Inclusive Practices for Assessing Relationship Diversity on Demographic Forms
By Rachel Anne Kieran, Psy.D.
*This resource was created with the help of Dr. Jen Rafcz and the APA Division 44 Committee on Consensual Non-Monogamy, of which Dr. Kieran is a campaign co-lead.
Demographic Forms as Culturally Competent Care
In many cases, demographic and other intake forms represent the initial contact between clinician and client. Research on the importance of a strong alliance (in any approach) would suggest that using this opportunity to begin building rapport is a good idea (for example - Wienke Totura et al, 2018; Norcross & Wampold, 2018; Norcross & Lambert, 2018). Despite this, many forms ask only for “Marital Status” - a legal distinction that may have little meaning to an individual who has never married, or be experienced as a microaggression by someone unable to access the privilege of legal marriage (for example LGBTQIA+ individuals previous to the Supreme Court ruling on Ogberfell v. Hodges in 2015). Common options limit clients to selecting “single, married, divorced, widowed, or other.” Legality aside, many unmarried clients in long-term relationships report that responding “single” feels disingenuous given the importance of their relationship, while responding “married” also misrepresents their experience. In the case of consensually non-monogamous (CNM) clients, questions of “Marital Status” may be experienced as a marginalizing way to inquire about relationship status, often limiting clients to explanations that fail to capture their reality (various clients, personal communications; also Schechinger et al., 2018), and ultimately threatening the continuation of the clinical interaction.
Consensual non-monogamy (CNM) refers to relational agreements in which partners have sexual and/or romantic relationships with more than one person, and in which all partners involved are aware that multiple relationships are occurring. Research interest in this area has existed since a flurry of activity in the 1980s on “polyamory,” however the more inclusive term is used to reflect the diversity of experiences reported, including varieties of sexual, emotional, temporal, and situational exclusivity. Approximately 22% of Americans have been in a CNM relationship at some point in their life (Haupert et al, 2017a; Haupert et al, 2017b), and approximately 4%-5% are engaged in a CNM relationship at any given time (Levine et al, 2018; Rubin et al, 2014). It is clear that when looking at standard demographic forms this experience is easily overlooked, as it is often invisible unless made explicit, and not captured on standard questions of “Marital Status.”
The importance of demographic questions relating to sexual, gender and relationship diversity is manifold. In the first instance, there is the simple importance of recognizing the existence of a population in order to better understand their unique needs. In addition, research into healthcare engagement and outcomes has demonstrated that disparities exist in marginalized populations, highlighting the importance of recognition of these populations and assessment of their needs. This research also suggests that individuals are likely to avoid engaging with necessary healthcare when they are not free to share the realities of their lives - things like relationship status and gender identity (Alpers et al, 2013). Collecting demographic data on an expansive range of intersecting identities is important as this information enables scholars, policymakers, and the general public to advocate for improvements in health and social outcomes. In addition, assessing relationship diversity on demographic forms provides an opportunity for a site/clinician to signal that they are at least aware of CNM.
Current research suggests the need for more education and training for clinicians on this topic. Clinical research suggests that clients working with clinicians who are dismissive or pathologizing of relationship diversity damages alliance and jeopardizes the longevity of treatment; both correlates of poor mental health outcomes (Schechinger et al, 2018; Horvath & Luborsky, 1993; Martin et al., 2000). While certainly this research speaks to the need for competency related to CNM across the clinical experience, this is only possible if clients remain engaged past the initial contact. Contextual information is often used to assess a clinicians’s credibility, their competence, and by extension, their safety (Sue & Sue, 2015; Comas-Dias, 2012). Intake and demographic forms are one of the first pieces of contextual information that clients are presented with (often after viewing a website, but before setting foot in a clinician’s office) (Liang & Shepherd, 2020). With that in mind, the importance of using inclusion to create rapport on demographic forms is surely as important as in the initial in-person contact.
Developing Best Practices for Demographic Forms
Myself, Dr. Rafcz, and the Division 44 Committee on Consensual Non-Monogamy have been engaged in inquiry regarding how best to capture relationship diversity on demographic forms. Part of this has included research on the current practices of clinicians working with these populations (Kieran & Rafcz, in progress). The results of these inquiries included multiple themes that have informed these suggestions for best practice.
One of the major themes observed was a preference of allowing clients to freely self-identify their relationship status. While the presence of one open-response item is the ideal, we recognize that there are settings and systems (both workplaces and record-keeping) in which there is pressure for the clinician to sort patients into categories. Where categorical choices must be used, the best option is to include categories, but allow for a written response in each of these categories, which would allow for data collection, while also allowing for self-identification by the client. Having an open-response available in every category avoids the “othering” nature of having a write-in option available in only one box (often literally marked “Other”). These options for self-identification even within categorical choices make sense particularly as relationship diversity, and the terms associated with it, are fluid and not easily put in a single category, however, similar research on sexual orientation and gender identity found that a majority of individuals were able to select a category, even though these are seen as fluid (Ellis et al., 2018).
Where categorical choices or examples must be used, it is also important to avoid using terms that may be dated, or which may rapidly become so. Also, avoid terms which may be considered pathologizing or demeaning by some. A strong preference was expressed for using broad, standard terms (eg. “non-monogamous”) and then providing possible example terms. It is also important to avoid conflating relational identity with relationship status, as these may be different, and to avoid conflating either of these with sexual identity, or gender identity. More training on the wide range of diversity within all of these areas, but particularly relational diversity, is needed in clinical training programs and continuing education.
Given the public’s growing interest in CNM (Haupert et al., 2017; Moors, 2017), it is possible clients may have some knowledge about CNM, however we cannot assume that and should be ready to explain the presence of any question asked on our forms. In this case, as suggested by the Institute of Medicine (Alpers et al, 2013), we survey who our clients are so that we can better assess the needs of those groups and acquire the tools (skills and training) needed to provide better care for those groups. We have been able to do so with gender identity and sexual orientation, as noted above. It is time to expand this to include relationship identity, and to replace the exclusive and stigmatizing questions on “Marital Status.”
There is also a need for increased clinical training on CNM. Discussions of the diversity of relationships are not currently a part of most clinical training programs, and this is often an overlooked area of clinical development in continued education. This is especially important given the changing language and increased visibility of individuals who identify with some form of CNM. These themes are consistent with other research (Graham, 2014; Schechinger et al, 2018). We strongly believe training and education around CNM is necessary for clinicians today, and should include suggestions about how to assess relational diversity both on paper and in interviews. It will also help prevent the problem of conflating relationship diversity with gender identity or sexual orientation observed in this study.
Finally, it is important to proactively address potential client privacy concerns - with regard to relational status as well as all other information. Many respondents expressed concern regarding other staff (clinical and non-clinical) having access to data on demographic forms, and the potential for discrimination this may present. This can be avoided by including training on relational (and other areas of) diversity for all practice staff, not just clinicians. In addition, providing plain-language explanations of confidentiality and privacy policies (and how all staff interact with them) with initial paperwork is useful.
Suggestions for best practice
Informed by a qualitative and quantitative exploration of approaches used by clinicians working with CNM-identified individuals, as well as review of related literature, the following practices are suggested:
Open format: When possible, allow clients to freely self-identify, using open-response format questions. This allows for optimal self expression and the client to share with their clinician what language fits them best.
Relationship Identity/Structure: __________________________________________
(eg: monogamous, consensual non-monogamy, polyamorous, questioning, etc.)
Relationship Status: __________________________________________
(eg: partnered, single, dating, etc.)
If a client uses a label with which a clinician is unfamiliar, consider inquiring how the client understands that label and/or what it means to them.
Where categorical choices must be used, include a write-in option for each choice and an ‘other’ option in case the included terms do not best capture the experience of the client. This allows for accurate data collection while also allowing for self-identification by the client.
Avoid using terms that may be dated, or which may rapidly become soor . Also avoid terms which may be or considered , pathologizing, or demeaning by some. Use broad, standard terms (eg. “non-monogamous”) and then provide inclusive possible example terms.
Avoid conflating relationship identity/structure with relationship status, as these may be different. They are also distinct from sexual orientation and gender identity.
When it comes to relationships, I think of or identify myself as:
-Non-monogamous (Polyamorous, Open Relationship, etc.) ____________________________
-Other relationship structure/orientation _________
-Prefer not to answer __________________________
I would describe my current relationship status as:
-Other relationship status __________________
-Prefer not to answer ______________________
Additional training on the wide range of diversity within all of these areas, but particularly relationship diversity, is needed in clinical training programs and continuing education.
Use of the term "relationship counseling" or “partners counseling” is suggested instead of using “couples counseling.”
In light of societal stigma toward CNM, proactively address and/or recognize potential client privacy concerns with regard to relationship diversity as well as all other information disclosed. Plain-language explanations of confidentiality and privacy policies (including how all staff interact with client data/records) on initial paperwork is encouraged.
Prevalence data reveals that consensual non-monogamy is perhaps more common than assumed by many clinicians. It is reasonable to assume that some blame for this lack of knowledge may be attributed to the prevalence of demographic forms that fail to capture the complete picture of a client’s relational reality. While inclusion of relational diversity in clinical training programs will go a long way to help avoid these mistaken assumptions, responsibility must also fall onto those of us in practice. We must create both a literal and figurative space for CNM clients to safely self-identify. There is evidence to support the use of more inclusive forms in the history of treatment for both sexually and gender diverse populations, and useful advice from lessons learned in these efforts. There is also ideological support, emphasizing the importance of evidence based approaches to every population, whose needs we can only know when they are identified.
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