{"id":1685,"date":"2023-12-31T13:20:13","date_gmt":"2023-12-31T21:20:13","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=1685"},"modified":"2023-12-31T13:20:13","modified_gmt":"2023-12-31T21:20:13","slug":"political-advocacy-and-psychotherapy-dont-mix","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=1685","title":{"rendered":"Political advocacy and psychotherapy don&#8217;t mix"},"content":{"rendered":"<div class=\"wp-block-image\">\n<figure class=\"alignleft size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"225\" height=\"275\" src=\"http:\/\/blog.stevenreidbordmd.com\/wp-content\/uploads\/2023\/12\/ID-100263327-1.jpg\" alt=\"\" class=\"wp-image-1687\" srcset=\"http:\/\/blog.stevenreidbordmd.com\/wp-content\/uploads\/2023\/12\/ID-100263327-1.jpg 225w, http:\/\/blog.stevenreidbordmd.com\/wp-content\/uploads\/2023\/12\/ID-100263327-1-123x150.jpg 123w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/figure>\n<\/div>\n\n\n<p>Two senses of \u201cpsychotherapy is political\u201d are often conflated.&nbsp; The first is the notion, popular lately, that psychotherapy either allows or demands political advocacy in the therapy room itself.&nbsp; The other is recognition that political factors influence the nature and practice of psychotherapy.&nbsp; It is a conceptual error to confuse the two, and a clinical error to justify the former by appeal to the latter.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Yes, psychotherapy is political (like everything else)<\/h3>\n\n\n\n<p>Viewing the practice of psychotherapy through a political lens, albeit one lens among many, can be valuable and revealing.&nbsp; 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.&nbsp; There is no reason to imagine psychotherapy is an exception, and indeed it is not.&nbsp; To cite just a few of the most obvious areas where politics intersects with psychotherapy:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>third-party payment, public and private, and out-of-pocket cost<\/li>\n\n\n\n<li>the choice of psychotherapy versus other types of help<\/li>\n\n\n\n<li>social stigma, both of mental disorders and their treatments<\/li>\n\n\n\n<li>social inequities that lead to despair, anxiety, and anger<\/li>\n\n\n\n<li>controversies over what counts as a mental disorder<\/li>\n\n\n\n<li>lobbying and other activities of professional organizations<\/li>\n\n\n\n<li>allocation of research funds<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\"><\/ul>\n\n\n\n<p>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.&nbsp; In other words, for empathy.&nbsp; None of these political issues speak to what psychotherapy is, or realistically offers.&nbsp; 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.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">One political view that matters<\/h3>\n\n\n\n<p>However, there\u2019s a different kind of political position that does affect psychotherapy itself.\u00a0 It\u2019s the degree to which one situates pathology in the sufferer, versus in his or her environment.\u00a0 Even Freud grappled with this.\u00a0 His early \u201c<a href=\"https:\/\/en.wikipedia.org\/wiki\/Freud%27s_seduction_theory\" target=\"_blank\" rel=\"noopener\" title=\"\">seduction theory<\/a>\u201d held that childhood sexual abuse led to neurosis.\u00a0 Yet he was unable to believe such abuse was widespread.\u00a0 Thus, he soon revised his account to say that young children had sexual (or sexual-like) <em>fantasies<\/em> that led to inner conflict.\u00a0 This revision justified treatment of the individual who harbored the conflictual fantasies.<\/p>\n\n\n\n<p>Conversely, some therapists today hold that emotional distress and dysfunction are always \u201cnormal reactions to abnormal situations.\u201d&nbsp; That is, the pathology lies outside the patient.&nbsp; This perspective justifies social action, not inner exploration.<\/p>\n\n\n\n<p>Where patients locate pathology affects how and whether they seek therapy.\u00a0 Those who frame their problems as existing entirely outside themselves \u2014 cruel bosses, uncaring spouses, or social pathology such as racial, gender, or class inequity \u2014 don\u2019t come to therapy to change anything about themselves.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Externalization<\/h3>\n\n\n\n<p>In the traditional language of psychotherapy, such patients <em>externalize<\/em>: they complain about the outside world, which psychotherapy can do nothing about, and disclaim responsibility for their plight.&nbsp; Typically, therapists are quick to challenge this stance when it comes to difficult bosses and spouses.&nbsp; After all, therapy can\u2019t change other people, only the patient.<\/p>\n\n\n\n<p>Curiously, despite identical logic, many therapists today accept externalization with respect to social ills.&nbsp; They see their role as providing support, validation, and \u201cadvocacy.\u201d&nbsp; They believe that focusing on the patient\u2019s responsibility for navigating the outside world is \u201cblaming the victim.\u201d<\/p>\n\n\n\n<p>Unfortunately, advocacy by itself isn\u2019t therapeutic.\u00a0 Validation and support don\u2019t lead to change.<\/p>\n\n\n\n<p>Advocacy in therapy \u2014 more accurately, advocacy <em>instead of<\/em> therapy \u2014 doesn\u2019t directly improve the noxious environment either.\u00a0 Framing the patient\u2019s distress as a struggle against \u201coppression\u201d 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.\u00a0 This false simplification may make both parties feel better for a time.\u00a0 At best it may inspire activism, which may help the patient feel better indirectly, depending on the presenting complaint.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">What political advocacy trades away<\/h3>\n\n\n\n<p>Of course, spurring political activism is not the purpose of psychotherapy.&nbsp; Psychotherapy is a treatment, not a pep talk or political rally.&nbsp; Therapy isn\u2019t designed to make the world less harsh or more loving.&nbsp; As the old joke says, the lightbulb has to want to change.<\/p>\n\n\n\n<p>In addition, much is traded away when political advocacy colors treatment.\u00a0 It\u2019s no secret that most therapists are on the liberal side of the political spectrum.\u00a0 Yet politically conservative patients may badly need a safe place to talk \u2014 not a lecture.\u00a0 Even patients who mostly share their therapists\u2019 political outlook may have mixed feelings, or be of two minds, about social issues.<\/p>\n\n\n\n<p>Fundamentally, political advocacy violates the precept of therapeutic neutrality.\u00a0 In Freud\u2019s original formulation, therapeutic neutrality meant not siding with one aspect of the patient\u2019s psyche over another.\u00a0 No favoring the superego over the id, for example.\u00a0 A more <a href=\"https:\/\/www.psychiatrictimes.com\/view\/the-therapeutic-attitude-in-psychotherapy\" target=\"_blank\" rel=\"noopener\" title=\"\">modern<\/a> way of saying this is that it doesn\u2019t help for the therapist to weigh in on a conflict the patient is struggling with.\u00a0 Casting a vote for one side or the other won\u2019t resolve the conflict.\u00a0 And let\u2019s be clear: patients who are sufficiently troubled by social injustice to seek therapy have intrapsychic conflicts that amplify the injustices they face.\u00a0 No one comes to therapy for problems they can figure out for themselves.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">The fundamental dialectic of psychotherapy<\/h3>\n\n\n\n<p>Marsha Linehan, the founder of dialectical behavior therapy (DBT), recognized back in the 1970s that neither blaming patients nor completely absolving them is helpful.&nbsp; Patients can learn to accept themselves, yet they need to change too.&nbsp; This apparent paradox is the \u201cdialectic\u201d in DBT\u2019s name.<\/p>\n\n\n\n<p>As I\u2019ve written <a href=\"http:\/\/blog.stevenreidbordmd.com\/?p=1448\" target=\"_blank\" rel=\"noopener\" title=\"\">elsewhere<\/a>, this dialectic of self-acceptance and change exists in all psychotherapy, not just DBT.\u00a0 That\u2019s 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.\u00a0 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.\u00a0 In doing so, they trade away the value of psychotherapy as an avenue for personal insight and development.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Working with people we disagree with<\/h3>\n\n\n\n<p>Needless to say, not all therapists and patients can work with each other.\u00a0 A gleefully misogynist or racist patient may stir up such intense anger in liberal therapists that they cannot work with that person.\u00a0 Conversely, a patient who repeatedly intones progressive talking points may anger centrist or conservative therapists.\u00a0 Therapists are human, and there are limits to what any of us can tolerate.<\/p>\n\n\n\n<p>These limits should be wide, though.\u00a0 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.\u00a0 (Not the converse: patients need not put up with therapists who share strong, potentially offensive viewpoints.  That&#8217;s one reason for therapists to tone it down \u2014 not be a &#8220;blank slate,&#8221; just leave enough room for the patient to feel comfortable and safe.)<\/p>\n\n\n\n<p>A strong working alliance does not require political agreement.\u00a0 Indeed, if political talk serves a defensive function, e.g., externalization, the therapist\u2019s job is to help the patient recognize that dynamic and look beneath and beyond it.\u00a0 In that sense, psychotherapy may be more effective when patient and therapist disagree somewhat politically, lest they unwittingly collude in defensive avoidance.<\/p>\n\n\n\n<p><em>Image courtesy of vectorolie at FreeDigitalPhotos.net<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"\n<p>Two senses of \u201cpsychotherapy is political\u201d are often conflated.&nbsp; The first is the notion, popular lately, that psychotherapy either allows or demands political advocacy in the therapy room itself.&nbsp; The other is recognition that political factors influence the nature and practice of psychotherapy.&nbsp; It is a conceptual error to confuse the two, and a [&#8230;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[4,8],"tags":[77,53],"class_list":["post-1685","post","type-post","status-publish","format-standard","hentry","category-current-events","category-psychotherapy","tag-politics","tag-psychodynamics","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1685","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1685"}],"version-history":[{"count":2,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1685\/revisions"}],"predecessor-version":[{"id":1689,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1685\/revisions\/1689"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1685"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1685"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1685"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}