Cultural and Religious Recommendations for Ethical Clinician/Patient Matches

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

Earlier in my 50 or so year career in psychiatry, self-disclosure was still frowned upon. This guideline was a remnant of Freud’s recommendation for a “blank screen” for the analyst conducting psychoanalysis. The reason had to do with allowing the clinician to more easily represent an authority figure in the patient’s transference to the clinician.

It was pre-internet, so it was difficult for would-be patients to find out much about me other than word of mouth. Occasionally, someone would also ask to see me because of a book of mine they heard about or read, like The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare, which might suggest to them that I was ethical!

How clinical self-disclosure has changed with the internet and social media! Now, intentionally or not, much personal material is available about most any clinician. Presumably, the benefit of that is that a patient could anticipate and even request certain characteristics of the clinician, including for a certain religious and cultural identity. That sets up an expectation of an initial positive therapeutic alliance. The usual underlying question is what are the benefits or risks of various patient/clinician cultural and religious matches.

However, there is an unanticipated problem with such open information about a would-be or current therapist. As I discussed in the August 15, 2024, column on “Blacklisting Psychiatric Clinicians,” colleagues can often support or deny certain referrals. For example, stimulated by the Israel-Hamas war, certain referral processes and listservs are recommending against any clinicians “with Zionist affiliations” since they contribute to White Supremacy. This stance also ignores that Jews are generally not part of the “white” population.

Extending this issue into the actual psychotherapy brings up the question of whether clinicians should convey their political, cultural, and religious preferences into the treatment interchanges. The risk is to offend the patient or to turn the therapy into a political discussion. On the other hand, psychotherapists must be humble, competent, and sensitive to the cultural concerns that patients may want and need to explore as part of their presenting psychiatric problems.

Whereas this column has often discussed how our expertise in patient care can be applied to society, these self-disclosures, intentional or not, are situations where society is intruding into individual patient care. Another example concerns climate change. Clinicians rightly concerned about the adverse health and mental health implications of climate change may also unnecessarily and erroneously push that into the sacred space of treatment.

While standards for handling these new challenges seem to be in flux, and might get even more complex as AI is increasingly used for matching, falling back on basic ethical principles can be invaluable. In The Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry, the Preamble clearly states that patient needs come first, not those of clinicians. That would imply that until proven otherwise, that as much responsibility for therapist preferences can be—and should be—given to patients. This approach also fulfills the bioethical principle of patient autonomy.

Secondarily, we have an ethical responsibility to colleagues, meaning political reasons for excluding colleagues are unethical. So is pushing the beliefs of the therapist onto the patient. It is ethical, however, for a clinician to choose who to treat based on their cultural identities and beliefs. Moreover, it is ethical for the psychiatrist to address their cultural and religious societal concerns outside of the patient care cocoon (Table).

Table. Ethical Cultural and Religious Guidelines in Patient Care

All of these cultural and religious matching processes have crucial implications for the initiation of psychiatric treatment. Accompanying that as best as possible comes ongoing human clinical expertise, empathy, compassion, and caring.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.