Alternative Facts in the Psychotherapy Office

A clinical conundrum

Source: Rowan Jordan/iStockcom used with permission

Many of us, patients and psychotherapists alike, have been flummoxed by recent political developments, especially the promotion of “alternative facts” in public discourse. When this discourse enters the psychotherapy office, it may be difficult for therapists to get their clinical bearings.

I realized this when Mark, a patient with whom I have a good working relationship, mentioned that Congress should not have certified the recent presidential Electoral College vote in order to further investigate possible voting irregularities. Mark also described a sense of camaraderie in participating in a social media site that promulgated this point of view.

As someone who does not question the validity of the Electoral College vote, a thunderclap of “What?!” reverberated in my mind, followed by a sense of disorientation about how or if to respond. I silently slipped into a social dissection of his views, invoking such themes as a pandemic-exacerbated sense of loneliness, a desire to belong, and a sense of power that arises from believing you know something others don’t yet perceive. Mark, however, hadn’t left the room during my musings and was looking at me, expecting that I would continue as his psychotherapist and not a socio-political analyst.

Responses of “Do you really believe that?” and “You’re misinformed about that” were on the tip of my tongue, but I sensed they would not be consistent with the usual clarifications or challenges I offer. Patients understand that in psychotherapy assumptions about themselves and others will be explored, but don’t presume that this extends to views that are socially shared and political in nature or consequence.

Although my instinct was to invoke psychodynamic themes previously explored with Mark such as his hypervigilance, fearfulness, and mistrust, I was mindful of the complex genesis of political views and the risk of over-emphasizing their psychological roots. And I was trying to respect the principle of patient autonomy and sustain a collaborative, not paternalistic, treatment relationship.

There may be circumstances when discussion of political viewpoints strengthens the therapeutic alliance, but this didn’t strike me as likely with Mark. A national study of this topic (Solomonov & Barber, 2018) found that patients who felt that their therapist probably shared their political views reported significantly higher alliance levels than those who felt that their therapist’s views definitely differed. But this study, conducted after the 2016 presidential election, didn’t assess the therapeutic alliance when patient and therapist don’t agree on what constitutes a fact, a schism not on the minds of researchers several years ago.

At a time when many in the public square embrace alternative facts, I wondered about my professional role in assessing Mark’s ability to discern what is reality-based. Much of our work as psychotherapists is rooted in the premise that we have an authoritative reference point in exploring with patients what is exaggerated, distorted, and untrue, as reflected in the evaluation of such phenomena as obsessional-compulsive worries, ideas of reference, or delusional thought. But when patients subscribe to shared misrepresentations or falsehoods that reinforce a particular way of seeing the world, I wondered what becomes of my role in helping patients understand their world more realistically.

Differences in political views, per se, need not raise questions about the therapist’s role. I’ve worked with patients with opposing political views that seem based on differing interpretations of facts or differences in personal or political values. In these situations, I try to subordinate my own feelings about politics to the therapeutic goal of understanding and experiencing empathy for my patients’ predicaments.

Mark challenged this stance. In these vexing times of social divisiveness, I have not been immune from the effects of political polarization. My silence with Mark masked how dismayed I was by his belief in the contestability of the election.

This dismay eventually subsided when I realized that the positive underpinnings of our treatment relationship hadn’t changed. Patient revelations in psychotherapy usually signal a closer working relationship and greater trust in the process and psychotherapist. This was likely a subtext of Mark’s disclosure. He stated that he couldn’t discuss his political views with friends who found them abhorrent and conveyed a sense of relief that he could share these views with me.

Although the genesis of Mark’s political beliefs was puzzling to me, his fears about instability in the world were not. Helping him understand his sense of vulnerability and loneliness remained a goal of treatment. I also remembered that patients’ perceptions of the world are never fully aligned with my own despite a wish for patients to agree with me during contentious times such as the present moment.

Loneliness Essential Reads

The Particular Loneliness of Losing a Spouse

How to Deal With Loneliness When You're Single

With these thoughts in mind, I regained my clinical and personal bearings with Mark. We resumed the back-and-forth iterations of a psychotherapy he greatly values and I re-entered the psychological world of his hopes and fears. I came to realize that I, too, had been influenced by a reflex to impose the stigma of “otherness” on those we disagree with, surprisingly so in this instance, as I had gotten to know Mark well over recent years and his essential qualities had remained unchanged.