Therapy to Prevent Abuse or Therapy as abuse?

By David S. Prescott, LICSW

Our recent blog on conversion therapy prompted lively discussions in social media.  While efforts around the world seek to end practices aimed at changing people’s sexual orientation, therapists working with individuals hoping to prevent further offending often use methods developed to help clients manage their sexual thoughts and urges. As we suggested in our earlier blog, it is important for professionals to consider the aims of the methods they use. Unfortunately, many laypersons only hear of these methods outside of the context in which treatment occurs. Research has long shown that the context of treatment matters. Used in the wrong context, treatment methods can cause harm. A scalpel that saves lives in surgery can become a murder weapon when used in a bar fight. Not all treatment contexts are alike.

The simple facts are: There are many people in the world who feel a sexual attraction to children but do not want to act on that interest. For them, many elements of daily life are challenging, and they often experience shame and self-hatred resulting from attractions they didn’t ask for and sometimes feel they cannot entirely control. Some of these individuals attempt to live as quietly as they can, while others seek out services, support groups, and other types of help. This has all been documented elsewhere and serves as the foundation to what follows. To be clear, however, sexual interest in children is not something that people ask for or a choice they make.  

While some degree of overlap in methods used in helping people manage sexual urges may also be employed in conversion therapy, there are substantial differences between programs that treat people with a sexual interest in children and conversion therapy as the world has come to understand it. One major difference is that behavioral treatments are only one component of a broader, a more comprehensive approach to helping people lead better, more self-determined lives.

The vast majority of programs treating individuals who have abused others regard their behavioral treatments as methods to help people to manage urges or fantasies that would lead to further harm to themselves or others if they acted on them. On the other hand, conversion therapy seems to hold out some kind of promise that the client will become a different person as a result of this treatment, viewing being gay as an accident to be cured, remedied, etc. It’s easy to write those words in a paragraph, but how they play out in the social context of the client and their alliance with the clinician can be quite another matter.

For example, the client who says, “Please can you help me. Even though I have some attraction to people my own age, I also have this strong desire for kids. I do not want to take the chance of hurting anyone. My thoughts about kids often interfere in my relationship with my girlfriend, which is already tenuous enough. I really want to do anything I can to manage these urges. Please can you help me?” In cases like this, where the client is asking freely and independently, there is the possibility that some of those methods may help, at least in the short term. Can we really compare that to the pain and suffering this video of this man who experienced conversion therapy as some kind of torture? And if there are things that might help, should we really put them off-limits? We’ll come back to that point.

Reading about the contexts in which conversion therapy has taken place can be horrifying. There are good reasons why these approaches, too often delivered intrusively and with prejudice and ignorance, are unethical in most places and illegal in many. But it’s not just the actual methods: They are often provided by people whose knowledge of sexuality harken back to a less enlightened era, and the professionals violate all the tenets of the therapeutic alliance. Further, they blithely ignore the principles of informed consent. These treatments are often unethical on their face in the ways that they run roughshod over clients’ autonomy and beneficence (central to the codes of ethics of all the helping professions).

All of this calls to mind some of the things that Thomas Szasz said in 1961: that therapy can only be ethical when the client comes to the therapist for help and is willing to pay out of their own pocket. His point (as someone who had fled then-communist Hungary) was that we should all watch out for the negative consequences that can occur when the state gets involved in providing treatment.  He might have added the family and societal pressures brought to bear on clients as well. We’ve written elsewhere on how these conflicts can be managed.

The techniques for helping clients manage their sexual behaviors are far less important than whether the treatment experiences:

·         are consistent with the client’s goals; goals that are personally meaningful and relevant, held strongly, and arrived at independently.

·         take place in an environment in which the client feels heard, understood and respected.

·         consider whether the client believes that the techniques of treatment are a good fit for him.

·         include informed consent for treatment that is reviewed frequently.

·         occur in context such that clients view the therapist’s role as that of a helping professional and fellow traveler.

One colleague expressed it like this: “I can’t change what people want; I can only help them to change how they behave around what they want.” Likewise, in describing Motivational Interviewing, Miller and Rollnick (2013) have said that, “Treatment is something we do for and with clients, not to and on them.” These two quotes embody the fundamental differences between legitimate treatments offered to individuals who have abused them and the more controversial conversion therapy that appears in the news and social media.

There are still reasons to be vigilant about implementing any kind of treatment under conditions where personal liberties hang in the balance. How consensual is the treatment when the informed consent was signed under the duress of being imprisoned longer? In addition, the therapist believes it’s important to use these methods. At the same time, the client is going along with the process in order to complete treatment even though they don’t want to. On the other hand, millions of us have signed consent for medical procedures that we didn’t want, that caused us pain and anguish, but that added many years to our lives. There are many, many nuances involved.

Ultimately, professionals have an obligation to consider all aspects of treatment that they deliver, including the context in which treatment occurs.