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When Personal and Professional Values

Conflict: Trainee Perspectives on
Tensions Between Religious Beliefs and
Affirming Treatment of LGBT Clients
a
Christine M. Paprocki
a
Department of Psychology, University of North Carolina at Chapel
Hill
Accepted author version posted online: 15 Nov 2013.Published
online: 12 May 2014.

To cite this article: Christine M. Paprocki (2014) When Personal and Professional Values Conflict:
Trainee Perspectives on Tensions Between Religious Beliefs and Affirming Treatment of LGBT Clients,
Ethics & Behavior, 24:4, 279-292, DOI: 10.1080/10508422.2013.860029

To link to this article: http://dx.doi.org/10.1080/10508422.2013.860029

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 ETHICS & BEHAVIOR, 24(4), 279–292
Copyright © 2014 Taylor & Francis Group, LLC
ISSN: 1050-8422 print / 1532-7019 online
DOI: 10.1080/10508422.2013.860029

When Personal and Professional Values Conflict: Trainee

Perspectives on Tensions Between Religious Beliefs and
Affirming Treatment of LGBT Clients

Christine M. Paprocki
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Department of Psychology
University of North Carolina at Chapel Hill

At times the personal beliefs or values of graduate students in training programs for professional
psychology can create complications in their providing therapy for certain patient populations. This
issue has been brought to national attention recently through several prominent legal cases in which
students have contested their expulsion from graduate programs due to their assertions that they were
unable to treat clients in same-sex relationships because of their own religious beliefs. The goals of
the current article are to (a) review the literature on values conflicts, (b) provide an analysis of how
portions of our professional Ethics Code directly relate to this issue, (c) describe a developmentally
sensitive theoretical framework that is designed to foster the growth of ethical reasoning over time,
and (d) provide a forum for trainee perspectives on this issue based on trainees’ responses to an
ethical vignette describing an intern struggling with a values conflict. The trainee quotations are used
to structure a discussion of practical recommendations for how to handle values conflicts within the
context of training and clinical supervision in professional psychology.
Keywords: ethics, values, training, referrals, discrimination, diversity

The primary goal of the current article is to examine the specific ethical principles and standards
of the American Psychological Association’s (APA’s; 2010) Ethical Principles of Psychologists
and Code of Conduct that are relevant to the dilemma that arises when the personal beliefs of
trainees create complications in their providing therapy to specific patient populations. In addi-
tion, to gain insight into the trainee perspective on this issue, a group of graduate students in a
clinical psychology Ph.D. program were presented with an ethical vignette in which a trainee’s
religious values led him or her to seek to refer out a gay client (see the appendix). The students
were asked for their reactions and practical suggestions for how to handle the situation. Selected
examples of their statements and suggestions are presented to frame a discussion of how training
programs might enact policy to address this issue in an effective, sensitive, and nonthreatening
manner for psychologists in training.
Professional psychology training programs are currently facing a critical ethical dilemma and
increasing legal challenges surrounding how to address conflicts between the personal values

Correspondence should be addressed to Christine M. Paprocki, Department of Psychology, University of North

Carolina at Chapel Hill, CB# 3270 (Davie Hall), Chapel Hill, NC 27599. E-mail: paprocki@unc.edu
 280 PAPROCKI

and beliefs of trainees and characteristics of the clients they serve through applied training
experiences. In recent years, this complex and often contentious issue has extended beyond our
own field and into the legal arena as reflected in several key court cases. For example, in 2009,
a student enrolled in Eastern Michigan University’s (EMU) graduate-level counseling program
requested that a client assigned to her be referred to another counseling student because the client
was in a same-sex relationship. The counseling student, Julea Ward, had stated that her faith
“prohibited her from ‘affirming’ or ‘validating’ the ‘homosexual behavior’ of counseling clients”
(Ward v. Polite, 2012, p. 3). Although the client was referred as she had requested, Ward’s request
initiated a faculty review of her capacity to continue in the counseling program, as her behavior
was seen by faculty as being in violation of the American Counseling Association’s code of
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ethics, which bars discrimination based on sexual orientation. As a result of this review, Ward
was expelled from the program. Subsequently, Ward brought legal suit against EMU, claiming
her First Amendment rights of free speech and free exercise of religion were violated. A district
court initially awarded summary judgment in favor of EMU, but this decision was subsequently
reversed by an appeals court. The litigation was recently resolved with a $75,000 settlement paid
to Ward, so it will not continue to a jury trial.
The details and legal ramifications of this case and another case centering around similar issues
(Keeton v. Anderson-Wiley, 2011) are expertly described in a recently published article (Behnke,
2012), one piece in a series in Training and Education in Professional Psychology exhorting our
field to attend to this dilemma within training programs before the legal system renders nuanced
discussion among professional training program faculty of how it should be handled a moot point
(Behnke, 2012; Bieschke & Mintz, 2012; Forrest, 2012). For example, in Arizona, a law was
enacted stating that training programs
shall not discipline or discriminate against a student in a counseling, social work, or psychology
program because the student refuses to counsel a client about goals that conflict with the student’s
sincerely held religious belief if the student consults with the supervising instructor or professor to
determine the proper course of action to avoid harm to the client. (HB 2565)

Similar laws, termed “conscience clauses,” have been proposed in Michigan and Nebraska and
may limit what actions program faculty might choose to implement in response to such cases.
It is important to examine whether the values-based referrals that result from such laws can be
considered ethical under our own professional code of conduct.

CAN REFERRALS BASED ON DEMOGRAPHIC CHARACTERISTICS BE ETHICALLY

APPROPRIATE?

At the core of this issue is the concept of referral, and when it is acceptable or recommended to
refer a patient to another provider. The Ethics Code states (2.01b):
Where scientific or professional knowledge in the discipline of psychology establishes that an under-
standing of factors associated with age, gender, gender identity, race, ethnicity, culture, national
origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effec-
tive implementation of their services . . . psychologists have or obtain the training . . . necessary to
ensure the competence of their services or they make appropriate referrals. (APA, 2010, p. 5)

In examining the final words of this standard, it would appear that Julea Ward’s request for refer-
ral when assigned a client in a same-sex relationship may be ethically defensible. However, it
 TRAINEE PERSPECTIVES ON VALUES CONFLICTS 281

has been argued (Shiles, 2009) that this standard conflicts with Standard 3.01, which states that
psychologists cannot discriminate based on the demographic characteristics just listed, and with
aspirational principle D, Justice, which entitles all persons equitable access to psychologists’ ser-
vices. Furthermore, the APA has released guidelines asserting that psychologists should aspire to
be respectful and knowledgeable about same-sex relationships (APA, 2012), and to be multicul-
turally aware in their practice (APA, 2003). These ethical standards and guidelines raise a series
of challenging questions in the context of training: When is a referral an appropriate response to
a lack of competence to work with a certain patient, versus discrimination based upon a demo-
graphic characteristic? Does it make a difference if the clinician is a trainee, as opposed to a
licensed psychologist in practice? What if the trainee’s lack of competence is based on their
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intentional avoidance of learning to work with an identified group because of personal values and
beliefs?
In its introduction the Ethics Code provides some guidance on how to interpret its use of
modifiers (e.g., reasonably, appropriate, potentially):

The modifiers used in some of the standards of this Ethics Code . . . are included in the standards
when they would (1) allow professional judgment on the part of psychologists, (2) eliminate injustice
or inequality that would occur without the modifier [emphasis added], (3) ensure applicability across
the broad range of activities conducted by psychologists, or (4) guard against a set of rigid rules that
might be quickly outdated. (APA, 2010, p. 2)

In Standard 2.01b, the wording is that “appropriate” referrals can be made. Given this wording, it
is reasonable to assume that in some cases referring out based on a demographic characteristic is
appropriate, and in other cases it is inappropriate. Although this is the core issue under contention
in the legal cases, it seems important to assert that point. Shiles (2009) discussed how the language
of the Ethics Code might lead to psychologists always choosing to refer out rather than gaining
the competence to work with certain demographic groups: “As it is currently worded, the either-
or language of Standard 2.01 may be interpreted as allowing psychologists the opportunity to
do the least amount of work necessary, providing a potential loophole to allow discriminatory
practices in the field of psychology” (Shiles, 2009, p. 147).
The issue of whether a referral based on a demographic characteristic is discriminatory
becomes more complex when it is being made due to personal or religious beliefs of the prac-
titioner, as the question of whether not allowing such a referral could be considered religious
discrimination against the practitioner arises. Such a complex situation escalated into a legal case
for a marriage and family counselor, Sandra Bruff, who was employed by a group practice in
Mississippi (Bruff v. North Mississippi Health Services, Inc., 2001). Bruff contended that her
religious beliefs would not allow her to counsel homosexual clients on relationship-related topics
and that she considered it her right to refer such cases to others in the practice. After attempting
to accommodate Bruff with another position in which such conflicts were less likely to occur, she
was eventually terminated from employment when no such position could be found. She sued the
group practice, claiming she was discriminated against because of her religion. An appeals court
ruled in favor of the defendants, finding that Bruff’s request to refer all homosexual clients desir-
ing counsel on certain topics would create an undue hardship on the group practice. This case
demonstrates some of the practical and logistic complexities of such values-conflict based refer-
rals and that asking an employer to accommodate such referrals may not be a legally defensible
position.
 282 PAPROCKI

Perhaps a time when a referral based on a demographic characteristic like sexual orientation
might be appropriate could be a case in which the clinician has not yet gained the necessary
competence to work with a certain client but is currently in the process of doing so—for example,
graduate student therapists struggling to adequately resolve a conflict between their personal
beliefs and their capacity to provide effective clinical services. Even in such cases, however,
perhaps referral should be seen as an option to consider only when there is concern that the
trainee’s services could be harmful to the client, that is, when there is a concern about lack of
competence rather than simply a lack of comfort in seeing a particular client, as our ethics code
requires that we take reasonable steps to avoid harming patients (Standard 3.04; APA, 2010,
p. 6). In the following sections, possible responses to this situation within a training context are
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discussed, first using a developmental theoretical framework to address the growth of ethical
awareness in trainees and second presenting trainee perspectives on this issue through a selected
sample of their own voices.

BECOMING AN ETHICALLY AWARE PSYCHOLOGIST

Within many graduate training programs in psychology, trainees are given early exposure to the
ethical guidelines of the profession (e.g., courses requiring study of the Ethics Code). Some
of the core ethical skills that psychologists develop over time include increasing awareness of
ethical issues, developing ethical reasoning skills, attaining the responsibility to act ethically, and
developing tolerance for ethical ambiguity (Kitchener, 1986). However, such skills cannot be
developed overnight, or within the context of a single course. Some psychologists with expertise
in ethics training have advocated for an “acculturation model” of gaining ethical competence,
likening it to becoming familiar with the social rules and moral structure of a foreign culture
(Bashe, Anderson, Handelsman, & Klevansky, 2007). Such a theoretical model is highly relevant
to the issue under discussion in the current article, as it suggests that conflicts in values (e.g.,
between trainees’ and clients’ values, or between trainees’ and supervisors’ values) are not only
common but a natural part of the development of an ethically aware psychologist. Bashe et al.
(2007) described different acculturation strategies that can occur: separation, in which trainees
operate using mostly their own personal values when making professional decisions; assimilation,
in which trainees rely mostly on the values set out by the profession (e.g., the APA Ethics Code);
or integration, in which trainees are able to hold both their own personal values (whether based
in family background, prior experience, religion, or culture) and the values of the profession
simultaneously, and can tolerate discrepancies between the two. To reach a state of integration
between personal and professional values is a process that takes a considerable amount of time
and self-reflection—for some this process might be more of a struggle than for others, depending
on the degree of discrepancy between these two sets of values.
Although introductory courses in ethical practice are often the first formal steps for trainees in
the development of their understanding of professional values, training directors and supervisors
should continually be seeking out creative and practical opportunities to facilitate trainees’ growth
in this area. For example, trainees should be encouraged (through courses or through one-on-one
supervisors) to increase their awareness of their own values and beliefs and how they might play
into their work with clients. This could be done through a variety of outlets: personal explo-
ration, journaling, coursework, or perhaps peer groups led by a postdoctoral fellow or advanced
 TRAINEE PERSPECTIVES ON VALUES CONFLICTS 283

graduate student to discuss issues such as values conflicts in a setting that would perhaps feel
less evaluative than if it were administered by a professor. Clinical practicum supervisors play
a key role in this process of ethical development as well, as they are often the first people who
will be aware of in vivo ethical dilemmas or values conflicts encountered by trainees in their
clinical practice. It is therefore important that supervisors of trainees are adequately experienced
and trained themselves in ways to skillfully handle values conflicts when they arise. Although
this is currently shifting somewhat, many supervisors have not actually received formal train-
ing in supervision, and rather “learn on the job.” Formally training supervisors through courses
or workshops that could incorporate discussions, demonstrations, and role-plays of mentoring
trainees who encounter sensitive values conflicts could be an important strategy moving forward.
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Further complicating this developmental process is the at-times ambiguous boundary that
is drawn between our personal and professional lives as psychologists (or as psychologists-in-
training). If one attends a church where it is preached that homosexuality is a sin, but then
in a professional role one is taught to be affirming of a client’s same-sex relationship, that
can understandably create a great deal of discomfort and cognitive dissonance, likely in both
one’s personal and professional lives. It has been argued that it is difficult to separate the per-
sonal and professional, and that these two domains are often entangled to an extent that this
distinction can at times lose practical meaning (Pipes, Holstein, & Aguirre, 2005). Although
the Ethics Code clearly states that its guidelines are for professional and not personal behavior,
Pipes et al. (2005) advocate for psychologists to use its aspirational principles (Beneficence and
Nonmaleficence, Fidelity and Responsibility, Integrity, Justice, Respect for People’s Rights and
Dignity) as a guide for personal behavior as well. These basic principles, which are in fact sim-
ilar to the core doctrine of many religions, can serve as a guide when conflict arises between
the more detailed requirements of professional values (e.g., enforceable ethical standards) and
personal values (e.g., specific religious teachings). Having the skill and insight to work through
such conflicts demonstrate a trainee’s advanced capacity for ethical reasoning and tolerance of
ambiguity.
Some psychologists have advocated for the identification of core values or dispositions that
are central to our field, and then to screen for such values in applicants to graduate training
programs. For example, such values as being respectful of differences, open and flexible to new
ideas, curious and willing to learn, and being self-aware and open to introspection have been
described as being important for psychologists to possess or to develop (Winterowd, Adams,
Miville, & Mintz, 2009). It is difficult to assess the degree of genuineness of these values in
applicants, however, as those under evaluation for admission into a psychology training program
are unlikely to admit to being rigid, close-minded, or unwilling to self-reflect. In 2009, a series of
articles was published in a special addition of The Counseling Psychologist, addressing the issue
of values conflicts within psychology training programs and how to ameliorate problems that can
arise (such as what happened in the Julea Ward case) through open disclosure of a professional
values statement (see Mintz & Bieschke, 2009, for an introduction to this series). The values
statement itself, endorsed by the Council of Counseling Psychology Training Programs (CCPTP),
describes the importance of learning to work with clients from diverse backgrounds who may hold
values and have beliefs different from that of the trainee therapist. It explicitly states that “both
trainers and trainees are expected to demonstrate a willingness to examine their personal values
and to acquire and utilize professionally relevant knowledge and skills regardless of their beliefs,
attitudes, and values” (CCPTP, 2009, p. 642).
 284 PAPROCKI

In the series of articles introducing the values statement, it is emphasized that it is important
to be explicit and provide full disclosure about diversity training goals to applicants consider-
ing entering a training program, and to again provide access to the values statements at new
student orientations and early on in the training process. In that way, students are not caught off-
guard when they find they are expected to work with and be affirming of clients who differ from
themselves—rather, this would be known in advance to be a core component of training. Having a
uniform, clearly stated policy upfront not only is beneficial in that it allows students to anticipate
what will be expected of them, but also may allow universities to protect themselves against legal
challenges. Within the appeal court’s ruling in the Ward case, a prior case is referenced in which
a veterinary student had refused to operate on live animals (Kissinger v. Board of Trustees of Ohio
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State University, 1993). In this case, the student’s suit was rejected, because the veterinary pro-
gram had very clear guidelines that students must complete the course in which vivisection was
a requirement in order to graduate. This requirement was applied across the board to all students,
and it was made clear from very early on in the program, as there was a statement on students’
admission acceptance forms that “objection to the use of live animals will not be grounds for
excuse from class.” Clarity and upfront transparency of guidelines would likely also be useful for
our own field, and furthermore they could gain power if they were included within an explicit and
legally defensible profession-wide statement that would outline the core competencies inherent
to training in professional psychology.
Thus far, we have discussed some of the ethical quandaries, theoretical frameworks, and legal
issues relevant to the primary focus of this article—how to address conflicts between trainee
values and the provision of care to clients with whom the trainee feels incompatible. In the fol-
lowing section, the discussion turns to the perspective of current trainees. How would they react
when faced with this situation? What are some of their suggestions, as they currently embody this
therapist-in-training role? Direct quotations from interviews with trainees are used to help frame
a discussion of what might be done pragmatically to help guide trainees through the process of
learning to be effective therapists with clients who are very different from themselves, and with
whom they might feel quite uncomfortable at times.

TRAINEE PERSPECTIVES

To obtain trainee perspectives on this issue, seven graduate students in a clinical psychology
Ph.D. program were individually interviewed. The seven students volunteered to participate in
the project after an e-mail was sent out through the clinical psychology graduate student e-mail
server, so they were not randomly selected; however, to obtain a broad developmental spectrum,
students were chosen from all training years of the program, ranging from a 1st-year student who
had not yet begun clinical work, to students in their 5th year of graduate training. All interviews
were audio recorded and transcribed in order to obtain exact quotes, and all students gave their
permission to be anonymously quoted in this article. Each student was shown a vignette repre-
senting an ethical dilemma in which a supervisor at a counseling center internship must decide
whether to honor the referral request of an intern with long-held religious beliefs who fears he or
she would be ineffective working with a patient who is in the midst of coming out as gay (see the
appendix for complete vignette). The graduate students described their reactions to this ethical
dilemma, offered suggestions on what could practically be done, and described some of their own
 TRAINEE PERSPECTIVES ON VALUES CONFLICTS 285

TABLE 1
Summary of Themes and Practical Suggestions

Common Themes Practical Suggestions From Trainees

Prioritize client well-being (i.e., citing principle of Consultation with psychologists in the community who
Beneficence and Nonmaleficence) share beliefs with the student struggling with a values
conflict
Distinguish between discomfort and Graded exposure through role-plays, demonstrations, and
impairment/incompetence as a result of values conflict cotherapy experiences

Traits of an effective psychologist: openness, willingness, Increase supervision (e.g., closer monitoring of session
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flexibility recordings, more frequent meetings)

Distinguish between discrimination and appropriate Peer group discussions of a variety of values conflicts
referral/reassignment (e.g., religious beliefs conflicting with treating an
LGBT client, feminist values conflicting with treating a
client who makes sexist comments)
Preserve trainees’ rights to their own personal and religious Help supervisees to develop the skills to hold conflicting
beliefs and values attitudes/values simultaneously (e.g., using techniques
from Dialectical Behavior Therapy)
Importance of an encouraging and safe supervision Consultation with partners in the religious community
atmosphere, especially when sensitive values conflicts who can offer insight/perspective on the student’s
arise values conflict

Note. LGBT = lesbian, gay, bisexual, transgender.

values conflicts with clients (see Table 1 for summary of themes and practical suggestions). This
was not intended to be a formal qualitative study. Rather, these conversations are used here to
frame a discussion of the ethical tensions that trainees most readily identified as relevant to this
situation, as well as their practical suggestions for how supervisors can help trainees facing such
values conflicts.
All of the students interviewed brought up concerns about the well-being of the client: “My
initial reaction is that the intern would do more harm in trying to treat someone they aren’t able to
be fully supportive of . . . especially because it’s a client who specifically wants to work around
issues of coming out” (Anonymous, November 19, 2012). Many students expressed discomfort
with the idea of the “quiet transfer” however, and struggled with knowing when it would be in the
client’s best interest to refer out, versus whether the intern might be able to see this client under
close supervision. They questioned whether the intern’s internal beliefs might somehow “leak
through” and be evident to the client: “I would worry not just about what the therapist is say-
ing, but also about their facial expressions and non-verbal behavior and if they’re coming across
as unsupportive, even if they’re saying the things they should say” (Anonymous, November 19,
2012). Several students cited the principle of Beneficence and Nonmaleficence as a primary con-
cern in this situation, stating that they did not want therapy to be an invalidating and possibly
harmful experience for this client. Indeed, research on common factors that are associated with
successful therapy across a variety of therapeutic modalities has shown that a sense of trust and
warm regard within the therapeutic relationship are of central importance (Sprenkle & Blow,
2004; Wampold, 2001), and one might wonder whether it is possible to develop rapport when the
therapist is facing such a conflict.
 286 PAPROCKI

Another broad theme that emerged is the importance of distinguishing discomfort from incom-
petence, and that this is a key distinction in determining whether the referral request should be
granted. Especially interesting to note is that discomfort was described as a common experience
for therapists-in-training, and it was emphasized that this wouldn’t be an acceptable reason not to
see a client:

I don’t think I have the right to turn someone away . . . just because I disagree with them, or just
because they are saying something that’s making me deeply uncomfortable. It’s probably something
I would want to seek consultation about . . . in terms of how to hold my own beliefs and work with
them in an effective way and still keep their best interests in mind, but I would like to think I would
be able to do that. (Anonymous, November 2, 2012)
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Discomfort was repeatedly described as simply part of the training experience for therapists,
especially when learning to treat a new presenting issue, or a client from a very different back-
ground for the first time. One therapist early in training explained, “When you are first starting,
you’re building your confidence and learning at the same time, you’re going to go in feeling
unprepared no matter how much you prepare . . . it feels a little bit like jumping off a cliff”
(Anonymous, November 19, 2012). Although of course the values conflict situation presented in
the ethical vignette includes additional complexities, there are in fact some salient parallels to
what students may experience in their early therapy experiences, in terms of feeling in over their
heads. However, despite the nervousness and discomfort, most beginning therapists are still able
to build effective therapeutic relationships with their clients.
Within the context of these conversations, students described examples of more and less subtle
values conflicts they experienced with their own clients, and how they dealt with them, sometimes
effectively, and sometimes with a sense of having erred. For example, several students described
highly valuing autonomy and individualism, and how they had to increase their awareness of
these values when working with someone with more collectivist values. Another student who
identified herself as being from a culture that highly values the family system caught herself at
times querying her patients about family issues or explanations when sometimes that was not a
direction the client felt was very central. A student doing family therapy became aware that she
highly valued the idea of “sticking it out and fighting for” a marriage, whereas one of her clients
did not share this belief. All of these examples provide support for the idea that therapists-in-
training are able to tolerate differences between their own sincerely held beliefs and those of their
clients, in the context of developing a supportive therapeutic relationship. In fact, many students
expressed gratitude that they had experienced such conflicts while still in training, so they could
gain insight on how to handle these situations from peers and supervisors.
In responding to the vignette, many of the students considered certain qualities that a psychol-
ogist must possess to be effective (or, alternatively, certain traits that might prevent someone from
being effective in the profession). A key trait that was discussed by five of the graduate students
was “willingness” or “openness.” If trainees adhered to beliefs and rules more rigidly, that was
seen as a warning sign that perhaps they would not be as effective:

If I were supervising someone and they were less flexible, more rigid in their therapeutic style, I would
have concerns about them becoming an all-around competent therapist more generally. I think part of
being a good therapist is being able to be flexible, being able to see things through all sorts of other
people’s eyes as much as possible. (Anonymous, November 2, 2012)
 TRAINEE PERSPECTIVES ON VALUES CONFLICTS 287

This idea of using certain traits such as openness or flexibility to identify people who might be a
good match for the profession has been argued by others invested in this issue (Winterowd et al.,
2009). The students further emphasized that when entering a training program, you are making a
deliberate choice to open yourself to new experiences and that to avoid or shut down that process
would potentially limit a critical opportunity for professional development.
Another broad theme that emerged was the question of whether the requested referral could
be seen as discrimination, or as a violation of the Ethics Code principle of justice. Students
distinguished between referring out because a presenting problem fell outside of a provider’s
realm of expertise, versus referring out based on a demographic characteristic:
If you feel that the person coming to you could get better services elsewhere then it is highly ethical
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to refer, but then at the same time I think that referring exclusively on demographic variables becomes
a concern, because then it starts to look a lot more like discrimination. . . . Let’s say you’re an expert
in treating anxiety disorders, and someone comes to you with panic disorder, and you say “Oh, but
you’re gay? That’s not my area of expertise, I need to refer you out.” I don’t think that’s legitimate.
(Anonymous, November 2, 2012)

Students also expressed concern about the pragmatics of how such a referral would work. What
if the patient’s sexual orientation was not discovered until several sessions into treatment? Then
a “quiet transfer” as described in the vignette would no longer be viable. They speculated that
this would likely be harmful to the client, and to the perception of psychotherapy overall, should
it be made clear to the patient that he or she was being referred out exclusively because of sexual
orientation. One argument made in the Julea Ward case was that Ward expressed willingness
to see homosexual clients if the treatment would not involve a discussion of their same-sex
relationships—so, in the previous example from the graduate student, it could be argued that
someone might agree to treat the panic disorder, so long as any relationship issues were kept
out of treatment. However, the centrality of close relationships in most people’s lives makes this
requirement problematic: “In effect, if a counselor refuses to counsel a homosexual client on
relationship issues, the counselor is refusing to treat homosexual clients” (Hermann & Herlihy,
2006).
The students struggled at times with balancing adherence to the principle of justice and not
wanting to invalidate or punish the intern for deeply held religious beliefs. They also expressed
concern that this intern could be discriminated against for his or her religious beliefs by the staff of
the counseling center or by peers. The more advanced students interviewed more readily took on
the perspective of a supervisor and discussed the importance of validating this intern for bringing
up the dilemma in supervision. One advanced student distinguished between using supervision
to discuss how to effectively treat the patient given the intern’s beliefs versus trying to push the
intern to alter her beliefs: “If people are telling her that her belief is not okay to have, or telling
her that she shouldn’t believe homosexuality is a sin, I don’t think that’s fair to say that to her”
(Anonymous, November 5, 2012).
Students expressed concern that if the staff of the counseling center was very liberal and per-
haps intolerant of the intern’s religious beliefs, it might turn into a “witch-hunt” against the intern
and feel unsafe and unsupportive. These concerns are perhaps not totally unwarranted given sur-
veys showing that mental health professionals (and particularly those within academia) are less
likely to describe themselves as religious when compared to the general population and that mul-
ticultural courses within training programs often spend little time detailing religious diversity
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and interventions (for review, see Hage, 2006). Religion has been described as a “blind spot” in
training, especially given the high rates of religious affiliation among the general population in
the United States. If the intern’s supervisor or the counseling center staff were to respond imme-
diately in an evaluative or punitive manner, students indicated that this would likely prevent any
learning or growth from taking place: “If you’re trying to gain a competency, then you can really
only do that if you feel safe, and if it’s a situation where you think that everyone is thinking
poorly of your values, that would probably feel pretty unsafe” (Anonymous, November 5, 2012).
This concern about students feeling safe and supported within the supervision context has been
echoed by other psychologists writing about this issue, who speculate whether it is possible for
students to address values conflicts effectively when being evaluated by a group of people who
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likely do not share or support their values:

. . .can we truly expect our students to engage in genuine self-reflection while under conditions of
evaluation if the clear expectation is that they change their beliefs and attitudes in a direction that
closely parallels our own and the prevailing attitudes of counseling psychology, which is, itself, a
culture-bound discipline? (McCutcheon & Imel, 2009, pp. 764–765)

Whether it is possible for trainees to work effectively and supportively with clients whose behav-
ior is viewed as sinful, without suggesting that they challenge or alter these views, is in fact an
important empirical question that deserves further investigation. However, some degree of empa-
thy and openness is likely required from both trainees and their supervisors when dealing with
such values conflicts in order for there to be any potential for a positive outcome.
Overall, students struggled with the practical challenges inherent in working with the intern
in a way that would be seen as validating, helpful, and promoting growth while also ensuring
that the message was not that the intern needed to change his or her own religious beliefs. One
student stated that she would want to bring in some outside help as a supervisor, seeing if she
could “find a therapist in the community who has these same religious beliefs and who has been
able to work with LGBT clients successfully and in an affirming way” (Anonymous, November 7,
2012). Consulting with someone who shares the intern’s beliefs would likely help the intern to
feel less isolated and perhaps aid in increasing the complexity of his or her thinking about the
issue. In addition to identifying colleagues to consult with, another avenue could be to consult
with clergy or religious leaders who would be amenable to discussing some of these conflicts with
the trainee (with the trainee’s permission, of course). This is perhaps an underutilized strategy
within a therapeutic context and may be useful within the supervision context as well when such
situations arise (Benes, Walsh, McMinn, Dominguez, & Aikins, 2000; McMinn, Aikins, & Lish,
2003).
Another practical strategy that the students suggested, instead of the “quiet transfer” requested
by the intern, was a graded exposure approach. The idea of cotherapy was mentioned by several
of the students, either with the supervisor as cotherapist or with a peer from the program. New
therapists described how this model has served as a “scaffold” for them at times when faced with
difficult clinical situations: “What was helpful for me was that there were moments when I didn’t
know what to do, so it was nice to be able to see how [my co-therapist] handled it, and then
talk to her about it afterwards” (Anonymous, November 19, 2012). Students described how this
model could be used to address concerns about competence, as it would be a way for both the
intern and the supervisor to “test the waters” and see if the intern would eventually be ready to
see the patient on his or her own, and then the cotherapist could be phased out. Alternatively, if
major issues related to competence were noted, the intern could be taken off the case. If the idea
 TRAINEE PERSPECTIVES ON VALUES CONFLICTS 289

of cotherapy was still too far up the patient’s “hierarchy,” if the situation is to be framed using
an exposure model, then other suggestions the students made included role-plays and reviewing
therapy tapes until more confidence was established. Of course, for any of these strategies to be
viable, the intern would first have to possess a basic level of willingness to work on this as an
area of competency.
If the intern was going to see the patient individually (as opposed to with a cotherapist), the
students had suggestions for the supervisor to monitor the case more closely than he or she might
otherwise. For example, “My first reaction would be to have the intern work with the client, but
maybe with me observing through a one-way mirror or listening to tapes as soon as the session
has ended” (Anonymous, November 5, 2012). In this process, again some students emphasized
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the importance of distinguishing between whether the therapist was simply uncomfortable, or if
there was a lack of competence being overtly displayed, and using that as the primary criterion
for determining whether to have another therapist take over the case. However, if the transfer was
necessary, the intern would then be supervised in appropriate professional development activities
to build his or her competence in this area, rather than simply moving on as if this issue had not
arisen.
Several students suggested that the supervisor could help the intern by connecting the client’s
presenting concern of coming out, which likely feels foreign and uncomfortable for the intern,
to something more familiar or universal: “If the intern were able to focus on the tough transi-
tion that this guy was going through . . . I think that would be a great way to help her develop
that competency” (Anonymous, November 2, 2012). Another student described other presenting
problems that had been challenging for her, and how her supervisor was able to link it to other
cases which were different on the surface, but with similar underlying themes. These strategies
could help to activate some higher order values that might be common to both the intern’s reli-
gious belief system and to the professional values of psychology. Within the ethical acculturation
model (Bashe et al., 2007), this could aid in the process of taking an integrated approach to eth-
ical reasoning, as opposed to feeling forced into accepting professional values (assimilation) or
rejecting professional values in favor of personal ones (separation).

CONCLUSIONS AND RECOMMENDATIONS

As stated at the outset of this article, this issue is of critical importance given that it has become
the focus of action by legislative and judicial bodies in this country. As Bieschke and Mintz
(2012) asserted,

What is becoming increasingly clear is that the courts and legislature are beginning to dictate the
training of professional psychologists. Indeed, we contend that failure to act swiftly and collectively
as a field is tantamount to yielding ownership of the training of new professionals within the field of
psychology. (p. 198)

A group has been established—the APA Working Group on Restrictions Affecting Diversity
Training in Graduate Education (2013)—to discuss this issue. This group recently drafted a state-
ment to represent the position that trainees must demonstrate competence in treating diverse
individuals regardless of complications that may arise due to their own worldviews or beliefs.
One goal of the current article is to raise awareness about this issue in the field more broadly
and to endorse this position statement. Another goal is to provide a forum for the perspectives of
 290 PAPROCKI

trainees on this issue, as their voices have not been heard outside of the few who have been the
subject of legal action. Trainees are acutely aware of the time and energy it takes to effectively
manage a variety of challenging clinical situations in training. They are also highly aware of the
power that supervisors and trainers can have over this process, which can either feel supportive
and validating or unsupportive and threatening, depending on how it is approached.
In summarizing the trainee perspectives represented here, several recommendations can be
made to enhance how this issue can be practically handled within a training context. First, it is
vital that supervisors validate trainees for discussing such values conflicts within a supervision
session, as it is likely difficult to raise them. It is also necessary to communicate respect for
trainees’ rights to their own religious beliefs, even if the supervisor feels such beliefs are mis-
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guided, contrary to their own beliefs, or perhaps even abhorrent. Supervisors and clinical faculty
should express humility when blind spots surrounding their competence in dealing with religious
diversity might be an issue and seek consultation from outside psychologists or religious lead-
ers when it could prove valuable. Such consultation would also serve to communicate respect
for the trainee’s religious beliefs and help him or her to feel less isolated within an environment
that might not be very welcoming towards such beliefs. The trainees interviewed also described
some practical strategies for helping a trainee with a values conflict to work with the client in
question, for example: using closer supervision, cotherapy, or role-plays and observation of ther-
apy sessions, as opposed to “letting them off the hook” and referring the client to someone else.
However, they also emphasized that for any of these strategies to be implemented, the trainee
must have the first essential ingredient of willingness to even begin the process of working on
this area of competency. Finally, trainees made it clear that discomfort and conflicts in values are
simply part of the learning process in becoming a therapist and that these conflicts become easier
to handle with exposure and practice.
To conclude, it should be stated that the training process takes time and that it cannot be
rushed or forced, particularly when trainees experience conflicts between deeply held values
and the central tenets of our profession. As training programs develop strategies for helping
trainees work through these issues, it will be important to take an empirical approach to determin-
ing which strategies might be most effective. Researchers interested in training and supervision
within psychology should take this on directly, to determine if certain strategies (e.g., role-plays,
encouraging self-reflection, exposure, cotherapy, etc.) produce more effective results than others
for trainees struggling with values conflicts. Careful attention should be paid to how the presence
of a values conflict psychologically impacts trainees in addition to attending to how it impacts the
work they are doing as therapists. Eliciting the opinions of current trainees on this matter through
broader surveys or more formal qualitative research could prove to be a fruitful avenue for this line
of empirical inquiry. Finally, it should be emphasized that communicating respect and validating
the difficulty of values conflicts will likely go a long way towards creating a training environment
that feels safe, nondiscriminatory, and encourages trainees to find ways of integrating their own
beliefs with the ethical mandates of our profession.

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APPENDIX: ETHICAL VIGNETTE1

You are the primary supervisor of a new intern who comes and urgently asks to speak to you
in confidence. The intern tells you that when they applied to the internship program they truly
thought that they could endorse the program’s clearly articulated value statement that includes
a commitment to affirming multicultural diversity. The intern reports to you that throughout
graduate training they worked hard to challenge long-held religious beliefs learned from their
family’s church that “homosexuality is a sin against god and nature”, however they had not actu-
ally worked closely with an LGBT client in their limited practicum training in graduate school.
Therefore, this issue had only come up as an intellectual consideration. Now the intern has been
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assigned to see an 18yo male first year college student who wants to come out to friends and
family as gay. The client also wants to begin dating for the first time. The intern reveals feeling
extremely uncomfortable hearing about this client’s thoughts and experiences and isn’t sure that
they can be fully supportive of the client if they work together. The intern understands counseling
center policy, but pleads with you to quietly transfer the client and not tell the other staff as the
intern anticipates that the very liberal counseling center staff would respond to this dilemma in a
negative or discriminatory manner.
• What would your personal/internal reaction be?
• How would you respond?
• What are the ethical, legal and training issues?
• What are your options?
• What would you do?

1 Printed with permission of the vignette author, Erica H. Wise.