Ethical Challenges in Private Practice
with Pagan, Polyamory, BDSM, and LGBT Populations
The experiences of couples and family relationships in many alternative lifestyle populations have not been well studied. Those populations included under the term alternative lifestyles include Pagan, polyamorous, BDSM adherents, and LGBT populations. This author plans on developing a private marital and family therapy practice devoted specifically to investigating and treating the unique counseling needs of these populations. This paper will examine the potential ethical challenges associated with working with these populations, paying particular attention to the issues pertaining to costs, payment options, risks of therapy, alternatives to therapy, diagnostic classifying, confidentiality, and multiple relationships. This paper also examines the author’s theoretical perspective, which is based on a blend of existential theory, Roger’s person-centered approach, and transpersonal psychology.
Ethical Challenges in Private Practice
With Pagan, Polyamory, BDSM, and LGBT Populations
The experiences of couples and family relationships in many alternative lifestyle populations have not been well studied. This author plans on developing a private marital and family therapy practice devoted specifically to investigating and treating the unique counseling needs of these populations. This paper will examine the potential ethical challenges associated with working with these populations.
Social and Cultural Composition of the Populations Served
The number of people self-identifying as some form of “Pagan” has grown to almost half a million or more in recent years (Robinson, 2004), not counting those who fear persecution if they disclose their religious affiliation. The word “Pagan” is an umbrella term, used to refer to people who follow one of a variety of non-Judeo-Christian, earth-centered spiritualities. Although there are many flavors of Paganism, in general, those things they have in common include a deep connection to and even reverence for nature, a polytheistic or pantheistic understanding of immanent divinity, respect for individual freedom, and an appreciation of and celebration of ecstasy and freedom (Adler, 1986; Collins & Raeburn, 2002). “As Pagans we celebrate our world, seeing the Divine in virtually everything and everyone” (Collins, 2004, p. 1).
Pagans view relationships differently than those of other religions (Collins & Raeburn, 2002). Some of these differences include the following: Sexuality is viewed as sacred, a divine gift, rather than as something shameful or dirty; choosing one’s own path, while endeavoring not to harm yourself or others, is a primary right and responsibility; there is no expectation that people will choose to mate for life; alternative relationship choices are honored and respected; and the genders are honored as “equal in value and potential” (Collins & Raeburn, 2002, p. 4).
Polyamory is a term coined by Morning Glory Zell Ravenheart to replace the term “responsible nonmonogamy” (Anapol, 1997, p. 5). It is a blending of Greek and Latin roots, which together translate as “many loves”. There are many different forms of polyamory or responsible nonmonogamy, each of which have their own more specific labels, but overall, this concept can be understood to mean “the philosophy and practice of loving or relating intimately to more than one other person at a time with honesty and integrity” (Walston, 2005, ¶1). Weitzman (2006) defines polyamory as “a lifestyle in which a person may pursue simultaneous romantic relationships, with the blessing and consent of each of their partners” (¶2).
Although unusual and unconventional, polyamory is becoming more widely practiced and accepted, especially in the homosexual and Pagan communities, and there is beginning to be studies done comparing polyamorous relationships and monogamous relationships on levels of marriage satisfaction, self-esteem, relationship longevity, and reasons for termination (Weitzman, 2006).
“BDSM, variously called bondage and discipline, dominance/submission, sadism/masochism, “leather”, “kink”, and fetishism, includes a variety of so-called “nonstandard” sexual attractions and behaviors” (Institute for Personal Growth [IPG], 2007, ¶10). In addition to the variety of attractions and behaviors, describing this population is made even more complex by the range of identities BDSM practitioners adopt. For some, engaging in some form of kink is occasional and used to “spice up” one’s “vanilla” (or conventional) sex life. For others, voluntarily committing to a full-time master-slave relationship is desirable (Moser & Kleinplatz, 2006).
This population has been studied, but mostly as a way of investigating the supposed pathology of the behaviors. There are no firm statistics of the number of people who incorporate some aspect of BDSM into their lives, but a Google search on “BDSM” reveals 18,400,000 “hits” (performed August 8, 2007). “Our estimates of the incidence and prevalence of SM behavior are rudimentary” (Moser & Kleinplatz, 2006, p. 8).
LGBT stands for lesbian, gay, bisexual, or transgendered. Between the 2000 U.S. Census and Harris Interactive’s market data statistics, Harris Interactive has identified approximately three million same-sex couple households and 15 million individuals who self-identify as gay, lesbian, or bisexual (Harris Interactive, 2007). The LGB population, of all those discussed in this paper, have become the most visible and most widely studied. However, people in this population still face a number of unique challenges, especially when it comes to family planning and obtaining well-informed, bias-free counseling.
Additionally, there is considerable overlap between the populations identified as LGB with all the other populations delineated in this paper.
The “T” in the above acronym refers to the percentage of the population who are “transgendered”, meaning their internal sense of gender identity does not conform to some degree with their external expression of gender (Firestein, 2000). As to their numbers, Moulton and Seaton (n.d.) state “only one thing is certain: little is known about how many transgender individuals live in the United States, but it is probably much higher than many have believed” (p. 9).
In working with the various alternative lifestyles populations described above, a blending of existential theory, person-centered theory, and transpersonal psychology theory seems most appropriate.
Existential theory places a lot of emphasis on developing the helping relationship, recognizing that the relationship is the primary vehicle through which growth can happen (Bauman & Waldo, 1998). “The relationship allows clients to unfold their actualizing forces” (Bauman & Waldo, 1998, p. 4).
Existential theory helps clients become self-aware and increases their awareness of the life choices and personal responsibility they have (Okun & Kantrowitz, 2008). Existential theory recognizes the “need to promote the overall wellness of clients rather than restricting the therapeutic focus to their symptoms” (Bauman & Waldo, 1998, p. 4).
This theory places the client in the driver’s seat of the therapeutic process, based on the premise that the client has the resources for becoming self-aware and self-actualizing. Providing an atmosphere of trust and safety, and developing a therapeutic relationship based on empathy and understanding, are the primary goals of this theory (Corey & Corey, 2007).
Transpersonal Psychology Theory
This theory is concerned with investigating the nature of being human and our interactions with that which is larger than ourselves. “Based on observations and practices from many cultures, the transpersonal perspective is informed by modern psychology, the humanities and human sciences, as well as contemporary spiritual disciplines and the wisdom traditions” (Association for Transpersonal Psychology, n.d., ¶1).
Summary of Theoretical Perspective
Because this author does not believe that individuals from the various alternative lifestyles mentioned herein are inherently bad, wrong, broken, or ill, it makes sense to draw on perspectives which see the person as basically “rational, good, and capable of assuming responsibility for themselves and making the choices that can lead to independence, self-actualization, and autonomy” (Okun & Kantrowitz, 2008, p. 128) as is represented by the person-centered approach.
It is also important to be able to provide people from these marginalized and misunderstood communities with helpers who can establish warm, empathic, understanding therapeutic relationships, in which the client feels safe and not judged.
The existential approach emphasizes “potentiality and becoming” (Bauman & Waldo, 1998, p. 2) and people from alternative lifestyles are actively engaged in redefining their lives on their own terms, often in opposition to what is socially, legally and politically acceptable by the mainstream, so it makes sense to apply an existential approach which already supports individuation and self-actualization.
Transpersonal psychology, with its emphasis on multiculturalism and recognition of the whole person, is ideal for working with alternative lifestyles adherents, especially those who also practice alternative spiritualities.
Issues of Informed Consent & Patient Rights
In this author’s private practice catering to the alternative lifestyles populations, it will be important to outline in a detailed informed consent document how the therapeutic process works, the therapist’s background and theoretical perspective, the costs of therapy and possible payment options, the average length of therapy and issues of termination, benefits and risks of therapy, alternatives to traditional therapy, client’s rights to file access, and diagnostic classifying (ACA, 2005).
Particularly important to point out to members of these populations are issues pertaining to costs, payment options, risks of therapy, alternatives to therapy, and diagnostic classifying.
Cost of Therapy, Payment Options, and Alternatives to Therapy
The Pagan community is notorious for being relatively “poor”. In fact, Ellwood (2007) describes the stereotypical “poor Pagan” who is always in debt, drives an older car in poor running condition, and suffers from bad credit. He explains the rationalization behind this: “This stereotype, when it comes to money, is justified by the idea that being poor is virtuous. The rationalization is that it’s okay if you’re in debt, and/or don’t have much money – you’re keeping it real by not being too materialistic or capitalistic” (Ellwood, 2007, ¶1).
Additionally, “there is a belief current in the Wiccan community that taking money for any of these activities is somehow to demean the religion” (Lark, 1996, ¶7). The combination of these cultural realities makes it difficult for anyone offering services specifically to the Pagan population to charge money for those services, especially if those services can be perceived as spiritual in any way.
The issue of payment and bartering does not seem to be as prevalent an issue in the other alternative lifestyles served by this practice; however, they will be treated equally, per the following guidelines.
The ACA (2005) states that bartering may be acceptable if “it does not place the counselor in an unfair advantage” (§ A.10.d.), if requested by the client, and is culturally acceptable. In the subculture of the Pagan community, bartering is often used in lieu of monetary compensation. This author plans on having a sliding scale payment system outlined in detail on the informed consent form. Costs and payment options will also be discussed explicitly with each client in the first session and throughout the counseling relationship. Barter will be accepted if it meets the ACA guidelines.
Risks of Therapy
Some of the risks associated with therapy include remembering unpleasant events, feelings, or experiences; dealing with difficult family issues; challenging established beliefs and perceptions; and changes in personal relationships (Riddle-Walker, 2004). Many people from alternative lifestyles have avoided therapy or have already suffered negative experiences with therapists not educated about their particular lifestyle. Thus, there is already a hurdle of trust to be overcome in working with these clients. It will be important to discuss the various risks of therapy with these clients, so that discomfort and counselor challenges are perceived within the proper context.
Based on the reality that BDSM practices are still listed in the International Classification of Diseases (as cited in Reiersol & Skeid, 2006), as pathologies, it will be particularly important to carefully consider the diagnosis of a client who is presenting with an issue related to their BDSM activities. There is also a fine line between healthy BDSM activities and abuse, which must be carefully considered during the counseling session.
Confidentiality Issues and Strategies to Protect Confidentiality
Polyamorous people cannot legally marry multiple partners, or they will be in violation of the bigamy laws (Law.com Dictionary, 2007). Therefore, they regularly commit the crime of adultery (depending on if they live in one of the 20 states in which adultery is a crime) (Grossman, 2003). This could be a major issue of confidentiality, as polyamorous people confront bias and discrimination in the workplace and in child custody cases.
Similar issues surround maintaining the confidentiality of clients who engage in BDSM relationships. Neither polyamorous people nor BDSM adherents have many legal protections as of yet, so their alternative lifestyles must often be kept secret. This could present ethical dilemmas for the uninformed counselor called to testify for or against clients on these issues and how they affect various court cases.
This author intends to adhere to the ACA Code of Ethics (2005), which allows for strict adherence to confidentiality, except in cases of imminent harm to the client or others. Any possible limitations to confidentiality will be covered in the Informed Consent material and discussed in detail during the intake session.
Delivery of Service Considerations
The primary concerns in this area are fees (already covered above under Issues of Informed Consent and Patient Rights), managed care issues, and use of telephone or online technology as alternative counseling options.
Due to the sensitive nature of the populations being served, this author plans on offering her services on a sliding scale, cash or credit card basis only. She does not feel comfortable with the restrictions involved in associating with a managed care company. After speaking with another Pagan therapist who operates his practice in this way, this author has decided that the ethical issues associated with conducting counseling under the aegis of a managed care company is not worth the referrals that could come through the company (M. Reeder, personal communication, July 24, 2007).
In urban areas, it is easier for people of alternative lifestyles to find others like themselves. It is harder for those who live in the suburbs or more remotely. It can also be difficult to identify others of like mind, even in an urban setting, since most people from these marginalized groups tend to try to "pass" as straight, or mundane, or mainstream, to avoid bias and criticism. There are far more opportunities for connecting with one another in an online medium. Additionally, because there are not yet very many therapists sympathetic to and knowledgeable about their particular lifestyle, it can sometimes be even more difficult to find adequate and acceptable mental health practitioners. The telephone and various online technologies may be used to assist people who are remote, and for marketing to those who are searching.
Problems Associated with Multiple Relationship Issues
Since this author already plays many different roles in the communities to which she intends to offer professional counseling services, there is considerable risk of developing multiple relationships. Some of the problems associated with multiple relationships include loss of therapist objectivity, conflicts of interest, an inability to maintain appropriate boundaries with clients, and payment issues (Corey, Corey, & Callanan, 2007).
This author plans to discuss the increased risks of multiple relationships with clients who originate in these communities. This discussion will also cover the possibility of the necessity to refer.
Analysis of Hypothetical Ethical Dilemma
These communities are fairly small and insular, and there is considerable overlap between them. Among Pagans, in particular, many people are involved in relationships with partners who do not subscribe to the same spiritual beliefs and often opt not to attend the Pagan partner’s social and spiritual events. Additionally, Pagans often choose pseudonyms for various reasons. Thus, it is entirely possible that the non-Pagan partner would seek out counseling, and the Pagan counselor would be unaware of the relationship she may have with the client’s Pagan partner, as she may never have met the spouse and the Pagan partner may not have revealed her legal name to the counselor in their social or spiritual interactions. It is possible that at some point the non-Pagan client may attend a Pagan event with his Pagan spouse, thus encountering the counselor. The counselor would then realize that she is friends with, perhaps even coven-mates with, her client’s spouse. This presents a clear dual relationship issue. The decision now becomes whether the counselor should withdraw from her social and spiritual relationship with the client’s spouse, withdraw from the counseling relationship and refer the client, or attempt to manage the conflict of interest inherent in the dual relationship.
The counselor first would initiate a conversation with the client during their next session about encountering each other at the social event. She would explain to the client the risks of the dual relationship and describe her misgivings about continuing to counsel the client in the face of this reality. Together, they would examine the options and the pros and cons of each. Before making any decisions with the client, the counselor would seek out a colleague to discuss the situation. She would document both her conversations with the client and with the colleague. Upon deeper reflection, she would decide, hopefully with the client’s cooperation and agreement, to find another suitable therapist and make a referral.
During the course of her conversations with the client, the counselor would also attempt to obtain from the client his permission to share the existence of their counseling relationship with his spouse. In a Pagan coven, there is an understanding that everyone enters with “perfect love and perfect trust.” To have to continue her spiritual duties with a secret of this nature hanging between her and her coven-mate, the counselor would find it difficult to maintain an attitude of perfect trust. She would feel she was betraying that trust and being unethical in her relationship.
This course has greatly increased this author’s awareness and understanding of the ethical challenges inherent in offering services to people within her own community. At the beginning of the course, she saw nothing wrong with the possibility of dual relationships, but now, she is experiencing great concern over this particular ethical issue. She will continue to read and learn from her professors, peers, and supervisors on how to handle these issues, and she will cultivate relationships with colleagues with whom she can discuss the intricacies of these situations as they occur.
Annotated Reference List
Adler, M. (1986). Drawing down the moon: Witches, Druids, Goddess-Worshippers, and other Pagans in America today. New York: Penguin Books USA.
This book explores the contemporary Pagan culture as it exists and is developing in the USA. This resource will be used to inform about the social and cultural composition of the Pagan population.
American Counseling Association. (2005). Code of ethics. Codes of Ethics for the Helping Profession (3rd ed.). Belmont, CA: Thomson Brooks/Cole.
The ACA Code of Ethics is essential for exploring the various ethical standards that come into play in any counseling relationship.
Anapol, D. (1997). Polyamory: The new love without limits. San Rafael, CA: IntiNet Resource Center.
This resource is invaluable for explaining the relationship structure known as polyamory, and for describing some of the problems and issues encountered by people in these relationships.
Association for Transpersonal Psychology. (n.d.). About ATP: Transpersonal perspective. Retrieved August 8, 2007, from http://www.atpweb.org/transperspect.asp
This website clearly describes the relatively new school of thought known as Transpersonal Psychology and will help the author describe how this system can be integrated into her overall theoretical perspective and counseling approach.
Bauman, S., & Waldo, M. (1998). Existential theory and mental health counseling: If it were a snake, it would have bitten!. Journal of Mental Health Counseling, 20(1). 13. Retrieved August 3, 2007, from Academic Search Premier database.
The author will utilize the information in this article to help explain existential theory and how it could be incorporated into her overall theoretical perspective.
Collins, C. J. (2004). The recovery spiral: A pagan path to healing. New York: Citadel Press Books.
This book describes how Pagans can apply the principles of the 12 steps in a more culturally-appropriate way. This resource describes Pagans and will help to illustrate this population within the paper.
Collins, C. J., & Raeburn, J. (2002). Building a magical relationship: The five points of love. New York: Citadel Press Books.
Collins & Raeburn describe the views on and types of relationship developed by Pagans, thus informing this paper about this topic.
Corey, G., Corey, M. S., Callanan, P. (2007). Issues and ethics in the helping professions (7th ed.). Belmont, CA: Thomson Brooks/Cole.
This book goes into detail about the various ethical issues encountered in helping relationships and fully explains the ethical standards put forth in various ethical codes.
Corey, M. S., & Corey, G. (2007). Becoming a helper (5th ed.). Belmont, CA: Thomson Brooks/Cole.
This book was used to describe the theoretical orientations of existential theory and person-centered theory.
Ellwood, T. (2007). The poor Pagan. Rending the Veil. Retrieved August 9, 2007, from http://www.rendingtheveil.com/article.php?article=21
Ellwood uses this article to describe the stereotype of the “poor Pagan”, which is referred to within this paper, in relation to the challenge of negotiating barter agreements with Pagans.
Firestein, B. (2000, March). Learning from my transgendered clients. Concepts and clinical issues in working with transgendered clients. Paper presented at the meeting of the Association for Women in Psychology, Salt Lake City, NV.
In this article, the author describes the transgendered population, which will inform this paper about this type of client.
Grossman, J. (2003). Punishing adultery in Virginia. FindLaw Legal News and Commentary. Retrieved August 9, 2007, from http://writ.news.findlaw.com/grossman/20031216.html
This site describes the legal issues around adultery, which is appropriate to this paper in examining some of the challenges that polyamory people face in negotiating their relationships.
Harris Interactive. (2007). The gay, lesbian, bisexual and transgender (GLBT) population at-a-glance. Retrieved August 8, 2007, from http://witeckcombs.com/pdf/glbt-market-research-highlights.pdf
This website was used to glean statistical information about the gay, lesbian, bisexual and transgendered population.
Institute for Personal Growth. (2007). Other sexual minorities. Retrieved August 8, 2007, from http://ipgcounseling.com/other_services.html
On this website, the author learned about BDSM practitioners and statistics surrounding this population.
Lark. (1996). The need for Wiccan clergy. Retrieved August 9, 2007, from http://www.tangledmoon.org/wiccan_clergy.htm
This article helps elucidate why the Pagan population needs counselors trained in their particular cultural perspective.
Law.com Dictionary. (2007). Bigamy. Retrieved August 9, 2007, from http://dictionary.law.com/default2.Asp?selected=65&bold=%7C%7C%7C%7C
This site describes the bigamy law that prevents polyamorous couples from making their relationships legal.
Moulton, B., & Seaton, L. (n.d.). Transgender America: A handbook for understanding. Retrieved August 8, 2007, from http://www.hrc.org/Template.cfm?Section=About_HRC&CONTENTID=29235&TEMPLATE=/ContentManagement/ContentDisplay.cfm
A lot more information about the transgendered population is presented in this publication.
Okun, B. F., & Kantrowitz, R. E. (2008). Effecting helping: Interviewing and counseling techniques. Belmont, CA: Thomson Brooks/Cole.
This books helps to describe the various theoretical perspectives the author intends to blend together to form her own unique approach to the various populations described herein.
Riddle-Walker, L. (2004). Benefits and risks of therapy. Retrieved August 9, 2007, from http://www.lrwalker.net/article_benefits.htm
Riddle-Walker describes on this site some of the benefits and risks of therapy, thus informing the author of potential problem areas associated with her practice.
Robinson, B. A. (2004). How many wiccans are there?: Our best estimates for the U.S., Canada, etc. Ontario Consultants on Religious Tolerance [Electronic source]. Retrieved August 7, 2007 from http://www.religioustolerance.org/wic_nbr3.htm
This site was helpful for gaining understanding on the statistics of the Pagan population.
Walston, J. (2005). Polyamory and the Unitarian Universalist Association principles and purposes. UUs for Polyamory Awareness. Retrieved August 7, 2007 from http://uupa.org/Literature/polyprinciples.html
This site assisted the author in describing the Pagan worldview and cultural composition.
Weitzman, G. (2006). Therapy with clients who are bisexual and polyamorous [Electronic version]. Journal of Bisexuality, 6(1/2). 137-164.
This article provided invaluable information pertaining to the particular challenge of counseling bisexual and polyamorous clients.
World Health Organization (1992). The ICD-10 classification of mental and behavioral disorders. Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: Author.
This site illuminated how the BDSM population are still stigmatized by their practices being misunderstood as psychoses in need of “fixing”.