​A is correct. This language is part of the BBS Statutes and Regulations Relating to the Practice of Marriage and Family Therapy, Educational Psychology,and  Clinical Social Work.  The other four groups are professional associations, not government agencies or licensing boards.

 
2.   The Harry Benjamin International Gender Dysphoria Association (now known as the World Professional Association for Transgender Health) authored Standards of Care which

a.       A therapist should be familiar with, before assessing a transgendered person’s readiness for endocrine or surgical therapy
b.      Therapists and physicians are NOT legally required to follow
c.      Are followed by most therapists and physicians who treat transgendered patients
d.     Are an example of a guideline for culturally competent treatment of a minority group
e.      All of the above

E is correct.  The Standards of Care are referred to by HIGBDA/WPATH as “flexible directions for the treatment of persons with gender identity disorders.”  They are not a legal requirement but are considered best practice by most therapists and physicians.  Understanding transgender culture and being competent to work with transgender issues would involve, among other things, being familiar with the Standards of Care.

 3.        If a therapist has not disclosed his/her sexual orientation, gender assigned at birth, or religion, and a client discovers it by accident, it would be ethically and clinically appropriate to

a.       Invite the client to discuss his/her reactions and feelings
b.      Offer the client referrals if the client decides he/she feels too uncomfortable to continue the therapy
c.       Report the client to the BBS for discriminating against the therapist if the client terminates therapy
d.      Tell the client he/she is being intrusive and terminate therapy
e.      Both A and B

E is correct.  It is generally considered a good practice to invite a client to discuss feelings when discomfort on the client’s part arises in the therapeutic relationship.  Many psychotherapy theories encourage observing and inquiring about such discomfort even when the client does not seem to be aware of it.  It is the client’s right as a consumer to terminate therapy at any time, for any reason (unless treatment is involuntary, as with a 5150 hold in a psychiatric hospital).  Terminating therapy with a client prematurely can be psychologically damaging and therefore could be considered negligent and unethical.  However, it is also unethical to continue therapy when it is not helping the client.  So depending on what happens next in this scenario, it is possible that at some point, the therapist might determine from the client’s behavior that the client’s trust is too disrupted for this therapy to be helpful, and suggest to the client that termination, with adequate referrals and linkage to other providers, is the best course of action.

 4.       If a client discloses his/her sexual orientation, gender assigned at birth, or religion, and the therapist feels uncomfortable about it, it would be ethically and clinically appropriate to

a.       Implement a treatment plan to help the client overcome his/her sexual orientation, transgender identity, or religious beliefs, respectively
b.      Seek consultation and education to become more culturally competent to work with clients like this one
c.       Offer the client referrals to therapists who are more familiar with and supportive of this client’s culture
d.      Stop practicing psychotherapy with any clients because therapists should never have personal biases
e.      Both B and C

E is correct. Attempting to change a client’s gender, sexual orientation, or religion through psychological methods would be unrealistic and possibly damaging (as research has shown in the case of sexual orientation).  In addition, this would be a treatment plan based on the therapist’s needs, rather than collaboration with the client.  It would be impossible, of course, for therapists not to have biases or feelings about clients. It is a therapist’s ethical responsibility to be aware of these feelings and biases (countertransference) and manage them in a way that does not harm clients.  Since it is unethical to practice outside one’s scope of competence, and unethical to discriminate against clients because of certain demographics (including gender expression, sexual orientation, or religion, among others), the most ethical way to practice would be, ideally, to become educated about as many demographic groups as possible.  When this is prohibitive, or when a therapist desires but has not yet pursued such education, one solution is to give responsible, appropriate referrals to meet the client’s needs.

  5.        Therapy attempting to change or inhibit a person’s sexual orientation with psychological or behavioral methods, sometimes called conversion or reparative therapy, is

a.       Illegal to perform on people under 18 in California
b.      Shown by research to have a high success rate and few harmful effects
c.       The subject of a resolution adopted by the American Psychological Association, which states that there is insufficient evidence to support it and that therapists should not promote it
d.      Mentioned in a CAMFT publication as something MFT’s do not condone
e.      A and C.

E is correct.  So-called eparative therapy is a highly controversial approach endorsed primarily by religious groups and, in the literature of psychological research, has been debunked many times over and found to be both ineffective and harmful.  California's SB1172 made it illegal for therapists to impose this unethical treatment on minors. No such protection is in place at this time for adult clients who consent to treatment. The California Association of Marriage and Family Therapists has never issued any kind of statement about reparative therapy.  In fact, in 2009 the CAMFT Board solicited and published articles by religious writers promoting reparative therapy in its official magazine, and then retracted them at the insistence of a number of its members and chapter boards.

 6.       In giving legal consent to treat a minor, an adoptive parent in California has the same rights as a biological parent.  This would apply to

a.       A man who married the child’s biological mother and adopted the child as a second parent
b.       A woman who is the biological mother’s registered domestic partner, legal spouse, or intimate partner with no legally recognized relationship, and adopted the child as a second parent
c.       A single gay man who adopted the child
d.      Both members of a couple who adopted the child, regardless of their gender
e.      All of the above

E is correct.  All of the examples are adoptive parents.  This is good news for the LGBT community because adopting a child as a second parent establishes a legal relationship to the child, even for a person who is denied the right to have a legal marriage with the child’s biological parent.  Therapists working with children should always be aware of who the legal/custodial parent(s) are and who has the right to consent to treatment.

  7.       MFT’s and LCSW’s are prohibited from advertising

a.       Christian counseling
b.      LGBT counseling
c.       Specialization in transgender issues, without an endorsement from the World Professional Association for Transgender Health
d.      Personal demographic attributes that might enhance their ability to understand and serve a certain population
e.      Any services they do not have adequate training and experience to provide

E is correct.  It would be unethical to advertise or provide services in a discriminatory way (therapy for LGBT clients “only,” e.g.), but letting the public know one’s specialization areas can be a way of helping consumers choose therapists who can best meet their needs.  So can letting clients know about personal attributes that make the therapist familiar with their culture, eg being a parent, an African-American, a Buddhist, a lesbian, etc.  WPATH has created guidelines for therapists but is not empowered to grant or deny a therapist the right to work with transgender clients.  The BBS prohibits therapists from advertising services they are not qualified and competent to provide. (Also, MFT Interns and Associate Social Workers are not allowed to advertise specialization but can state in advertising that they have a particular interest in certain populations, diagnoses, or issues.)

8.       There are NO same-sex couples who

a.       Are currently legally married in California
b.      Have children
c.       Have experienced domestic violence
d.      Have sought the services of an MFT or LCSW
e.      None of the above

 E is correct.  Many same-sex couples have children, for example, through adoption, artificial insemination, or previous opposite-sex relationships.   Like all types of families, same-sex couples sometimes require and seek the services of MFTs and LCSWs, so it is important for MFTs and LCSWs either to be familiar with LGBT culture or be prepared with culturally competent referrals.  Therapists sometimes miss warning signs of domestic violence in same-sex couples because this issue is so often associated with opposite-sex relationships, particularly those with rigid gender roles and extreme imbalances of power.  Stereotypes about men being tough or women being weak might influence a therapist to assume, not always consciously, that no serious physical harm can take place in same-sex domestic violence.  The legal status of a couple’s relationship is a useful thing for a therapist to know in treating any family, and political events have made the legal status of same-sex couples particularly varied and complex.  On June 26, 2013, the U.S. Supreme Court finally ruled that both Proposition 8 (California’s 2008 referendum to write marriage discrimination into the state constitution), and the federal Defense of Marriage Act’s discriminatory Section 3, were unconstitutional. That decision made same-sex marriages legal in California, and also said that wherever marriages are legal within a state, they are legal at the federal level as well. On June 26, 2015 (2 years to the day), the Supreme Court finally made same-sex marriage the law of the land, making it illegal for any state to write marriage discrimination into their laws or state constitutions.

 

9.       The following behavior might compromise a therapist’s ability to form an alliance with a transgender client, because it could reasonably be perceived by the client as a sign that the therapist lacks sufficient cultural awareness and sensitivity to understand the client’s experience.

 a.       Referring to a male-to-female transgender client as “he” when the client has not specifically expressed a preference for that pronoun
b.      Referring to the gender assigned at birth as someone’s “actual biological sex”
c.       Assessing a client as not ready or eligible for endocrine or surgical therapy because the client dresses in an androgynous manner
d.      Telling a client who identifies as “third gender” or “other gender” that it is important to choose one sex or the other to attain optimal psychological health
e.      Any of the above

E is correct.  While transgender people are a diverse population and may not agree on all of these points, these are behaviors that tend to happen when health and mental health providers are out of touch with political, clinical, and cultural developments in the transgender community.   Generally, male-to-female transgender people want to be seen as women and prefer the pronoun “she”; and female-to-male transgender people want to be seen as men and prefer “he.”  However, individual preferences vary and also may change at different stages of transition.  Gender exists on a continuum and some people do not identify with binary male-female definitions.   The best way to establish trust with a client is simply to ask about preferred pronouns and the client’s individual experience of gender.  Most people, transgender or not, think of the gender they experience themselves to be as their “actual” sex , and dismissal or invalidation of that identity could be particularly harmful coming from a therapist.  Biological research is discovering that gender in the human body and brain is influenced by complex and varied physiological processes, such as hormonal and other chemical exposure at key developmental stages of the fetus.  This may have a part in explaining why some people’s subjective experience of their gender does not match the obvious anatomical features that others use to label them male or female.  Expecting transgender people to dress in stereotypically feminine or masculine styles to prove their readiness for transition is an antiquated idea from a time when the many and varied reasons for needing  endocrine or surgical intervention were not well understood by health professionals, and when the mainstream community was less accepting of androgynous dress in general.  In addition, this expectation poses logistical problems and could even endanger clients, for example, if a therapist suggested that someone who has not yet had hormones and still has strong physical characteristics of one gender, should regularly appear in public wearing clothes associated only with the opposite gender.

 10.   A therapist treating a same-sex couple who are raising children together and thinking of separating should

a.       Listen carefully to their story and then give them advice about whether to stay together
b.      File a Suspected Child Abuse Report, because some people believe that having two parents of the same sex is psychologically damaging to children
c.       Give them referrals, as needed, to legal professionals who are known for their knowledge and experience with laws affecting LGBT families
d.      If asked, disclose how much clinical training and experience the therapist has with LGBT families
e.      Both C and D

 E is correct.  CAMFT’s ethical code states that therapists do not advise clients about whether to stay in relationships.  Stereotypes or public opinions about parenting, of course, have no part in professional clinical assessments or mandated child abuse reports.  Telling a client what your qualifications are can be part of obtaining their informed consent to engage in therapy with you.  Since legal services are outside a therapist’s scope of practice, clients in this situation would need referrals to meet these needs, and they will be met best by professionals who are culturally competent in their own field.

 11.   CAMFT’s Ethical Standards state that “ “Marriage and Family Therapists advance the welfare of families and individuals.”  In considering the welfare of a client who identifies as gay, lesbian, bisexual, or transgender, a therapist should take into account

a.       Financial, legal, and social stressors brought on by political and legal events affecting LGBT individuals and families (such as California’s ongoing controversy over marriage rights)
b.      The degree of acceptance for sexual orientation and/or gender identity that the client finds in his/her overall support system
c.       Cognitions, attitudes, and symptoms that might be indicators of internalized homophobia
d.      Personal strengths the client has exercised in the course of coming out and/or coping with incidents of discrimination and prejudice
e.      All of the above

E is correct.  Social influences and support systems affect a person’s welfare, and this is particularly true for minority groups who are more likely to encounter prejudice, discrimination, and even violence in their lives. Oppressed minorities often internalize prejudice and hate directed at the group they belong to, and therapists are in an ideal position to interpret and help clients recover from these harmful internal cognitions.  A thorough assessment of any client’s mental health and general well-being should include strengths as well as symptoms of pathology or distress.

 12.   "Challenging social injustice" is

a.       Part of the National Association of Social Workers code of ethics
b.      Part of the California Association of Marriage and Family Therapists code of ethics
c.       Incompatible with psychotherapy because some clients might disagree with the political views of a therapist, or with public statements made by a group or association of therapists
d.      A sign that a client is socially maladjusted
e.      All of the above

A is correct.  CAMFT’s ethical code is markedly silent on the subject of social justice and socio-political issues.  Professional associations of therapists often issue resolutions on topics their leaders see as important to the profession.  For example, the American Psychological Association issued a resolution on reparative therapy (noted above).  While some might say that this “liberal” political perspective might alienate prospective therapy clients who have conservative views, others would argue that therapy professions have a responsibility to educate and take a stand on matters where public opinion has been influenced by stereotypes or misconceptions that research in our field has shown to be false.

 13.   A therapist treating a bisexual person who is married to someone of the opposite sex should

 a.       Assume that sexual orientation is the primary issue the client wants to discuss, especially if the client asked for a therapist who has experience working with bisexual clients
b.      Question the client’s need to identify as bisexual while living in a socially and legally accepted marriage
c.       Get  education or consultation about the effects of discrimination against bisexual people, which the client might encounter in the queer community as well as society at large
d.      Feel free to talk to the client’s spouse about the therapy, since the client’s sexual orientation is probably causing marital problems
e.       Feel free to talk with the client’s spouse only if the spouse already knows about the client’s sexual orientation

C is correct.  Clients who belong to minority groups may request or prefer a therapist who belongs to or understands that group, simply because they do not want to have to be the first to educate the therapist about their cultural experience and norms; it does not necessarily mean that they are having psychological issues with their identity in that group.  A common misconception that has been used to trivialize discrimination against sexual minorities is the idea that sexual orientation is a “lifestyle choice.” Cultural competence includes being aware of the kinds of discrimination people in a minority group are likely to encounter.  While awareness has risen regarding bisexuality as a valid sexual orientation and a minority culture in its own right, it is still true that bisexual people can be misunderstood by lesbians and gay men, and be made to feel like outsiders in both the “straight” world and the gay community.  It would be illegal and unethical to violate a client’s confidentiality by talking about the therapy with his/her spouse without a release.

 14.   Performing services outside one’s scope of practice is illegal.  An example would be

a.       Offering legal advice to a client who wants to marry his/her same-sex partner
b.      Telling a client who wants to marry his/her same sex partner about local political action groups and legal services that might offer support
c.       Advising a client to stop using a prescribed psychiatric medication that is not working
d.      Coaching a client to communicate more clearly with his/her psychiatrist about a medication that is not working
e.      Both A and C

 E is correct.  Legal and psychiatric services are clearly outside the scope of practice for MFTs and LCSWs, while efforts to improve communication skills and social support systems fall well within the scope, i.e. “helping people achieve more adequate, satisfying, and productive marriage and family adjustments” (MFT), or “social adjustments” (LCSW).

 15.   Performing services outside one’s scope of competence is unethical.  An example would be

 a.       Working with a client who is a member of a minority group, such as a lesbian, gay, bisexual, or transgender person, a person with a disability, or a person of color, without consultation, education, or personal experience that would make the therapist familiar with the norms of that group, and with social factors affecting the mental health and welfare of that group
b.      Trying out a treatment method, such as reparative therapy, without being familiar enough with the research to determine whether the method is effective and safe
c.       Trying out a treatment method that research DOES support, without personally having studied it
d.      Working with a client who is extremely depressed and may become suicidal
e.      A, B, and C

E is correct.  Being competent to work with a client includes having knowledge about the client’s culture and societal, familial, or psychological issues members of that culture tend to encounter.  Therapists who are taking care not to harm clients familiarize themselves with accepted best practice standards and research findings, and obtain adequate training, before implementing a treatment method.  Depression, its severity, and its risks are not, per se, about scope of competence, but as with any diagnosis, a therapist should not take on a case involving depression unless he/she has adequate training and experience to treat it.

 16.   Informed consent might include

a.       Informing a client that therapists sometimes have to make mandated child abuse reports
b.      Telling a couple that therapy will not necessarily help them stay together
c.       Letting a client know what the accepted research indicates about the risks and benefits of a treatment method the client is requesting, especially a controversial method such as reparative therapy
d.      Answering a client’s questions about the therapist’s qualifications, including the therapist’s knowledge about the client’s cultural or minority group
e.      All of the above

E is correct.  Clients have a right to know the legal limits of confidentiality rights (such as mandated reporting laws).  They also have a right to know the limitations, risks, and benefits of treatment, and the qualifications of the provider. 

Answer Sheet

Law and Ethics with an LGBT Focus Part One

​1.    “Enforcement of laws designed to protect the public from incompetent, unethical, or unprofessional practitioners” is a function of

a.       The California Board of Behavioral Sciences
b.      The California Association of Marriage and Family Therapists
c.       The National Association of Social Workers
d.      The American Psychological Association
e.      The American Medical Association