Introduction
As the twenty-first century became established, the importance of multicultural counseling has become well-recognized. Several different cultural, racial, and sexual groups are now being recognized as that having unique counseling needs. Traditionally, researchers have identified cultural identity as a broad concept that includes demographic variables such as religion, gender, physical ability, economic and social status, and sexual orientation alongside ethnographic variables (Bidell, 2005). This research focuses on gay, lesbian, and bisexual issues including language and general guidelines, as proposed by the American Psychological Association’s 2002 Ethical Principles and Code of Conduct. This study also makes suggestions for revisions of guidelines and language used for the 2014 ethics code revision.
Ethical Concerns: Sexual Minorities
Only a few decades ago homosexuality was considered a pathological and deviant form of human sexuality. Homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) only in 1973 (Cheng, 2003). Going even further, it has been completely removed from the diagnostic system only in 1987. Consequently, there are two major concerns for psychologists that result from the history of attitudes towards sexual minorities. Firstly, this is stereotyping on the side of practitioners and, secondly, this is a lack of proper, unbiased word selection. Both of these factors result from a lack of knowledge on the side of psychologists; nevertheless, the consequences are dramatic (Crisp, 2006).
The most direct consequence of stereotyping and lack of knowledge about external factors that influence sexual minorities throughout their living is inferior treatment (Gamst et al. 2004). Several studies confirm that sexual minorities are likely to be misdiagnosed due to the inability of a psychiatrist to consider the individual and unique patterns of behavior that are common for a given minority group, either minimize or exaggerate the importance of sexual orientation of gay/lesbian orientation in person’s life, devalue client’s feelings or experiences, value clients strictly in terms of their sexual behavior, inform clients that they are not gay or lesbian if they fail some standard criteria, assume that gay or lesbian relations are just phases that come through, perpetuate self-hatred experienced by some lesbian or gay clients, change the topic when the client is speaking about gay or lesbian issues. Attitudes are an important component when it comes to practice with gay men and lesbians, and still, attention should also be given to external social and economic factors that influence and shape the personality of sexual minorities.
As such, there is a distinct need to increase psychiatrist awareness of the multidimensional factors that influence sexual minorities including risks resulting from social stigmatization, impact on family relations, challenges in social relations. The situation gets even more complex if several factors are combined when an individual belongs both to a sexual and an ethnic minority; these cases require individual attitude and deep understanding of cultural and societal factors not to misdiagnose and provide effective treatment.
The second issue that has come under a lot of attention, once homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders, is the unbiased language use (Kocarek & Pelling, 2003). At the present moment, no rigid guidelines for terminology exist. However, some suggestions have been given by scholars. Because of the usage of language that patients may associate with negative attitudes towards him/themselves, it is vital to ensure that psychologists select language attentively when communicating with patients. Particular attention has been given to using terms that do not associate with homosexuality being an illness, as it has been considered before 1973.
APA Ethics Code of 2002 and Guidelines
American Psychological Association’s 2002 Ethical Principles, “Guidelines for Psychotherapy with Lesbian, Gay, & Bisexual Clients” alongside the “Avoiding Heterosexual Bias in Language” are the major enhancements that influenced directly professionals’ views of multicultural competency. APA Ethics Code contains greater sensitivity towards the needs of cultural, linguistic, and sexual minorities as compared with the previous documents.
APA Ethics Code contains implications for trainers providing a clear mandate to enhance the development of competence in working with a wide range of diversity including race, socio-economic status, sexual orientation, gender, and religion. It already became imperative that practitioners in the field of psychology must know the cultural heritage, background, and traditions of minority groups. When defined broadly, multicultural competence involves three major dimensions including awareness of attitudes and beliefs, knowledge about cultural differences, and skills when it comes to working with diverse groups. As such, psychologists must pay particular attention and further develop skills in every one of these fundamental areas.
By the new standard 9.06 of the 2002 Ethics Code, psychologists must incorporate in their reports situational, personal, cultural, and, most importantly, linguistic factors that might influence test scores and further interpretations. Consideration of the complexities of different minority groups will have a positive impact on the objectivity of assessment and decrease the possibility of stereotype threat. APA Ethics Code of 2002 mandates a gradual change from monocultural methods of assessment to multicultural procedures (APA, 2002).
Standards 2.01b emphasizes the importance of psychologists’ competence in the assessment of cultural, disability, and diversity factors and prohibits the provision of services if practitioners lack the required scientific and professional knowledge as well as an understanding of the age, gender, race, ethnicity, culture, religion, sexual orientation factors, that are essential for the provision of effective services (APA, 2002).
When it comes to language selection, it is suggested to use the term “sexual orientation” instead of “sexual preference”, since the word “preference” suggests a voluntary choice and, therefore, might inadequately present the nature of orientation (APA, 1991). The terms “lesbian” and “gay male” are preferred, as the term “homosexual” is associated with criminal behavior and pathology. Terms “same-gender sexual behavior”, “male-male sexual behavior”, and “female-female sexual behavior” are appropriate when it comes to specific instances of sexual behavior. It is also suggested to use “gender” instead of “sex” to avoid misunderstanding, “bisexual women and men”, “bisexual persons”, and “bisexual” since these terms are oftentimes omitted creating an impression that people relate exclusively to one gender. These guidelines intend to reduce heterosexual bias and, at the same time, increase the representation of sexual minorities (APA, 1991).
Furthermore, “Guidelines for Psychotherapy with Lesbian, Gay, & Bisexual Clients” strive to provide instructions in the four major spheres: attitudes toward homosexuality and bisexuality, relationships and families, issues of diversity, and education (APA, 2000). These guidelines provide general directions and emphasize the importance of understanding social, economic, and interpersonal factors that influence sexual minorities; these factors must further be considered by psychologists when assessing patients and when choosing their pattern of communication.
Proposition: Guidelines for Psychotherapy with LGB
Guidelines for Psychotherapy with Lesbian, Gay, & Bisexual Clients lack 6 major characteristics that should be considered when revising the document for 2014. First, guidelines lack specificity and can be understood in different ways uncovering additional layers of information. Second, guidelines do not cover suggestions on understanding the personal reaction of psychologists even this can be a starting point of subsequent bias. While guidelines list several factors related to understanding the behavior of lesbian, gay, and bisexual clients and how they can be affected by therapists’ implicit or explicit attitudes, they do not provide directions on how to understand the mechanism of personal reaction; as such, guidelines “cure” consequence, but the cause. Third, guidelines do not set contextually appropriate boundaries for behaviors of psychologists about sexual minorities. Fourth, guidelines do not include directions on understanding the limits of professional competency. Even though general directions are provided in Ethics Code 2.01b that prohibits the provision of services, given a practitioner lack the required skills and knowledge, nevertheless, the boundary, which distinguishes a knowledgeable psychologist from a non-competent in a given field, is not provided. This issue is left up to psychologists’ consent, which might result in a lack of objectivity. Fifth, guidelines do not provide instructions on which assessment and intervention techniques to use given sensitivity of a situation with either gay, lesbian, or bisexual patients. While guidelines do state that a psychiatrist should consider special problems and risks, cultural norms, values, and beliefs (Guidelines #9, 10, 11, 12), they do not provide a selection of assessment strategies that should be used in frequent and yet sensitive situations. Finally, guidelines do not provide an overview of appropriate environmental surroundings that should be considered when providing services to sexual minority groups.
Guidelines for Psychotherapy with LGB in 2014 should address all of the six concerns listed above. There is a distinct need to revise the present guidelines since they tend to “expire” as the knowledge base expands, empirical evidence confirms, and the practice of psychology and society evolves. Guidelines should be more specific and cover situational factors providing instructions on how to act in situations considering to what minority group a patient belongs. Guidelines should include the recent empirical investigations in the field of psychotherapy with LGB, as the major cause of bias and inability to understand client needs and causes of concerns – is the lack of knowledge and lack of systematized accessible information.
Proposition: Language Clarification Guidelines
When it comes to speaking about the language ethics for faith-based religious psychotherapists to engage in conversion therapy to cure homosexuality, there is doubt whether this therapy should be allowed per se. Several studies indicate that homosexuality cannot be cured; going even further, such therapy can hurt patients, as there have been cases when gay men and lesbians committed suicides as a result of conversion therapy failure (Stone, 2003). Going even further, the proposal for language ethics revision is inconsistent because faith-based religious psychotherapists represent a minority trend, whereas guidelines issued by APA are general (Stone, 2003). Instead, language ethics can be revised only for the cases when patients are seeking counseling in their exploration of sexual identity. In this case, the presently suggested language might not be appropriate and there is a need for “grey terms” for those currently in search of their sexual identity.
As such, a suggestion for the 2014 change in language ethics is to introduce terminology for those who counseling on their sexual identity, since there might be sensitive cases when there is no generally adopted terminology for a given situation.
Conclusion
The stated above suggestions for revision of guidelines and language terminology for 2014 are consistent with the present Code of Ethics and Guidelines issued by APA. The stated above guidelines simply expand and cover a greater number of situational factors that influence the quality of services provided by psychologists to sexual minorities. The proposed guidelines are a logical consequence of the evolution of the practice of psychology.
References
American Psychological Association. (2000). Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients. American Psychologist, 55, 1440-1451.
American Psychological Association. (2002). Ethical Principles and Code of Conduct. American Psychologist, 57(12), 1060-1073.
American Psychological Association. (1991). Avoiding Heterosexual Bias in Language. American Psychologist, 46(9), 973-974.
Bidell, M. P. (2005). The Sexual Orientation Counselor Competency Scale: Assessing Attitudes, Skills, and Knowledge of Counselors Working with Lesbian, Gay, and Bisexual Clients. Counselor Education and Supervision, 44(4), 267.
Cheng, Z. (2003). Issues and Standards in Counseling Lesbians and Gay Men with Substance Abuse Concerns. Journal of Mental Health Counseling, 25(4), 323.
Crisp, C. (2006). The Gay Affirmative Practice Scale (GAP): A New Measure for Assessing Cultural Competence with Gay and Lesbian Clients. Social Work, 51(2), 115.
Gamst, G., Dana, R. H., Der-Karabetian, A., Aragon, M., Arellano, L., Morrow, G., et al. (2004). Cultural Competency Revised: The California Brief Multicultural Competence Scale. Measurement and Evaluation in Counseling and Development, 37(3), 163.
Kocarek, C. E., & Pelling, N. J. (2003). Beyond Knowledge and Awareness: Enhancing Counselor Skills for Work with Gay, Lesbian, and Bisexual Clients. Journal of Multicultural Counseling and Development, 31(2), 99.
Stone, C. B. (2003). Counselors as Advocates for Gay, Lesbian, and Bisexual Youth: A Call for Equity and Action. Journal of Multicultural Counseling and Development, 31(2), 143.