Sunday, November 28, 2010

The Ethicist On Whether Shrinks Should Lie to Keep Their Clients

I hope everyone had a wonderful holiday! We've been busy brining, basting, baking, eating, and visiting with family. Sad to go back to the daily routine.

In today's NY Times Magazine the ethicist entertains the question of whether it's okay for a psychiatrist to lie to keep his clientele. (!)

I am a psychiatrist who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another psychiatrist. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?


If you want the ethicist's answer, check out the column here.

I think that most of us would agree that it's not okay to lie with the intention of keeping business. What if a patient asks how long you've been practicing, and your sense is that the patient wants an experienced psychiatrist-- would it be okay to say 10 years, rather than 1 year? Clearly not.

Personal questions can be awkward, however. In traditional psychodynamic therapy, the therapist doesn't answer personal questions---the "blank screen" is necessary for the treatment, and the meaning behind the question is explored. This can be very off-putting to some patients, and for myself, I find that it feels disingenuous, and I prefer to simply answer questions. It helps that I don't get many questions: Do you have children is the most common, I've been asked my religion a couple of times, if I have a dog (Yes, two, would you like one?). Here and there, I've been asked rather unusual questions (Do I have a cook? Who has a cook? No, but I'd like one!)

It seems to me that if something like this is essential to the patient's comfort level, then they should ask this on the phone before the first session. Does it all matter? Who knows---they make good therapists in all shapes and sizes and the interpersonal fit often is found in the least expected place. And my guess is that the ability to accurately diagnose and treat a mental illness has relatively little to do with any of these matters. Probably people are more picky about the personal lives of their shrinks than their brain surgeons, but maybe they shouldn't be.

Related Posts:

Self Disclosure and Being Genuine

A Shrink Like Me


Anonymous said...

The ethicist was bang on.
If I needed a brain surgeon, I wouldn't wonder too much about his or her personal stuff. If I am going to sit in a room with a shrink talking about my personal stuff, chances are i will wonder sometimes where they stand on certain issues or what their background is . That doesn't mean every question gets asked and not every one that is asked requires an answer. Sometimes I wonder things that I honestly would not want the answer to.

Sarebear said...

For some people, namely me, I guess, not that I've asked him whether he believes in God, but I know at least that he USED to be my religion, and that I only know because he wrote a book once on depression aimed at it from the perspective of the particulars of how LDS people tend to THINK; he was ahead of his time there, in the LDS book market, and I've wondered sometimes if how it was received may have led to his leaving the church or anything, but that aside, I'm pretty sure that he's now NOT LDS because of little details I've gleaned from when he chooses to tell a story to illustrate a point, like the rare time I was there on a Monday, in a story of his it came up that he had gone to Yoga the previous day, twice. An LDS person wouldn't do that, on a Sunday. They might do it in their house, but they wouldn't go to the gym. An active LDS person wouldn't, anyway. It actually was one of the most jarring things, later that day when I realized, wait, I was here on a Monday, that means he was PROUD of having done that stuff on a Sunday, it was really wierd to me (wasn't judging him, it's just not what I would do, and since I feel like he understands my value system, to have something contrary to it come up was wierd. It was fine, and not judging him no matter that it sounds like it! I know it's more that the feeling out of sync with our usual "togetherness" in therapy, in the therapeutic relationship, our "partnership", I think, is what this pointed out for me; it made me feel more separate from it.)

Um, I've rambled. Lol. It all is on subject though, sort of! (cont)

Sarebear said...

What I WANTED to say was that I suspect some people want to know of their therapist believes in God, so that when they start to talk about spiritual stuff, they'll feel like their therapist has a frame of reference, even if it's a different spiritual set than their own (for someone like me who can recognize that it doesn't need to be the same beliefs for people who have spiritual experiences to have some understanding of each other's feelings or some commonality of what that feels like to them), they'll feel like their therapist can empathize better, they'll feel like their therapist can understand them better. Now, I'm not necessarily saying a therapist HAS to believe in God for these things to be able to better happen in therapy, I'm just saying that this may be how the patient feels.

I know I feel that, knowing that my therapist at least once had spiritual beliefs, gives me a sense that he'll understand what I'm talking about. More specifically to me, knowing he was once LDS, even though he hasn't said so, (well he sort of has, because in talking about the temple, and how nervous I am about going eventually (I'm a bit unusual for a married person in that I haven't been yet, we were married in a civil ceremony), he told me that there's nothing to worry about in there, he reassured me), lets me know that he will understand specific ISSUES like when I talk about how terrified I am about going to the temple, and that he'll understand about not talking about the specifics of what goes on in there because it is too sacred (he didn't mention specifics, just reassured me about it), and that he'll understand other LDS cultural issues like well he made the joke recently about how they say there's supposedly no boring speakers in church, only uninspired audiences, which made me laugh, because High Council members are notorious for being boring . . . heh, then again mebbe I'm uninspired, lol.

Sarebear said...

Because, in contrast, when I say that I feel someone with very different religious beliefs, we can still have a common understanding of spirituality and they can understand me better, if they have some kind of belief, as opposed to being an athiest, well my psychiatrist is Buddhist, and I'm Mormon. That's rather different, lol!

(I've never wondered before now if I would or could see a mental health professional who is atheist, and for me, the answer is No. I may have to think and write further on this, although it may come simply down to having been raised, told growing up so much that psychiatry can really mess with your head, it's not like it came up ALOT, but I remember it. I also suspect that most Mormons would answer no to the question of would you see a mental health practitioner who was atheist, but that's just a wild guess; I don't speak for the religion or its membership or know, just thought my feeling on that would interest you.)

Sorry for so many posts, at least for once I was on topic!

Sunny CA said...

I have wondered about the religious belief question and asked my psychiatrist about it about a month ago. I did not directly ask him if he believes in God (though I do not think he does), but as an atheist myself, I frequently say nothing in social situations when religion comes up. I wondered how he handles it when religious clients bring up spiritual issues. His response was that in Berkeley, CA just about everybody is an atheist so it is a non-issue for him. Yet, a friend of mine's belief system is so different from mine that it is an issue between us at times. As a follower of the book, "The Secret", she believes that any person can materialize what they want by thinking about it. She wants to own a house, so she thinks that by thinking positive thoughts such as "I have a house" stated in the present tense, she will suddenly have a house materialize in some way (such as by inheritance or winning a contest). Hence she will say "I lost 20 pounds" in conversation to me which has nothing to do with her having lost weight already, but is her way to bring "positive energy" about weight loss "into her environment" so she can lose 20 pounds effortlessly in coming weeks. She is not "nuts", she just believes intensely that believing something is so, will make it so. It becomes annoying to me because when I was job hunting for a teaching job and not getting one she said it was my fault for not thinking positively enough, (not the fact that 20% of the teachers in my state were laid off this year). If I get a cold it is because I had negative energy that brought the cold to me, not that there were 6 kinds in my classroom coughing on me. I have wondered how a psychiatrist would deal with a patient that will only say what they WANT to be true, instead of what IS true because of their belief system. The other stance I find difficult to handle as an atheist is the often said and widely believed "It is God's will". So when I was job hunting a friend would tell me that "If God wants you to have a job you will get one and if you don't get one that is God's will". I believe in personal effort, hard work, and doing our best and that there are sometimes circumstances beyond our control. I DID finally get a job, but in my perspective it was because I had not settled for just a biology credential, but I went ahead and got credentialed in chemistry, earth science, general science and foundational math. My current job I requires me to teach high school physics, chemistry, biology and earth science, so it is not a job that everyone would consider a dream job, but I am working. I still don't think God had anything to do with it, but the fact that I applied for about 40 jobs and got way more credentials than the average person, and researched possible interview questions and prepared answers, plus brought a portfolio that I worked on all summer were the factors.

Anonymous said...

My shrink has certain political views that I do not share. We come from different cultural backgrounds and religions. My shrink is also one of the most ethical and intelligent doctors I have ever met. That's where it begins and ends for me.

Unknown said...

I have found that the actual answer about the particular detail of the psychiatrist's life is less important than the reason the patient asked.

Usually all these questions boil down to one: "Can you understand where I am coming from?"

Sometimes I say, "I would be glad to answer." Then I do. And then I sometimes ask, "Can I ask you why now?"

Inevitably there are consequences.

Some patients have told me that the new information makes them more or less reluctant to discuss certain subjects because of assumptions they now make about me.

moviedoc said...

I wonder whether Dr. Gabbard, a psychoanalyst I believe, made it clear in his response to the ethicist whether he was referring to the ethics of psychodynamic/psychoanalytic psychotherapy, or the ethics of psychiatry. What may be unethical in the former might be ethical in the latter.

tracy said...
This comment has been removed by the author.
moviedoc said...

Nor must one open his mouth to speak true or false: By wearing a ring on that certain finger, or not, the psychiatrist tells the patient either "I am married." or "I am not married." If psychoanalytic/psychodynamic psychotherapists really want to maintain that blank slate, they must wear gloves.

Alison Cummins said...

Wearing a ring says they are married. Not wearing a ring usually says they are not married, but I am legally married, live with my beloved and don't wear a ring. It isn't anyone's business.

Anonymous said...

He's practicing in the Woodlands. What does he expect? It's an area of Texas that is very conservative, lots of evangelicals, people do tend to have a little more money there so maybe that's part of the draw. I would think his name alone might tip people off to the possibility that he might not be Christian.

I grew up in the Bible Belt and I saw a psychiatrist (once or twice) who had a giant and I do mean giant cross over the front desk. I consider myself Christian but that was a tad bit overkill to me. The receptionist even commented one time that it was National Prayer Day or something or other. I was a little freaked out by the overt religious stuff going on in the psychiatry office, even being Christian. That was one of the main reasons I didn't continue with her. There were probably a lot of patients that liked it, though. You can't please everybody, and it's not always a good fit.

As for the wedding ring, I know a couple of therapists who wear rings even though they're single to discourage any hopefuls. Conversely, I had a male psychiatrist who wore a ring sometimes other times not. He told me and other female patients he was divorced even though he was really married because he was trying to score a date. So, I guess you don't always know the truth on that one.

Anonymous said...

I have a divorced friend who wears a ring on the wedding ring finger. I am married and often do not wear my ring.
A Jewish name does not always mean one is a Jew. Many practising Christians have Jewish names because they had a Jewish father. Many Jews are atheists and that holds even if they have menorahs or other things in their office. They could also be Messianic Jews, which is to say they are by definition not Jews by virtue of their acceptance of Jesus as Messiah. Judaism may be a culture/tradition one is part of while rejecting the religious aspects.

tracy said...

Anon and others. i did i know that somehow, some way, that post would get me in trouble....? Story of my efffing life.

But at least have the courage to post with a name.

Anonymous said...

What's in a name? How many people here post with a real name and if I posted under Andy or Bart or Sleeptite, could you find me, and for what purpose? Name or no name, pretty much all posters are anonymous.

Lucas S. Draganovici

Anonymous said...

Lucas S. Draganovici

Is that better than anonymous?

Anonymous said...

As other people have mentioned, this is an issue that tends to be more "can you understand me?" or "are you going to misinterpret what I say?" Religion is an issue that a lot of people end up thinking other people are crazy over. This ends up seeming very important to anyone who might consider mentioning anything of a religious nature to a psychiatrist. Statements like "I felt that God was speaking to me" are very common in many religious circles, and many people would be concerned that an atheist psychiatrist might interpret something like that as delusional, especially if they weren't familiar with that style of speaking. Some psychiatrists also tend to think that if someone hasn't planned something fully, they must be self-sabotaging, while most religious people tend to believe that they should leave room for God to direct their lives--the whole "manna in the desert" thing. (I've particularly noticed this on the children vs. career topic.)
Psychiatry is simply not like most medical specialties, in that psychiatrists have to diagnose based mainly on mental symptoms, which can be rather subjective. Religious views can significantly impact what beliefs, anxieties, actions, etc., seem appropriate and reasonable.

Anonymous said...

In response to those who commented that a name doesn't mean a person is of a certain religion. Of course you're right. That's why I was careful to say that his name might tip people off to the "possibility" he might not be Christian. It's a possibility not a given. Statistics being what they are, that was a possibility. So, if that's something that's a deal breaker I'm just a little surprised those patients made the appointment to begin with.

The psychiatrist I saw who had the ginormous cross hanging above the front desk, was from a country with a Christian population of about 2% (if you believe Wikipedia) so I knew before I met the psychiatrist there was the possibility she might not be Christian. It obviously wasn't that big of deal to me because I made the appointment. And, she was Christian.

I would be interested to know how the psychiatrist is so certain that the reason they did not return was because he told them he was atheist. Maybe they didn't like his bedside manner, the treatment plan, it was too far to travel to his office, they couldn't get off work, he didn't crack a smile, they felt like they were talking to the wall, or a dozen and one other reasons why people don't return. He might be making assumptions here that are not entirely accurate. Then again, his assumptions may be true. Who knows.

I would say I do disagree with him that his religious views are irrelevant to what he does. I didn't care if the psychiatrist shared my religious beliefs because I already had a therapist and I wasn't doing therapy with her. But, if I'm in therapy I want to talk to someone with a similar worldview for many of the reasons that Maggie listed in her post above.

Anonymous said...

If you want a Christian therapist or a Jewish one or a Muslim one or a Buddhist etc etc, or an atheist one, please understand that you are reading a whole lot into the religion thing and could be making some assumptions that are faulty. I would have to think that an atheist shrink would, if they were much of a shrink at all, make an attempt to be culturally sensitive and aware of the fact that not everyone is an atheist. Their job is not to convert you to their way of thinking or judge your religious beliefs but it is your job to help educate your shrink about the role religion plays ,or does not, in your life. My shrink is not of the same religion and somehow has managed to figure out how parts of me have been shaped by my experiences, religious and otherwise. Shrink also remembers when my holidays are celebrated. And, one person's brand of any religion is often very different than another's. If your shrinks is Jewish, there is no guarantee that they do not celebrate Christmas. Your shrink could be Christian and go to church for weddings and funerals or might be studying for the priesthood on the side.
Hitchens and Dawkins are not shrinks as far as I know.
We all want a shrink who will be respectful of our differences. Being of the same religion does not ensure you will not have differences.
Most shrinks specializing in geriatrics do not qualify as elderly yet but they do a pretty good job of trying to understand.

L.S. D.

Anonymous said...

LSD, I understand what you're saying, but some of my concerns were religious in nature and I couldn't very well get a Christian perspective from someone who wasn't Christian. It might not be relevant to some people, but it was relevant to me at that time in my life. Therapy is incredibly expensive, and finding a therapist with a similar (not identical) worldview was important to me.

I thought the psychiatrist who wrote in was going a bit overboard to be offended that patients preferred to work with someone who shared similar views. There are also going to be people who aren't going to see him because he's male and they prefer talking to a female. Others prefer to work with males. He needs to learn to accept that not everyone is going to want to work with him.

Anonymous said...

I certainly respect the need some may feel to have a therapist with a similar world view. I do think it is also possible to make mistakes about a therapist's world view just by taking their stated religion into account. For a long time I felt I needed a therapist of the same religion and I had one. This person did me a good deal of harm because they were a lousy therapist and no longer practising as a result. Next time around, it did not matter to me what religion the therapist was. It did matter that they tried to understand me. In the process, I got to learn a little about another world view and also how to describe my experiences to an "outsider". It stunned me that this therapist got it, but I do think that one sign of a good one is the ability to truly listen to people and to do so, sometimes put their own world view aside.

Anonymous said...

LSD, of course there are going to be lousy therapists and good therapists of any religion. For nearly any characteristic someone might have, there are going to be people who you like and people who you don't, people who are good at the jobs and people who aren't, etc. And it's never helpful to see a shrink who is just bad at their job. There's no way to "ensure that you will not have differences" with somebody else, there are always differences. But the fact that you saw a bad therapist of your own religion doesn't seem particularly relevant to the point of the validity of wanting to see someone who shares your beliefs in areas you consider particularly important.
I'm inclined to say that if a psychiatrist thinks that it's okay to lie in order to establish a therapeutic relationship, they're probably not someone I'd want to see, regardless of religion.
I would say that the growing population of people who call themselves "spiritual but not religious" could probably be considered "inter-religious" and don't usually have beliefs that directly contradict many religions. The psychiatrist who wrote that letter to the Times seemed to just hold contempt for religion, though. Besides on multiple-choice polls, describing one's religion doesn't tend to be a one-word thing. This doctor is severely underestimating what religion means to people, and how it affects them. That right there demonstrates to me why a religious person wouldn't want to see him more than just his self-identification as an atheist.