Tuesday, January 22, 2008

Leave your religion at the door?

I'm only writing this because I've done it myself. I'm guilty of it (well, not all of it).

I've let patients feel closer to me, better understood because we share the same Judeo-Christian values. That's not bad per se, but I think when it comes at the expense of someone else, it is bad.

It's a very subtle form of triangling and I don't think we, as therapists, need to triangle anyone, least of all someone's partner or spouse, mother or sibling, to have a good therapeutic relationship. Yet it's such a temptation.

Almost anytime a therapist disses someone else this process is probably insidiously at work.

Occasionally I'll get a caller looking for a frum therapist. Frum, in my world is a reference to religious observance. In this case, Jewish and Orthodox. This kind of call is really about the importance of ethnic and ideological values in people's lives.

People want their therapist to validate, not confront, their religious values. We all want a cheer-leader sometimes. We want someone who is culturally sympathetic when we talk about what bothers us.

A religious parent with a gay child, for example, does not want or need to be told, Hey, you're out of touch. Get with reality. He's not going to get married to a nice Catholic (Jewish, Baptist, Christian) girl. Lose the dream.

I actually don't think most therapists ever talk that way.

But I can see how a person might be afraid that we would. It's no longer cool to be homophobic. Heterosexism (the assumption that everyone is a heterosexual until proven otherwise) is a program that the American Psychiatric Association, American Psychological Association, and the National Association of Social Workers have deleted.

So our professional dogma, our authority isn't religiously-orthodox-friendly, exactly, and patients from this perspective might tiptoe carefully when choosing a therapist who will be emotionally supportive. One might even prefer to choose a professional who waves his or her religion like a flag, wearing their own personal orthodoxy assuredly. An organization for parents and friends of "ex-gays", Exodus International, has support groups and therapists who hope to change the sexual orientation of the conflicted many with love and twelve step programs.

It's not so farfetched that religiously orthodox patients worry that secular therapists might emphasize a modern agenda, not empathize with the pain of a parent, for example, who has to adjust to a child/spouse's sexual minority orientation. Or sexuality in general.

People worry about therapy hurting, sometimes legitimately. Hence that joke,
therapist = the-rapist.

These fears pop up over other issues, as well.
Pre-marital sex.
Abortion.
Intermarriage.

But despite what people think, it's not true that therapists will necessarily lack empathy for religious values that they do not share. Indeed, more "secular" therapists try even harder to understand languages that are new to them.

A good therapist will not preach liberal values or anything else, for that matter. Psychoeducation is not thumping a bible. Nor is it thumping a text book.

So the best way to choose a therapist is not to seek cultural sameness and the hope of shared values. What people really need to look for in a therapist is someone well-trained in the craft.

(So sure, get even more training somehow along the way, go beyond that masters. You don't have to get a PhD to get certification in most subspecialties.)

Someone who is well-educated, who keeps up with the profession, who has empathy, good diagnostic skill, and heart will take you where you want to go.

A good therapist knows how to zero in on the pain and knows whether or not to discuss it. The patient isn't supposed to be zeroing in on anything about the therapist, particularly, not the doc's religion, not the doc's shoes. The patient should be looking inside.

(It's why I personally don't wear much jewelry or loud clothing, you know, always an excuse for people to skip topic. I love your sweater, a present? And it's why I don't want to talk about Chanukah or the other Jewish holidays. )

Let's talk about you, I say.

But if a person wants a therapist of a certain color or creed, that's all well and good, it really is. It can be hard to explain one's world view, one's religious thinking, to someone who is unclear on the concept. Religious concepts affect how we think, and how we think affects how we feel. Religious cognition can play a huge role in psychotherapy.

One's ideology, such as a religion or ethnic value system, is also a cognitive map. So a patient might prefer a therapist who already knows his or her way around town.

The problem with that, of course, is that a religious or ethnic map is not the only map in the patient's head. Using this map to the exclusion of others will surely circumvent a therapy doc's direction, reinforce the confusion.

If you need to know how to get to Albany from New York City, having a map of Manhattan is nice, but it's not enough.

And people of the same religion and race are indeed a heterogeneous lot, very different from one another. Most people interpret and see things differently, even with shared values. More importantly, we live very different lives.

So knowing about religion, race, and cultural differences, while important, is not going to crack a case or even necessarily be much use to a therapydoc.

And yet, we have a professional responsibility to learn about cultural differences. Cultural diversity is taught to professionals in graduate schools (social work and psychology for sure) and has been since the 1990's.

Don't take those classes lightly, friends. One's cultural toolbox should always be open at the office. Even a cursory understanding of ritual observance and cultural mores will serve mightily. You might learn in school, if you pay attention, the answers to questions like these:

Do African Americans really need to hear how your day has been so far to be comfortable enough to open up? (some do).

Does it matter if a patient is a DOS or an SOS (daughter of a survivor/son of a survivor)? (uh, huh).

What are the laws of family purity?

Should an Indian woman from India expect to move into her father-in-law's home after marriage?

Oy. There's so much to know. How can we possibly know it all?

Which is exactly why some prefer talking to their local clergy person or finding a frum therapist.

It's the training that will matter in the long run, however, not knowing the patient's world view before the first session. Patients will teach us their world view if we shut up and listen. If we let them.

This is not to judge therapydocs who carves a niche solely based upon their cloth. On HMO panel applications sometimes there's a question asking providers to check off specialties. One of them is "spiritual counseling." Once I accidentally checked it. (These applications take a lot out of a person).

That meant MANY rejections from first time callers.
Oh, I wanted a CHRISTIAN therapist.
Never mind.

No matter what the world view or ideology of the therapist, to get back on topic, we have to address this triangulation thing.

It's not okay to ally with one person in therapy by beating up on someone else using cultural or religious values as sticks. (We're talking beating with words, obviously, insinuating that another family member or perhaps even boss, friend, is bad). This isn't a good idea even if the one taking the beating isn't there in the office.

When it comes to first degree relatives, no matter how awful you, as a therapist, think another family member has behaved, it's not your job to meet out the judgment.

It's pretty hard not to do that, believe it or not, not to call someone who has sexually abused a patient a bad name. Deep breaths, sighs, slow turns of the head, nods. These communicate disapproval just as well. And yes, when it comes to abuse of all kinds, feeling disapproval is okay.
It has to be. Communicating it and how, deciding IF you should be communicating it, is the issue.

Sometimes yes. Sometimes no. It's a call that should be based upon context. It's a thoughtful call.
Remember your patient either has chosen, birthed, and may share quite of bit of that other person's DNA. So it's best not to join with the patient's anger. It's not your job to be righteously indignant.

Someone has to stay level.

A nice example of what I call beating on the sinner is when one partner/spouse presents as a victim of another's infidelity. This spurned partner comes to therapy and says something like:

"My wife (husband/partner) came on to a co-worker (friend, tennis pal)

And they did it in our living room (bedroom/dining room/car)."

Disgusting, you want to say.

But do you? Do you even dare judge the partner who cheated? Do you even know that it's true? Is your patient such a virgin? So many other possibilities going on here.

In such a case the patient clearly wants empathy for the pain, the rejection. That's the therapist's job. And the patient needs where to go from here. Although punitive fantasies (don't you want to just kill him/her?) can be therapeutic, they're not to come from you. You're a therapist, not a cheerleader--not a judge. You look at your patient and say, Tell me more. This must have hurt, this indiscretion.

Believe it. It hurt.

There's no beating up the partner, whether he or she is around or not. No thumping or pointing to the Bible, and no assumption of guilt or that the complainant is even telling half of the story. But we can't intimate our doubt, diminish the power of a patient's narrative, regardless. We stay empathetic.

And when the "errant" partner is in therapy with us, we can't say, not ever, What were you thinking?! People beat themselves up enough without our help. (Okay, you actually can ask that question, but NO attitude. )

For not being a rabbi, I preach pretty well, no?

Religious values can and should be part of therapeutic dialogue. The values we talk about matter because they are the patient's values. They are what drive many of the patient's thoughts, and as such are clinically invaluable data.

Our values are irrelevant. Our values aren't under discussion. When a patient asks us, Well, what do you think? we turn it back on them, What do YOU think? Seriously. Tell me.

Or:
And how did that make you feel?
What did you want to do about that?
What would it be like, doing that?
Do you want to work on it?
Do you want to talk to her/him about it?
Does he/she want to talk to me?
Why not save this relationship?
Should we work to save this? Is that a goal?

Sometimes people don't want to save it. And that's okay, too. I always suggest they wait awhile, however, before signing on the dotted line, dissolving the relationship for good. Work on it in therapy, try to get past the hurt and anger in any case.

Anger especially, is never easy. Yes, it can take many months, sometimes over a year to get past the indiscretions and hurt. But most of us have time. And just leaving the "problem" doesn't always make us feel better. (Sometimes it does. Sometimes it doesn't).

Best first to look him or her in the eye. Take a good look at the reality of the situation. Talk about it. At length. Change. Both of you change. Because you know, after all, that everyone needs therapy.

And you can always talk about where that soul is going with your clergyperson.

copyright 2008, therapydoc

19 comments:

Jack said...

People want their therapist to validate, not confront, their religious values.

I would think that if you are struggling to understand how to get beyond whatever your troubles are it has to be disheartening to be told that you have made a bad choice.

It is hard enough to confront whatever demons/challenges you might have without feeling like your life is one series of poor choices.

therapydoc said...

Exactly. And a therapist can have a huge impact on that, for better or worse.

LR said...

From NYC to Albany? hahaha -- my own life trajectory.

Though I acknowledge my method for selecting a therapist (closest to where I work and NOT in an office park) was risky it worked out well.

Her values were not relevant when I wandered into her office. But it has been terrific to learn that she shares many of mine.

Maybe it just seems important since I realized that my healing will likely take longer than college.

Do you think that values and background may have greater significance when therapy is a long term adventure?

therapydoc said...

Sure.

There's still transference, though, and no matter what a doc says, people don't believe the words as much as what's in their own heads about what they think the doc means.

Even in the long-run, it's pretty hard to really know your therapist.

And that's as it should be. But over time, it's likely that your doc IS going to tell you about her vacation. We let our guard down.

Should we? I don't know. So many variables. Sometimes yes, sometimes no.

The Insighter said...

I would propose the only truly essential shared values for therapy are a fundamental respect for humanity and a belief in growth and change. All the rest can be worked through given time, patience and an open mind.

Great points you make here! In classic mythology "psyche" meant "soul", so no wonder the theology/psychology dilemma rages on - they're forever enmeshed!

therapydoc said...

Which is so ironic.

MT said...

Isn't it not just what has value but how much and how different people prioritize their mostly similar values? I can't be sure what you mean by "value" and I'm not sure it's all that narrow a concept, but to me being and living in the world involves a pitting of one's "values" against each other and a search for an optimum rather than an ideal. When we talk about feeling "conflicted" we imply conflict isn't natural or necessary, and I think our complaint might be more accurately described as unhappiness with a balance or prioritization we've struck or will have to. If somebody wants to prioritize compulsory female genital mutilation above all else, you can help them achieve such health and happiness as that allows, but you may be abetting the violation of human rights as you construe them and/or committing malpractice as your certifying board and professional licensing board defines it. I suppose your policy is like patient confidentiality or treating chemotherapeutics as poisons--a prudent rule of thumb, for which prudence also calls for some specific exception making, but as a judgment call over some of which judges will disagree according to their "biases." Does Scalia have a religious bias? Not as he rationalizes his opinions. Policing your own biases is hard to do, and societally the law is fuzzy about what's a legitimate source or sensibility on which to support a bias.

therapydoc said...
This comment has been removed by the author.
therapydoc said...

It's really hard to do. Thanks for the reminder.

PhD in Yogurtry said...

You've helped clarify why I feel reluctance facilitating a referral to a particular-religion based therapist, i.e., christian counselor. Seeking one's own world view as the primary qualification for a therapist seems short sighted at best, therapeutically limited at worst. But at the same time, I understand it and sympathize. I wouldn't want to pay good money seeing someone who would knock my fundamental beliefs, vocally or silently, i.e., a therapist who sides with the husband's right to view pornography anytime he feels like it.

Mariposa said...

Honestly, I don't put any restrictions on who will be my therapist or who will counsel me...I tried seeing both a medical therapist and a spiritual director and it never got me to a point of confusion...both were liberated enough to accomodate my concerns...and i was not holding back on anything at all...in fact i was able to mix topics of concern to both of them without problem...the therapist was from LA (bec i had my medication then) and my spiritual director was a filipino priest who was from Spain's Opus Die center. I have to give those details to emphasize the disparity, yet, both were giving me positive things...im not on therapy now...but i still see or communicate to them once in a while...

personally, i pratice openness of religion...im so open about it...im raised catholic...i read the bible...i read about other religions, and i say, they all give me the fundamentals i need...to have something to believe on...and it teaches me to love myself and others....

thanks for this nice post...

therapydoc said...

I used to say, They're all good. And then I read up on Scientology. So now I say, they're almost all good.

Julie said...

School is pretty adamant that their students should be in some kind of supervision, so I'm in the process of finding a therapist here in NYC. I've been thinking about whom I'd like to see. Female... Jewish... frum...? How much does it matter? What if he/she doesn't understand all of the intricate details of yiddishkeit? Your post definitely helped clarify what I should be focusing on in my search... Thanks!

Feminist Gal said...

Your post was very well written and clarified a lot for me. As a future therapist, i think these are important topics to think about so that we realize where our own biases are.

On the other hand, do you think this is such a "thing" for those outside of Judaism? I often find that i make a lot more of religion than non-Jews do simply because I feel religiously isolated a lot more frequently than non-Jews. I have over 30 co-workers and only one is half-Jewish. When i learn someone is Jewish, when they finally feel comfortable enough to disclose that, i feel a sudden connection with that person - regardless of my other opinions about the individual, his/her being Jewish almost forgives everything else (strange, huh?) Thinking about choosing a therapist with this in mind, i would absolutely want a Jewish, and female for that matter, therapist because of how important both those identities are to me. I would probably want her to be a self-identified feminist as well. I wonder if this is just me or a not so rare thought for minority groups to have?

therapydoc said...

Don't get me wrong. I'm not at all against getting a cultually in sync therapist, it's great and it might feel good. But it's not the only thing to look for, not by a long shot.

And no, you're not at all alone in wanting to connect with people who have the same heritage/genetics/cultural memory, maybe even relatives :)

muse said...

Honestly, I think that there is no such thing as "the same Judeo-Christian values." It's not Jewish what they keep saying we have in common. True Judaism isn't a worship of FDR, Liberalism ad nauseum.

Marie said...

I've been spending some time in your blog today -- I really like the information you provide . . . you write well and I have found myself having several "ah hah!" moments while reading.

And I like your humor!

I'd be interested in reading your thoughts (maybe in a future post?) about therapists who use therapy as a way to evangalize . . . that is what happened with my T "Mark" (that blow up is soon to be revealed on my blog).

- Marie

therapydoc said...

I'll have to read it!

Anonymous said...

Thank you so much for this post. I'm currently doing my PhD in Psychology, doing my thesis on the consideration of religious and spiritual beliefs in mental health care. I have been preparing for a presentation to a group of clinicians (actually, I was googling 'religion, therapy, cartoon') when I came across this post!

I've come across several articles that mention how religious clients are often reluctant to seek treatment from secular therapists for the fear that their beliefs would be pathologised, judged, or misunderstood. Although this does occasionally occur, and clients do sometimes feel that their beliefs aren't taken into consideration, those who see secular therapists truely willing to 'learn the client's language' often find that seeing a secular therapist really isn't all that bad.

If you're interested in the research by the way, I'm currently running an international survey at www.beliefs-survey.co.nz or you can email me b.d.clark@massey.ac.nz.

Keep posting - I'm enjoying the read!!

Cheers
Bronwyn.