2943 related to unlawful business practices specifically targeting those who practice modern forms of Conversion Therapy, now called Reparative Therapy, which do not involve invasive practices and are fully consented by the client.  Though there are certainly questions related to the efficacy of this therapeutic modality, to outlaw it does more harm to client rights than those of practitioners'. Further, this bill prohibits the use of therapies that seek to change sexual orientation for those under the age of 18 which is in complete disregard to the fact that youth under 18 are the ones who are most often seeking psychotherapy related to their sexuality/sexual orientation. To be a participant in this practice, even to assist with the anxiety related to sexuality, can be construed as harm against the client.

Let's use a hypothetical to illustrate: Let's say that I was referred a client who lives in California. Let's call her Sarah. She is 16 years of age, good family life, participates in extra-curricular activities, drinks socially, and is struggling with her sexuality. She wants to want to have a boyfriend and later a husband but she is currently attracted exclusively to her female peers. She feels more distracted in class and some of her grades have slipped while, in the pool, she has found her lifeguard training classes to be more difficult. The anxiety she feels is more than she can take and she has considered self-harm as a way to ground herself. I discuss with her four directions that we can go in therapy focusing on the anxiety and developing better distress tolerance and emotion regulation. Though she definitely wants those coping skills, she also wants to know more about her sexuality and how she can come to get what she truly wants (her current concept of her ideal self).

Though I am practicing out of Ontario I have to be mindful that my client is in California and anyone, including her parents, could misconstrue any plan developed with Sarah having to do with her sexuality as an affront to AB-2943 and I could face disciplinary action from the College of Registered Psychotherapists of Ontario if legal action is taken. That in mind, my client's wishes come first - ethically, professionally, and personally.

This is where practice and government run into a powerful impasse. Technically, we're both in the right! Conversion Therapy practices have rarely shown any true effect (some anecdotal evidence and a handful of clients who claim to be cured) and Reparative therapy is basically just a combination of other techniques (CBT, DBT, Psychodynamic, Attachment, etc.) used in a mix-and-match way according to the client needs and informed consent is required for any therapeutic process to be ethical and licit. By meeting the client's needs and using effective approaches and acknowledging the goals of treatment I am keeping my ethical standards in check.

Why write this blog post up only to come to such a conclusion? Essentially this law allows the California legislature to pander... actually mock... a valid constituency while also fueling an anti-psychiatry fire that is already fully lit (though oddly citing the APA in the script of the bill...). 

For more information on the practice of psychotherapy as it relates to sex and sexuality please do not hesitate to contact Parker Psychotherapy for more details.