termination might be a separation

strategy if psychologists are acting on their personal reactions and values, and
forgetting their professional obligations to patients. Premature or hasty referrals
also might represent an assimilation strategy if psychologists are striving
to obey the letter of the APA Ethics Code but are failing to consider the need
to have compassion for others.
Integration strategies allow psychologists to incorporate their compassion
with their professional obligations. Except when there is a serious risk of
physical harm to third parties or the self, we believe that respect for patient
autonomy requires psychologists to strive to honor the their patients’ worldview,
including patients’ religious or cultural beliefs, without trying to impose
their own (nontherapy) beliefs on their patients. We call this judgment-neutral
psychotherapy, which does not require psychologists to abandon their own
beliefs. Rather, it only restricts psychologists who attempt to use psychotherapy
as a means to alter the “immoral” beliefs and behaviors of others when
those beliefs are not relevant to the therapy.
Judgment-neutral psychotherapy does not mean that psychologists should
passively accept whatever patients say. They may, and should, actively engage
patients in discussions of their beliefs and the implications of those beliefs for
their long-term well-being. For example, a patient may be so deferential in her
marriage that it contributes to a major depression and leads to self-defeating
behaviors. Given the severity of the harm, her psychologist may question
those portions of her beliefs about marriage that support this emotional turmoil.
The actual process of challenging beliefs can be nuanced, however,
and involves conveying concern and caring for the patient, respecting the
patient’s worldview, and being honest with ourselves about whose needs are
being met.
Of course, it is legitimate to ask patients to explore and reconsider their
major life choices. If a patient states that she wants to change her sexual orientation,
then it is entirely legitimate (and indeed desirable) to discuss her priorities,
goals, alternatives, and moral values. Conscientious psychologists will
be informed by the scientific findings on reorientation therapy (evidence for
its effectiveness is weak, and anecdotal evidence has indicated that it can be
harmful; APA, 2009). The judgments involved in balancing support and probing
with patients can be delicate—some might even prefer the word messy.
For example, psychologists who ask patients to explore the nature of their
roles within a marriage need to be aware of their own motivations; a risk exists
that psychologists may allow their moral judgments to influence the extent to
which they identify patient beliefs as harmful. These psychologists should ask
164 ethical dilemmas in psychotherapy
themselves if they would have spent as much time “helping” patients who
desire options more consistent with their own belief system. “Let’s explore
that decision. How do you think about it?” is a question that psychologists
might be more likely to ask when their patients’ inclinations differ from their
own. It also is a question that psychologists may need to ask themselves. The
goal of these questions and discussions, however, should be to help patients
evaluate situations and determine what they want to do, as one would with
any major life decision, regardless of the psychologist’s values.
Similarly, psychologists may encounter individuals who feel conflicted
about their same-sex attraction, because these feelings run counter to their
religious beliefs. It is quite appropriate for psychologists to respectfully ask
probing questions so that patients may establish a methodology for reconsidering
these religious beliefs. It may mean educating patients about the
pernicious effect of internalized homophobia, informing patients about the
research on the biological bases of same-sex attraction, or connecting them
with religious sources or leaders who do not see a conflict between faith and
homosexuality (Lasser & Gottlieb, 2004). Ultimately, however, psychologists
need to respect the decisions that their patients reach, even if it means that
the patients determine that same-sex attraction is unacceptable because it violates
their deeply held religious beliefs. The therapeutic goals are to maximize
self-determination by “permitting the patient to decide the ultimate goal of
how to self-identify and live out his or her sexual orientation” and to “integrate
sexual orientation concerns into a self-chosen life style” (APA, 2009, p. 6).
The goal is to aid patients to prioritize their goals and values (Yarhouse, &
Beckstead, 2007).
Consider the conflict that might arise if a psychologist were to treat a
woman patient who has agreed to submit to a marriage arranged by her parents
with a spouse who believes in a submissive role for women in marriage. Ev