Eating Disorders and LGBTQ
Standard of care issues and competency to treat vs. discriminatory laws
Posted Apr 25, 2016
On April 11, 2016, the Tennessee legislature passed HB 1840. The Bill allows private practice therapists and counselors to refuse to treat patients if their "goals, outcomes, or behaviors" would violate the "sincerely held principles" of the provider. The Bill now goes to Gov. Bill Haslam who has not yet signed it in to law.
If passed, the legislation would make Tennessee the only state that allows therapists to deny treatment to patients based on the therapists’ belief systems.
I have been treating eating disorders for more than 20 years. I have undergone countless years of training and supervision, my own psychotherapy and psychoanalysis and routinely seek out learning opportunities to further my knowledge about disorders that are regularly researched and which continue to evolve in terms of etiology and in finding effective treatments. I consider myself a specialist and have been called an expert in the field. I am qualified to treat eating disorders as I have a thorough understanding of the theories of causality, in diagnosing, making appropriate referrals when necessary, and in the various methods of treatment.
I live and now practice in North Carolina. I was born, raised and lived many years in New York, primarily in New York City and Westchester County. Many of the patients I treat currently in NC, including some with eating disorders, are Baptist. I am not a Baptist and make it a rule to tell new patients for whom their faith guides their life and decisions that I cannot speak to the specifics of their faith. I was raised Catholic and, although I have a solid understanding of the teachings of Jesus Christ, I am no longer a practicing Catholic.
I convey that I will do my very best to listen with both a respectful ear toward their faith and with a psychological and analytic ear as well. When doing family therapy, I express that I will do my best to align with their family values and point out where there are inconsistencies in communication, defeating family patterns and dynamics or any psychological or relational issue that stands in the way of their family’s closeness, connection or respect of each member as individuals or as members of the family system. That is my job and responsibility to my patients. If my patient(s) are not comfortable with this disclosure, I will refer them to someone else who may be a better fit.
The fact that the state of Tennessee is attempting to legislate something that most clinicians take as obvious - do not treat anyone or any condition that you are not qualified to treat or have confidence that you can deliver competent and compassionate care. Simple.
If there is to be legislation, perhaps there needs to be tighter constraints on clinicians’ proving that they are qualified to treat specific conditions. For instance, when joining insurance panels to be considered a participating provider who treats eating disorders, clinicians merely have to indicate (often by simply checking a box) that they treat eating disorders. Many of us who are qualified to treat Anorexia, Bulimia, Compulsive/Binge Eating Disorder have come upon more than the occasional patient who has received care by a practitioner claiming to treat these conditions who has limited experience, training or sophistication about the myriad of causes and methods of treatment. If we don’t legislate some standard of care issues, how is it appropriate therefore to legislate based solely on the “sincerely held principles” of the provider?
How is it that the state of Tennessee can seek to provide a way out for clinicians to treat LBGTQ patients and yet does not set tighter standards for clinical practice overall? There are lots of eating disorder therapists who are not duly qualified to treat them, but nothing is done to legislate over this I am not suggesting that there ought to be such legislation as I believe it is incumbent upon the clinician to know their areas of expertise and limitations and act accordingly.
The decision making on whether to treat or refer a patient ought to lie with the integrity of the clinician.
Why would a clinician who is not comfortable or knowledgeable about LBGTQ issues provide treatment? In this situation, it would be incumbent upon the clinician to seek out greater training and/or supervisory opportunities. How competent would the care be by the provider toward the patient seeking services if the clinician were not qualified or comfortable? How just is that toward the patient to provide inadequate care? It would be right for the clinician to make a referral to another provider solely on the grounds that the clinician does not feel qualified, competent or even comfortable to provide treatment.
Most reasonable people are in agreement that the Tennessee proposed law remains a smoke screen for greater issues of discrimination. This is and ought to be unacceptable.
All significant counseling professions (Psychiatric, Psychological, Clinical Social work, Marital and Family Counselors, Addiction Specialists, Psychiatric Nurse Practitioners as well as Christian Counselors, The American Association of Pastoral Counselors) prohibit unfair discrimination against patients and would violate each respective professions’ Code of Ethics.
Tennessee’s Bill specifically targets the American Counseling Association’s (ACA) 2014 Code of ethics which indicates that professional therapists/counselors may not deny treatment to clients based on, “…age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital/partnership status, language preference, socioeconomic status, immigration status, or any basis proscribed by law." The Bill would prevent the ACA from "disciplining an applicant or licensee based on a violation of A.11.b of the 2014 American Counseling Association Code of Ethics."
If clinicians refuse to treat someone because of sexual orientation or for a particular condition like eating disorders when they are duly qualified is breaking the law and in direct violation of their professional Code of Ethics. When a clinician feels ill-equipped, lacking in training or expertise or professional comfort in treating anyone, it is the right and ethical and compassionate decision to refer the patient to another clinician who is qualified and comfortable in treating that person.
There are practical solutions i.e. trusting the provider of care will be guided by ethical decision making when the overt issue is the issue. When the issue is really a cover for another agenda i.e. discrimination, legislation to sanction behavior in this regard is discriminatory and not only diminishes the integrity of the practitioner to make appropriate decisions, but also violates the trust people have in the competency of their providers to act justly and appropriately.
Judy Scheel, Ph.D., LCSW