Thank you to everyone who responded to our February Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
February Quandary: A therapist has been working with a client who has started expressing some very strong and misinformed views—rooted in conspiracy theories. Should the therapist confront the client with real information?
1) Keep the Focus
In Acceptance and commitment therapy (ACT), the concept of experiential avoidance offers us a pathway for working with people who believe in conspiracy theories. Experiential avoidance occurs when we focus on things that are outside our control—in this client’s case, a conspiracy theory. Assuming this client’s misinformed views aren’t what led them to your office, but they’ve brought them up, focusing on them may be a way for the client to avoid their presenting problem. If that’s the case, I’d want to help the client identify their values, and then identify actions and behaviors in line with those values.
By keeping the focus on the client’s values, the therapist can shift the client’s perspective from experiential avoidance to experiential acceptance, leading them to take a nonjudgmental stance toward his or her thoughts and feelings and work toward accepting their life in the present moment. Maybe, with this new clarity, the client will recognize that some things—like the conspiracy theory they believe—is outside their control.
Any time the client begins to veer off topic and start discussing the conspiracy theory, I’d gently redirect them back to these values and values-based actions. I might ask questions like, “How are these beliefs in line with your values?” “Is this belief helping you get any closer to your goal?” and “If this belief is true, how does that help you in particular situations?”
As to whether you should or shouldn’t confront the client with real information, use your clinical judgment, just as you would if deciding whether to use self-disclosure. It may be more beneficial to stick to the above questions whenever the client starts going down the path of avoidance. This way, you can maintain unconditional positive regard while empowering the client to question their own thoughts and feelings.
Shane Kavanaugh, PhD, LMHC
2) Be Curious and Compassionate
As a child and adolescent psychotherapist, I constantly work in the midst of ambiguity, often with parents and children who oppose each other and each think they’re in the right. I expect these differences of opinions in my day-to-day clinical encounters. If children or their parents express strong views or beliefs, I ask myself, Who’s informed or misinformed? The question of who’s right is a matter of debate. But personally, I approach such ambiguity by trying to make sense of both viewpoints. Two ethical positions guide my clinical approach: do no harm and act in the best interest of the child. If, let’s say, the child’s well-being is threatened due to the parent’s misinformed view on a social issue, and they refuse to follow my clinical suggestion, I might tactfully explain to the parent that continuing to work with them is in violation of the law and I’ll be unable to continue to offer my services.
More often, I approach different beliefs and values—even extreme ones—with compassion and respect. I try to make sense of why clients may hold such strong views. I sometimes tell clients, honestly, that I don’t know the absolute truth about anything, but try to understand things to the best of my knowledge and weigh them on a case by case basis. Often, the client appreciates my honesty. Once we establish a safe clinical place to explore where these different views came from, we can trace them back to their origin. It’s at this stage that we as therapists develop a creative curiosity about how and why such thinking came about.
George Halasz, Adjunct Senior Lecturer, Monash University
3) A Fine Line
In therapy, everything is context dependent. If you don’t understand what a client is saying, then you haven’t yet fully grasped the context in which he or she says it. Often, once we understand context, things start making sense.
As therapists, we don’t choose the topics we discuss in therapy. Frankly, I don’t care what my client’s stance is on conspiracy theories unless that thinking is a danger to them or someone else. I don’t care if I’m working with a science-denier, an antivaccer, a Trump loyalist, or a far left liberal. I’m more interested in why we’re talking about what we’re talking about and what’s being asked of me relative to the topic. I’m interested in the context of the topic. I’m interested in the relevance of the topic to the client’s decision to seek therapy. I’m interested in what I’m trying to help resolve. If I cared about whether my client’s views were informed or not, then where would I draw the line? Politics? Social issues? History? Climate change? The list is endless.
To confront a client with “real” information suggests that I know something my client does not, and therefore, something is wrong with my client’s own assessment. In truth, I probably am more knowledgeable than my client about certain things, but opinion is opinion and facts are open to interpretation, so prioritizing my opinion over my client’s is not something I believe is helpful to the work. If asked about my personal stance, I’ll engage. Otherwise, I try not to bend my clients’ will to my own thinking. A curious inquiry may naturally shift perspectives just the same.
Making the determination about what’s true and false is a fine line for a therapist to cross. Our either/or world causes us to think one way versus the other. Each side is equally certain of the veracity of their position and maligns the other. Do we really want to perpetuate that in therapy?
Larry Laveman, LCSW, BCD
Solana Beach, CA
4) Focus on the Implications
Talking to people about conspiracy theories reminds me of telling a teenage child you don’t like who they’re dating. While your first impulse is to try to talk them out of the relationship, that strategy often makes them so defensive that they quit listening altogether. When people make poor choices, we try to figure out what internal needs they’re trying to meet and how to help them meet those needs in more productive ways. I’d argue we need to take the same approach to understanding why people endorse conspiracy theories.
We know that our brains are predisposed to seek order, to create patterns out of ambiguous stimuli. Just think about how often we see faces in tree bark, animals in the clouds, and engage in superstitious behaviors! Perhaps we shouldn’t be surprised that when people feel vulnerable, or fear change, they’re drawn to belief systems and conspiracy theories that enable them to revise reality. Not only does this give them a sense of control, but there’s comfort in feeling like you belong to a group of people who have privileged information. It doesn’t help that in our media-rich world, it’s quite easy to ignore information we don’t agree with and amplify the importance of things we want to believe.
In this case, I’d focus less on what the client believes and more on the personal and behavioral implications of his beliefs. Is believing these theories causing him to lose family or friends? If so, does that bother him? Do these beliefs help him cope with a fear of change or feeling out of control? If so, are there ways I can help him develop more effective strategies for addressing those concerns?
Perhaps we decide that acquiring new work skills or changing jobs would help him better address the issues we find he cares about. Or maybe we discover there are ways for him to develop better communication skills. Conspiracy theories can sometimes reflect wishful thinking because they provide an alternative to a disappointing reality. If this is the case, then helping him take steps to improve his situation could be helpful.
As therapists, our role is to help people find clarity and function more effectively, not make them see the world as we do. The exception, of course, is if these beliefs pose a significant threat to the client or others. If your client is advocating violence, then you need to consult with a colleague or perhaps even legal counsel to make sure you’re protecting the rights and safety of all involved. However, the fact that this client is engaging in therapy indicates that he does recognize something in his life needs to change.
Mary McNaughton-Cassill, PhD
San Antonio, TX
5) Be Empathetic
I would venture to guess that most therapists weren’t trained to work with conspiracy theorists. After all, who could’ve anticipated that we’d be living in a post-truth era, ushered in by a president who normalized conspiracy theories? Remarkably, a significant percentage of Americans believe that COVID is a hoax and President Biden stole the election.
In clinical encounters, we typically have a deep understanding of the conditions we treat, like depression and anxiety. I think having a better grasp of the conspiratorial mindset would be similarly helpful. Ultimately, we’re all vulnerable to believing conspiracies. For most of our evolutionary history, humans lived in small groups as hunter-gatherers, in which our ancestors had to fend off various threats. They worried not only about predators, but also clashes with other tribes. In the ancient world, your chances of survival were higher if you were suspicious of outsiders rather than blindly trusting them. The paranoiac tendency to scan the environment for potential threats would have also promoted survival. Thus, being paranoid and suspicious conferred an adaptive advantage. In keeping with this evolutionary logic, studies show that conspiracy theorists tend to have greater paranoia and suspiciousness than others.
So how can we best work with conspiracy theorists? It seems to me that we can do this by treating the root of the problem: fears about living in an uncertain world. Fostering a positive therapeutic alliance and empathizing with our clients’ fears can help assuage anxiety. And by being a consistent and benevolent figure in their lives who’s curious about what they think and feel, we can build trust. By contrast, challenging suspicious patients about their views might play into a suspicion that you’re not to be trusted. Instead, it might be more helpful to mirror the client and repeat their words back to them in a nonjudgmental manner, thereby encouraging insight into their beliefs.
As clinicians, we can also help combat conspiratorial thinking outside the therapy room by raising awareness. We’re hardwired to rely on heuristics and patterns for survival. But in our modern world, social media and “fake news” floods us with misinformation, overwhelming us when we’re trying to make sense of things that can be confusing and scary. While we can work with our clients to help them feel more safe and secure, it will take impactful policy to stem the tide of misinformation to fully address the problem. As America confronts the increasing challenges of political division and a changing social landscape, this is more important than ever.
Vinita Mehta, PhD
Next Month’s Quandary: I have a client I’ve been seeing for eight years now. Although we made a great deal of progress early in our work, I fear we’ve stalled out. I find myself getting bored in sessions with her, and dreading the hour we’re scheduled to see each other. I’ve brought up the possibility that perhaps it’s time for us to end therapy, but she’s insisted it’s still helping her, despite the fact she doesn’t say much has changed from week to week. What should I do?
Photo © iStock/Ignatiev