Effective talk therapy is premised on complete privacy and trust between the patient and therapist. These are the foundations for the open, candid and difficult conversations necessary to get to the root of personal issues. But during many of my recent sessions, it’s felt as if there were more than two of us in the room.
In a world that is increasingly hostile to differences of opinion, my patients and I find ourselves afraid of using our voices.
The overreach of cancel culture from across the spectrum is making its way into therapy offices, and that is worrisome for clinicians and patients alike. Both parties need to feel free of social litmus tests and politically motivated legislation that constrict the conversation and reduce complex psychological questions into right and wrong ideological stances.
Mental health is best served when therapy is not merely a confessional but helps people realize change in their lives. Such change comes about when therapists use their expertise to promote self-awareness in patients, which the patients can then act on. The changes in behavior may be as subtle as asking for forgiveness for a mistake or as profound as leaving an abusive relationship. If either the patient or the therapist is walking on eggshells, the opportunity for the meaningful dialogue that leads to such healing is greatly diminished. Yet in a world that is increasingly hostile to differences of opinion, my patients and I find ourselves afraid of using our voices.
In some cases, fear of social repercussions creates a new type of isolation and anxiety that makes it hard for my patients to process their emotional responses to events, even with some of the closest people in their lives. One of my patients, for instance, has a transgender daughter. As she walks this journey with her, she often complains to me that she must put up a false front to the outside world. “To express anything short of joy that my kid is trans makes me look unsupportive and risks criticism, or worse. I only feel safe telling you all my complicated feelings. I love my kid and will defend her to the ends of the earth, but I need time to process this change and come to accept it.” Her legitimate concerns that others will hear her struggle as unsupportive have led her to distance herself from friends and relatives, and delete her social media presence.
Another patient, a faculty member at a university, went through a brutal tenure review because he held a conservative viewpoint that differed from his colleagues. This experience brought him into therapy because he wasn’t sleeping and was afraid of losing his job. He was vulnerable and worried about being misunderstood, so before he would trust me with the details of his situation, he spent many sessions making sure my leanings on issues related to his field wouldn’t affect my view of him. “I don’t understand how they can espouse academic freedom when they expect me to toe a line that is the opposite of that,” he told me. I reassured him that I was there to offer him the help he needed regardless of my own views, and that there was no political line he had to toe in our sessions. Giving him the room to speak openly about his beliefs was critical to his ability to continue to function at his job.
The very palpable reality that holding a differing view is not just uncomfortable but also potentially dangerous makes it difficult for someone to speak their truth. If patients’ self-expression runs the risk of them losing jobs or friends, it’s hard to argue that they should share their thoughts. Yet as therapists, we know that staying silent leads to distance in relationships and harms people’s self-esteem.
Further complicating matters is the reality that therapists are not immune to the culture any more than patients. The opportunity for give and take can only happen when there is mutual trust and the penalty for a breach in that trust is the hurt of misunderstanding, not the revenge of a lawsuit or defamation on social media.
Yet some states have passed laws saying that doctors can’t talk about options with their pregnant patients and that teachers can’t discuss LGBTQ identity with students. It’s not unreasonable to conclude that therapists could start looking over their shoulders and worrying about the potential fallout if they broach certain topics.
The fear is particularly acute for therapists working in institutional settings who might already be covered by these laws, laws that may go so far as to dictate what can and cannot be discussed in sessions. From supporting a young person’s decision to come out to their parents to asking about the presence of guns in the home, the content of these sessions can now feel risky for job security. There is also a genuine worry that someone could record a session and post it.
There can also be barriers that patients themselves erect with therapists. Historically, therapists have worked with people from varied backgrounds with an array of issues different from their personal experience. For instance, as a heterosexual woman I have created therapeutic relationships that have helped male patients and members of the LGBTQ community. But in our current climate, a difference in identity can be viewed by patients as a sign that their therapist lacks understanding of their situation and can be reason for distrust. Yet it is both unrealistic and limiting to expect therapists and clients to perfectly mirror each other’s experiences. In fact, respect for differences is part of building trust.
At the same time, I’m aware of ways that I am sometimes the one who has put limits on interactions. During the pandemic, I found myself asking patients about their vaccination status and use of masks out of concern for my own health. As a medical professional I was within my rights to request this information, but my questions about vaccinations and requirements for masks made my position clear to all of my patients and might have alienated those with differing views.
It is imperative that patients can be open about their true concerns — no matter how unpopular their perspectives may be — if they are going to get the help they need. Clinicians, too, need to be open and trust that their words will not be taken out of context and weaponized against them. There are no easy answers here, but avoiding difficult conversations is certainly a recipe for disaster for both therapists and patients.
The perils of cancel culture make it too easy to seek comfort in echo chambers and resist exposure to differing opinions. By standing up against legislation and speaking out against cultural norms that aim to shut people down and divide us, we can help keep the promise of therapy as a place to address the full range of the human condition. Our world is in desperate need of more bridges and fewer silos.