Culture Wars, COVID-19, and Countertransference: What America’s Cultural Rifts Might Mean for Psychiatry

COMMENTARY

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 US cities, revealing that “not everyone is on board with the new, government-mandated limits on public assembly and economic activity.”²

Reports in the New York Times and other sources indicate that these protests are not of grassroots origin but are driven, at least in part, by “an informal coalition of influential conservative leaders and groups.”³

According to Timothy J. Lombardo, PhD, 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 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 antirestriction protests. That said, as a physician and an 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, PhD, and psychiatrist Matthew Goldenberg, DO, suggest that about 76% 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 Goldenberg⁷ 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%) in 29 states, after controlling for physician age, gender, and religiosity, the authors found that:

[P]olitical 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 (eg, 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, PhD,⁸ concluded that:

[N]eurobiological 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, PhD, 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 and colleagues 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, although 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

Conclusion

In the ongoing 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. However, 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 working with patients whose political views make it very difficult to address their emotional needs.

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of Psychiatric Times (2007-2010).

References

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. Updated April 22, 2020. Accessed May 7, 2020.

2. Russonello G. What’s riving the right-wing protesters fighting the quarantine? New York Times. www.nytimes.com/2020/04/17/us/politics/poll-watch-quarantine-protesters.html. April 17, 2020. Accessed May 7, 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 7, 2020.

4. Lombardo TJ. The far right hates liberals, government and the media — and now, quarantines. Washington Post. www.washingtonpost.com/outlook/2020/04/21/far-right-distrust-quarantine. April 21, 2020. Accessed May 7, 2020.

5. Peters JW. How abortion, guns and church closings made coronavirus a culture war. New York Times. www.nytimes.com/2020/04/20/us/politics/coronavirus-protests-democrats-republicans.html. April 20, 2020. Accessed May 7, 2020.

6. Sanger-Katz M. Your surgeon is probably a Republican, your psychiatrist probably a Democrat. New York Times. www.nytimes.com/2016/10/07/upshot/your-surgeon-is-probably-a-republican-your-psychiatrist-probably-a-democrat.html. October 6, 2016. Accessed May 7, 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(2):86-94.

9. Spangler PT, Thompson BJ, 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 regs. Medscape. www.medscape.com/viewarticle/927556#vp_3. March 26, 2020. Accessed May 7, 2020.❒

LETTER TO THE EDITOR

Response to Dr. Ronald Pies:

I read with interest Dr. Ronald Pies two articles, “Culture Wars, COVID-19, and Countertransference What America’s Cultural Rifts Might Mean for Psychiatry,” and “Masks, Machismo and the American Man-Child.” Both articles were timely given the expanding cultural rifts exacerbated by the COVID pandemic. My intent is to add further insight into the discussion.

Although Dr. Pies strove for impartiality, the topics are so ripe with undercurrents of economic uncertainty and political nuances that it is often difficult to see the forest from the trees.Although the magnitude of the difference between the liberal versus the conservative prism is great, psychiatrists need to be consistent and nonjudgmental with all patients regardless of political bent. However, the insertion into the mix of COVID has made the delineation between the two sides more apparent as even health care providers have opposing views along with the rest of the population.

Dr. Pies pointed out the underlying rage of conservatives witnessed during the initial protests against the economic shutdown and asked the question as to what psychiatry’s role is in dealing with the rage and resentment underlying the antirestriction protests.Although the worry about the virus spread is valid, the economic devastation caused by the shutdown must be understood to answer Dr. Pies’ question.Blue collar and small business owners suffered disproportionately compared to white collar workers who were able to transition with little change in income.Many small business owners who had used up their savings became dependent for the first time on government assistance.Psychiatrists need to be cognizant of the effect the prolonged shutdown has had on their patient’s health and wellbeing.It is an opportunity for psychiatrists to be aware that the real threat of financial ruin is a contributor to the underlying rage and resentment against the forced economic shutdown observed in some of their patients.

Battle lines according to party affiliations have been drawn around the use of facial coverings.The face mask has become representative of the widening cultural chiasm between those who use and those who don’t. Whatever the reason for mask refusal, Dr. Pies’ negative depiction of the older male mask refuser as a self absorbed, irresponsible, emotionally immature individual does more harm than good and reflects his own internal bias.

Psychiatrists are aware that both acute and chronic stressors lead to both healthy and unhealthy coping mechanisms.In an atmosphere of loss of control in many aspects of life, mask refusal may be the one avenue for some to regain perceived control over body and spirit and feel a connectedness with other like-minded individuals during a time of social isolation and economic stagnation

Despite deep differences in cultural and political ideologies, psychiatrists who are open minded and nonjudgmental can establish therapeutic relationships even with their most culturally misaligned patients and work towards development of mutual respect and COVID safe practices.

Elizabeth A. Varas MD

Response from the author

I thank Dr. Varas for her thoughtful and thought-provoking letter. In the end, I don’t believe our views are very far apart, regarding the psychiatrist’s responsibility toward patients whose political, religious, or other views are at marked variance with our own. At the same time, I stand by the main conclusions of both articles Dr. Varas references.

Specifically: I agree with Dr. Varas that--within a certain range of political views--“psychiatrists need to be consistent and nonjudgmental with all patients regardless of political bent.” Thus, in general, we need to guard against reflexive moral judgments, even when we strongly disagree with the patient’s “politics.” However, I don’t believe we need to be “nonjudgmental” no matter how hateful or bigoted a patient’s political or religious views may be. Guidedbyour own values and those of our profession, we may rightly judge a patient’s political views to be “bigoted” “distorted” or “extremist” in certain limited instances; for example, when a patient’s political views lead him or her to the conclusion that African Americans are “inferior;” or that Jews should be rounded up and put into concentration camps; or that all immigrants should “go back where they came from.” (These, of course, are extreme examples).

But merely “judging” the patient’s views is not sufficient. If we continue to work with the patient, we have the further obligation of self-reflection, introspection, and perhaps consultation with a colleague, as to whether our disapproval (and resultant counter-transference) is of such intensity as to compromise our ability to be of help to the patient. That premise was the foundation of my article on “counter-transference.”

Furthermore, if we continue to work with the patient, we also have a professional obligation to understand how the patient came to develop such extreme views, and—if possible—to develop some degree of empathy for him or her. Indeed, I learned this first-hand in dealing with an extremely anti-Semitic (and quite psychotic) patient in my care—more on that presently.

Dr. Varas opines that the current pandemic provides “…an opportunity for psychiatrists to be aware [that] the real threat of financial ruin is a contributor to the underlying rage and resentment against the establishment observed in some of their patients.”

I certainly agree with this. Indeed, in an earlier article Dr. Varas may not have seen, I stated:

“Many [anti-restriction] protesters voiced perfectly understandable concerns about lost jobs, missed opportunities, and social isolation. These individuals deserve our empathic understanding.” [https://www.psychiatrictimes.com/view/freedom-does-not-mean-being-loose]

Dr. Varas writes that, “Dr. Pies’ negative depiction of the older male mask refuser as a self-absorbed, irresponsible, emotionally immature individual does more harm than good and reflects his own internal bias.”

Indeed, I believe these terms—self-absorbed, irresponsible, emotionally immature--are largely accurate characterizations of the views and behaviors of many, if not most, individuals who adamantly refuse to wear masks during the pandemic. I acknowledge that my conclusion may reflect my own “internal bias”—e.g., as someone who self-identifies as “progressive” politically--but that does not render my conclusion incorrect.

Nevertheless, my claim is, at most, a hypothesis—not a fact—and it ought to be subject to empirical verification or falsification. For example, it would be interesting to see how adamant “mask refusers” score on validated measures of narcissism, sociopathy, and emotional immaturity. [see, e.g., http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.676.3624&rep=rep1&type=pdf]Yes, I could be mistaken—but I’ll wager that most of these individuals will score “high” on one or more of these three personality traits.

None of this is inconsistent with Dr. Varas’s hypothesis—which seems plausible to me—that

“In an atmosphere of loss of control in many aspects of life, mask refusal may be the one avenue for some to regain perceived control over body and spirit and feel a connectedness with other like-minded individuals during a time of social isolation and economic stagnation.”

Consequently, I would agree with Dr. Varas that, if we find ourselves treating such individuals, we have an obligation to “put ourselves in their shoes” and try to find an empathic connection with them, if possible. These individuals are, like all of us, fallible human beings. They deserve our compassion and good-faith efforts to help them. But we are not obligated to withhold the judgment that they are behaving in a self-absorbed, irresponsible, and immature manner.

In this regard, I would distinguish between judging a person’s beliefs and behaviors, on the one hand; and judging the totality of the person, on the other. In the case of the extremely anti-Semitic patient I treated, I judged his views (and still do!) to be thoroughly reprehensible—but I never regarded him as a reprehensible human being [https://www.nytimes.com/2006/01/31/health/psychology/after-polite-sessions-letters-filled-with-antisemitism.html?auth=login-email&login=email]. As the late Dr. Albert Ellis reminded us, “bad acts” do not imply a “bad, wicked, or rotten” person. [Ellis A, Harper RA, A Guide to Rational Living, Melvin Powers, 1975, chapter 12]

Again, I thank Dr. Varas for taking the time to write on this important topic.

Ronald W. Pies, MD