Two senses of “psychotherapy is political” are often conflated. The first is the notion, popular lately, that psychotherapy either allows or demands political advocacy in the therapy room itself. The other is recognition that political factors influence the nature and practice of psychotherapy. It is a conceptual error to confuse the two, and a clinical error to justify the former by appeal to the latter.
Yes, psychotherapy is political (like everything else)
Viewing the practice of psychotherapy through a political lens, albeit one lens among many, can be valuable and revealing. Political analysis of this sort can be applied to nearly all human endeavors: war, housing, work, romantic relationships, childrearing, sports, nutrition, medical care, media, etc. There is no reason to imagine psychotherapy is an exception, and indeed it is not. To cite just a few of the most obvious areas where politics intersects with psychotherapy:
- third-party payment, public and private, and out-of-pocket cost
- the choice of psychotherapy versus other types of help
- social stigma, both of mental disorders and their treatments
- social inequities that lead to despair, anxiety, and anger
- controversies over what counts as a mental disorder
- lobbying and other activities of professional organizations
- allocation of research funds
Note that none of these dictate how therapy itself should be conducted, aside from the value of understanding and appreciating what the patient is dealing with. In other words, for empathy. None of these political issues speak to what psychotherapy is, or realistically offers. Even issues such as gender and racial dynamics within psychotherapy itself, while important to be aware of, need not alter the way competent therapy is conducted.
One political view that matters
However, there’s a different kind of political position that does affect psychotherapy itself. It’s the degree to which one situates pathology in the sufferer, versus in his or her environment. Even Freud grappled with this. His early “seduction theory” held that childhood sexual abuse led to neurosis. Yet he was unable to believe such abuse was widespread. Thus, he soon revised his account to say that young children had sexual (or sexual-like) fantasies that led to inner conflict. This revision justified treatment of the individual who harbored the conflictual fantasies.
Conversely, some therapists today hold that emotional distress and dysfunction are always “normal reactions to abnormal situations.” That is, the pathology lies outside the patient. This perspective justifies social action, not inner exploration.
Where patients locate pathology affects how and whether they seek therapy. Those who frame their problems as existing entirely outside themselves — cruel bosses, uncaring spouses, or social pathology such as racial, gender, or class inequity — don’t come to therapy to change anything about themselves.
Externalization
In the traditional language of psychotherapy, such patients externalize: they complain about the outside world, which psychotherapy can do nothing about, and disclaim responsibility for their plight. Typically, therapists are quick to challenge this stance when it comes to difficult bosses and spouses. After all, therapy can’t change other people, only the patient.
Curiously, despite identical logic, many therapists today accept externalization with respect to social ills. They see their role as providing support, validation, and “advocacy.” They believe that focusing on the patient’s responsibility for navigating the outside world is “blaming the victim.”
Unfortunately, advocacy by itself isn’t therapeutic. Validation and support don’t lead to change.
Advocacy in therapy — more accurately, advocacy instead of therapy — doesn’t directly improve the noxious environment either. Framing the patient’s distress as a struggle against “oppression” draws an oversimplified battle line, with patient and therapist comfortably on the same side. It promotes a primitive fight-or-flight duality instead of creative, nuanced alternatives. This false simplification may make both parties feel better for a time. At best it may inspire activism, which may help the patient feel better indirectly, depending on the presenting complaint.
What political advocacy trades away
Of course, spurring political activism is not the purpose of psychotherapy. Psychotherapy is a treatment, not a pep talk or political rally. Therapy isn’t designed to make the world less harsh or more loving. As the old joke says, the lightbulb has to want to change.
In addition, much is traded away when political advocacy colors treatment. It’s no secret that most therapists are on the liberal side of the political spectrum. Yet politically conservative patients may badly need a safe place to talk — not a lecture. Even patients who mostly share their therapists’ political outlook may have mixed feelings, or be of two minds, about social issues.
Fundamentally, political advocacy violates the precept of therapeutic neutrality. In Freud’s original formulation, therapeutic neutrality meant not siding with one aspect of the patient’s psyche over another. No favoring the superego over the id, for example. A more modern way of saying this is that it doesn’t help for the therapist to weigh in on a conflict the patient is struggling with. Casting a vote for one side or the other won’t resolve the conflict. And let’s be clear: patients who are sufficiently troubled by social injustice to seek therapy have intrapsychic conflicts that amplify the injustices they face. No one comes to therapy for problems they can figure out for themselves.
The fundamental dialectic of psychotherapy
Marsha Linehan, the founder of dialectical behavior therapy (DBT), recognized back in the 1970s that neither blaming patients nor completely absolving them is helpful. Patients can learn to accept themselves, yet they need to change too. This apparent paradox is the “dialectic” in DBT’s name.
As I’ve written elsewhere, this dialectic of self-acceptance and change exists in all psychotherapy, not just DBT. That’s why most therapists stake out a middle ground that recognizes real-life hardships and tragedies, as well as the reality that psychotherapy is for personal, not social, change. Unfortunately, therapists who primarily see themselves as advocates for their patients conflate the political factors surrounding therapy with a false need to be political IN therapy. In doing so, they trade away the value of psychotherapy as an avenue for personal insight and development.
Working with people we disagree with
Needless to say, not all therapists and patients can work with each other. A gleefully misogynist or racist patient may stir up such intense anger in liberal therapists that they cannot work with that person. Conversely, a patient who repeatedly intones progressive talking points may anger centrist or conservative therapists. Therapists are human, and there are limits to what any of us can tolerate.
These limits should be wide, though. Just as surgeons must tolerate the sight of blood, and dermatologists cannot recoil from disfigured skin, therapists must work with personalities and viewpoints we find offensive. (Not the converse: patients need not put up with therapists who share strong, potentially offensive viewpoints. That’s one reason for therapists to tone it down — not be a “blank slate,” just leave enough room for the patient to feel comfortable and safe.)
A strong working alliance does not require political agreement. Indeed, if political talk serves a defensive function, e.g., externalization, the therapist’s job is to help the patient recognize that dynamic and look beneath and beyond it. In that sense, psychotherapy may be more effective when patient and therapist disagree somewhat politically, lest they unwittingly collude in defensive avoidance.
Image courtesy of vectorolie at FreeDigitalPhotos.net
It seems like this post is more about partisan views in therapy as election season heats up, but I am more interested in the responding to the broader notions of politics you bring up:
“None of these political issues speak to what psychotherapy is, or realistically offers.”
I will add that politics shaped the development and trajectory of what therapy is, realistically offers, and to who. I don’t think psychotherapy is political in the way everything is political, but its entire existence as treatment modality is rooted and shaped by politics.
At the very least, if there is seemingly a misunderstanding between popular notions of what psychotherapy realistically offers and what it does, and you think even therapists propagate those misunderstandings, I think it is paramount that you (you as in therapists who believe this) explain this to patients before agreeing to start engage in psychotherapy.
“Where patients locate pathology affects how and whether they seek therapy”
I think this also applies to therapists? When every nail of a problem is framed as internal pathology, every solution starts to look like the hammer of therapy. If claiming an expanded definition of therapeutic neutrality, I might add that reserving some of judgement on to what extent a problem may be “external” or that such easy division between internal/external are possible or meaningful for some problems pathologizing a patient as an externalizer.
“Yet [Freud] was unable to believe such abuse was widespread. Thus, he soon revised his account to say that young children had sexual (or sexual-like) fantasies that led to inner conflict.”
Was this a personal or political failing of Freud? Does it matter? Sexual abuse of children was widespread and continues to be along, along with the reach of political apparati to obfuscate and minimize the abuse. I think there is a good claim that psychotherapy itself became medically popular as such a political apparatus–it existed to funnel victims to doctors to be rendered legally untrustworthy and to question their role in their own victimization. I mean, Freud doesn’t have that many published cases (and his honesty in them is questionable)–in 2024 that Dora was coerced into treatment by her father not believing that his friend made an unwanted advance on her and to keep her from destabilizing the affairs her father and this man were having makes a lot more sense to me than that she was suffering from effects of sexual conflicts, fantasies, and wishes.
There is certainly a take that the political climate of physicians in Freud’s world led Freud to change to change his summation of findings re: widespread sexual abuse in order to have a career, let alone fame. That he could and did believe sexual abuse was widespread, but dealing with it was inexpedient to his goals of being a noteworthy physician. Was it good that he didn’t “externalize” the problem of a bunch of powerful men refusing evidence of widespread sexual and other abuse and working on addressing that but instead worked “internally” to “change” his beliefs to fit with the prevailing political milieu to render reports of sexual abuse as fantasy? I don’t think so.
“In the traditional language of psychotherapy, such patients externalize: they complain about the outside world, which psychotherapy can do nothing about, and disclaim responsibility for their plight… Casting a vote for one side or the other won’t resolve the conflict”
What is the transmutation that bridges the world of therapy, and, you know, the world. We may speak of them metaphorically separate but they are not. Even you claim that psychotherapy is enmeshed in the political–how does it exist somehow outside it?
I don’t know, this sounds to me more about therapist impotence in helping make changes in the real lives of their patients because their patients don’t live in their offices, and finding ways to express that frustration in a way that further blames patients for real problems beyond the scope of therapy they face in the world. It’s pithy to minimize complaints about bosses and partners as externalizing when people live in worlds where they need jobs, homes, and access to their children, etc. which are often dependent on bosses and spouses.
Remaining neutral in these issues can have a negative effect on wellbeing as perhaps the only space and person seemingly “outside” of the real world patients can access to speak about them with a degree of meaningful freedom, the therapist and the therapy room, becomes another trusted person/place where those issues become relocated as problems stemming from the individual. From the therapist’s perspective, this may be because that is what they can work on, but from a patient’s perspective, I don’t think that intent really matters. Even if framed as a dialectic at best, affirming a patient as they are and also trying to show areas of potential change to meet their goals or provide them more freedom–it kind of misses the point of that a person who purports to provide a place of safe expression by proclaiming neutrality must fail acknowledge “external problems” as such.
Like, if a teenage client reports frequent bullying in school, despite attempts to engage parents and teachers about it and interrupt it themselves, and that client has made links to that bullying and their clinical decompensation, is it the job of the therapist to stay neutral in regards to what their client is experiencing? I feel like by your logic what becomes areas of exploration are the personal factors of why a patient thinks they are being bullied, what about the bullies is so upsetting, how their response to the bullying can be affecting their wellbeing and how childhood experiences may have led to those responses, strategies to disengage bullies, etc, as those are in the purview of the consultation office. However, none of these “internal” avenues validate that teenagers shouldn’t be bullied. Even if framed as a dialectic, the full stop of the statement above, becomes muddled in an internalizing focus of change that renders the problem, bullies, unaddressed.
I think it is on the therapist to recognize that there are problems people face that are not amenable to the typical work of psychotherapy and perhaps their role in those situations is not be neutral, even if they are not in position to change the outside world. I get that a therapist can’t stop bullying a patient is experiencing, but I don’t think it serves their patient to refuse to claim that they shouldn’t be bullied and that the actual problem here is bullies. That might be the only way they can help for such external problems, to share in the indignation and injustice, as refusing a clear stance simply relocates external problems incorrectly onto internal issues of patients. If the problem isn’t the bullies, what it is it, the person being being bullied.
I guess one could argue that non-therapy amenable issues should not be talked about in therapy, but then perhaps then there needs to be some more guidance about free association and talking about whatever one wishes.
Hi Nathan,
Yes, my post was more about partisan views in therapy.
The development of psychotherapy was and is very much a product of political and cultural context. The same is true of the other domains I mentioned; their “entire existences are rooted and shaped by politics.” Curiously, this universal truth serves as a “gotcha!” by those skeptical of a practice or institution, while being completely ignored otherwise. Psychotherapy is no more or less a political-cultural product than the public school system or the Super Bowl.
I wasn’t defending Freud’s ignoring of childhood sexual abuse. On the contrary, it’s an example of having blinders on — just as some social-activist therapists have equal and opposite blinders about personal responsibility. And I certainly don’t believe therapists can ignore stress and trauma in patient’s lives.
Telling a patient they shouldn’t be bullied is empathic. Nothing wrong with that. But things quickly get complicated. A patient may consider it bullying when her sister offers one piece of advice, while another perceives no bullying after being sexually exploited at a fraternity party. Therapists empathize with the frustrations and indignities of life, large and small — and regardless of how much we personally would be troubled by the same thing. We aim to understand how the patient feels, not pass judgment on which complaints are “real” or merit our endorsement.
Therapeutic neutrality means not taking sides in an internal conflict the patient is having. We can and do “take the side” of patients living richer, less troubled, more satisfying lives. I typically do this by suggesting that others are “constants, not variables” — it doesn’t pay to wait for your parents or spouse or coworker to change — and that it’s incumbent on the patient to choose how to deal with this reality.
Not to overspeculate on the internal life of Freud, but I think there is some evidence that his shift from seduction theory to unconscious conflicted desire as etiology of hysteria was not really do to a shift of beliefs, but to keep publishing. If it came to an actual shift of belief, that says a lot about some of the dangers of focusing on internalizing problems that may be external just because the internal is what can be done more expediently even if it is wrong. Like, Freud couldn’t wait for all of the work he’d have to do to change patriarchal medical establishment to acknowledge sexual abuse, so he just made a new theory that located the problem of hysteria not on abuse of children but on children’s conflicted sexual desires. It wasn’t going to pay to work to convince his colleagues, so the reality of the difficulty of it was to disavow the reality of the abuse.
As for political advocacy, I think a lot of new therapists come from social work backgrounds, which does place psychotherapy itself in a broader context of tools and interventions to promote wellbeing that range from micro to macro level scopes. If a goal is to minimize distress, which is often the goal of clients seeking psychotherapy, tying individual distress not only to intrapsychic and relational conflicts, but to broader social, political, and economic ones are part of that analysis. Perhaps you are mostly noticing a shift on in the backgrounds and demographics of psychotherapists that come to their profession from a different route?
As for the political constructions of everything as a “gotchya,” in regards to therapy, the issue is not simply that its political so hence suspect, but what are its politics. Folks are evaluating who does this institution actually serve? For what purposes? What beliefs are implicit in its practices? Folks who criticize particular institutions don’t do so simply because they are institutions, but because they think they are evaluatively bad.