The 2016 Election Is Raising Ethical Questions for Therapists

In a profession that traditionally prizes neutrality, most therapists have considered presidential elections an issue outside their professional domain. After all, isn’t it almost a cardinal rule that therapy and politics don’t mix?

Recently, however, concerned about the stakes in this year’s election between Donald Trump and Hillary Clinton, some therapists have been wondering whether they have a professional, and even moral, obligation to bring politics into the consulting room. In June, University of Minnesota professor and couples therapist William Doherty launched Citizen Therapists, a grassroots campaign challenging what he calls Trumpism—an ideology he believes is “antithetical to everything we stand for as therapists,” including democratic values, upholding the rights of ethnic and religious minorities, and combating hypermasculinity and the denigration of women. Bold lettering on the Citizen Therapists’ home- page poses a central question: “Are you increasingly alarmed by Donald Trump? Do you recognize that he represents an ideology that won’t go away even if he loses in November? It’s time that we say these things publicly, as therapists, and not just behind closed doors.”

More than 2,200 therapists who support Doherty’s initiative have signed the anti-Trump manifesto on the Citizen Therapists’ website, including leading figures such as Salvador Minuchin, Susan Johnson, Mary Pipher, David Burns, and John and Julie Gottman. The campaign has an active Facebook group, which invites therapists across the country to dialogue about the clinical and ethical implications of discussing the election publicly as a profession and privately with clients. Obviously, this raises questions about whether it’s appropriate for therapists to speak out on political matters and the pitfalls of revealing their political views to clients.

For months, there’s been no lack of psychological analysis of Trump’s personality and its effects on the public. A May piece by Robinson Meyer in The Atlantic, “How to Preserve Your Mental Health Despite the 2016 Election,” declares that Trump may be the cause of more mental stress than any candidate in a prior presidential election. “Trump Anxiety,” Washington Post columnist Paul Schwartzman called it back in March. And according to psychiatrist Glenn Swogger in a March Forbes article, Trump would be more “narcissist-in-chief” than commander-in-chief, with all the DSM qualifiers for narcissistic personality disorder. In response to this widespread psychoanalyzing, the American Psychiatric Association issued a warning in August reminding clinicians of its 1973 “Goldwater Rule,” named for the 1964 Republican presidential candidate Barry Goldwater, also once the subject of clinicians’ scrutiny. “It is unethical for a psychiatrist to offer a professional opinion,” the rule states, “unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

Either way, Doherty says publicizing a psychological analysis of Trump doesn’t go far enough. He contends that therapists, as experts in emotional functioning and healthy relationships, are not only qualified to speak out on matters affecting public mental health, but have a duty to take a stand. Simply offering a diagnosis for Trump “seems to communicate that all we can do is talk our psychological language,” says Doherty. Instead, he insists clinicians have room to broach politics in and outside of therapy, provided that they do it in a noncoercive way that doesn’t come at the expense of the client’s autonomy and well-being. The end goal of Citizen Therapists, he says, is to encourage clinicians to feel more comfortable discussing political issues—and even to share their own views with clients—despite long-held professional taboos about doing so. “I want to create a space where we see having these kinds of conversations as an option,” Doherty says. “This is an open-ended invitation that can actually deepen therapy.”

Initially reluctant to move into the ethical gray area of political activism as a therapist himself, Doherty changed his mind in spring 2016, when he took a tour of Sigmund Freud’s house in Vienna while vacationing with his wife. A video documentary on display recalled Freud’s hurried escape from Austria after the Nazis burned his books and interrogated his daughter, Anna. Then, on a walking tour several days later, Doherty passed a neofascist youth group clad in sash-draped uniforms, and was shocked by how much they resembled Hitler Youth. Back at his hotel room, Doherty began reading about the silence of mental health professionals in condemning the rise of German fascism. He booted up his laptop and began typing the first draft of what would soon become the Citizen Therapists’ manifesto.

“I realized there was a way for therapists to make a collective statement without politicizing the profession,” Doherty says. He insists Citizen Therapists isn’t about trying to influence clients to vote a particular way, which Doherty says would be tantamount to malpractice. Instead, asking open-ended questions at the start of sessions such as Are you following what’s going on in the world? or Are you being affected? allows clients to share as much or as little as they’d like, and doesn’t take clinical work off course.

If a client brings up concerns about Trumpism, for instance, therapists can explore specific issues further and validate the client’s reactions to them. At this point, Doherty notes, therapists might follow up with their own concerns about Trumpism that relate to mental health, such as hypermasculinity or demonizing those with differences. And if a client expresses support for Trumpist positions, he recommends trying to connect with their underlying concerns, such as a fear of terrorism or a sense of being displaced in today’s economy. At any point during this conversation, he adds, the therapist can choose to move on to other issues while acknowledging the client’s beliefs and modeling a respectful sharing of differences. “Sometimes we can start something big,” Doherty says, “and discover the sky isn’t going to fall.”

But getting therapists to take collective action—let alone sign a manifesto that some might interpret as biased or divisive—is a challenging task. Shortly after launching Citizen Therapists, Doherty started receiving concerned letters from therapists. “Suffice it to say, I simply don’t share your conviction that political idealism should frame our therapy work,” wrote one. “Political ideologies should inform our therapy work, but they should never autonomously ‘drive the bus.’” Others saw a lopsided focus on Trump. “Hillary Clinton and Donald Trump personify two sides of a similar coin—abuse of power and manipulation,” wrote another. A colleague from Kentucky drew a similar comparison. “I think that Hillary Clinton’s behavior rises to the level of pathology (entitlement, manipulation, lying) and sends a terrible message as well,” he wrote. “Are any of these people really models of emotional health?”

“What Trump stands for,” Doherty responded to the Kentucky therapist, “is qualitatively different from the policies that Hillary Clinton stands for and represents. I see a big difference between personal pathology that sends a bad message (even if that pathology is equal on both sides) and the deliberate stirring of dark forces of xenophobia. I do respect you and your careful reflections on this. My goal is to get us therapists into conversation about the connection between the public and the personal—both in our offices and in society.”

In the weeks following the launch of Doherty’s Facebook group, several members expressed a need for more concrete steps to speaking out against Trumpism without seeming overly partisan or exhibiting the same divisive qualities they oppose in the Trump campaign. Doherty responded with a customizable agenda: focus on expressing concerns about Trumpism to fellow therapists and clients with connections in swing states, such as Colorado, Florida, and Iowa. Reach out to colleagues and friends through social media with focused messages—not rants—explaining the dangers of Trumpism. Share your motivation for signing the Citizen Therapists manifesto and send along a link so other clinicians can sign it too. Write letters to news editors, op-eds, and talk-show hosts who cover politics, mental health, or relationships. And if you decide to discuss the election with clients, look for connections between Trumpism and what they might be working on in therapy. Follow your clients’ leads, and emphasize their agency in supporting or opposing political positions. Meanwhile, avoid resorting to personal attacks on Trump, or elitism, and demonstrate empathy for those supporting Trump’s message. “Take all these suggestions in the light of each client and the clinical relationship,” he wrote on Citizen Therapists’ website. “But I encourage you to stretch and be a bit bolder than you might have been before, because the current risks to public mental health and American democracy are so grave.”

In contrast with Doherty’s campaign, the major credentialing organizations for mental health professionals have adopted a stance of studied neutrality, mindful of restrictions imposed by their 501(c) nonprofit status. According to Jim Sliwa, director of public affairs at the American Psychological Association (APA), “We can take a stance on issues,” like the APA’s 2015 condemnation of enhanced interrogation techniques, “but not on candidates.” Likewise, the National Association of Social Workers (NASW) contains a political action committee known as Political Action for Candidate Election, which endorses and financially supports particular candidates, but candidates’ identities are privy only to members with NASW website login credentials. “Because of our tax status,” says NASW senior field organizer Dina Kastner, “we’re required by law to talk only to our members about whom we endorse.”

The clinicians who support Citizen Therapists have embraced Doherty’s agenda to varying degrees. Couples therapist Julie Gottman says the unprecedented level of vitriol expressed by the Trump campaign persuaded her to sign Citizen Therapists’ manifesto. “The venom that’s been spouted by Trump, the xenophobia, and the dehumanizing of different races and classes have been painful to watch,” she says, adding that several of her Middle Eastern clients have expressed anxiety about how Americans now treat them. “Whatever we therapists feel politically, we need to use our networks and our profession to voice our beliefs,” Gottman adds. But she rejects the notion of discussing Trumpism in the consulting room. “I don’t tend to mix my social activism with my therapy,” she says. “I’m not here to influence my clients’ value systems.”

Others, like couples therapist Terry Real, believe therapists have room to be more open with clients about their political beliefs, especially in the case of Trump, who he says exhibits the aggressive, self-aggrandizing behavior he sees in many of his struggling male clients. “Can we stand by and be neutral in the face of political movements that are adversarial to the human vision that underlies therapy?” asks Real. “I believe that we therapists are moralists, whether we believe it or not.”

For Real, the remedy for Trumpism lies in calling out abusiveness when clinicians see it, even at the expense of therapeutic neutrality. Although clinicians shouldn’t necessarily argue politics with their clients, Real says, it’s unreasonable to expect them to be the blank slates of traditional psychotherapy. “That’s not the therapy most of us do any more,” he says. “What’s so terrible about putting a bumper sticker for a particular candidate on your car and having a client see it in the parking lot? My clients can know where I stand. We can agree to disagree.”

Some, like Minneapolis therapist Patrick Dougherty, believe that clinicians need to take their willingness to speak about political issues a step further. After the Orlando nightclub shooting in June, Dougherty says he felt an urge to address the despair he saw in the world around him. He put a personal letter in his waiting room, asking clients if current events were taking a toll on their mental health. After nearly two-thirds of his clients responded, the tactic was added to Citizen Therapists’ list of ways to broach Trumpism in the consulting room. “My clients told me I’d been avoiding these issues for too long,” Dougherty says. “At the same time, I think they’d assumed there wasn’t a place to talk about this.” Dougherty admits that he initially had hesitations about signing Citizen Therapists’ manifesto. “A lot of people out there are willing to single you out and go after you,” he says. But he claims he could no longer ignore the mental health implications of political hate speech. “I’ve always tried to protect the sacred container of therapy from the outside world,” he says. “But this doesn’t work any more. I know these events are affecting the vast majority of people. Right now, we have to be the kind of therapist our clients need.”

Of course, taking up the mantle of political activism can have ramifications beyond rubbing a client or colleague the wrong way, says Mitchell Handelsman, an ethics specialist and psychology professor at the University of Colorado Denver. The distinction, he says, is the degree to which therapists’ politics detract from clients’ well-being, as it would if a therapist tried to indoctrinate clients to follow their political position. Whether there’s an ethical breach depends on how much taking a stand wrongfully invokes the legitimacy of psychotherapy. For example, if a therapist lobbies for a neighborhood to be rezoned so as to benefit financially but says rezoning is a mental health issue, that would be a misuse of professional identity.

However, Handelsman adds that depending on clinical specialty, therapists may have an “affirmative responsibility” to be politically active and thereby do indirect good for clients. Whether this is the case can usually be inferred from the accrediting organization’s code of ethics, he says, and can be undertaken in the form of lobbying Congress, writing letters to local politicians, joining a psychological association, or chairing a political committee. Also depending on specialty, directly addressing politics in therapy can be an integral part of treatment, Handelsman adds: “Having clients understand the political dimensions of their own experience and having them lobby for issues about depression or anxiety, for instance, could very well be part of treatment.”

Undoubtedly, the ethos of Donald Trump’s campaign, the voices of those who bristle at it, and the ethical dilemmas facing politically active therapists will persist beyond the election. Questioning what it means to reconcile obligations as both a citizen and a therapist is likely to continue. As for Doherty, he says he does want to thank Donald Trump for one thing: “He’s helped me see more clearly the connection between therapy and democracy. We therapists have taken for granted how much our work relies on a democratic tradition that gives people a sense of personal agency—the ability to create new narratives and take personal and collective responsibility for themselves, their families, and their communities.”