What do you say to a patient who endorses a racist or extreme view during a therapy session? What about someone who is determined to learn your political or religious affiliation, or someone who figures out who you voted for and sees that as a problem?
“Politics, especially in the past 5 years, has been so polarizing and so emotionally triggering for people,” said Nili Solomonov, PhD, an assistant professor of psychology in psychiatry at Weill Cornell Medicine in New York who has studied political disclosures in therapy. “It’s a really tricky and controversial topic.”
When politics, religion, cultural differences, or other sensitive topics come up during a session, it can be tough to know how to respond. Therapists may have an emotional reaction to beliefs they consider extreme. They may unintentionally disclose their views to a patient who disagrees, harming the therapeutic alliance. Or they may be caught off guard by a direct question and wonder how to respond.
APA’s Ethics Code does not include specific guidance for these types of issues, nor have most therapists received training on how to handle them. Fortunately, ethical standards on self-disclosure, cultural competence, and conflicts of interest can help.
“The population is pretty evenly split politically, so there are many people who may need our services that will disagree with their psychologist’s political beliefs,” said Scott Fischer, PhD, ABPP, a clinical psychologist who owns Acumen Psychology in St. Paul, Minnesota, and is a member of the APA Ethics Committee. “To be aware of that, and to not be dismissive of that group, is extremely important.”
Many therapists believe that self-disclosure—especially around tricky topics like politics and religion—is generally something to avoid. If a patient asks a question deemed too personal, it’s often standard to decline to answer, remind them that their welfare is the priority, and refocus the conversation on their needs. In some cases, a therapist may also choose to further explore why the question was asked.
But political self-disclosures may be more common than people think. In a pair of surveys of 268 therapists and 604 patients conducted after the 2016 election, about two thirds of each group reported political discussions and self-disclosures. When political views were aligned, those disclosures were linked to a stronger therapeutic alliance (Journal of Clinical Psychologyopens in new window, Vol. 74, No. 5, 2018; Journal of Clinical Psychologyopens in new window, Vol. 75, No. 9, 2019).
“Our data also showed that almost 50% of patients were worried about the political climate and would have liked to speak about politics more,” said Solomonov, who coauthored the study with Jacques P. Barber, PhD, ABPP, dean of the Gordon F. Derner School of Psychology at Adelphi University in Garden City, New York.
That presents a dilemma for providers: Should they engage in such conversations, and if so, to what extent? If a patient endorses views that are hateful or discriminatory, is it more ethical to stay silent or speak up?
“While there isn’t any standard in our Ethics Code that directly addresses this, good clinical skills and judgment about the case at hand can guide practitioners to make ethical decisions in this area,” said Lindsay Childress-Beatty, JD, PhD, APA’s interim ethics director.
Here’s advice from experts on how to navigate these sensitive topics in therapy.
Reflect on your views
Either on your own or in supervision, reflect on where you stand on the current events that might creep into therapy, Solomonov suggests. Is there a specific issue, such as immigration or criminal justice, that you feel particularly strongly about? Do you have fears around interacting with someone whose political or religious beliefs differ from your own? Consider that your patients may be experiencing similar fears and may even worry about facing judgment if they speak up.
Avoid unintentional disclosures
While most therapists are trained to avoid explicitly disclosing their political beliefs, some may inadvertently signal their stance on a certain issue by using what some experts call “colorized language”—terms that hint at a red- or blue-leaning political perspective.
For example, the terms “illegal immigrants” and “undocumented immigrants” suggest different views on immigration policy, which may lead to assumptions about political party affiliation. Other terms, including “systemic racism,” “reproductive freedom,” and “cancel culture,” may also provide hints to patients about a practitioner’s political and sociocultural orientation, said Fischer.
“Therapists should be aware of colorized language and take steps to avoid using it,” Fischer said. “In the event that you do inadvertently communicate your beliefs and the client picks up on that, there fortunately are some things you can do.” A clinician who detects a problem with the therapeutic alliance might ask a pointed question, for example: “How did you feel when I used the term ‘racial justice’ during our last session?”
Respond to questions from patients
Patients are naturally curious about their therapists. Early in therapy, questions may come up as a patient seeks acceptance and reassurance that you can help with their problems, said Innocent Okozi, PhD, a clinician at the Southdown Institute in Ontario, Canada, who holds a doctoral degree in counseling psychology. In the same way that a patient may ask if you are married when describing a conflict with their spouse, they may ask about your religious faith, political affiliation, or beliefs on an issue that is important to them.
“The underlying concern for the client at that point is: Can you really help me?” said Okozi, who is also the president of APA’s Div. 36 (Society for the Psychology of Religion and Spirituality).
In such cases, he recommends reassuring the patient and refocusing the conversation on their needs, for example by saying: “I’m wondering if you’re trying to find out if I can actually understand your struggles.” Then, reiterate their presenting concern and tell them you’ll do your best to help. You might further explore whether the patient worries about your judgment and reassure them that their views about firearms or abortion, for instance, don’t diminish your concern for their welfare or your desire to help them.
When the therapeutic relationship is more established, a patient with similar views may have guessed your political orientation. Self-disclosure, which in this case would likely strengthen the therapeutic bond, may be appropriate, said William Doherty, PhD, a professor of family social science at the University of Minnesota Twin Cities who cofounded the political depolarization initiative Braver Angelsopens in new window.
“If they’re bringing it up because they feel a sense of kinship with you, the norm would be that you could feel free to briefly comment,” he said, rather than drawing a hard line against discussing the issue in therapy.
On the other hand, a patient who detects a lack of alignment may be asking pointed questions (“Who did you vote for in 2020?” “Do you believe in God?” or “Are you divorced?”) because their views on a given topic are a key part of their identity.
“If you have somebody for whom this is a big deal, chances are that’s part of why they’re in therapy,” Doherty said. “They may see the world in black-and-white terms. They may have alienated friends and family members who feel different from them.”
Handle a disagreement therapeutically
If a patient has learned or guessed your views and sees them as a problem, Solomonov recommends using that as an opportunity to help the patient learn to cope with disagreement in the context of other relationships they value. It’s likely they are facing similar challenges in other interpersonal relationships, she said.
Doherty suggests exploring how the way the patient feels toward you may relate to the way they feel toward other people in their life—family members, friends, colleagues—whose beliefs differ from their own.
“Try your best to hang in there with them, always giving them the right to withdraw from therapy,” he said. “But I would really take this as grist for therapy, as almost a call for help.”
Question hate speech
Opposing views are one thing, but what if a patient veers into rhetoric that is hateful or prejudiced toward others, such as using a racial slur?
“I have an important responsibility not to condone or appear to agree with comments like that, so silence doesn’t seem like the right approach to me,” said Laura Anne Winter, CPsychol, a senior lecturer at the University of Manchester in England who studies the intersection of politics and therapy. “But a direct challenge might not always be the most productive.”
Doherty recommends responding with a question. For example, when a father made a disparaging comment about Black women during a family therapy session, Doherty circled back to the comment and said, “That was pretty strong language. How do you feel about saying that in front of your son?”
In individual therapy, he suggests prompting the patient with: “When you used that expression, how were you thinking I might respond to it?”
Avoid pushing back on misinformation and conspiracy theories
In a society rife with misinformation about COVID-19, elections, and other issues, it’s no surprise that extreme theories can crop up in therapy. Though practitioners may feel a strong pull to correct misinformation, Fischer warns that patients may already be entrenched in their beliefs, and any pushback is more likely to alienate than aid them.
“It’s never a good idea to enter a fact-checking match in a therapeutic session. Ask yourself: Is addressing this going to be therapeutic for the client?” said Solomonov.
Some patients may express distress about extreme views held by friends or family members. In that event, Fischer suggests reminding the patient that others’ beliefs are typically outside of our control and helping them come to terms with that.
Provide a referral
In rare cases, a therapist may conclude that they are not competent to treat a patient because of an extreme conflict or difference of opinion. For example, a Jewish practitioner may elect not to move forward with a patient who expresses anti-Semitic views and denies that the Holocaust occurred.
APA’s Ethics Code standard on personal interest (3.06), which was written to address traditional conflicts of interest, could prove useful in such circumstances, said Childress-Beatty. If a practitioner determines that the conflict is great enough to “impair their objectivity, competence, or effectiveness” or to risk “harm or exploitation” they should terminate the relationship, she said.
On such occasions, “our Ethics Code is very clear that you provide clients with good referrals to practitioners who are competent to treat them,” she said.
Seek support
With tricky topics like these, mistakes can happen. If you feel out of your depth, Okozi suggests consulting with a colleague who can help you explore how to respond to a patient, repair a breach of the therapeutic alliance, or determine whether a referral is necessary.
“Humility is always good with these kinds of situations, to be aware that we can blunder because of our strong feelings and we can have blind spots,” said Fischer. “Hopefully therapists get good at identifying their blind spots, but nobody is perfect.” n
