April 24, 2007

The psychotherapist's confidence in his own empathy.

Richard A. Friedman casts doubt on those patients who want psychotherapists who share their traits. The gay patient wants a gay therapist. The old patient wants a therapist who is at least not too young. The feminist wants a feminist.
What is critical to understanding someone is not necessarily having had his or her experience; it is being able to imagine what it would be like to have it. Thus, I do not have to be black to empathize with the toxic effects of racial prejudice, or be a woman to know how I would feel about being denied promotion on the basis of sex.
Even if we believe this feat of imagination is possible, how is the patient supposed to know that a therapist is sufficiently imaginative to do this well? You may think you have a great imagination. A lot of people do! But that doesn't mean that what you are imagining is accurate. I've known some individuals who have devoted an astounding amount of mental energy to thinking about what other people are thinking and coming up with plenty of material -- that imagination is grinding away like mad -- but it's all quite wrong.

There's a different level to the problem. Quite aside from whether or not the patient is right about who will empathize, there's the question of whether is morally wrong for the patient to discriminate based on the characteristics of the therapist.
Sometimes... patients should get exactly what they ask for in a therapist. One of my residents once saw a young woman from Africa who had survived hideous torture and rape and said that she didn’t think she could see a male therapist.

That struck me as entirely appropriate. Given her trauma, she simply could not have put her trust in a male therapist, no matter how empathic he might actually be.

What about patients whose demand for a particular therapist springs from nothing more than everyday prejudice? I remember a patient who once stormed into my office and demanded a white therapist to replace his therapist, who was black.

That’s a request I turned down, even knowing that this patient’s biased beliefs were an appropriate target for treatment. To do otherwise would have vindicated his prejudice and fundamentally compromised the therapy from the start.
Note that Friedman doesn't say that race discrimination is so morally wrong that he cannot be a party to it. He justifies his refusal on therapeutic grounds.

ADDED: Neo-Neocon responds.

25 comments:

reader_iam said...

That’s a request I turned down, even knowing that this patient’s biased beliefs were an appropriate target for treatment. To do otherwise would have vindicated his prejudice and fundamentally compromised the therapy from the start.

I do think race discrimination is morally wrong. Refusing to enable it is laudable. (Better to just say that, though, as you point out.)

That said, on the larger issue, my buck sort of stops here: If I'm paying, I get to pick the therapist. (Which, of course, may mean I have to a different practice; that's my problem.) Even if I'm not paying, there should be some room for personal choice and control.

Friedman strike me as an arrogant sort, one of those paternalistic professionals that rub me the wrong way. Maybe that's not fair--but he's just the type that would make me...request a different psychotherapist, one that suits my outlook better!

And I'm just cynical enough to wonder: Had a black patient stormed into his office demanding a black therapist to replace his white therapist, would his reaction have been the same?

Mortimer Brezny said...

No, he would have called the police.

reader_iam said...

God, I hope not.

Joe said...

All of this assumes therapy actually works. While I have no doubt some degree of psychological therapy is beneficial, I do think that we, as a society, have more faith in the psychiatric profession than is warranted.

Bissage said...

My pacemaker will be installed by an African-American.

My liver transplant will be done by an Irishman.

My spleen will be vented by a Spaniard.

One can never be too careful about these things.

Fitz said...

The field of psychology has become so politicized that one is hard pressed to believe any of its claims. Nowhere is this more obvious than in issues of human sexuality. Its seems that on a daily basis one deviant behavior is crossed of a list, while another, previously unknown behavior is being advertised as treatable with medication.

This kind of political pressure even threatens doctors with license removal or suspension for helping patients overcome homosexual inclinations or strive to live chaste lives.

David53 said...

Tom Cruise says psychiatry is "nazi psuedoscience." Maybe he could debate Friedman. That would be interesting.

Pogo said...

I have mixed feelings about this. Boomer women are increasingly asking for female MDs, which isn't a big deal. Aspects of it make quite a bit of sense.

Oftentimes these women doctors get burned out seeing only women patients. Some limit their percentage of women, get out of that line of work, or go part time. Some make businesses out of women-only centers. Smart. Because there would never be enough female practitioners to abide by this practice, a market could sort out how important this was to women.

Few men seem to care. But some men should never ever have a female MD, because they quickly get touchy grabby creepy.

One of my colleagues is a Jewish doc, an expert in his field, and an expert's expert in the one disease an Arabic man had. The man dictated "no Jews", so no MDs or nurses or janitors, etc. Surprisingly, despite the money being waved aroud, my bosses declined and said in short, "this is what we are, go elsewhere if you want something else".

He decided to let the Jewish specialist treat him. Oddly enough, just 2 years later I saw this as plot in an episode of the West Wing, but turned around, where the Arab was being denied a Jewish doc's exclusive expertise. The prez commanded him to treat.

Mindsteps said...

Fitz said...
The field of psychology has become so politicized that one is hard pressed to believe any of its claims.

Psychology is probably vulnerable to abuse from all types of ideology because of it's ephemeral nature.

While I agree with you that the politicization of psychology does the profession a disservice, in the applied areas, economic forces have had a much more powerful impact on the profession. Indeed, there is really no mental health 'system' in this country. Calling it a 'system' is dignifying it. Mental Health Care in this country is terribly fragmented. Because psychology is so difficult to define and mentally ill people are not a wealthy and powerful voting bloc, mental health care in this country has been gutted by special interests and given little attention by our society or leaders.
(See the article by following article by Arthur Caplan, Ph.D.director of the Center for Bioethics at the University ofPennsylvania on the Broken Mental-Health System: http://www.msnbc.msn.com/id/18262056/

As to empathy, this is an area that has been the subject of some very compelling research of late. With the advent of new technologies to explore the brain, we are learning more and more about the neurodevelopmental basis for empathy. At some point somebody is going to develop an FMRI machine or something similar that allows us to study real time human interaction at behavioral and neurophysiological levels in exquisite detail.

Already, Neuroscientists have identified "mirror neurons", theorized to be the seat of empathy (see http://www.apa.org/monitor/oct05/mirror.html) and considered by some to be the fundamental defect in autistic spectrum disorders.

New ways to study reciprocity between infant and mother allow researchers to explore the moment to moment synchrony (and disruptions to communication) between caregiver and baby and follow the individual through time to learn about his or her development, strengths, and vulnerabilities.

I wonder what the payoffs might be (if any) if we were to invest more in pursuing a science of both empathy and failures in empathy.

Revenant said...

mindsteps,

Some areas of psychology, especially the neurosciences, are making amazing strides year after year.

Psychotherapy, on the other hand, is still pretty much a pseudoscience like palm reading or astrology. It CAN be helpful, but only because talking to people can be helpful, and because helping people figure out their problems is something that some people are good at, and everyone gets better at with experience.

But I am very, very skeptical of the idea that we as a society should be supporting or funding the therapy industry. If I'm going to be asked to pay for a treatment I want, at a bare minimum, proof that it works (unlikely to happen in a field as sloppy as psychotherapy), and preferably a scientific explanation of WHY it works (largely impossible at this point).

oklio said...

Yeah sounds cool

spammy@vjn.fi

TMink said...

Interesting ideas, thought provoking article.

Rev wrote: "It CAN be helpful, but only because talking to people can be helpful, and because helping people figure out their problems is something that some people are good at, and everyone gets better at with experience."

I agree with you till you say that everyone gets better at it with experience. If you change that to "most healthy people" I am with you all the way.

I think that the mistake is in thinking that the therapist has to have the same life experience as the patient to empathize and be helpful. Empathy and life experience are different and have nothing to do with each other.

Having TOO similar a life experience can actually hurt. I work with a kid who was abused in a way very similar to me, and it is difficult for me to conduct HIS therapy instead of mine. I have to work harder to stay with his experience because mine resonates so loudly. Both of us were severly starved, and usually this is not a problem for me as it is a rare form of abuse. That is a good thing, as it is a bit exhausting to stay focused and provide good services with him.

Since empathy is different from experience, people may THINK they are getting empathy when they sign up for a twin for a therapist. One of the best people I ever worked with made me nervous because she had a button on her purse that read "If you ever wondered what a radical feminist looks like, now you know." I thought "Oh shit, here I am with a rad fem and I want to talk about getting a divorce. She will eat me alive." I was totally wrong, she was completely helpful because she took time to understand my situation and could empathically resonate with it.

Some people are empathically gifted, and it makes things go much quicker for many people in therapy. I do a lot of work with sexually abused children, as well as sexually abused women and men. I never had that experience, but I can do the empathy thing, so I have a waiting list.

The research shows that you know if you can work with the therapist after two visits. The intake does not count. Two visits! Matching does not improve after 8 or 16 visits. It is not possible for researchers to predict what will make or kill a good match, but the patient knows it fast.

I generally tell people this and tell them that they will eventually fire me anyway, so don't waste time, if you don't feel it is a good match, fire me quick.

But people that seek a therapist of specific personal characteristics are judging a book by it's cover. And they may be dissapointed at what they end up reading.

Trey

Mindsteps said...

Revenant said...

Psychotherapy, on the other hand, is still pretty much a pseudoscience like palm reading or astrology. It CAN be helpful, but only because talking to people can be helpful, and because helping people figure out their problems is something that some people are good at, and everyone gets better at with experience.

Revenant:

I believe your skepticism about psychotherapy is well placed. Too many who are in practice are unfamilar with the scientific foundation (and in many cases, the lack of a scientific basis) for a large number of psychotherapies. There are, however, some psychotherapeutic treatments with empirical support that rivals pharmacological agents (for example, right now the most effective interventions for autism are behavior based). If you are interested in learning more you can go to the following website to obtain information on empirically supported treatments:
http://www.apa.org/divisions/div12/cppi.html

Unfortunately, the current climate in the area of mental healthcare is heavily weighted toward managing the financial aspects of assessment and treatment. The quality and effectiveness of interventions (be they pharmacological or psychological or both) too often take a back seat to these financial concerns.

boston70 said...

I am also not one who believes in therapy (for myself). If it helps others all the power to them.

I did, when I was younger, try therapy. I ended up going through somewhere around 5 therapists.

I had gay therapists, females, straight males etc.

As a gay man I actually did not like having a gay therapist and would specifically request a straight therapist. In the end I came to the conclusion that my happiness or lack of happiness is my responsiblity and me spouting off to someone for an hour once a week didn't help.

I actually do not like having a gay masseuse, gay person cut my hair or gay yoga instructor gay doctor or gay dentist-I even don't like interacting with other gay people at work. Obviously, this is some type of internalized homophobia which means I should be seeing a therapist but I don't believe in therapy. I think gays tend to judge each other severely as well as being incredibly competitive. I judge myself enough I don't need a gay yoga instructor to tell me my chokras are out of alignment and my downward facing dog sucks.

vnjagvet said...

Why would a patient that wants a therapist of a particular type (for whatever reason) accept someone who they do not want?

TMink said...

VNJ, I have no idea. For me it is more interesting to wonder when they ask for a specific demographic of a person, male, gay, abuse survivor, what ever, will they get what they think they are asking for?

Oh, and I really think that with addictions it is key to have someone that is in recovery themselves to work with you. Especially early in the treatment. I see folks who are in recovery, but I have never flet or been succesful in helping them get there.

Trey

Synova said...

Boston, "Obviously, this is some type of internalized homophobia which means I should be seeing a therapist but I don't believe in therapy."

And then you talked about competition and judgment. That's not homophobia, is it?

And it makes sense to me to prefer interacting with people with whom you don't feel put on the spot. I would have not wanted to go to an all-girl college because I felt in competition with women and didn't feel competitive with men. Men were more comfortable. But with men the comfortableness was always in conflict with attraction. There was always the low grade worry that someone who was my friend would ruin it all by expressing attraction. Some women are much better at girlfriends than I ever was, but I don't think I'm all that unique.

The dynamics changed when I became part of a couple. Safely "off-limits" has it's own comforts, but mostly a lessening of the feeling of competition with other women. A male friend who expressed attraction would be worse now than before I had a permanent partner, so girlfriends are more important.

Lesbians make me a little bit uncomfortable, even though I'm straight, because I've got all the other varieties of interpersonal stuff worked out. No doubt knowing more lesbians would solve that problem.

Which comes to gay men, who are the most comfortable possible friend for a straight woman. There are just no complications at all. No competition. No attraction.

So is it really weird that you feel uncomfortable around other gay men?

That actually seems logical, to me.

Howard said...

Why go thru therapy when prescription drugs will fix you? That way I don't care if some feminist dyke can identify with me or not.

TMink said...

And then there are all the gay men who were sexually abused by their uncle. That is enough to make you uncomfortable around gay men. Of course most guy guys are not pedophiles, that is not my point. But there may be a perfectly reasonable process behind your discomfort that has nothing to do with homophobia.

Since you are out, you have obviously dealt with a good deal of internalizaed homophobia. Way to go!

I have found that there is a perfectly reasonable explanation for most feelings, but that it is sometimes buried a bit because we misunderestimate the importance of early learning.

Or it could just be you aren't interested in thinking about getting laid when you are getting a massage. Works for me! One of my golf buddies is bi and gets frisky when he is drunk. I ride in the other cart. It is fine that he thinks my butt is cute when he gets loopy, but I want to think about other things, especially on my backswing.

Heh!

Trey

Galvanized said...

Doesn't the therapist whom one chooses seem simply like a matter of preference. It's a matter of in what vein you like to get your advice -- from a friend or someone who "has been there," or from an objective authority. Some look to the therapist as a confidante and even, in some situations, even a mentor, while others look to the therapist as an imparter of solutions, a better perspective. The relationship with a therapist is highly personal and a subjective role. Just as there are different types of professors, ministers, even parents, the role of therapist is no different, just a question of the best fit.

Galvanized said...

However, the role of a therapist is not as a commiserator but a facilitator of resolving personal problems. And the therapist, being in a professional and licensed position, must be objective and tolerant with regard to people of all races, ethnicities, religions, sexual orientations, and of both sexes. There can be no "isms" at work in a therapeutic relationship.

TMink said...

Galvinized, I think you are right that we should refer out the people that we cannot help due to personal issues or history.

I think it is folly and narcissistic to think that we can be free of them.

Trey

Momentary Madness said...

Who was it said: fools deserve each other, and by this they will learn or discover themselves; drinking down to the dregs of their disorder.

Steven said...

You have a nice blog.Author and licensed counselor, David P. Diana, just released a fascinating eBook called “Change Therapy”. Once you dive into this collection of articles you’ll never look at the mental health profession the same way again.
http://www.davidpdiana.com/about-2/change-therapy-e-book-download/

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