After what seemed like a period of relative national unity in the face of the COVID-19 pandemic, we now find wide cultural rifts emerging in the American landscape. As reported recently by CNN: 1
Divisions have emerged along a timeworn North vs. South divide, on ideological and geographical grounds nationally and within states, and on the level of respect accorded by political leaders to epidemiological science.
Furthermore, we have witnessed what the New York Times called “a rash of well-organized protests against state restrictions” in several U.S. cities, revealing that “not everyone is on board with the new, government-mandated limits on public assembly and economic activity.”2
Reports in the Times and other sources indicate that these protests are not of grass roots origin, but are driven, at least in part, by “An informal coalition of influential conservative leaders and groups.”3
According to Timothy J. Lombardo, Ph.D, a history professor at the University of South Alabama, these protests reflect “an underlying rage at elites, liberals, government, and the media that is part of a half-century tradition of right-wing populism.”4
It is not my intention here to dive headlong into the political fray or the “culture wars” that seem so much a part of American life these days.5 (Personal disclosure: I have voted for candidates of both major parties but consider myself progressive and left of center, politically). Rather, I want to raise the question of psychiatry’s role, if any, in dealing with the kind of rage and resentment that seems to underlie these anti-restriction protests. That said, as a physician and ethicist committed to ensuring the public’s health and safety, I can only deplore the lack of social distancing seen at several of the protests—virtually guaranteeing more cases of COVID-19 infection.
Psychiatrists and Politics
Psychiatrists, like other physicians, are not politically homogeneous or uniformly liberal or conservative. However, there is good evidence that most psychiatrists lean to the left on the political spectrum.6 Indeed, data from political science professor Eitan Hersh, Ph.D, and psychiatrist Matthew Goldenberg, DO, suggest that about 76 percent of psychiatrists who have a party registration are Democrats. In contrast, around two-thirds of physicians in surgery, anesthesiology, and urology who have registered a political affiliation are Republicans.6
How might the leftward political leanings of most psychiatrists affect their response to protests driven largely by conservative or right wing groups? And how might the liberal leanings of a psychiatrist affect their countertransference to, say, a very conservative or extreme right wing patient?
I am not aware of research that has examined precisely that question, and I acknowledge that terms like liberal, conservative, right wing, and left wing are open to various definitions. However, the research by Hersh and Goldenberg strongly suggests that the medical decisions primary care physicians make are indeed influenced by their political leanings. In their survey of 1529 physicians (with a response rate of 20 percent) in 29 states, after controlling for physician age, gender, and religiosity, the authors7 found that:
Political beliefs predict the professional decisions of primary care physicians. On politicized health issues, like marijuana and abortion, physicians’ partisan identity is highly correlated with their treatment decisions. Because physicians regularly interact with patients on politically sensitive health issues and because the medical profession is increasingly politicized (e.g., state governments are regulating politicized aspects of medicine), it is necessary to understand how doctors’ own political worldviews may impact their actions in the medical examination room.
There is also an intriguing literature suggesting that neurobiological factors may mediate or influence one’s conservative or liberal tendencies, in surprising ways. In a review of this issue, Mario F. Mendez, MD, Ph.D, concluded that:8
Neurobiological factors mediate where people fall on a general conservative-liberal axis that involves social, cultural, religious, economic, and other domains, as well as political ideology… Conservatism-liberalism is also associated with differences in personality, attention, memory, perception, emotional reactions, problem-solving, and response choices.
Mendez observed that “Political ideology divides people, societies, and nations, often with serious consequences.”8 Indeed, taken together, the findings of Mendez, Hersh, and Goldenberg suggest that a serious political mismatch between psychiatrist (or psychotherapist) and patient could lead to disruptions in the therapeutic alliance, as well as to strong transference and counter-transference reactions.
Navigating the Minefield
In a provocative article titled, “Navigating the Minefield of Politics in the Therapy Session,”9 Patricia T. Spangler, Ph.D, and colleagues raise just such a possibility:
In the aftermath of one of the most contentious presidential elections in recent US history, many of us have noted a marked increase in our clients’ expressions of anger, anxiety, and depression. At the same time, we have been challenged by managing our reactions to the election results and subsequent heightened societal tensions… Even if a client does not ask about our views, the books on our shelves or artwork on our office walls can reveal our values without us speaking a word. Within the current climate of general cultural divisiveness and mistrust, political self-disclosures—whether overt or unwitting—can potentially lead to ruptures [in the therapeutic alliance]…Although society has been growing increasingly polarized over the past two decades, the 2016 election was a tipping point for many. Until that point, unresolved anxiety about election results was not an obvious source of countertransference for most psychotherapists…
Sprangler et al. observed that “In managing any countertransference, gaining awareness is the first step, specifically by recognizing our political hot button topics and the triggers for them.” Ethical dilemmas may arise when a patient’s political or religious views are so deeply offensive to the clinician’s own that the therapeutic alliance becomes almost impossible to sustain. Sprangler et al. opined that “while we may not impose our own views, we must not condone others’ prejudicial activities. The dilemma arises when a client presents a bigoted view that is integral to the client’s political identity.”9
There are no simple solutions in such cases, though, ideally, the therapist can explore the roots of the patient’s bigoted beliefs and “provide data from the client’s own experiences to counter these views.”9
In the on-going crisis of the COVID-19 pandemic, psychiatrists are understandably focused on helping their patients deal with feelings of isolation, anxiety, and often overwhelming stress. And, to be sure, many of our colleagues on the front lines—especially in inpatient settings—are deeply concerned about their own health and safety as well as that of their families. Owing to the risk of contagion, telepsychiatry has now nearly replaced the traditional face-to-face sessions. It presents challenges of its own, as when treatment calls for monitoring the patient’s vital signs.10
It may seem a bit of a luxury to begin an examination of our countertransference at a time when life itself hangs in the balance. Yet the recent wave of protests against pandemic-related restrictions should remind us that deep currents of anger and resentment are roiling the waters of American culture—and that we, as clinicians, may be treating patients whose political views make it very difficult to address their emotional needs.
1. Collinson S. Divisions on battling coronavirus deepen as Trump and Southern states push opening. CNN Politics. www.cnn.com/2020/04/22/politics/donald-trump-coronavirus-economy/index.html. April 22, 2020. Accessed May 1, 2020.
2. Russonello G. What’s Driving the Right-Wing Protesters Fighting the Quarantine?, New Yok Times. www.nytimes.com/2020/04/17/us/politics/poll-watch-quarantine-protesters.html. April 17, 2020. Accessed May 1, 2020.
3. Vogel KP, Rutenberg J, Lerer L. The Quiet Hand of Conservative Groups in the Anti-Lockdown Protests. New York Times. www.nytimes.com/2020/04/21/us/politics/coronavirus-protests-trump.html. April 21, 2020. Accessed May 1, 2020.
4. Lombardo TJ. The far right hates liberals, government and the media — and now, quarantines. www.washingtonpost.com/outlook/2020/04/21/far-right-distrust-quarantine/. April 21, 2020. Accessed May 1, 2020.
5. Peters JW. How abortion, guns and church closings made coronavirus a culture war. www.nytimes.com/2020/04/20/us/politics/coronavirus-protests-democrats-republicans.html. April 20, 2020. Accessed May 1, 2020.
6. Sanger-Katz M. Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat. www.nytimes.com/2016/10/07/upshot/your-surgeon-is-probably-a-republican-your-psychiatrist-probably-a-democrat.html. October 6, 2016. Accessed May 1, 2020.
7. Hersh ED, Goldenberg MN. Democratic and republican physicians provide different care on politicized health issues. Proc Natl Acad Sci U S A. 2016;113(42):11811-11816.
8. Mendez MF. A Neurology of the conservative-liberal dimension of political ideology. J Neuropsychiatry Clin Neurosci. 2017; 29:86-94.
9. Spangler PT, Thompson BT, Vivino BL, Wolf JA Navigating the minefield of politics in the therapy session. Psychotherapy Bulletin. 2017);52(4):20-25.
10. Brauser D. COVID-19: Dramatic changes to telepsychiatry rules and Reg. Medscape. www.medscape.com/viewarticle/927556#vp_3. March 26, 2020. Accessed May 1, 2020.