Psychotherapy in Fractious Times

On the day after Barack Obama was elected president nine years ago, Mike walked into my office seething with a mixture of hate and panic. He and his wife were sure that this black president would soon be assassinated and that hordes of black people would invade his lily-white suburb, take away their guns, and kill or starve them out. They were frantically stocking up on provisions and drawing up plans for a bomb shelter. They planned to augment their large collection of guns, though there was no evidence that they considered shooting anyone unless attacked. At this moment, Mike feared for his survival at the hands of a mob. I, in contrast, was feeling elated and foresaw a bright future ahead for America. I was shocked by the intensity of Mike’s state of mind, diametrically opposite to my own. How could I as a psychiatrist respond at that moment?

When patients shock us by presenting in a state of mind that is sharply antithetical to our own, our therapeutic professionalism is intensely challenged. We are at a moment in history when this is very likely to happen. We are a nation divided with feelings running high on both sides of a profound partisan antagonism. The two sides are driving for diametrically opposite objectives. Some of this is inevitable and healthy in a democratic society, and it must be respected. But beyond that, in people on both sides of the divide, there is a sense of deep existential anxiety—an anxiety that arises from feeling that one’s very existence, individually or as a nation, is threatened.

That psychiatrists feel this anxiety in their personal lives is evident from the highly publicized, awkward efforts of some to circumvent the “Goldwater Rule.” The uneasy feeling runs in the background when we see patients. We are unaccustomed to it, though it is reminiscent of many eras in this country and abroad when the foundations of government and civil society were shaken. The September 11 attacks caused an acute state of such general anxiety. How do we approach psychotherapy with our patients when we feel this way?

It would be hard to work without acknowledging the large animal in the room if the patient brings it up. In this respect, we and our patients share the human condition. If the patient seems to be avoiding the obvious, we might address that defense. We also must sort out an existential threat from ordinary political differences, even when they are fierce. That given, we must set our shared angst aside and get down to work with whatever the patient brings to us, because that’s where the energy is. Sometimes a focus on the tweetstorm of the day is a diversionary maneuver on the patient’s part to avoid something that is much more troubling to the patient but difficult to address. Militant public protests may also be a distraction from profound personal troubles. We may be tempted to identify with such doings (or object to them), but instead we keep our focus on understanding the patient’s unique state of mind. Our patient is not there to help us with personal existential angst.

What if we were politically liberal and our patient were an angry white, middle-class male Trump follower who frequently expresses his delight at the president’s aggressive actions and the destruction of the Obama legacy? Most likely we would experience the cognitive dissonance I felt when Mike revealed his reaction to Obama’s election. How could we work with this?! With Mike, he and I were fortunate to have a longstanding treatment relationship in which we could acknowledge our differences with some humor (and I could recognize that he was baiting me, suggesting transference and countertransference issues at play). I had to tease out the extent of his paranoia and do some risk assessment, of course. In ongoing sessions, it became apparent that a great deal of this passively aggressive man’s fear for his life (or his wife’s life) and his rage had to do with his extremely anxious, needy, bullying, and outrageously intrusive wife. Ironically, the anxiety about Obama subsided over the years as the couple, now working together against a common enemy, bought a farm in the country, built a farm house with a bomb shelter under it, and ultimately began to realize the commercial possibilities of their property along a highway, allowing them to work more as a team. This particular clinical example is of a supportive therapy, since it does not help the patient move beyond a somewhat brittle defense system but rather helps him use it as adaptively as possible.

A politically conservative psychiatrist would no doubt respond equally professionally in dealing with the outrage, fear of civic disintegration, and sense of violation that many liberals feel. As in Mike’s case, the task would be to partner with the patient in looking past the issues to the personal meanings, internal conflicts, and life situation that fuel the distress. However, where there are extreme differences (political or otherwise) that a therapist feels would make it impossible to work together, it is appropriate to decline and recommend appropriate care elsewhere.

As psychiatrists or psychotherapists, we have the training to look beyond the anxieties of general society that our patients bring to us and focus on the unique psychic life of each patient, and thereby help them focus, understand, and master their challenges. That does not relieve us of the burden of being intelligent, engaged citizens of the troubled society in which we live when we are away from the office. ■