When Patients are Controversial

Awhile back, I was invited to be a guest lecturer in a colleague’s class. It was a group of budding professionals who were not going directly into the mental health field, but they knew they would encounter mental health issues. One particularly insightful student asked a question that provoked a lot of discussion. The topic has become no less relevant today. Below is the question and my response.

How do you not have your own opinion when discussing something controversial (e.g. abortion, sexuality, ethical issues)?

The key to answering this question is knowing your role. As a human being, I have thoughts, opinions, ideas, and reflections about many things. When my patients come to me for help, almost everything they say or do evokes some reaction for me. That reaction may be small, large, low or high intensity, and, at times, may cut to the core of my identity or values.

Approaching controversial issues is never about not having an opinion. On the contrary, what is most important is knowing with absolute clarity what your opinion is. The reason this is so vital may be different than what you think. It has nothing to do with how or if you share that opinion. Instead, it has to do with what you choose to do with it. As a psychologist, my job is rarely to coach, advocate, or advise my patients. Therefore, my opinion about their lifestyle, choices, ethics, etc. is only relevant in how (or if) I treat the patient. Put another way, my views and opinions are only relevant in determining if I can put the patient before myself.

For example, if a patient comes to me engaging in a behavior that I find morally objectionable, my responsibility is never (or at least, very rarely) to confront that patient or their behavior, nor to render my opinion about it to them. Instead, I need to be absolutely clear where I stand on the issue so I can make the most appropriate, ethical decision about treating them. So if my patient likes to hurt puppies in their spare time and is coming to me to be a better puppy-hurter, since I find puppy-hurting morally objectionable, I need to know this about myself very clearly. Again, not so I can chastise the patient’s desire to hurt puppies – this is not my role as a psychologist – but so I can tell the patient I am not the best practitioner for them and refer them elsewhere (to someone more sensitive to puppy-hurting).

This example may seem a little silly and extreme. Perhaps most psychologists and others would just confront the patient in such a socially unacceptable behavior. But don’t miss the point. In an era where there are many controversies that are polarizing us, it’s not difficult to imagine a patient bringing or representing one of those. For example, imagine how you would react if one of the following presented for therapy:

  • Formerly incarcerated child sex offender
  • A person who manipulates vulnerable women for sex
  • Someone who embezzles money from a poor, nonprofit organization
  • A person with very outspoken racist/sexist views
  • Someone who takes inappropriate photos of unsuspecting victims
  • A person who is very proudly on the opposite side of the political spectrum

This list could go on and on. In each, your personal disagreement with the patient’s objectionable behavior should not result in a confrontation (save for a legally or ethically required report), but instead, a friendly and professional conversation and then a referral. If you cannot sufficiently set aside your own views, feelings or opinions on the matter, you are likely to do more harm than good.

My role is always and only to focus on and help the patient. My opinions matter only insofar as they impact my ability to fairly, objectively, and ethically help my them. If my opinions interfere with these abilities (as is the case in morally objectionable or controversial matters), then my obligation is to not treat that patient. The APA ethics code is very clear about this. Psychologists are to avoid harm, know the boundaries of their competence, recognize when personal issues may interfere and assure patients are not lost in the midst of any of these issues. In short, the patient comes first.

As you can imagine, even in cases where our beliefs clash with those of our patient, it is not always as easy as referring them away. As such, we may end up treating someone who is living a life and/or holding a fixed belief that we find objectionable. In these cases, as I stated above, confidently knowing where I stand is of the utmost importance – perhaps even more so with cases such as these. The reason is that I must hold true to my beliefs, ethics, and morality. Pragmatically, this means that while my patient may be engaging in morally/ethically objectionable behavior, I cannot permit myself to passively or actively, implicitly or explicitly reinforce, advocate, or suggest agreement with their choice/lifestyle. This can be a very thin line and a slippery slope. The bulk of this battle is fought in my own mind over what I can and cannot, will and will not say.

Now, just in case your mind was not already reeling with all of this philosophy, here’s a little more to bend you: All of this applies even when your opinion is congruent with your patient’s!! Even when you find their choices, politics, lifestyle, etc. desirable and appropriate, your opinions are your own and have nothing to do with your obligations and responsibilities to your patient. There are very few instances in which your affirmative opinion should be offered to the patient. This is a dangerous step in the therapeutic relationship toward the patient doing what I want them to do or what I feel is best for them. If I am passively or actively affirming behaviors, etc. that I personally agree with, while discouraging others, I am losing my objectivity and have put myself, my views, and my opinions before my patient.

In those cases where a patient asks me directly for my opinion on a matter, I must very cautiously weigh the impact of my response. When this occurs, I am less concerned about whether the patient will agree or like my viewpoint on the matter, and more concerned with what my view/answer will do to the patient and, more specifically, to the relationship between us.

At the end of the clinical day, my obligation and responsibility is to my patient. It’s not about me – even when it’s controversial or rubs me the wrong way. It’s still not about me when I think my patient is on the right side of a controversial issue and is being a crusader for a cause I support.

In 2020, this is issue is getting more complex. Although the Ethics Code is fairly straightforward about competence and assuring no harm to our patients, some laws and changing social customs may make referring patients out seem discriminatory. Put another way, it’s possible in this day and age to be accused of or sued for discrimination for engaging in the ethical requirement of referring a patient you cannot treat based on personal objections. This is a difficult territory to navigate, as many ethical issues are. Nevertheless, the patient still comes first and it seems to clearly be the right thing to assure they get an objective therapist who can provide the best care.

We are human and always will be. The problem often is that our patients do not give this much thought. They see us as a job, a title, a role – not a person. Thus, since our obligation and responsibility is to the patient’s well being – at all costs – we allow them to view us in this way for their benefit, even if at our own loss. What you (and I) need to weigh, is how much loss we can – morally, ethically, and personally – afford to endure before we have compromised the truth and reality of who we are as a person, professional, and human. It is never appropriate to use the therapeutic relationship to work out this conflict. It is your professional and personal battle. If you are struggling, it’s time to seek consultation and/or supervision to get some clarity.

If you’ve done well, your patient will never know how hard you worked (on yourself) to help them.

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