Conversion Therapy and Affirmative Therapy

Now that the LPC government has tabled Bill C-4, it's probably a good time to examine the two terms that are inevitably going to be argued about the most with this legislation.  Specifically, I want to talk about the terms "Conversion Therapy" and "Affirmative Therapy".  

I will be doing this primarily through the lens of mental health therapy, although in the coming debate over Bill C-4, you can expect that to get conflated with medical interventions such as surgeries or hormone therapies.  The relationship between mental health and medical interventions is a separate matter that will be addressed in another article. 

Conversion Therapy

Conversion Therapy has a long, and very dark history.  It was originally the default position that therapists were expected to take - especially in the days when homosexuality was both socially and legally frowned upon.  It has worn multiple names over time, including "Change Therapy", "Reparative Therapy", and "Conversion Therapy".  

Conceptually, the concept of Conversion Therapy rests upon the idea that sexual and gender identity is malleable, and therefore changeable.  In particular, this was believed to be true of alternative sexualities like homosexuality and transgender identities (which were at the time assumed to be sexual identities as well).  In some respects, the idea is that homosexual or transgender identities are malleable derives from the epistemological idea "Tabula Rasa" (Blank Slate), which postulates that behaviours are learned, and are therefore are subject to being changed through therapy.  

There have been numerous forms of conversion therapy attempted over the years, based on various ideas around the formation of homosexual identity. At the end of the day, there is no evidence that any conversion therapy model has actually worked, in spite of many claims of single case success (often disproved later by relapses to prior behaviour).  

Therapeutically, the common aspect of any conversion therapy model is that it puts the therapist in a very powerful position of being the person that's going to "fix" the client. Often regardless of whether the client is a willing participant or not (we'll come back to this point). This makes conversion therapy models intrinsically coercive. The client is with the therapist, and the therapist is there to help the client "fix" whatever's wrong through some combination of cognition and behavioural changes. In other words, the client isn't necessarily in control. Even if the client is there voluntarily, they are still asking the therapist to "fix" them.

This is pretty much the opposite of actual good therapy, where it is an alliance between the therapist and the client to resolve problems.

Affirmative Therapy

Affirmative Therapy starts from a very different place, therapeutically speaking.  Affirmative models start with the supposition that the client is, in fact, the expert in their experiences. As a therapist, you meet the client where they are at, and work from there in terms of pursuing their goals. The therapist's role in this context is to act as a facilitator and guide as the client works through their issues. Various therapeutic tools may come into play to assist the client, but at all times the client is actually the person in control. 

The first and biggest difference from Conversion Therapy is that unlike Conversion Therapy, Affirmative Therapy does not have a specific outcome in mind. Conversion Therapy starts from the misguided assumption that it is possible to change someone's sexual orientation (or gender identity).  Affirmative therapy makes no such claim.  

This is not to say that if a client walks in demanding immediate referral for medical interventions that it "just happens automatically".  There are still ethical and practical reasons that a reasonable assessment needs to happen. This isn't "on demand" access, rather it's about not setting out to frustrate a client's desires. Instead, it's about working with the client where they are at, and helping them make reasonable decisions. 

Those familiar with psychology will recognize this as being very reminiscent of Carl Rogers' "Person Centred Therapy" with good reason. Affirmative models are naturally closely related to Rogers' ideas. It's a good thing here because it embodies the key ethical principles of psychology that put the client at the centre of the focus without presupposing that the therapist "knows" anything the client doesn't already know. 

The Transgender Angle

Much has been made about how banning conversion therapy creates problems for therapists working with transgender clients. After all, how can you discuss ideas like not transitioning without being accused of "conversion therapy"? 

The short answer here is that reasonable exploration in an affirmative setting includes discussing valid alternatives with the client. What it doesn't allow for is trying to persuade a client to make a particular decision - which is ethically inappropriate as a therapist in the first place.  

Similarly, if a client in the process of their transition decides to take a step back, pause things, or to detransition entirely, there is no reason not to discuss with them where they are heading and why.  Detransition is not equivalent to "conversion therapy" for several reasons, not the least of which is that it is initiated by the client in the first place.  

Lastly, let's talk about the scenario where a transgender client comes in and says "Therapist, I want you to make me cisgender".  The ethically appropriate response to this is not to say "okay, that's what we'll do" because there is essentially zero clinical evidence which supports this path. The therapist's valid response is a combination of psychoeducation to help the client understand that such efforts are rarely successful, and that a more fruitful path is to work towards developing self-acceptance. 

Conclusions

Hopefully, I have laid out the differences between coercive therapy models that live under the rubric of "Conversion Therapy" and more ethically and methodologically sound approaches that live under the rubric of "Affirmative Therapy".  

Claims made about how banning Conversion Therapy will somehow create unintended complications for therapists and clients simply do not make any sense.