MOSF 17.9: “Can I Withhold Care from a Bigot?” A Brown Psychiatrist’s Perspective

Memoirs of a SuperFan 17.9: “Can I Withhold Care from a Bigot?” A Brown Psychiatrist’s Perspective

by Ravi Chandra. Posted on June 25, 2022

The primary objectives of this 3500-word essay are to highlight health care and society’s exposed and critical needs for psychological insight and enhanced empathic connections. I do this through an examination of an ethical dilemma posed in a recent and widely circulated New York Times article. One of my regular concerns is that journalism and politics are largely devoid of comprehensive psychological wisdom. We are caught up in narratives of widening differences instead, giving rise to themes of hostility and futility in opinions held by defensive identity, but without common humanity, and without attention to the central unchanging and essential needs of nurture and the relief of suffering. Without this deeper awareness, we forget ourselves and are lost to each other. We must not avoid psychological understandings or the fundamental task of psychoeducation any longer. Mental and socio-political health demand them, and our well-being is inextricably intertwined with them.

Caregivers and caregiving teams in health care, education, and child care have reported increased stress during the pandemic. Burnout and resignations have reportedly increased. Simultaneously, issues of racial justice, and LGBTQIA+ and women’s rights have risen to the forefront of broad public consciousness, triggering both calls to action and reactionary, defensive pushback. Socio-political issues clearly have an impact on caregiving. They can either divide us, or bring us together in service to broader, essential, critical, indispensable duties of caregiving. This essay is an attempt to offer insight, clarity and allyship from my position as a psychiatrist and writer for all those impacted by these tensions, and thus assist affinity, study, support, and action groups that continue to form.

Here’s an example of a team I trust. Adobe stock image by annagarmatiy, licensed by Ravi Chandra

The New York Times ethics columnist and NYU professor of philosophy and law, Kwame Anthony Appiah, provided a skillful answer to the question posed by a physician reader: “Can I Withhold Care from a Bigot?” (New York Times Magazine, June 7, 2022) The physician was the leader of a medical team on an inpatient service caring for a white woman with a bacterial infection and a history of a substance use disorder. A few days into her hospital stay, the woman began using racial and homophobic slurs with members of her care team. This obviously challenged the team’s ability to care for her. The physician-leader, who is a Hispanic cis-gendered male, took measures to both protect the team and care for the patient. He consulted with nursing staff and the hospital’s risk management team before talking to the patient, and then told her that her language was unacceptable, and if she persisted, she would be discharged from the hospital, against her will if necessary, with a course of oral antibiotics. Fortunately, the patient complied with the demand. The physician asked Appiah whether it would have been ethical to proceed with the discharge option had she not complied, given that this option posed potential risks to the patient’s health.

Professor Appiah correctly notes two central features of the case:

1. The medical team’s ethical and professional responsibilities are to care for the patient; and

2. While the patient’s language is in fact unacceptable, the medical team should not blame and punish her, because she is being affected by medical conditions and thus perhaps should not be held responsible.

Appiah concludes that the medical team would have in fact been behaving unethically if they had discharged the patient. He writes “Clinicians have duties of care to patients, even odious ones. And the more serious the likely consequences of refusing care, the larger the burdens they should be willing to accept.”

This is a reasonable answer. However, it does not fully take into account the psychological issues involved, which are in fact coming to the fore at our cultural moment. The perspectives of mental health professionals would have been helpful in managing this case, and it is unfortunate that a psychiatric consult was not made. This would be my main additional suggestion to the treatment team. Clearly, this patient needs mental health and substance abuse treatment, and these conditions are complicating and compromising her physical health care needs. Appiah’s answer also ignores the real and present dangers to the medical team from such a patient.

It seems plausible that this white woman patient feels she is under threat, for several reasons:

1. because of her physical and mental health conditions, including potential biological and neurological deficits which make it extremely challenging to marshal the ability to self-soothe and maintain perspective; and

2. because she seems to have a poor and worsened ability to tolerate distress and accept help; she has become fragile when vulnerability and the reality of interdependence has been exposed and; and

3. because she is being cared for by a Black, brown, and gay team, in a society that is looking increasingly like that team.

She has likely been primed and influenced to express her disinhibited slurs by political leaders who are similarly disinhibited and strategic in their expressed hostilities. In that context, her slurs could be a distorted attempt to assert power when she is feeling (but not in fact) disempowered. She might be scared, but about the wrong things, and thus acting out. Her actions could have conceivably split the treatment team along lines of race, gender, and sexual orientation.

The worst possible outcome of these attempts to assert power is that such a patient could consciously and strategically scapegoat a member or members of the caregiving team, as Amy Cooper did with birdwatcher Christian Cooper in Central Park on May 25, 2020, the same day George Floyd was murdered.

Name calling; bullying; manipulation; unethical, selfish, power-hungry behavior; splitting; scapegoating – sound familiar anyone? Asking for a nation. Who ordered this package anyway? To paraphrase Krishnamurti, we don’t think our own thoughts or act our own actions – we think the culture’s thoughts and act the culture’s actions. This patient can also be thought of, in this situation, as a kind of noxious squeeze toy of an excessively individualistic culture which is primed towards social dominance orientation using antagonism to attain dominance. When a distressing reality squeezes her, she bursts into epithets. I don’t write this to judge or absolve her, but to recognize that she has been under the influence of biological, psychological, social, familial and cultural forces that were not entirely of her making. She has actually been made by them. This is the conditioning of her existence.

Can we unhook ourselves from that, and transform these conditioning forces? Again, asking for a nation.

I have compassion for this patient. It seems highly likely that she has not been the recipient of significant enough compassion and care in her life. The world’s primary problem might be that too many of its “caregivers” have not provided care, and many have in fact been primarily interested in their own selfish aims and power motives. This can create a situation of deep mistrust, fear, and even rage when care is needed by the offspring of what some might call narcissistic or sociopathic transmissions.

In this sense, she was not hostile at the treatment team, she was hostile for herself. Her anger and hostility were likely all that was holding her together at that point. She was pure protoplasm and poison, for a time at least. As psychologists Murray Bowen and Satsuki Ina have pointed out, hostility and scapegoating “bind” the anxiety of a threatened individual or culture, empowering them in the short term, while wreaking havoc on their targets. (See reference 4.)

She likely has not learned how to appropriately soothe her own distress without attacking others. We usually absorb the capacity to self-soothe from nurturing relationships, and she has likely not had enough of those. Whatever toxicity and trauma she has received in life, she is transmitting and not transforming it in this incident. She is beholden to emulation, repetition, and escalation, not transformation. In fact, the very position of requiring care may trigger paranoia and hostility in some patients, because caregiving has been associated with abuse, powerlessness, and loss of control and agency, in their lives.

Whatever the pathway(s), her behavior is demanding and even dangerous to the team. It is particularly dangerous for any team members who have had either mental health challenges or who are recipients of the traumas of prior abuse, marginalization, and subordination. These team members need extra support and attention during this time of distress, something the physician-leader provided by setting limits. I have no doubt that working with such a patient leaves a long tail of aftereffects which must be consciously addressed to heal and “build back better.”

This patient’s actions made her the center of attention of the team, but this could have in other circumstances led them to provide substandard care by creating bias. That they did not is testimony to their professionalism and her privilege. Caregiver biases have historically led to substandard care for BIPOC, women, LGBTQIA+, and patients with mental health challenges and other disabilities. By contrast, American health care can be described as favoring the needs of the individualistic White dominant culture, and even there, has a spotty track record, to put it mildly, for the poor and middle-class.

The limits of our caregivers and caregiving teams are being gravely strained and tested. Caregiver burnout is at a peak. Compassion, self-care and self-compassion are not typically taught in training programs and only recently have begun to make headway in workplaces. Those caregivers coming from marginalized communities face particular and significant pressure under current and historical socio-political tensions. They also carry significant and profound wisdom and clarity that is critical for the nation’s health care system and society as a whole.

Hostility (macroaggressions) and microaggressions can cause a variety of effects, including depression, anxiety, and suicidal ideation. Devaluations such as these erode human dignity and are inherently toxic. They are disproportionately borne by those marginalized by the dominant culture. In fact, such devaluations and hostilities are tools strategically used by the dominant culture to assert dominance, privilege, and power, and in so doing, harm members of minority groups. Harassment of caregivers is the tip of the iceberg of what we in minority groups have to deal with “on the regular,” and is particularly vexing as it is an overt attempt to malign, frustrate, subordinate, and disempower compassion and common humanity themselves. Caregivers must then either become technically skillful, unfeeling, and robotic, or more adept at dealing with the challenge presented (through teamwork, insight, and building relational skills and emotional intelligence, for example).

Some simply drop out of caregiving altogether. Nurses, doctors, teachers and others have resigned in droves during the pandemic, at least in part because their mental and physical health have been unsupported and at risk. Racism, sexism and homophobia have been part of what we have faced. (See references for some additional reading on this.)

I offer the following in order to serve the community of caregivers in the treatment of patients who present with complicated mental and physical health conditions that intersect and tax the ability to give care and remain present, skillful, and compassionate.

***

Cases in physical health, such as the one Appiah writes about, as well as cases in mental health, partly or wholly involve managing the “transference” and “countertransference” in service to the patient’s well-being. The patient’s life and wellness, in all cases, do depend on the caregivers’ understanding, skill, compassion, trust, and ultimately, in fact, the caregivers’ well-being. These are severely strained or even demolished when the patient is hostile, or society is hostile to virtues implicit in good health care such as compassion, common humanity, and human dignity.

In psychoanalysis, transferences were originally defined as the feelings and relational experiences “transferred” to the analyst from the patient’s early life experiences. The “countertransference” was thought of as the analyst’s unbiased reactions to the patient’s transference, as the analyst was supposedly a “blank screen,” “fully analyzed” and thus fit for receiving and working with the patient’s projections. However, we now formally understand that there is no such thing as a “blank screen,” and in fact the therapist/analyst’s relational identity is actually central to the healing process. This includes their life experiences, cultural understandings, humility, proactive learning processes, and affirmation of human values outside the therapy hour.

Adobe stock image by surfupvector, licensed by Ravi Chandra

In addition, it seems clear that the strategic withholding of empathy in order to maintain the façade of being a “blank screen,” often part and parcel of classical psychoanalysis, is actually a formidable obstacle to healing as well as an obstacle to the therapist’s own wellness and connection to the patient. It is also a way the dominant culture has misunderstood, marginalized, and pathologized understandable human reactions to abuse of power, and assumed that these were just up to the individual to work out within their own inner lives without outside nurturing. Some schools of thought still hew to an incorrect and easily disproven belief in individualistic self-regulation of emotion, or even an extraordinarily problematic dismissal of emotions themselves. People trained in this methodology don’t readily “give.” They are bystanders to distress, or think interpretations are the bread and butter of the work. Classical psychoanalysis, in other words, can be a distorting lens and abusive tool of power, as can any aspect of medicine and mental health care which comes up short on empathic engagement and understanding in key moments or continuities of relatedness.

I have known exceedingly nurturing psychoanalysts. But there are some out there whom I’d describe as cruel and sadistic, unapologetically wedded to technique and privilege rather than the well-being of the patient. In the past, they hewed to a misanthropic misunderstanding of human sexuality, leading to bias against LGBTQIA+, BIPOC and women patients, for example. If the patient is dissatisfied, they find a way to make this the patient’s problem. While this may be partly true, it avoids the exigency of mutual repair of ruptures, and the admission of the therapist’s potential blind spots. This applies to other schools of therapy as well, such as those who idolize reward-and-punishment behaviorism, perhaps cynically, for pecuniary gain and media attention. Man does not live by carrots and sticks alone, or even at all.

Lookin’ at you, Dr. Phil, and also late-capitalism-judgy-Jesus!

Modern psychotherapy recognizes that a “intersubjective relational field” is created between the therapist and the patient, and the therapist uses their perceptions of what is happening “in the room” as a guide to understanding the patient’s inner life and life outside the therapy hour. Both patient and therapist are reacting and responding to the other’s relational identities, but the therapist is professionally trained to understand this interaction and the patient’s predicament in depth.

In practice, this process is not only beneficial to the patient, but can also lead to the therapist’s own growth, insight, and capacity to treat patients. While the patient is the one suffering and seeking relief, the therapist is indeed put to task, emotionally, cognitively and relationally, to help the patient. Understanding what is happening in the relational space is often an ongoing task, as new material and experiences shed new light on the patient’s humanity, as well as the humanity of the therapist. Therapy at its best is a profoundly humanizing venture for all parties involved.

Speaking personally and from what I know of my colleagues, we do in fact often “take our work home.” Better preparation, formulation, and collaboration helps us understand and manage what is happening “in the room” to better serve our patients. Understanding and managing hostile transferences, which might be characterized as racist, sexist, homophobic, narcissistic, sociopathic, or “simply” paranoid, psychotic, jealous, envious, or manipulative, can be quite the challenge. As a psychiatrist and human being, I strive to live in my true self, which is compassionate, generous, and truly dedicated to the well-being of those who seek my attention and care. This works well when a therapeutic alliance is formed and maintained, and there is a sense of mutuality and respect in our common endeavor.

I would say our true selves as caregivers are challenged:

1. when the patient enters therapy with a great deal of mistrust, fear, or even paranoia because of their condition or societal conditions, or

2. when the patient has strategic aims and they objectify, devalue, manipulate or even scapegoat the caregiver solely as a means to their ends, and they do not see the caregiver as a human being with feelings and basic needs, or

3. when the patient carries a burden of biases about the therapist or their identity, or a preconceived (and incorrect) notion of what care “should be,” thus finding inappropriate fault with the caregiver; or

4. when the therapist is unaware of or party to their own biases about the patient’s humanity, or develops dislike of the patient, or even, in rare cases, hatred (see D.W. Winnicott’s classic article “Hatred in the Countertransference,” in references).

From a presentation by the author

In MOSF 17.6, I wrote about my wonderful mentor, the late analyst and psychiatrist Seymour Boorstein, who always asked “do you love your patient? Because if you don’t, then the therapy won’t work.” He also said “don’t add insight to injury. Give them a crust of bread.”

I always took this as an instruction to work harder at loving my patients. I’m still a work-in-progress, imperfect and human. It’s sometimes hard to stay in the zone when you’re under attack, and in fact one’s reactions and responses to the attack, as well as subsequent repairs, might be necessary to get to mutuality and collaboration as opposed to subordination or dominance.

Yup folks, it is a real relationship, and a laboratory for relatedness, but one which is in service to the patient’s growth and well-being. This must include the therapist’s well-being, or the therapy will not work. The efficacy of any particular therapy may well depend on a therapist’s capacity to “go there,” get into the weeds of the places where the patient does not have well-being and therefore becomes demanding, lost, confused, controlling, manipulative, self- and other-injuring, etc. In other words, the most challenging and distressed patients are the ones who have trouble relating to everyone else and usually themselves too, and thus will have trouble relating to their therapists. Every therapist develops an understanding of how far they will or can go, on their own or with a team. But we have not yet reached the limits of what therapy and society can do for the distressed and suffering. Not nearly.

Love, in all these cases, is therapeutic love, or the application of mindfulness, compassion, relatedness, creativity, and insight to the service of the patient’s well-being and relief of suffering. I have been told by some that I have developed a reputation for compassionate care in difficult circumstances, but this is an ongoing growth challenge, which I’ve found requires good relationships with, support from, and influence by family, friends, community and fellow therapists and psychiatrists. I also have found self-compassion and mindfulness to be indispensable tools. Therapy is “art in the medium of relationship,” and self-compassion helps me hold the brush of my identity steady as I treat patients. (I am offering a one-off and an eight-week workshop in mindful self-compassion specially geared for caregivers and those affected by societal marginalization this fall. For details scroll to the bottom of this article.)

From a presentation by the author

Our jobs as therapists can be extremely isolating, and this is a danger to us and the work itself. The most challenging work I’ve seen is with patients who seek to control, isolate, insult, manipulate and even blame, scapegoat and split the therapist or therapeutic team.

Even in these cases, I recognize that the patient isn’t strictly “at fault.” They are transmitting their personal, cultural and historical experiences, and it is up to me (hopefully with the patient’s collaboration) to decode these experiences in service to their well-being. In this process, of course it is important to set boundaries and limits for accountability, in order to establish and maintain a therapeutic alliance.

Most patients come to me for relief of suffering or for exploration, growth and development. In rare cases, patients seek power, which might be self-empowerment or egoic power. Patients might hold some combination of all of the above motivations, because we are complex and have many parts seeking attention and expression. All of these come from the ways they hold their humanity, vulnerability, relatedness, and cultural context. Their deeper needs are either apparent or become amplified or escalated, and then need to be understood or soothed. My job is really to see their humanity and allow this to bring me deeper into my own humanity and professionalism.

But exceedingly selfish and “confused” folks can really take us therapists for a spin.

It’s actually great when patients with these problems around power, disempowerment and self-worth actually do come to us for therapy. Frankly, most of them don’t, and they end up causing a lot of problems in the culture at large. I think most of my patients essentially come to therapy because they’ve been burned by exceedingly selfish and confused people and systems, and they’re trying to figure out how to feel good or better in the wake of damaging relationships and a culture distorted by abuse of power. Sociocultural and political tensions have risen dramatically, making these kinds of situations more prevalent and insistent for our closer attention. Our attention is required in service to better outcomes and reducing or eliminating caregiver stress and burnout.

I think the best approach is to build our teams by recognizing and naming the harms of hostile behavior and attitudes, and commit to our own well-being and personal growth in service to our patients. We must simultaneously improve our capacity to understand and work with challenging patients and situations.

Finally, it really helps when the team can get to a non-blaming, non-judgmental and compassionate stance towards the patient and all members of the team as they process their reactions to “offending and traumatizing stimuli” so to speak. This is all extremely triggering, and the team needs lots of love and support to do their work, really. Our work as therapists depends on our emotional and interpersonal sensitivity and empathy. It is hard to do our work when our sensitive and empathic identities are under assault.

As I wrote in MOSF 17.6,

“How many of us are worth throwing under the bus to protect White feelings?”

Society and society’s “leaders” need to ask themselves this question as well. Throwing caregivers under the bus of the dominant culture’s distorted and cruel power demands does not bode well for either health care or society. It’s possible that when these power demands come to us in the form of a patient, they can be workable. At best, these situations can be growth challenges for individuals and teams. At worst, they could wreck caregivers’ well-being and destroy teams. I think hostile patients know this, on some level.

What happens when hostility comes to society in the form of politicians such as former President Donald Trump? We’re seeing that process unfold. I hope the nation takes stock and marshals itself to make choices on behalf of the greater good. Trump’s example has amplified and unleashed a very dangerous part of American society and the human psyche.

If I were being compassionate and generous, I would say that distorted, cruel and selfish power demands come from underlying vulnerability and insecurity, combined with historical privilege and a kind of talent, enacted in harmful schemes, gaslighting, and selfish short-term strategies and manipulations.

To repeat: At best, these situations can be growth challenges for individuals and teams. At worst, they could wreck our well-being and destroy teams. I think hostile patients (and people such as President Trump) know this, on some level – but they have an unconscious or conscious penchant for controlling others in an attempt to manage their own buried distress. As I’ve often said, “people who can’t control their own distress try to control others.”

At the same time, emotional self-regulation is a myth – as social beings, we co-regulate each other’s emotions “on the regular.” In this way, dissatisfied parts of our own inner lives can control a big chunk of our psychic energy. We are being collectively dysregulated by the times – the January 6 hearings can be seen as an attempted measure at setting limits and thus assisting our co-regulation.

“Growth challenges” come at great risk for those who continue to care and adhere to duty to a bigger picture over selfish exhibitionism and crude power. Creativity is possible when one contains ego in service to duty – but aggression and drives to control others brings great danger. We do not yet know what will survive our national and international struggles. I hope this essay has been helpful in naming what’s at stake.

Finally, I would again reiterate that Black and Indigenous peoples, as well as other BIPOC, LGBTQIA+, women, and other marginalized peoples, have suffered incalculable harms at the hands of biased caregivers, leaders, authorities, and abusive people and groups. These biases affect care in the form of horrible and sometimes willful misunderstandings of physical and mental health care needs, and poor, crass judgments instead of compassion for marginalized identities. So perhaps establishments and institutions can pay attention to us when we say we are at risk.

We do in fact understand what causes harm.

We can in fact help heal the wounds of this distressed nation.

For more:

The following Mindful Self-Compassion workshops for BIPOC, LGBTQIA+, and allies, with particular emphasis for caregivers (in medicine, education, etc.) will be held this fall:

SF Love Dojo 3-hour Mindful Self-Compassion workshop will be held on Zoom on Saturday, September 10 from 10 am – 1 pm PT. Register here. $95. Inquire for sliding scale option.

SF Love Dojo 8-week Mindful Self-Compassion class will be held on Saturdays from 9:30 am – 12 noon PT beginning Saturday, September 24^th. Register here. $475 early bird (before September 11)/$575 full fee/$350/sliding scale compassionate care.)

For further reading:

1. Trogen B, Caplan A. When a patient is a bigot, what can a doctor do? Chicago Tribune, June 29, 2017.

2. Winnicott D.W. Hate in the Countertransference. Originally published 1949, republished 1994 with an introduction by Glen Gabbard. Full article accessible at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330380/pdf/348.pdf

3. On bias against caregivers-in-training, see McFarling UL. ‘It was stolen from me’: Black doctors are forced out of training programs at far higher rates than white residents, Statnews, June 20, 2022

4. Chandra R. Dismissing Microaggressions Is Insensitive and Even Racist, Psychology Today, July 1, 2020

5. Chandra R. Dr. Satsuki Ina on Migrant Detention, Racism and COVID19, Psychology Today, April 6, 2020

6. Henry TA. Medicine’s great resignation? 1 in 5 doctors plan exit in 2 years, American Medical Association website, January 18, 2022

7. Guggenbühl-Craig A. Power in the Helping Professions. Spring Publications, 1971. (Formative and essential reading on these central issues.)

8. Chandra R. Hamaguchi’s “Drive My Car” and the Myth of Self-Regulation, Psychology Today, February 7, 2022

9. Shang Z, Kim JY, Cheng SO. Discrimination experienced by Asian Canadian and Asian American health care workers during the COVID-19 pandemic: a qualitative study. CMAJ Open. 2021 Nov 16;9(4):E998-E1004 (For further reading on hostilities, aggressions and microaggressions faced by Asian Canadian and Asian American health care workers from May-September 2020.)

Photo by Bob Hsiang

Ravi Chandra is a psychiatrist, writer and compassion educator in San Francisco, and a Distinguished Fellow of the American Psychiatric Association. For fourteen years, he was lucky to have his MOSF posts published by the Center for Asian American Media, and now looks forward to broadening and building a diverse creative community and coalition through reflecting on culture and psychology for East Wind eZine. Sign up for updates here, and see all the posts here. He writes from the metaphorical intersection of The Fillmore and Japantown in San Francisco, where Black and Asian communities have mingled since the end of the incarceration of Japanese Americans during World War II. He literally works there, between two Indian restaurants, go figure, though one has permanently shuttered during COVID. His debut documentary was named Best Film (Festival Director’s Award) at the 2021 Cannes Independent Film Festival. The Bandaged Place: From AIDS to COVID and Racial Justice is available on-demand, and with the discount code “Awake” you can get a 20% discount. His nonfiction debut, Facebuddha: Transcendence in the Age of Social Networks, won the 2017 Nautilus Silver Award for Religion/Spirituality of Eastern Thought. You can find him on Psychology Today,  Twitter,  Facebook,  Instagram,  YouTube,  SoundCloud, or better yet, in the IRL.