Wednesday, August 27, 2008

Things to Ponder

I've decided to start a series of thought-provoking (I hope) scenarios. These aren't real patients, they're just food for thought. Please chime in.

So how much should one psychiatrist say to his patient about another psychiatrist? Here's the specifics-- a patient wants a referral for her friend. The friend is having difficulties related to his sexual orientation and the patient asks for the name of a gay therapist to give to her friend. She's only asking for a name, nothing about insurance or the specifics of any mental illness. Is it okay for the psychiatrist to give her the name and phone number of a gay psychotherapist to give to her friend? What are the assumptions that are being made here and is this a reasonable thing to do?


Unknown said...

No, I wouldn't do it.

I'd have the patient ask her friend to call me. I would get his contact information, then pass it on to the gay therapist to allow him to make contact.

Maybe I am overly cautious, but there is a small but significant fraction of the population which considers homosexual people as targets. I'd hate to be the one whose helpfulness and trust led to another assault or death.


Alison Cummins said...

The usual way to handle this specific situation is "I can't say anything about this psychiatrist's orientation, but I know she/he does a lot of work with gay people." Unless of course the psychiatrist in question is out professionally, advertising in the local gay weekly etc.

I'm not sure what "gender orientation" means. Gender identity? Sexual orientation? Because those are two quite different things. Many therapists are comfortable working on sexual issues with both straight and gay/bisexual/questioning people, whatever their own orientation - though I can see that someone would prefer a gay therapist who they could trust to keep neurosis and mental illness in separate categories from orientation. (Alternatively, one they could trust to thoughtfully link an individual's sexuality and other problems without interference from disgust or prejudice.)

However, transgender struggles are a different kettle of fish. Most therapists - straight, gay or bi - are not prepared to accompany someone trying to understand their own gender identity and would have little to bring to the encounter beyond a good listening ear. In that case you could say you would ask around for someone experienced with a trans clientele, and would it be ok if that therapist weren't gay? And I would take it as a teachable moment to explain the difference between sexual orientation and gender identity.

*** *** ***

"Gender" is not a polite euphemism for "sex." There are two words because they mean different things.

Sex is biological and is usually determined by looking at the shape of the genitals. In humans most people are either/or male/female, but a significant proportion are intersex. In the sixties and seventies most intersex babies were surgically "corrected" to make their genitals look either male or female (usually female) but since the late eighties there has been a bit of a trend towards waiting to see what the child grows up to want for themselves.

Sexual orientation refers to who you want to have sexual relations with. Most people prefer one sex or another. Other people are bisexual or place a higher priority on other qualities - for instance, they may prefer a partner with an ambiguous gender identity, or they may not care as long as their fetishes or paraphilias are being addressed.

Gender is a more global concept than sex. It includes biological sex, but also the meaning of that sex in a person's culture and the relation of the individual to their sex.

Gender identity refers to how one understands oneself. Most people understand themselves as being the gender associated with the genitals they were born with. For other people it's more complicated. Some people completely identify with the gender usually associated with genitals they do not have. Others identify with a multilayered persona, for instance a stone butch or a drag queen. Most gay, lesbian and bisexual people have very straightforward gender identity: it matches their genitals in a very simple way, just like for straight people.

Dinah said...

I was thinking sexual orientation, so I changed it. It's not a real person, so if it's a transgender friend or a gay friend.

Advertising is an interesting issue, people 'advertise' in different ways.

What if the patient's friend wanted a referral for a therapist of a specific gender (oh, say a woman) or a specific race, or someone who speaks his native language, or someone who understands the subtleties of his religion? Would that be different? Some people can't help but advertise their pasts-- say a therapist who wears specific religious garb, or one with an obvious physical disability (like being in a wheelchair).

Awake and Dreaming said...

I know as a social worker what I'd probably say is something like this.

"I can give you the names and numbers of some people to give to your friend. These are people who have experience working with sexual and gender identity issues. Just because a therapist is gay, doesn't mean that they'll be the right therapist for your friend. There are also some resources I can give you to give your friend in the meantime. Here's the number for (insert organization) they may also have some recommendations."

Then I'd probably try and draw the conversation back to them.

Alison Cummins said...

Right, some people are out professionally as straight, for instance, and some are not (no family pictures, remove wedding ring in the office). If someone asked for a reference to a straight therapist, my understanding is that the appropriate answer would be the same: "I can't say anything about this therapist's orientation, but I know she/he does a lot of work with straight people." Unless the therapist were out professionally as straight, which many are.

From my point of view it gets weird when you're talking about talk therapy because some therapists get really excited about transference and like to leave everything open. If we're talking about accountants or personal trainers - no problem. If the person is out, they're out. You want to patronise a gay-owned grocery store? Sure, right over there. You want a lesbian gynecologist? Sure, I totally get it, I see a nice one at this clinic. But therapists? Some want to be able to have the "What would it mean to you if I were straight/gay/married/Jewish?" conversation and keep it all about the client.

Anonymous said...

Today I saw my first psychiatrist ever (this could be the subject of whole other post). I was referred by my doctor for an opinion and treatment plan. The pdoc’s view was that I needed a combination of meds and therapy and I should see a psychiatrist to ensure an integrated approach to care. The psychiatrist who was male said he was able to do this. However my preference was to be referred to a female psychiatrist because of a past incident of violence involving a male perpetrator. As Dinah has commented, in this case the “advertising” was obvious and so made my decision making somewhat easier. From a patient/client/consumer point of view, being comfortable with the therapist is paramaount.

Anonymous said...

While of course you wouldn't want to out anyone, I think the idea of referring someone to a specific type of therapist that they're more comfortable talking to is totally fine. I personally don't buy that the therapist is a completely neutral party. It's a great image, but life doesn't work that way--we all have our biases and perspectives.

My experience is with religion. As a patient, I have found that religion was looked down upon by a therapist I talked with. I was getting attacked at my church as not being a Christian because I was depressed (really helpful, eh?), and the therapist I was talking to was so negative about the church, situation, AND religion that it was not a topic I could talk about with her.

If I'm trying to live my life by what I think is a specific objective truth that you don't buy or even know much about, why would you be the best person to talk to?

I made sure that with this go around with depression that I found someone who would be at least spiritually sensitive. How could you do that if no one was willing to use labels for therapists?

Anonymous said...

One has no right to pass on personal information about other professionals, without their explicit permission.For me it is as black and white as that. With your patients permission you can discuss this with the other 'gay'professional and leave it in their mutual hands as to what is done.

Alison Cummins said...

anonymous 2:

Does this rule of No Personal Information Ever hold for straight professionals as well? What if someone wanted a marriage counsellor who was married themselves - would it be ok to give names of married therapists?

What about someone who wanted their child's pediatrician to be a parent? Would revealing a professional's parental status be unethical?

Or does the No Personal Information Ever rule just hold for slimy, shameful secrets like a deviant sex life? Because for most people, including lesbians and gay men, their life partner is not a shameful, slimy secret.

Anonymous said...

Alison said: But therapists? Some want to be able to have the "What would it mean to you if I were straight/gay/married/Jewish?" conversation and keep it all about the client.

But shouldn't therapy be about what the patient/client wants and needs? It sounds like, in this scenario, the prospective patient is looking for someone who can relate to the unique experience of being a gay male in America (not that the experience is the same for everyone, by any means). Maybe the patient needs someone who is a little more comfortable with appropriate self-disclosure, rather than simply a mirror for the patient to project fantasies onto?

It seems that an alternate approach might be for the original psychiatrist to tell her patient she'd like to give the issue some thought, then call and consult with the referral she has in mind and see what his feelings are?

Around here, we have MHP who specialize in GLBT issues, and this particular psychiatrist may or may not be one. If not, he may be a good resource for referrals to someone who is more appropriate for the gay friend.

I hope that made sense... thanks to reading the Shrink Rap archives, I'm still on my first cup of coffee.

Anonymous said...

Edit: mirror s/b "blank slate."

Alison Cummins said...

Most recent Anonymous: yep. I don't happen to like therapists who do the transference/mirror thing. I've seen a couple and they both made me worse. They say it's about keeping the focus on the client, but in my experience it was about keeping all knowledge with the therapist. (One, when asked directly what her role in therapy was as a therapist, would not answer more than "I'm here to help you." When I asked whether that meant I could bring my mending to the office and she would do it for me, she looked blank, blinked, and repeated that she was "here to help me." But she refused to explain how, or say anything about what therapy was or what I could expect to get out of it: that was for me to figure out.

But if that is the kind of "therapy" someone practices, then there's not much point in referring someone to them on the basis of who they are. (In my opinion, no matter who they are, they are going to do more harm than good anyway.)

If someone is gay and practices appropriate self-disclosure ("is out professionally"), then go to town. Refer all you want. Still Dreaming's answer is excellent.

But if they do not practice appropriate self-disclosure ("is not out professionally"), then it wouldn't help anyway.

*** *** ***
RE advertising: it happens at different levels and can lead to miscues. Some really very nelly men are straight. It can get awkward. Lesbians are easier for me to identify: they hold my gaze longer than straight women do, because women are interesting to them. If you know a therapist well enough to know their orientation and to know what kind of therapy they practice, then you can judge on that basis whether it makes sense to refer them to someone looking for a therapist who shares their orientation.

Anonymous said...

wow, someone can id lesbians because they hold their gaze longer since they are interested in women.i am fascinated by women for reasons i don't need to get into but i am not attracted to them sexually which would would be key in determining whether or not i was a lesbian.
that is off topic though. we all read of people who get married and then years later it comes out that they are gay so plenty of people pass for who they are not and it isn't necessarily anyone's business.other people are members of one faith group and then convert for various reasons. people also have operations to change just about anything possible.all been careful when you put in an order for a straight female catholic therapist;you could end up seeing the same person in a few years just as a gay male jewish therapist and if they are any good at what they do, you won't care.

Anonymous said...

Would say no, he or she is probably way over 18 years old and old enough to decide for himself and look for a therapist,
regards Dr Shock

Anonymous said...

"What are the assumptions that are being made here and is this a reasonable thing to do?"

The answers are all very interesting but......

Assumptions? Whose? Ours as people responding to your scenario? The initial shrink? The patient? The friend? The to-be-referred-to shrink?

You used gayness as an example but was the real question whether personal experience of a situation means that the shrink is better "qualified" to provide support? How important is empathy?
And if, as a professional body of people you don't consider lack of either to be a hindrance, then how does that sit with the perception by some (many?)patients that theoretical knowledge is not enough?


Gerbil said...

If I were the psychiatrist, I would first ask the patient whether her friend knows she's looking for referrals for him. Regardless of her answer (which might spin off into a conversation about her desire/need to help others), I would actually provide her with some names of colleagues.

My reasoning: if I feel confident in these colleagues' skills as clinicians, I probably know them well enough to know whether they're out to their clients. I'd never refer anyone to a provider I'd never met myself. The very act of providing the referral implies that I know this person is a capable clinician.

I might also recommend that my patient's friend check out any local LGBT therapists' organizations (which some large cities have), and/or resource centers. Unless I am in a capitated practice (which wouldn't matter in this case anyway, as the friend isn't my patient), I give multiple names anyway--to avoid implying that only this one person can help.

Doc said...

I have made referrals to current patients in similar circumstances. For those cases, I think the safest and easiest thing is to discuss any potential referrals on the basis of personal status with the professional. Just because a professional is gay, married, or a parent, does not mean that they wish to have a specific referral. Some prefer not to have referrals under such requests.

Also, this is a request for recommendation on the basis of secondhand information. Why would we assume that a referral to a "gay" psychotherapist would be appropriate?

I try not to make specific recommendations for "friends" beyond "they may wish to speak with a (medical, legal, psychological) professional."

Anonymous said...

I would ask myself, as the referring therapist, why am I hesitating to refer someone to an out gay or lesbian therapist if that's an identity factor the person is explicitly seeking? If the therapist isn't out, then it would not be my business to out him or her.

btw - I love the concept of presenting scenarios to your readers. Thanks for doing so.

Aqua said...

I am an example of how a patient may not really understand that in therapy having someone who is just like you as your therapist, may not be the best fit.

I always saw female therapist, because I was certain a man would not understand, that I could not talk to a man openly, and that I simply preferred therapy with a woman.

My psychiatrist now is a man, and he has helped me immensely. We have been able to challenge many of my difficulties, past and present with men, in the here and now of the therapeutic relationship. It really has opened my eyes to being more open about who I seek help from.

I now believe it is not the gender, or the sexual orientation, or anything except whether or not the therapist is competent, intelligent, non-jugemental, accepting, patient and truly caring and compassionate; and of course also, that the patient feels confident, comfortable and safe opening up and allowing themselves to be vulnerable and open in their sessions. Trust is so important to therapy.

Anonymous said...

Wow, I must be from a completely different background and area. It had never occurred to me that anyone would ask for names of gay therapists to target them.

I've also found that it's incredibly hard to find a compatible therapist, and recommendations (with a couple of personality descriptors for each possible therapist) from a friend's existing therapist is an incredibly useful resource. Picking names out of an insurance company's directory just doesn't cut it, even if you can search for areas of specialty. It's perhaps worse than going on blind dates, because you're then out $100-200 in addition to an hour of your own time.

Yeah, don't "out" therapists who aren't professionally out. Give names of one or two you know who are generally good and "out," as well as one or two who are good and work well with issues of sexual orientation. I don't understand why this wouldn't be the obvious thing to do, if the patient who's asking seems to be asking in good faith for her/his friend.