[CN: homophobia, thought experiment-ish discussion of bigotry]
The topic of therapists refusing to work with particular clients due to differences in values is one that came up often when I was in graduate school, and continues to come up often as therapists-many of whom come from traditional Christian backgrounds-confront the reality of practicing in diverse settings.
"Differences in values" usually refers to homophobic therapists not wanting to work with lesbian, gay, and bi/pan clients, but it can actually apply to tons of different marginalized identities: trans, poly, kinky, atheist, Muslim, and more. Differences in values can also impact therapeutic work with clients who are making decisions that the therapist strongly disagrees with for whatever reason, such as getting a divorce, getting an abortion, accusing someone of sexual assault, and so on.
Although it might seem counterintuitive, competent and ethical therapists occasionally choose not to work with particular clients for all sorts of reasons. They may feel that they lack sufficient knowledge or experience to help a client with a particular niche issue or disorder, and that they can't make up for it with extra training quickly enough to avoid harming the client. They may be triggered by some aspect of the client-for instance, some therapists cannot work with convicted/admitted rapists, especially if pedophilia is involved. They may realize they're too closely connected to the client within their community-for instance, the client is the parent of the therapist's child's best friend, or the client is dating a close friend of the therapist. (Although in these situations, openly discussing it with the client and setting some boundaries and expectations also goes a long way.)
Regardless, if a therapist chooses not to work with a client, it's their ethical responsibility to refer the client to another professional who can work with them effectively. So it's never just like, "Nope, can't help ya, sorry." And if you ever get that response while seeking therapy, know that you're entitled to get some help finding someone else.
So choosing not to work with particular clients due to lack of knowledge/skill, personal triggers, and boundary issues is accepted in the field. How about choosing not to work with particular clients because you cannot accept their identities or lifestyle choices?
Something about that concept rankles many people, and rightfully so. A therapist choosing not to work with a gay client because the therapist thinks homosexuality is immoral feels...well, discriminatory, because it is. The therapist is denying services to someone on the basis of their sexual orientation, and even though they have that legal right (if they're in private practice, that is), it seems wrong. It seems like the therapist shouldn't be able to "get out" of doing their job so easily. And that's not even to mention how it might feel for the client if they know that that's why they're getting referred to someone else.
The most reasonable argument against therapists referring out clients they don't want to work with due to prejudice is: what if there aren't any other therapists available? This could conceivably happen in small towns, or even in bigger towns if your identity is sufficiently stigmatized.
In an extreme case, the argument goes, a client might commit suicide because they were unable to get therapy, and maybe even a therapist who is bigoted against them could have prevented that outcome.
The idea that a bad therapist is still better than none at all is rather bizarre: we don't think that way about any other vital profession or service.
But if you think about it, the idea that a bad therapist is still better than none at all is rather bizarre. We don't think that way about any other vital profession or service. A bad teacher can hold back the rest of a student's academic career, so much so that maybe that student would've done better teaching themselves. A bad accountant can wreck someone's financial future. A bad doctor can permanently injure or even kill someone. Even if you were pretty sick, you'd probably rather rest and hope for the best than go to a doctor who has a history of making massive errors with people with your symptoms-let alone a doctor who to hurt you.
Of course, "Bad Therapists" (as we're defining them here) don't want to hurt you-or, at least, they don't think they do. They want to save you from damnation, help you see that your lifestyle is unnatural and unhealthy, stop you from ruining that poor innocent man's life with a false accusation (after all, therapists have to be concerned with the good of the broader society, too), share Christ's love with you, whatever.
But this is where excessive charitability is unhelpful. These actions are objectively harmful to LGBTQ people, to sexual assault survivors, to atheists and people of minority faiths (even if they don't directly harm each individual in each instance). It doesn't matter that the therapist sees them as therapeutic. Just because I firmly believe that your life will be better if I punch you in the face doesn't give me the right to punch you in the face, and it won't make it hurt any less.
So while I'd have to see some research to know for sure, right now I'm doubtful that a therapist could be at all effective with a client that they're actively bigoted against. Note that when I say "actively," I specifically don't mean therapists who are like, "Meh, my beliefs tell me that this person's going to hell because of their homosexuality, but whatever, none of my business, I'm just here to help them learn some better coping skills for anxiety." I mean therapists who are like, "I can't stand working with these disgusting people and I'd rather just refer them to someone else, but I'm betting no one else around here would want to work with them either and I don't want to get in trouble if they kill themselves." That's not a basis for a healthy therapeutic alliance.
A better argument is that, fine, therapists should probably refer clients they can't effectively work with, but if you can't effectively work with entire groups of people due to your own prejudice, you shouldn't be a therapist. (It's just like those pharmacists who refuse to prescribe birth control: maybe they should choose a different career.)
That's something I agree with in principle, but I'm not sure I agree with it in practice. In principle, yes, those kinds of prejudices go against what this profession is supposed to be all about. For instance, here are some key parts of the National Association of Social Workers' Code of Ethics :
Social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people. Social workers' social change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice. [...] Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. [...] Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.
(Although not all therapists come from a social work background, many of them, including me, do. If you're practicing therapy under a social work license, you're expected to uphold the social work code of ethics.)
But in practice, I'm not sure what more we can realistically do to weed out prejudiced people from the field. My graduate school education heavily emphasized these values and we were required to read that entire code of ethics and reflect on it all the time. (I mean, was our anti-racist curriculum perfect? Hellllllllll no. But you definitely could not leave that program with the impression that it's ok to discriminate on the basis of any of those aforementioned categories, unless you somehow slept through the whole damn thing.)
At what point is it reasonable to, say, kick someone out of a Masters program or deny them their first social work license (the one with which you're still practicing under supervision and still considered to be in training) due to prejudicial attitudes? At the point when they say, "My religious beliefs do not condone homosexuality?" At the point when they say, "I'd rather not work with gay people in my practice?" At the point when they say, "I intend to refer any gay clients I get to another therapist?" (I would argue that at the point when they state an intention to practice conversion therapy would definitely be a good time to bar them from practice, though.)
And of course, if we were to start kicking people out for saying these things out loud, they'd simply stop saying them out loud. They wouldn't stop believing them, and we'd be no better off than we are now.
A slightly more controversial counterargument is that while a bigoted conservative Christian therapist may not be effective with LGBTQ and/or secular clients, they could very well be effective with straight, cis, Christian clients, who are the majority by far. These clients need therapists too, and if we remove every bigoted therapist from the field, there won't be enough to serve them either. (Unfortunately, bigotry is probably fairly common.) Without getting into specifics, I'm pretty sure that most of my current clients would be just as well served by a conservative Christian therapist who hates queers and atheists as they are by me. (Maybe even better.)
I'm reminded of the common sentiment that if only all those people who are super into traditional gender roles in dating would just pair off with each other and leave the rest of us alone. Likewise, it would be nice if all the bigoted conservative Christian therapists would just work with the (possibly also bigoted) conservative Christian clients, and all the queer, trans, secular, poly, or otherwise marginalized clients would be served by therapists who don't hate them.
But that goes back to what I was saying earlier, which is that the worst outcome for a marginalized client is not having a bigoted therapist refuse to work with them. It's having that therapist agree to work with them out of a sense of obligation or a lack of self-awareness, and then do serious damage.
The kinds of therapists who would think, "You know what, I can't condone this client's lifestyle and therefore I can't work with them effectively" are actually leading the pack when it comes to self-awareness and professionalism. While their beliefs about the "lifestyle" in question are truly regrettable and have no place in the field, at least they are able to be honest and proactive about their own limitations and potential to harm a vulnerable person. I'm much more concerned about the therapist who either fails to recognize their bigoted attitudes entirely or just thinks, "Well, I need the money, so I'll work with them anyway."
I'm also concerned (although to a slightly lesser extent) about therapists who are aware of large gaps in their knowledge or skills and choose to use clients as educational tools to fill those gaps. While it's true that much of a therapist's skills can only be acquired through experience, there should be a foundation of knowledge that they have learned in graduate school, supervision, continuing education, and independent study. If I were to show up to therapy and say that I'm bisexual and currently in a monogamous relationship, it's not good enough for the therapist to be like, "But I thought that bisexual people can't do monogamy, oh wow, learn something new every day," no matter how open they are to being corrected. That bisexuality is not synonymous with polyamory or "promiscuity" is a basic fact about bisexuality that every mental health professional needs to know. It should not be the client's job to teach that to them.
Although these kinds of "innocent" questions and comments (a.k.a. microaggressions) don't seem to do as much harm as overt rejection of the client due to their identity, they build up over time and make people doubt themselves and internalize all kinds of negative attitudes about who they are. If I had a choice between seeing a therapist like that and having that therapist say, "I'm afraid I'm not knowledgeable enough about your presenting concerns to help you, here's a referral to someone who's more experienced," I'd obviously choose the latter.
But then again, the kind of therapist who doesn't want to work with [insert marginalized identity] clients probably doesn't know any other therapists who would want to work with them, either-in professional networks as well as personal ones, people tend to gravitate towards those that share their beliefs. On the other hand, even the most cluelessly homophobic therapist could at least point a queer client toward a local LGBTQ center that provides mental health services.
There will be bigoted therapists as long as there is bigotry.
I feel like I keep going in circles because ultimately, there will be bigoted therapists as long as there is bigotry, and there is no way of getting bigotry out of the mental health field without getting it out of society. Yes, our field should theoretically be "above" all that, but (un)fortunately, our field is made up of humans who struggle and fail just like other humans do.
I do, however, have some ideas about reducing the harm of bigoted therapists in the meantime:
- Therapists who wish to practice from a Christian perspective should try to work for agencies that explicitly operate from that perspective, not for publicly-funded agencies or non-Christian agencies. That way, they are most likely to be getting clients who will benefit from their practice, or at least not be harmed by it. (I don't mean to imply that all bigoted therapists are Christian or all Christian therapists are bigoted, but in practice, this seems to be where the issue most often comes up.)
- Therapists should ensure that their professional network contains practitioners with all sorts of perspectives. If I ever get a client in my private practice someday who wants counseling from a Christian perspective, I should be able to refer them to someone, just as these conservative Christian therapists should be able to refer their queer/trans/secular/poly/kinky clients to me.
- Therapists are required to get continuing education units (CEUs) to stay current in their practice. They should use this as an opportunity to get training that challenges their biases and prejudices.
- Even after therapists get their independent license and are no longer required to be supervised, they should seek out more experienced practitioners to help them expand their perspective.
- Clients should feel comfortable "firing" a therapist who doesn't seem to be able to work with them effectively. As I've written here before plenty of times, therapists work for , not the other way around. You don't owe them anything besides the payment you have agreed to render, and you can stop seeing them at any time, with or without explanation. Don't feel like you have to out yourself (if you haven't already). Your safety and mental health come first.
- Even if you live in a small town and cannot find a therapist who can work with you effectively, you may be able to do video chat therapy with a therapist in a different town, as long as they live in the same state. (Therapists need to have a license in every state they have long-distance clients in, so your best bet is to find one in a bigger city in your state and see if they'd be willing to work with you over video chat.)
- Clients should be aware that it's a therapist's ethical responsibility to refer them to another therapist if they can't work with you, so if you find a therapist and they claim they can't work with you because [reasons], ask for a referral.
- Clients can use directories of therapists who are competent with particular issues/populations. Some examples include the Bisexuality-Aware Professionals Directory, the Kink-Aware Professionals Directory, and the Secular Therapist Project. Local LGBTQ groups and meetups are also great places to find lists of resources.
- Here's a great question to ask in an initial phone call, email, or appointment with a therapist: "What's your experience working with [group]?" Beware the therapist who says they haven't had any [group] clients but are happy to work with them. They had [group] clients. They just haven't come out to the therapist. (And while therapists should not be giving out specific details about their clients, they should be able to make a general statement like "I frequently see clients from the LGBTQ community in my practice.")
- Word of mouth can be a great way to find a therapist if you're part of a community of people who share your identity or lifestyle. Although it can be difficult to open up about seeking therapy, you're not alone and you'll probably find that your friends are eager to talk about their great (or not-so-great) therapy experiences.
The idealist in me knows that there is something fundamentally unfair about bigoted therapists getting to just avoid having their beliefs challenged by referring the clients they're bigoted against to other therapists. Bigotry ought to be challenged.
But, unfortunately, the therapy session cannot be the place for it, at least not for the therapist (and perhaps not for the client, although that's a much more complicated topic for another time). We need to keep improving our training programs, both at the graduate level and the professional level. We need to keep researching effective ways to "unteach" bigoted attitudes in clinicians. Most importantly, we need to keep supporting clients, including would-be clients, in finding competent and ethical mental healthcare.
