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On being a politicized practitioner
By Rahim Thawer, MSW
Agree or disagree:
If a client brings up something political, it’s our job not to engage.
This is one of many questions I’ve posed to social workers, counselling students, and psychotherapists in my workshops across Canada and South Africa. People have strong feelings about politics and
whether or not they belong in the clinical space. Some suggest it’s our role to be engaged in current political discourse and prepared to engage with the topics brought forth by our clients. Others argue that we have to work hard to maintain and “hold space”
until there’s an opening to explore the personal impact and emotional consequence of what’s being shared. Relational therapists, whether Gestalt or psychoanalytic, would infer that the client brought this topic up
because of the very people that are in the therapeutic relationship — that
it’s part of the `relational field’
or the transference — and
therefore cannot be seen as merely incidental to treatment.
I invite you to read the remaining multiple-choice questions from my workshop surveys and consider how you might respond. Reflect on whether or not your position on each question has evolved since your
initial clinical training.
How do you understand the value of `self-determination’ in social work or psychology?
a) Professional
How do you understand the value of ‘sex-positivity’ in direct practice?
a) Professional
How do you understand the value of being `pro-choice’ in direct practice?
a) Professional
If I’m working at a community organization that serves people living in poverty, my work is:
a) Professional
If I’m working at a community organization to support people living with HIV, my work is:
a) Professional
There’s a new addition to your outreach or clinical team. Your co-worker says to you that she only got hired because she’s a woman of colour. You are likely to:
a) Say nothing
You’re in a consultation meeting and a colleague says, “I have an attention-seeking female client that wants to use male pronouns.” You are likely to:
a) Say nothing
If a client brings up something political, it’s our job not to engage.
a) Agree
If a client were to say, “It’s hard for me to find work because there are too many immigrants willing to work for less,” I believe:
a) This is within my scope to address/explore
If a client says, “I feel like I’m treated differently at work as a Black person,” I believe:
a) This is within my scope to address/explore
A client says, “My eldest child is having difficulty. Her teacher thinks the cause is ADHD, and they want to put her on medication. I’m worried.” I believe:
a) This is within my scope to address
Overall, I believe my professional work is political.
a) Agree
Reflect on your responses overall. Is your work ethic more or less political than you might have initially thought? What are the nuances that came up when you considered your responses to these questions?
Our clinical approach and appreciation of the scope of practice will inevitably be informed by our own social locations: age, race, gender, disability, sexual orientation, and class. As a result, different
emotions and intensities will be evoked in the therapist based on their own lived experience and political orientations. For example, when I circulated this survey, almost all respondents indicated they were comfortable with responding to the concerned mother
whose child is being evaluated for ADHD. However, when it comes to a client’s subjective experience of racial mistreatment, respondents indicated a range of responses, among them a feeling of being personally triggered. When the racialized therapist is triggered
in this context, it can lead to a range of trauma responses: over-identification in a fight response, redirection in a flight response, or dissociation in a freeze response. Most survey respondents shared in the discussion that they wanted to believe the client
at face value. Others stated the importance of maintaining some level of curiosity about the context and where the experience fits into individual behavioural patterns. This approach is absolutely okay (you’re not inherently `blaming the victim’ by being curious).
However, curiosity without the politicized lens about how racism operates, and more specifically how anti-Black racism operates, can instead be experienced as persecutory suspicion that works against the client’s interest.
Developing a politicized lens with clients at the centre
People want to talk about political events in therapy because they are directly affected by them in their daily lives. Climate crises, the cost of living, bodily autonomy, police brutality, and fears
of being stripped of constitutional rights — these
are but a few of many politicized issues that may arise. My social work training lends itself to an entry point that utilizes anti-oppression as a framework for interpreting these large-scale topics. Anti-oppressive perspectives dominate the political left
so clients who are culturally saturated in these narratives will need their therapists to help them separate a structural analysis from interpersonal dynamics; micro-aggressions from narcissistic injury; and historical marginalization from residual anger.
As therapists, we listen on multiple levels. In my own practice, I listen with a political ear, a psycho-dynamic ear, and a cognitive-behavioural ear, but also a Gestalt heart. These ways of listening
are what distinguish therapy from mere conversation. As a politicized practitioner, I notice that it’s harder for me to access my own empathy when a client seems to have a strong perspective that’s working against them. For example, I’ve had numerous clients
bring to therapy their charged positions on inter-community conflict, like publicly exposing a person who has caused harm (sometimes overstated as abuse), actively engaging in an internet war (phone in hand, Twitter feed open) during a session, or choose to
call the police on a neighbour in a community where the police likely aren’t well equipped to respond appropriately.
I can recall the tightness in my chest when a gay male client processed in therapy whether or not he would want to report HIV non-disclosure from one of his sexual partners (who posed little risk for
actual transmission to my client). Politically, I am firmly against the criminalization of HIV non-disclosure. However, I needed a way to access my empathy so I could also listen on other levels. I affirmed that summoning the state to intervene in his relationship
was an option but that I’d like to explore other parts of his experience. I asked about when my client’s anger actually began for the man he’d been pursuing. We identified that the problem was actually about the other man’s emotional unavailability which felt
cold before they even had sex. It turned out, this also mirrored the kind of coldness he experienced from his family of origin, particularly his father and older brother. This meant that the man he’d been pursuing for some time was triggering past interpersonal
trauma and leaving him anxious about the possibility of rejection or mistreatment. With this in mind, we considered if calling the police was actually about accountability from the sexual partner (again, who posed no risk to the client) or displaced anger
about longstanding mistreatment from the men in his life.
Moments like these challenge therapists to suspend their strong reactions and create a safe container for the issues that invite anger and distress. While a therapist can never truly be a blank slate,
the effort to maintain some neutrality and grasp for curiosity in place of a punitive response is important (and specifically our job). A therapist sharing too much of their own political analysis (too quickly, without exploratory questions) is poorly managing
their own countertransference. This response is a disservice to the client and the profession.
When it comes to politically-based countertransference, Spangler, P. T. et al. (2017) write,
We as psychotherapists are as subject to the political climate as any member of society. In managing any countertransference, gaining awareness is the first step, specifically by recognizing our
political hot button topics and the triggers for them. Are there particular topics that rile? Does denial of global warming or scientific methods in general set you off? Or are questions about voter fraud likely to be a focus of unresolved material? Whatever
the issue, awareness that it is a trigger is important, as is understanding the underlying source of the countertransference.
Consider a South Asian woman in her late 30s whose family migrated from India to Canada in the 1970s. She comes to therapy to talk about her anger toward her mother for being oddly competitive and mildly
narcissistic. Her therapist, also a South Asian woman, deploys her political analysis inappropriately by (unintentionally) siding with the mother and introducing the impact of migration and racism on the nuclear family. The client can access this kind of affirmation
and systemic analysis through community care. She needs her therapist to cultivate cultural safety by being aware of the trauma of immigration while also holding space for the anger toward the `bad mother.’ Being a politicized therapist isn’t about proving
to your client that you have a particular systemic analysis; rather, it’s about understanding the political context and intervening in a way that is meaningful for your client as an individual.
In cases where clients are immersed in the realm of the political, our task is often to hold space for the deep impact of both proximal and distal events, support psychological integration of the material
(i.e. facilitating somatic and cognitive metabolizing), nurture safety so that grief can be identified and expressed, and help our clients access a clearer mind as they proceed. Our interventions are individual and therefore limited. We know from our clinical
experience, however, that individuals who feel supported by their therapists can then participate more optimally in collective settings.
Vignettes, deconstructed
Conservative psychiatrist Dr. Sally Satel argues that anti-racism and critical race theory are “encroaching” on a profession that should be neutral and apolitical. I disagree with her wholeheartedly.
However, I do believe the following statement by Satel (2017) to also be true:
When therapists use patients as receptacles for their worldview, patients are not led to introspection, nor are they emboldened to experiment with new attitudes, perspectives, and actions. Patients
labelled by their therapists as oppressors can feel alienated and confused; those branded as oppressed learn to see themselves as feeble victims.
Nevertheless, I also cannot imagine a clinical assessment that is not grounded in a political context. Below I have provided a snapshot of four different clients I have worked with, followed by notes
on what a purely medical model and apolitical way forward might be. I then offer notes on the political context from my worldview and discuss my politically informed clinical approach with each client.
Client A
Snapshot:
Medical-apolitical approach:
Political context:
My approach:
Client B
Snapshot:
Medical-apolitical approach:
Political context:
My approach:
We explored the BPD diagnosis at length: “What does this label mean to you and how do you understand it? What do you think it summarizes about your past? What does it mean for you in everyday interaction?
In what way do the criteria of this diagnosis make you feel relieved and/or defensive?”
Then we addressed the function of alcohol and underlying anxiety. I worked to hold space for his paranoid thinking and the shame underpinning his narcissistic injuries, while also helping him see the
evidence of his own skills, talents and positive attributes that comprise his self-worth. We agreed there are times when he experiences anxiety more intensely or feels slights from other people more deeply than others might — that’s
the BPD at work. I didn’t dispute that micro-aggressions exist in his world (because I believe they do), but we talked about
how his reaction to them might be different given his baseline anxiety, frequent state of inebriation and early experiences of trauma. The politicized goal for therapy was not skills-based training (though I did refer him out to attend a group); rather it
was to neutralize the stigmas of his diagnoses, unearth the schemas following his sexual abuse, and as the therapist, offer “the gleam of the mother’s eye” (Kohut, 1971) that was never afforded to him as a child.
Client Q
Snapshot:
Medical, apolitical approach:
Political context:
My approach:
Client Experience 5: Client R
Snapshot:
Medical, apolitical approach:
Political context:
My approach:
I became a container for much of her dysregulation and anger. We slowly talked through the very things her other providers couldn’t: their concerns about liability, clarity about her surgical expectations,
the prospect of future mistrust, the consequence of not following a post-surgical dilation regimen. She asked me if I believed that people were “against her.” I said, “I have no doubt that you’ve been treated badly. I don’t share the view that everyone is
presently working against you. But it doesn’t matter because you have a right to surgery.” We also talked about the possibility that she will suspect her care team isn’t working in her best interests. The alternative thought we landed on was this: “Providing
me with good care is connected to their reputation so I should assume they want to do their best.” My drive to support this client was nothing short of political.
Politically-informed clinical inquiry
In their article,
Navigating the Minefield of Politics in the Therapy Session, Spangler, P. T. et al. (2017) discuss the concept of political cultural competence, particularly following the 2016 American election of Donald
Trump, which left the country divided: personal identities became about political affiliations. They state:
…few training programs address political affiliation as a component of culture or identity or how it may inform treatment or affect the therapy relationship. When clients bring differing political
views into the therapy room, it can cause us unease, a sense of not knowing the way forward. It requires us to bracket our views and our privilege and dive beneath political opinions contrary to our own to find the human being and the experiences at the source
of these opinions.
Review the case studies below. Each is written with the reader as the therapist. The clients either bring up something specifically political or their statements require the therapist to be politically
aware to some degree. I will provide some notes on the politicized layers of the case and then lead with a sample of exploratory questions that I hope will demonstrate political-cultural competence.
Case Study 1: Anil
This client is in his early 30s, racialized and heterosexual. He has been assigned to you for case management after being discharged from the hospital. He was admitted for severe alcohol dependency
that led to psychotic symptoms and a suicide attempt. To begin to work with Anil, you come up with a safety plan and harm reduction strategies. At the end of your second meeting, he shared that he doesn’t feel safe at home. When you probe further, he says
that his neighbours are a gay couple, and he believes they embody the devil and are using black magic to disrupt his sobriety. As a social worker and a queer person, you feel activated by this.
Political and conceptual notes:
· Anil could be unaware that I’m queer and he’s plainly homophobic.
Clinical inquiry:
· You bring up something interesting that we haven’t talked about. Can you tell me a bit about your spirituality and experience with magic?
Case Study 2: Karena
Karena is 28, female, and white. She has been referred to you through an employee assistance program. Karena works at a finance company and has been having difficulty focusing. Recently, she made a
series of small mistakes on an important client account and was reprimanded. She told her manager she was struggling. When you begin to work with her, you identify quickly that she is struggling with anxiety driven by self-doubt and an unsupportive partner.
As you empathize with her and begin to explore the issue, she states that her Black co-workers are very loud and disruptive, which makes it hard for her to do her job. You’re taken aback by this statement.
Political and conceptual notes:
· The client’s narrative is clearly informed by anti-Black racism.
Clinical inquiry:
· Can you share a bit about how you have fit into work and social situations throughout your life?
Case Study 3: Mubin
Mubin is a 38-year-old male, straight and single. This client self-refers to you for private therapy services (and you are a woman). He states that his last three relationships have failed and he is
feeling very frustrated. The first three sessions are fairly calm and he participates willingly and fully. In session four, you begin talking about jealousy. You say that it’s normal but can also be toxic. Mubin gets agitated and says, “You women always criticize
men, but what about when you cheat on men and treat us like garbage? My ex basically forced me to stalk her.” You take a pause and feel your heartbeat pick up pace.
Political and conceptual notes:
· The transference of `the dismissive partner’ began when he selected you as a therapist; this attack is an important re-enactment (though it might feel a bit scary for the therapist).
Clinical inquiry:
· I’d like to slow us down. We began by talking about you, and then it was suddenly about all women versus all men. Have you felt embroiled in a gender war of sorts? Tell me about when or where that
began.
Conclusion
Clients will seek out therapists based on their political stripes, just as they do for preferences of gender, sexual orientation, and race. This is absolutely reasonable. However, the presumption of
absolute value alignment is faulty. We cannot reduce people to their social locations of race, gender, class, sexual orientation, or disability. No one is just that one thing. But as therapists, we also have to be ready to engage with the politics of identity.
Clients will inevitably bring politics into a session and we have to decide how to manage it. Being able to identify when you’re feeling triggered or defensive in response to a client’s statements is an important step toward successfully moving through the
therapeutic process. Most of my therapy clients have scanned my social media profiles before contacting me. They know when to opt-out. Someone who is staunchly Zionist likely won’t want to work with an anti-apartheid therapist like myself. Having spent hours
examining such a case in my own clinical supervision, I know that my countertransference may render me a poor match for this type of client. But make no mistake — they
also deserve mental health care. And, if they wanted to work with me it would be my responsibility to sort through the conscious and unconscious dynamics at play.
Social workers and therapists are doing political work on an individual level. Conceptualizing our practice as political doesn’t mean we need to express political opinions. Rather, our politics get
expressed in the way we do our work with clients (Sharma, 2019). Clients are presenting problems that often have political roots — we
must be conscientious about when it’s appropriate to explore the symptoms, the environment, or the political context.
The politicized practitioner is not morally superior or always right; rather, they are aware of their politically-based countertransference while trying to access their own empathy. They know when to
seek supervision and they can appreciate that their worldview is constructed. As a politicized practitioner, I believe everyone deserves access to health care, which includes access to mental health services. In a world made up of oppressive systems, helping
and healing are both inherently political.
References
Satel, S. (2021). When Therapists Become Activists.
American Enterprise Institute,
www.aei.org/op-eds/when-therapists-become-activists/
Spangler, P. T., Thompson, B. J., Vivino, B. L., & Wolf, J. A. (2017). Navigating the minefield of politics in the therapy session.
Psychotherapy Bulletin, 52(4). Retrieved from
https://societyforpsychotherapy.org/navigating-the-minefield-of-politics-in-the-therapy-session/
Sharma, P. (2019). Should therapy be political? Influence of social factors on mental health may make a case for such an approach.
Firstpost.
https://www.firstpost.com/living/should-therapy-be-political-influence-of-social-factors-on-mental-health-may-make-a-case-for-such-an-approach-6942831.html
Further reading
Psychoanalytic
Theory and Cultural Competence in Psychotherapy
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