Sunday, November 28, 2010

Psychiatrists, God, and Lying

A psychiatrist in Texas submitted an important question to Randy Cohen's "The Ethicist" column today. I've taken the liberty of copying the question and Randy's response below, with my own comments in bold italics:
I am a psychiatrist who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another psychiatrist. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?


To rephrase your question slightly: May you lie to a patient to initiate a relationship of trust? O.K., I’ve rephrased it totally and unflatteringly, but the answer — no — is provided by the American Psychiatric Association’s “Principles of Medical Ethics,” which requires you to be “honest in all professional interactions.” And rightly so.This is vintage Randy Cohen writing. His question brings out the "right answer" without being weighed down by tedious theorizing. And the quote from the APA shows that the profession agrees. But we should ask (a) what's going on when patients ask Dr. Iyer about his religion, (b) why honesty is so important in the patient-doctor relationship, and (c) what the wisest response is.

What you may do is decline to answer such questions. Glen O. Gabbard, a professor of psychiatry at Baylor College of Medicine, told me in an e-mail that “it is not dishonest to use restraint in responding to questions of a personal nature.” He added, “One can also inquire about the reasons for the question.” The patient’s reply might offer insights useful in treatment. Glen Gabbard is perhaps the most eminent clinical teacher in contemporary psychiatry. His advice, as usual, is spot on. Especially in psychiatry it's crucial for Dr. Iyer to know what patients are communicating about themselves when they ask him about his religion.

Many years ago I had a first meeting with a gay man in recovery from severe substance abuse problems. At the end of the appointment I said - "I've asked you a lot of questions. Do you have any questions for me?" He replied - "Just one. Are you gay and in recovery?" I responded - "If it's OK with you I won't answer directly. I'm not sure what form of treatment I'm going to recommend, and in some treatments it's best to explore questions like this, not to answer them directly." He said - "That's OK. I know the answer - it's 'yes.'" He felt comfortable with me and felt understood, which to him meant I must be gay and recovering with a history of substance abuse. (Neither was true, but the treatment went well.)

The patient’s question need not reflect mere prejudice but could express a desire for a psychiatrist whose personal experience will yield a deeper understanding of the patient. On such benign grounds, some women seek a female psychiatrist, some homosexuals a homosexual. But it is also true that you need not be a Presbyterian to effectively treat a Presbyterian. Even a gay female Presbyterian.

It's crucial to consider the context here. "Iyer" is typically a South Indian Hindu name, which leads me to guess that Dr. Iyer is of South Indian background.The Woodlands is an almost all white, upper middle class community near Houston. It's just a year since the Fort Hood killings, for which Dr. Nidal Hasan, a Muslim of Palestinian background, is the presumed killer. Some of Dr. Iyer's patients may be wondering if he is Muslim, which, sadly, is the focus of widespread prejudice. At an unconscious level they may fear that psychiatrists are not trustworthy and treatment will do them harm. Patients who feel good rapport with Dr. Iyer may tell themselves "he looks foreign, but I know he's really a good Christian, like me," much as my patient assumed I was gay and recovering from substance abuse.

And so you should respond courteously to such queries, answering those about your training and technique but not those you deem irrelevant to the work. Are you Jewish? A Republican? An opera buff? This demurral could cost you a patient or two, but so be it. A patient’s determination to make an unwise decision does not justify a doctor’s deceit.
I wish Randy had picked up on Dr. Iyer's comment "I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s."

When I visited the Indian National Institute of Mental Health and Neuroscience in 1989, I was told that many rural Indians, but also educated urban dwellers, only consult a psychiatrist if religious practice - puja - hasn't relieved their symptoms. And in my clinical office I often felt that an anthropologist would see underlying structural similarities between medical practice and religious practice. The line between "priest" and physician" isn't as absolute as Dr. Iyer's question implies!

I think Dr. Iyer's comment about accountants is correct, but not in the way he intended it. Unless we're looking for an accountant to help us cheat, as Enron and its ilk did, the accountant's character matters a lot, just as it does for a physician. Accounting isn't just a matter of adding up numbers - it rests on decisions about how to deal with expectations about how we conduct our economic lives and meet expectations of the state (ultimately, our fellow citizens). If we only trust an accountant (or physician) who belongs to our own denomination (including the atheistic denomination) we'll miss out on some good ones and trust some bad ones. Dr. Iyer's patients are wrong to focus on his theological beliefs, but correct to be concerned about what kind of a human being he is!

(For an excellent film in which the name "Iyer" is central, see "Mr. and Mrs. Iyer."For previous posts about Randy Cohen, see here and here


Trainee Psychotherapist said...

Here in the UK religion isn't as much of a big deal as it is in the US, but there are people who are still very into their religion.

As an atheist myself, I can say that I've never thought that a client would refuse to work with me on the basis of that. I don't know if I could simply tell a client I didn't want to answer them either. For me this goes against the principle of openness which I think is required to make a therapeutic bond.

I know if roles were reversed and I asked a therapist a question about themselves and they refused to answer, I'd feel as if they had a distrust of me perhaps and would feel that the connection between us would be weakened.

Jim Sabin said...

Dear Trainee Psychotherapist -

First, thank you for sharing your thoughts, and congratulations on your blog, which I had a look at and, as a former teacher of mental health trainees, found very interesting.

I expect that over the years there will be potential clients who would choose not to work with you if they think of you as an athiest, just as there would be potential clients who would avoid you if you were a committed member of a religious faith.

I agree with you about the value of openness, but in my view it doesn't always require disclosure. With the patient I mentioned in my post (my custom is to use the term "patient" for my "clients") I was open about why I wanted to defer a response and might have persisted in non-disclosure, if I felt doing so would advance the treatment. And, a therapist might be asked things that simply seemed too personal ("how much money do you have in the bank?" "how often do you have sex?").

I agree that simply refusing to answer a question could weaken the therapeutic alliance, but a thoughtful response to explain why one is responding as one is can actually strengthen the alliance, at least sometimes.

Brits may be less involved with organized religion than Yanks, but I believe they're just as concerned with questions about life's meaning!