Free speech vs. patient care

Julea Ward was a student in a master's-level counseling program at Eastern Michigan University when she was assigned to counsel a gay client. While she was prepared to counsel the client on issues unrelated to sexual orientation, she did not want to address issues that might involve a same-sex relationship, which violated her religious beliefs. She sought advice from faculty regarding the situation, explaining that her religious faith prohibited her from affirming homosexuality and suggesting that the client be referred elsewhere before the counseling began. The program did not agree with her proposed solution and suggested remediation. After declining to participate in remediation, Ward was eventually expelled.

On one side of the lawsuit that followed was the university's view that Ward had violated the program's curriculum requirements and the profession's code of ethics. On the other was Ward's claim that her First Amendment rights to free speech and free exercise of religion were being violated. The case ended with a $75,000 payment to Ward.

The implications go far beyond Ward and the client she refused to serve. Psychologists warn that her case and others like it may be harbingers of things to come in graduate psychology training. In 2011, Arizona passed a law prohibiting psychology, counseling and social work programs from disciplining or discriminating against a student who refuses to counsel clients about goals that conflict with the student's sincerely held religious beliefs if he or she consults with the supervising instructor or professor to determine the proper course of action to take to avoid harming the client. Similar legislation has been proposed in Michigan and Tennessee.

Now, APA is taking action. Its Board of Educational Affairs (BEA) Virtual Working Group on Restrictions Affecting Diversity Training in Graduate Education is warning that such laws threaten psychology's ability to prepare professional psychologists who are competent to serve an increasingly diverse public. The working group is also creating resources to help training programs prevent and address potential conflicts between trainees' beliefs and program policies.

"The issue is whether trainers of professional psychologists are going to retain their control over the nature of training," says Clinton Anderson, PhD, director of APA's Lesbian, Gay, Bisexual and Transgender (LGBT) Concerns Office. "From a public interest perspective, the biggest issue is whether people ... are going to have their access to care affected by these ‘conscience clause' requirements."

Opting out

Conscience clauses have their roots in conscientious objection laws that have allowed people with religious objections to sit out conflicts as far back as the Civil War, according to the American Bar Association.

Conscience clauses moved into the health-care realm following Roe v. Wade, with laws allowing health-care professionals to refuse to provide abortions. Conscience clauses then migrated into other fields. "Right of refusal" laws allow pharmacists to refuse to fill prescriptions for birth control, and emergency contraception, for example, while other laws allow students to opt out of assignments or curricula they say conflict with their religious beliefs. And such laws are proliferating, the association warns.

Now psychology and other mental health training programs are confronting conscience clauses. A year after Arizona passed its law, Michigan's House of Representatives passed a similar bill for its public colleges and universities, but the legislation died in the Senate. Earlier this year, Tennessee legislators introduced similar legislation, prompting more than 10,000 emails to legislators from psychologists and others opposing the legislation. The bill passed the state's Senate but was tabled for further consideration in the state's House of Representatives.

Psychology training directors and anyone else concerned about ensuring a competent psychology workforce should find that trend disturbing, says Linda Forrest, PhD, who chairs the BEA working group. Created in 2011, the group is charged with providing recommendations and creating resources to inform training directors; students; state, provincial and territorial psychological associations (SPTAs); and the public about conscience clauses.

"Our position is that all trainers need to help students be fully prepared to see a wide cross-section of different kinds of clients," says Forrest.

Plus, she says, APA's Ethical Principles of Psychologists, and Code of Conduct includes an anti-discrimination clause. "We don't want to be supporting statements on students' part about not wanting to provide services to certain groups of clients," she says.

At first glance, conscience clauses may not seem so bad. "On the surface, it sounds reasonable," says Judith A. Kovach, PhD, a BEA working group member and public policy consultant to the Michigan Psychological Association. "It doesn't benefit patients for someone to see them who doesn't want to see them or doesn't hold them in high regard."

But, she says, APA's accreditation standards require students to learn cultural competency and psychology's ethics code requires psychologists to put patients' needs first. While it's one thing for professionals in practice to select the kind of clients they serve, says Kovach, students who refuse to learn how to treat all kinds of clients are limiting the public's access to services, especially in rural areas where referral options are limited.

And it's not just the LGBT population such laws potentially harm, adds Kovach, who testified against Michigan's legislation. "The way the bill in Michigan read, it could apply to students refusing to see people contemplating a divorce, engaging in extramarital sex or contemplating abortion," she says. "Students could also refuse to see someone based on their racial or ethnic identity."

Taking a stand

Now the APA working group is developing resources to help training programs, the SPTAs and others take action.

The working group has developed a statement called "Preparing Professional Psychologists to Serve a Diverse Public: A Core Requirement in Doctoral Education and Training." Approved by BEA, the statement (PDF, 63KB) is designed to help training programs address conflicts between trainee beliefs and professional psychology's commitment to offering culturally responsive services to everyone.

The document explains that training programs must commit to creating a supportive training environment; ensuring transparency in educational expectations, policies and procedures; and establishing and maintaining standards for professional competence to protect the public.

"The working group has worked very hard to create a statement that welcomes all students and encourages trainers to work respectfully with all students, helping them learn how to see clients who are different from them or present difficult challenges for their belief systems," says Forrest. "We want trainers to treat students with sincerely held religious beliefs with great respect; our job as trainers is to help these students in a developmental manner to learn how to serve all different types of clients in a noninjurious, beneficial manner."

The working group has also developed a flow chart that guides training programs on the steps they need to take to prevent and respond to conflicts between trainee beliefs and program policies. The steps include adopting a policy for working with clients who have beliefs that differ from trainees' own, providing informed consent to trainees, integrating the policy into education and training, and maintaining consistent and respectful expectations of competence. The flow chart also offers advice on what to do if a conflict isn't resolved. Recommendations include documenting the trainee's unwillingness to attain required competencies and consulting institutional leaders and legal counsel, for example.

The group is also developing a bibliography and additional resources to help SPTAs and others advocate against these bills as they're introduced.

Of course, First Amendment rights are important, says Lance T. Laurence, PhD, director of professional affairs for the Tennessee Psychological Association.

"We agreed it was important to be able to take into account everybody's individual rights," says Laurence. "But while the other side was talking about the treatment provider's rights, we were more concerned with the patient's rights."

Helping to balance the two viewpoints is the goal of the BEA working group's statement, adds Forrest.

"The statement communicates psychology's position on the education of professional psychologists, which balances respect for students' First Amendment rights with the importance of trainees learning to provide noninjurious, beneficial care to all different types of clients."

Rebecca A. Clay is a writer in Washington, D.C.