Psychotherapy Bulletin

Psychotherapy Bulletin

Clinical Impact Statement:This article provides information to mental health clinicians, clinicians in training, and those who educate and train them regarding the impact of the current political climate on multicultural competence, the therapy relationship, countertransference management, and ethics. Specific guidance and resources are provided to assist mental health clinicians and trainees in addressing these issues. Questions are posed to stimulate further discussion on this area of growing interest and concern among clinicians.

If, indeed, the personal is political and the political is personal, where does that leave psychotherapists—whose profession is intensely personal—when clients voice strong political views counter to ours or when their political stress resonates with our own sense of a rending of the civic and cultural fabric of the country? In the aftermath of one of the most contentious presidential elections in recent U.S. history, many of us have noted a marked increase in our clients’ expressions of anger, anxiety, and depression. At the same time, we have been challenged by managing our reactions to the election results and subsequent heightened societal tensions.

In the weeks surrounding the November 2016 election, many clients came to therapy fearful and angry about what the future would bring (Panning, 2017; Stosny, 2017), whereas others came in with joy, vindication, and excitement about a new direction for the country. According to a March 2017 survey (“New Study Shows,” 2017) more than half of Americans (59%) were anxious because of the November 2016 election results. Half (50%) of Americans were looking for ways to cope with the negative environment and more than a quarter (26%) were engaging in negative behavior such as drinking or smoking more often, eating unhealthily, or arguing with loved ones more frequently as a result of their election-induced anxiety. The months of acrimony since the inauguration have precluded a return to political or cultural normalcy. Instead, our citizenry has grown more polarized, with greater public visibility of extremist views (e.g., Charlottesville), a marked increase in civic activism and protest (e.g., the Women’s March), and a general sense of unease, anxiety, and fear. A Washington Post-University of Maryland poll conducted nine months into the new administration found that 7 in 10 Americans believe the current political divisions in the country are as least as severe as those during the Vietnam War and that the current climate likely represents a “new normal” rather than a temporary state (Wagner & Clement, 2017).

Psychological distress arising from the current sociopolitical tumult is being brought into the therapy session, and the factors informing this fraught clinical material are as diverse and nuanced as our clients. In keeping with the theme of difficult dialogues, we focus here on four of those factors: cultural competence as it relates to client and psychotherapist political identity, how political differences and similarities may affect the therapy relationship, managing countertransference related to political views, and ethical concerns. In this unprecedented time, we have as many questions as we do observations and insights. Our goal in writing this article is to contribute to the growing pool of resources and to stimulate further discussion.

Political Cultural Competence

Political analysts have noted that party or candidate affiliation has become a primary component of identity for many Americans, a phenomenon that psychotherapists may be unsure of how to address in session. The sense many individuals have of not being represented, not mattering, or not being heard by the governing class was reflected in J. D. Vance’s stark memoir, Hillbilly Elegy (2016), and the public response to it. The sense of being politically overlooked is believed to have formed the core of a backlash against perceived “identity politics” in the 2016 election.

Psychotherapist multicultural training has rightfully focused on ethnicity, age, gender identity, sexual orientation, nationality, ability, socioeconomic status, and religion as essential components of client and therapist identity. But few training programs address political affiliation as a component of culture or identity or how it may inform treatment or affect the therapy relationship. When clients bring differing political views into the therapy room, it can cause us unease, a sense of not knowing the way forward. Yet, as psychotherapists, we can and must enter the world of the other openly, curiously, and compassionately. Indeed, this is what multicultural understanding and competence rest upon. We have found that working with clients with political identities different from our own has engendered a deeper understanding of our clients’ issues as well as the factors that drove the 2016 election results. It requires us to bracket our views and our privilege and dive beneath political opinions contrary to our own to find the human being and the experiences at the source of these opinions. Working with difference helps us to grow in understanding and compassion. Outside of therapy, it is incumbent upon us to step outside our own political, cultural, and professional “bubbles” to gain awareness and knowledge of the cultural and political influences (e.g., news and social media) underpinning our clients’ intersecting identities and concerns.

Impact of Politics on the Therapy Relationship

Although many clients have readily brought into session their concerns about the current political climate, others may be unsure of the appropriateness of discussing such concerns or whether it is safe to do so. If anxiety about the country’s political state is a client’s primary presenting issue, we must cultivate a sense of relational safety. Some psychotherapists suggest opening up the topic for discussion from the outset of treatment, either via optional intake questions or an open letter placed in the waiting area stating the psychotherapist’s openness to concerns from anywhere on the political spectrum (Doherty, 2017).

Given an offer of openness, clients may expect reciprocity, which compels psychotherapists to consider how much of their own views they should make known. If a client tacitly or overtly asks for your political views, when is it appropriate to disclose them? General caveats are that self-disclosures should be clinically relevant and that the psychotherapist should not disclose about unresolved issues. If clients ask about our political views we should, as with any disclosure, consider their reasons for doing so, which presents an opportunity to process the therapy relationship. We may ask why it is important for the client to know and then carefully consider the response. Will it help the client to feel safer, closer, or more supported? Or, is it an attempt to enmesh with us or induce collusion on other issues? What was the status of the therapy relationship prior to the question and what are our own reasons for disclosing or not? Feeling our own unmanaged distress about the political climate may speak to not disclosing. On the other hand, is it fair to our clients not to disclose our beliefs and biases so that the client is informed about our values?

Even if a client does not ask about our views, the books on our shelves or artwork on our office walls can reveal our values without us speaking a word. Within the current climate of general cultural divisiveness and mistrust, political self-disclosures—whether overt or unwitting—can potentially lead to ruptures. How, then, to address such ruptures? Are the methods for repair different when divergent political views are at the root of the sundering?

Psychotherapists who in other situations might turn to immediacy to facilitate repair may feel there is risk of further damage with a politically induced rupture. If the client views the psychotherapist as an intractable other—as another source of political, public, and personal stress—how can the relationship be restored? If the therapy relationship is well established and the client has felt safe in the past, despite the discovery of “otherness,” we can use the differences to foster growth both in our clients and ourselves. A qualitative study (Williams & Levitt, 2007) on personal values in therapy indicated the majority of a sample of eminent psychotherapists viewed psychotherapy as inevitably values laden, that they attempted to remain aware of values in the therapy room, that they generally deferred to clients’ values, and that they encouraged clients to evaluate their values. By maintaining our empathic stance and providing space for clients to feel they are heard and their values understood, we can provide an opportunity to ease their anxieties and model a way for them to humanize the political “others” in their daily lives.

Managing Politically Based Countertransference

Although society has been growing increasingly polarized over the past two decades, the 2016 election was a tipping point for many. Until that point, unresolved anxiety about election results was not an obvious source of countertransference for most psychotherapists.

We as psychotherapists are as subject to the political climate as any member of society. In managing any countertransference, gaining awareness is the first step, specifically by recognizing our political hot button topics and the triggers for them. Are there particular topics that rile? Does denial of global warming or scientific methods in general set you off? Or are questions about voter fraud likely to be a focus of unresolved material? Whatever the issue, awareness that it is a trigger is important, as is understanding the underlying source of the countertransference.

Many of us have family members or friends across the political divide with whom we have broken or grown more distant over issues similar to those presented by clients. Understanding these complications helps us to manage behaviors in session and enables us to be more open to our clients’ beliefs. Consulting with colleagues or bringing the issue to peer supervision is obviously a useful resource. In addition, just as we have recommended that clients minimize their exposure to social media and newscasts, we may consider spending less time plugged into the negativity and divisiveness currently saturating all media.

Ethical Dilemmas

Perhaps the most perplexing aspects of the election fallout are ethical. Our role as psychotherapists is to help clients explore their values and beliefs and to use these values to help clients solve their problems. Yet the current climate and our clients’ responses to it present us with some ethical dilemmas. What do you do when a client states as fact something heard on talk radio or seen on social media that is verifiably false? What is our role in educating clients about politically related facts? Is this a question of identity or culture or is it evidence of the need for reality testing? If the client came in and stated something as true about something nonpolitical that you knew was untrue (e.g., the earth is flat; it is impossible for people to change), would your response be different?

As mental health professionals, we are charged with following a code of ethics. The American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (APA Code of Ethics; 2017) states that psychologists must exercise reasonable judgment and take precautions to ensure that their potential biases do not lead to misuse of their influence. We must try not to impose our political views on clients and we must respect their right of self-determination. Yet, psychologists are also charged in Principle E of the Code of Ethics to “not knowingly participate in or condone activities of others based upon such prejudices” as age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status (APA, 2017). Similarly, regarding personal values, Standard A.4.b of the 2014 Code of Ethics for the American Counseling Association (ACA) states,

Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.  

Thus, while we may not impose our own views, we must not condone others’ prejudicial activities. The dilemma arises when a client presents a bigoted view that is integral to the client’s political identity. There is an opportunity to explore the basis for such beliefs and to provide data from the client’s own experiences to counter these views, thus ideally enabling us to adhere to both seemingly conflicting principles. But we do not practice in an ideal world; we may be faced with the dilemma of a client’s intransigent bigotry or misogyny. If political views in session become irreconcilable, is it ethical to refer a client to another psychotherapist? Would it be unethical not to refer the client on? Only the individual psychotherapist can judge (or someone with whom you consult) whether these differences are enough to qualify as interfering with therapy.

Looking Forward

Our nation, our clients, and we ourselves have experienced profound changes in the past year that have propelled us into uncharted territory. Many of us have struggled to find a way forward not only clinically, but in our larger societal role as mental health professionals. Since the election, thousands of psychologists, psychiatrists, psychotherapists, and counselors have spoken out to question the president’s fitness for office and to express concern about the toll the political climate is taking on the mental health of our citizens (Karlamangla, 2017; Lee, 2017).

New resources and associations have developed to provide support around these issues. For example, Dr. William Doherty has founded an online association of psychotherapists with the mission to spread ways to practice therapy that address clients’ public stress, help individuals within their communities to maintain their values and emotional balance, and to engage publicly to resist antidemocratic ideologies and practices (https://citizenpsychotherapists.com). We can address the politically informed clinical needs of our clients by relying on such resources, as well as on our training and values, and by remaining open to change in ourselves. As the political turmoil continues, there will be further challenges in negotiating our professional roles and responsibilities in the public sphere and in navigating how these may integrate with clinical work. Looking to the future, if this is in fact our new normal, what is our responsibility with regard to political issues and speaking about them both to clients and in a public forum? As we engage in these difficult dialogues with our clients, it is also important to expand the dialogues among ourselves, in our training programs, and in our associations about best practices in this new era.

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Cite This Article

Spangler, P. T., Thompson, B. J., Vivino, B. L., & Wolf, J. A. (2017). Navigating the minefield of politics in the therapy session. Psychotherapy Bulletin, 52(4).

References

American Counseling Association. (2014). Code of ethics. Retrieved from https://www.counseling.org/resources/aca-code-of-ethics.pdf

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code/

Doherty, W. J. (2017). New opportunities for therapy in the age of Trump. In B. X. Lee (Ed.), The dangerous case of Donald Trump: 27 psychiatrists and mental health experts assess a President (pp. 235-243). New York, NY: St. Martin’s Press.

Karlamangla, S. (2017, February 21). Why psychotherapists are having such a hard time talking about Trump. Los Angeles Times. Retrieved from http://www.latimes.com/local/california/la-me-ln-trump-psychotherapists-20170223-story.html

Lee, B. X. (2017). The dangerous case of Donald Trump: 27 psychiatrists and mental health experts assess a President. New York, NY: St. Martin’s Press.

New study shows majority of Americans still suffer from election results anxiety asPresident’s 100th day draws near. (2017, April 20). Retrieved from https://www.caredash.com/press-release/nervous-nation.pdf

Panning, J. C. (2017). Trump anxiety disorder: The Trump effect on the mental health of half the nation and special populations. In B. X. Lee (Ed.), The dangerous case of Donald Trump: 27 psychiatrists and mental health experts assess a President (pp. 235-243). New York, NY: St. Martin’s Press.

Stosny, S. (2017, April 22). How to cope with Trump anxiety: There’s hope for a nervous nation. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/anger-in-the-age-entitlement/201704/how-cope-trump-anxiety

Vance, J. D. (2016). Hillbilly elegy: A memoir of a family and culture in crisis. New York, NY: Harper Collins.

Wagner, J., & Clement, S. (2017, October 28). “It’s just messed up”: Most say political divisions are as bad as in Vietnam War era, poll shows. The Washington Post. Retrieved from https://www.washingtonpost.com/politics/its-just-messed-up-most-say-political-divisions-are-as-bad-as-in-vietnam-era-poll-shows/2017/10/27/ad304f1a-b9b6-11e7-9e58-e6288544af98_story.html?utm_term=.781cac398b62

Williams, D. C., & Levitt, H. M. (2007). A qualitative investigation of eminent psychotherapists’ values within psychotherapy: Developing integrative principles for moment-to-moment psychotherapy practice. Journal of Psychotherapy Integration, 17(2), 159-184. http://dx.doi.org/10.1037/1053-0479.17.2.159

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