“I find there are personal limits I come up against”

Psychotherapists should be impartial. But how to react if patients make contemptuous and discriminatory remarks? Interview with Samual Thoma, psychotherapist and psychiatrist at the mental health centre of the Immanual Klinik Rüdersdorf, one of the MHB university hospitals, about his experience with extreme right-wing patients and his views of politics in day-to-day clinical practice.

Dr. Thoma, you work at a Brandenburg clinic. What is the impact of politics on your work?
There are many different effects. Over the past months my colleagues and I have observed an aggravation of social hardships. In therapy sessions, more patients have simple but crucial questions such as: how to pay my gas bill, how much money is left to buy food, will I have to go to the soup kitchen?

What have such questions to do with politics?
These are sociopolitical questions. Sometimes I wonder whether we therapists understand the seriousness of the issue. As therapists we are part of the middle classes and financially secure. Along with all others, I am naturally shocked by higher gas bills. But I need not worry whether I can afford the bus ticket to get to the therapy session. These issues often involve embarrassment, so I make a point of addressing them, above all if patients do not do so themselves; and most react with relief.

In 2019 you wrote that you treat life crises, and not the social system. But is not the social system to blame for the social issues presented by your patients?
The point is that in psychotherapy I am always concerned with the individual. And ultimately it is always about correlations between specific individual and social context. If, for example, we say that accelerated capitalism leads to more burnout and therefore to the depression of that person in front of me, then this line of thought is too abstract. The person facing me was born and raised somewhere, was a member of this or that family, had this or that training and education, had various jobs and experiences. The aspect of which government we have or which economic system comes to bear at a very late stage or only indirectly. The economic system certainly plays a role in shaping our living conditions. But nothing is achieved if your first impulse is to point a finger at the “evils of capitalism” or the “evil red-yellow-green coalition government”.

What can therapists do in the face of such worries?
I believe it is important to address the concrete situation. I ask the patient: “You may feel defenseless in your situation, but what specific action can you take now?” This involves more than just a prescription or a reappraisal of one’s childhood. It also involves questions such as: What exactly can I do in my current situation in life? Who can I talk to? With whom can I get together so that I won’t feel so helpless? I may also suggest to a patient to become politically active.

But what do you do if the anxiety to be treated cannot be separated from racism, for example?
In such moments I try to get close to patients’ experiences. If they speak collectively of, for example, “the Syrians” or “the Afghans”, I will try to understand what exactly happened to the patients. I stay with the individual experience in order to later reconstruct the origins of the generalization. In most cases the generalization is nothing but a handling or defense strategy.

So your reaction is to let racist statements pass for the moment?
If my first reaction is to say: “Wait a minute, that’s a racist remark”, I would bring politics into therapy in a way that would destroy all therapy efforts. If a female patient speaks of abuse and blames “a refugee”, I do not respond by immediately presenting my own anti-racist attitude. The focus is on the patient’s suffering. At a following stage I would point out that it cannot be inferred from the experience – and has actually been disproved – that refugees in particular tend to abuse children or women.

How do you respond to criticism of the government?
You can often agree on this kind of criticism. Therapists always aim to develop an understanding for everything. But sometimes such criticism is combined with certain allusions.

Which allusions?
For example: “We don’t know whether this is actually a virus.” I am not only a psychotherapist but also a physician, and in such situations my answer is: “I prescribe medication, but if you refuse to believe scientists then you should conclude that medication is not effective.” Nobody has found a quick-witted response so far.

Is this your strategy to cope with blatant remarks: quick-witted answers?
I had to learn how to react. In 2019 I had a patient who tested my limits. The experience induced me to delve into the issue more thoroughly.

What happened?
The patient was a member of the AfD („Alternative für Deutschland“, right-wing political party) and used to dress up in Thor Steinar clothing for her hospital appointments. She repeatedly talked about “refugees” and “the refugee wave”, and that “Germanness is no longer allowed”. For group singing she requested the national anthem. She really brought me and my colleagues to our limits. Therapy lessons frequently drifted off into political debate.

What was your reaction?
I felt overwhelmed but nevertheless tried to keep up the conversation. I contradicted her when she expressed crude theories and opinions. But at some point, things couldn’t continue as they were. I realized that I must draw a line when someone uses the therapy context for political propaganda. And this is what she did. She used every single group therapy session and smoke break to influence the others.

Do you think your reaction would have been just as allergic to left-extremist slogans?
People either seek therapy contexts because they need help, or they want to engage in politics. Perhaps my reaction to left-wing slogans would not be quite so fast; but therapy should not be used for political propaganda. And the crucial difference is that right-wing ideology is contemptuous of human life and dignity.

Would you say you can only treat persons you can sympathize with?
No, of course not. And I am certainly able and willing to work with patients whose opinions – specifically political opinions – I do not necessarily share. But of course there are certain sympathies you may share with the person in front of you. Every therapist will confirm this.

Was your patient of 2019 an extreme case?
This case was actually exceptional, a culmination of the issues in question. But similar arguments have occurred ever since. One big issue was migration in 2015/16, followed by Corona, now it is the Ukraine crisis. The topics are varied but the strategies are more or less the same: strategies from right-wing debates and conspiracy theories, with a great potential of mobilizing intensive political feelings. It is all the more important for therapists to see where therapeutic contexts are abused for certain political strategies or concepts.

Is it your intention to stay as disinterested as possible and become engaged as a human being only if necessary? Or do you make deliberate political statements to become more discernible for your patient?
I was going to say: as neutral as possible and as political as necessary. But the point is to decide when a response is necessary for political reasons. My method is to ask whether I understand the patient correctly, and then I decide whether to ignore a remark or to comment on it.

What do you do differently after that incident in 2019?
I am more confident, and more prepared to acknowledge situations where therapy objectives are in danger of becoming obscured. When political issues are mentioned then I address them and state my position, with emphasis on personal experience. Then I try to return to the therapy context. But if a patient insists on a political agenda, I am now more ready to admit that we are stuck.

When did you successfully solve a situation by sharing your experience?
On the topic of Corona, I said, for example: “What you are saying makes me concerned and sad, because it would mean that you believe those people on our intensive ward did not really suffer and did not die.” In this way I can reconnect with my patient. I do not want to convince the person in front of me of my political stance, but I want to express the emotions evoked in me. My experience is that there is no point in bringing political authority into the therapy conversation, nor is it helpful to strictly avoid any political remark. There should be room for political statements, but then you should return to what the therapy is really about.

Was the issue of politics ignored for too long as a factor in psychotherapy?
Please do not misunderstand me: I don’t want therapists to resort to bar room slogans or stereotypes; but we must certainly confront the issue more thoroughly. In my experience, the field of politics is ignored in psychiatry training, although psychiatric hospitals are the melting pots of society. We receive no preparation for political debates in therapy sessions.
There is this image of a very disinterested therapist, strictly focused a patient’s biography and inner state, and politically absolutely neutral – as if therapists are no political beings themselves.

Should the requirement of neutrality be given up?
It is of importance to patients and to progress in therapy that they perceive a therapist not only as a neutral, anonymous shell but as a human being, made of flesh and blood and holding political beliefs as well.

Giving room to political beliefs, that sounds great. But what if roles are reversed? If a patient is left-wing, and the therapist right-wing?
I would still wish for the therapist to show his or her convictions in certain instances. But to follow up on your question, it sounds as if right-wing and right-extremist could be randomly exchanged for left-wing and left-extremist. Neutrality would be a nice compromise if that were true. But this compromise is an illusion. I am a political being and cannot be neutral. As a therapist I need to take a stance at some point. I recommend a stance specifically against right-wing extreme and contemptuous attitudes because I believe that they are a danger not only to the therapy context but also to our society around this context. A seemingly neutral avoidance of positioning is a statement in itself, and it gives rise to such danger.

Interview by Lea Schönborn.

Personal details:
Samuel Thoma, Dr. med. and Dr. phil., born 1985, specializing in psychiatry at the mental health centre of the Immanuel Klinik Rüdersdorf, a university hospital of the Brandenburg Medical School, and co-editor of the journal “Sozialpsychiatrische Informationen”. Research interests: philosophical foundations of social psychiatry.

Source: Berliner Zeitung, Thursday, 29 Dezember 2022, page 2