Women & LGBT clinicians

[sockit]

A few threads have touched on aspects of this, and it's possible I've missed it if it's already been discussed (apologies if so), but, what's it like dealing with adult cis male clients with issues on the externalizing / antisocial side from the positions I mentioned above?

edit: maybe i should explain why i'm asking that. of course training should equip clinicians to perform equally well regardless of personal background and likely does. but, i am wondering whether there might be issues particular to this sort of dynamic.

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[MCParent]

A few threads have touched on aspects of this, and it's possible I've missed it if it's already been discussed (apologies if so), but, what's it like dealing with adult cis male clients with issues on the externalizing / antisocial side from the positions I mentioned above?

edit: maybe i should explain why i'm asking that. of course training should equip clinicians to perform equally well regardless of personal background and likely does. but, i am wondering whether there might be issues particular to this sort of dynamic.

I'm not sure I'm grasping your question. You're asking what it's like working with externalizing or antisocial cisgender men if you're a woman or a gender/sexual orientation minority? It feels like there's another question implied there somewhere.

 

[AcronymAllergy]

I'm not sure I'm grasping your question. You're asking what it's like working with externalizing or antisocial cisgender men if you're a woman or a gender/sexual orientation minority? It feels like there's another question implied there somewhere.

This is what I was wondering as well. Are you asking if there would perhaps be insults and derogatory comments made, and/or physically-threatening behavior exhibited, and you're curious how folks have dealt with that?

 

[sockit]

This is what I was wondering as well. Are you asking if there would perhaps be insults and derogatory comments made, and/or physically-threatening behavior exhibited, and you're curious how folks have dealt with that?

This is exactly what I meant to ask, sorry! (Well done, AcronymAllergy!)

I am sort of feeling (from my untrained state, at least) that insults, threats and other kinds of aggression might be pretty effective at decentering me.

 

[sockit]

Actually thinking about it, it might be that male-presenting therapists (regardless of preference) might be more likely to get open aggression than female-presenting therapists. But I don't know.

I am thinking this is a population I might prefer to stay away from, given a choice.

 

[CheetahGirl]

This is where building an alliance, proceeding with caution, and being a 'good listener' significantly come to play. I can speak from a woman's point-of-view (and even my LGBT colleagues may say the same), but there is no need for a patient to want to physically-threaten or spew derogatory comments at you from the very beginning (i.e., intake), usually something you say or do provokes these types of behaviors. If the patient is verbally abusive, there is a point where you will decide whether you want to proceed, but if this type of behavior is a clinically indicative of their pathology, then this is where being a thick-skinned clinician is important.

Perhaps some of the folks who work in prisons can speak to your concerns better than I, but I had experiences with patients who were former felons, with histories of abusing staff, and I got along fine with them (although at first I was admittedly scared to be alone in the room with them)....and my therapeutic services were actually beneficial. I think respecting every human soul from the very beginning is key, regardless of their histories & pathologies. Although, I know my biases and cannot work with/or offer this same respect to offenders of crimes perpetrated on children, so I choose to NOT work with this population. However, I have enough strength in me to professionally make it through an intake (or multiple session intake), and then, would work towards transferring this type of person to another clinician.

 

[MCParent]

I've perceived it to be more common among non-antisocial pts that, after building some rapport, pts with sexist/racist/homophobic/etc beliefs sometimes put out some feelers about those issues by saying things in those veins. I think pts often assume therapists are fairly liberal and are not always forthcoming with opinions like that. Maybe that filter would be removed for anti-social pts but I couldn't say.

I think respecting every human soul from the very beginning is key, regardless of their histories & pathologies. Although, I know my biases and cannot work with/or offer this same respect to offenders of crimes perpetrated on children, so I choose to NOT work with this population.

I give my students who say this a thought experiment: if you don't have that (unconditional positive regard, or whatever you want to call it) for any one group or based on any behavior, do you actually have it for anyone? As in, any of your patients could at any time tell you that they have committed a sexual crime against a child. Isn't that by definition conditional positive regard for everyone?

 

[PsyDr]

This is where building an alliance, proceeding with caution, and being a 'good listener' significantly come to play. I can speak from a woman's point-of-view (and even my LGBT colleagues may say the same), but there is no need for a patient to want to physically-threaten or spew derogatory comments at you from the very beginning (i.e., intake), usually something you say or do provokes these types of behaviors.

I cannot disagree enough with this fantasy. IME, I had a pt assault me when I walked in the door before I said anything. Pt did not want to be admitted. I have had similar experiences in prison, when I walked in after being called for SI eval. Again, walk in the door and have them go after me.

 

[sockit]

I guess I am also wondering if the skin thickening process might be different for clinicians who, by virtue of their identities, might have experienced a greater proportion of isms in their ordinary life. I'm wondering what it's like to see them reflected in pathology.

(Is it possible to avoid conditions and biases? I'd have thought being aware of them and addressing them in the service of the client/patient would be the best anyone could realistically hope to do.)

Edit: jeez, PSYDR. That must have been terrifying.

 

[CheetahGirl]

I give my students who say this a thought experiment: if you don't have that (unconditional positive regard, or whatever you want to call it) for any one group or based on any behavior, do you actually have it for anyone? As in, any of your patients could at any time tell you that they have committed a sexual crime against a child. Isn't that by definition conditional positive regard for everyone?

Maybe I should clarify that I don't have unconditional positive regard (a la Rogers) for EVERYONE under the sun...I am human after all. You are correct it is "conditional" positive regard, but it starts off as "unconditional" to all human life. I would be in a significant dilemma, if I built up a strong alliance with a patient after months/years, and then this person revealed to me that they did in fact, sexually abuse a child (either once or repeatedly). I would then, have to keep my clinician hat on, personal bias aside, and consult my peer supervision group on how to proceed. I would not abandon my patient, and from this very dilemma I would grow as a clinician. And actually, come to think of it, I have worked with many parents who admitted to corporal punishment/physical abuse of children, and I am curious about ways we can circumvent the parents' problematic behavior. I think my bias holds with male offenders of sexual childhood abuse...that takes one skilled clinician (like my former supervisor), and I may change my tune after years of practice.

I cannot disagree enough with this fantasy. IME, I had a pt assault me when I walked in the door before I said anything. Pt did not want to be admitted. I have had similar experiences in prison, when I walked in after being called for SI eval. Again, walk in the door and have them go after me.

Okay, so maybe the fantasy holds with non-violent offenders. But this is why I said we need to hear from folks with real experiences working with these populations. I knew a prison doctor who was kicked in the back by a prisoner who braced himself with the guards on either side to do some serious damage to the doc because "he did not approve an extended stay in the infirmary." But, violent and/or psychotic patients are usually dealt with immediately by staff and psychiatry...hopefully...we hear stories every day of incidents that went all wrong.

 

[AcronymAllergy]

Speaking to both what CheetahGirl and PSYDR have said, I think the evaluation context can be very important here. Also, a thorough records review is always a good idea (when possible).

If, for example, a patient has multiple behavior flags on their chart and has a history of being aggressive toward clinicians, that's likely going to change the expectations I have (for better or worse) going into the first appointment. Likewise, when I worked with criminal forensic patients, my expectations going into the evaluations were different than when I saw students at the university clinic for psychoed evals.

However, I definitely do think there are times and ways in which the clinician's nonverbal (and perhaps overtly verbal) behaviors can exacerbate or defuse some situations. If you initially come across as skeptical, suspicious, or demeaning, you're of course going to potentially pull for "acting out" behaviors from a patient if he/she has a history of exhibiting them. Likewise, if you're going into a session with a patient who has a history of being manipulative (as might be the case with folks with antisocial and/or borderline characteristics), and you present as unsure and lacking confidence, they're potentially going to test some boundaries. But if you present as confident, empathic, and genuinely interested in the patient's well-being (as well as perhaps giving them a few minutes to vent at the beginning of an appointment if they're already very irate for whatever reason), that can go a long way toward fostering rapport.

However, as PSYDR essentially said, if a patient has it in his/her mind to assault you from the outset, there's not a whole lot you can do about it. All you can do is go into every session with a new patient knowing that this might happen, particularly in adversarial contexts.

Edit: As for developing thick skin, it's a natural progression that happens over time. However, no matter how seasoned you are, there will still be specific patients and/or specific things that can be said that will affect you and throw you emotionally "off-center." Being able to recognize when this happens and knowing how you respond is helpful, but hey, we're all human. So if you somehow mess up (assuming it's not some huge ethical transgression like just openly smacking someone), address it afterward as is appropriate and/or refer out when necessary.

 

[CheetahGirl]

However, as PSYDR essentially said, if a patient has it in his/her mind to assault you from the outset, there's not a whole lot you can do about it. All you can do is go into every session with a new patient knowing that this might happen, particularly in adversarial contexts.

Agreed.

 

[psych84]

Well, I don't have experience working with patients but as a gay man who has played sports all his life and been in plenty of dressing rooms and heard all that, it doesn't really bother me. I don't take it personally.

 

[smalltownpsych]

As a straight male who is cis, I think, (had to google that term so not sure of the definition), I am assuming that the question was specific to the poster, but would just want to point out that I am uncomfortable with anti-social clients, as well. I have worked in jails and other institutional settings where antisocial people come into contact with therapists and I have found that they are usually just trying to game the situation. My own counter-transference when encountering dangerous individuals is to put up a huge emotional wall and I usually just go with that. After hearing many wife-beaters and child molesters try to blame the victim, deny, minimize and other forms of song and dance, I just don't have that much sympathy for their plight. When an individual takes full accountability for their behavior and begins to actually change, that is a whole different story and I have seen that more with substance abusers than with other more violent antisocial personality types.

 

[dale.gribble]

I cannot disagree enough with this fantasy. IME, I had a pt assault me when I walked in the door before I said anything. Pt did not want to be admitted. I have had similar experiences in prison, when I walked in after being called for SI eval. Again, walk in the door and have them go after me.

I wholly disagree with turning the idea of how important unconditional positive regard is on its head by dubbing it a fantasy, which all too easily begets dismissing it entirely, at any point in time. Obviously in the experiences you mentioned there was a lot going on prior to your arrival, and rather than turn the attacks inward as something you could have affected in any way, my guess is you were just a new person to take it out on. In such cases, I can't imagine a better approach than one with UCPR irrespective of what they say or do.

Particularly in prisons, too. IME (my father was a prison guard for 30 years, and I "hung out" there a TON) and from what I've heard from my dad, the easiest way is to work with someone based on assumptions and categorical schemas. Just like speaking to elderly persons with baby talk will probably lead to your getting assigned the title of "dingus," working with someone in prison from the perspective of "they're a deplorable individual with faulty mental faculties and engage in disturbing bxs for no reason other than a lack of control and respect for authority," you'll get it right back in spades. All this is to say that, assuming you're conducting yourself correctly, I don't see a reason why there's any greater risk of any of the things mentioned in this thread.


Regarding the OP, I'm not still sure of the main question, but, hands down, no question--women have been way more discriminatory to me than men (even back when my ID was obvious). So, I don't think LGBT practitioners are at any greater risk. But I don't doubt it's different when it comes to women.

 

[PsyDr]

I find it hard to take advice from someone whose identified credentials are that they went to work with their dad, who talks about unconditional positive regard while simultaneously making fun of special needs children.

The fantasy I was referring to was that the victim is somehow always to blame.

I found it hard to convey anything other than turning blue and losing consciousness in one of the above instances, in another I was able to say "uhhh" after being tackled.

But please, tell me how to express positive regard in those instances.

 

[CheetahGirl]

I found it hard to convey anything other than turning blue and losing consciousness in one of the above instances, in another I was able to say "uhhh" after being tackled.

But please, tell me how to express positive regard in those instances.

After reoxygenation occurs, you could say something like "I see we got off to a rough start. What was going on for you just now? Right before you lunged at me?"

 

[sockit]

I can't imagine enduring an assault like the ones you described, PSYDR - at all - and for this to be something to count among the possible outcomes of any given working day is even more beyond me. I'm sorry you experienced that. I hope that you were offered support by your employer (medical, legal and otherwise) after those events.

My original question (I now see) had to do with the role of fear in (what is, I see, more elegantly captured by) 'countertransference' in relation to a clinician's positionality. Regular life throws up a sort of low-level threat to women and minorities (of all categories) through micro- and more macro aggressions. ( I appreciate that not everyone who is a women or minority is afraid, that's not what I mean to say. But for those who do or have experienced something on a continuum of fear of violence in day to day life, maybe, it might come into play in professional dealings with people for whom physical or psychological violence is part of their clinical picture.)

It was less intuitive, to me, to think about the likelihood that clinicians falling into majority, socially dominant categories* might be seen as direct threats and maybe more prone to experiencing actual violence in settings where that falls within the realm of expectation.

Thank you, Acronym Allergy, Cheetah Girl, PSYDR, smalltownpsych and MCParent for offering your experiences and insights on this.

*and of course people might be in multiple categories at any given time, and the setting might make one more salient than another.

 

[sockit]

tl/dr: what's it like to be a little bit afraid of your clients, whoever you are? <-- is what my question should have been. but i don't necessarily expect further responses, as people have been very open already. thank you for that.

 

[dale.gribble]

I find it hard to take advice from someone whose identified credentials are that they went to work with their dad, who talks about unconditional positive regard while simultaneously making fun of special needs children.

The fantasy I was referring to was that the victim is somehow always to blame.

I found it hard to convey anything other than turning blue and losing consciousness in one of the above instances, in another I was able to say "uhhh" after being tackled.

But please, tell me how to express positive regard in those instances.

Thank you for clarifying; my interpretation was that you were referring to UCPR as a fantasy. I'm sorry you felt the need to get upset and react so smugly. Also, I'm sure you're not reading my post correctly, as I in no way (or anything close to it) made fun of special needs kids. Finally, I didn't realize we had to compare credentials before commenting--I didn't see you list yours. For all these reasons (and what you indicate in your post, as well as the way you've reacted so disproportionately here), I indeed doubt you're suited for working with inmates or other volatile individuals. I sincerely hope you're working in a more appropriate setting.

In any event, if someone is hostile, there's no difference in how one displays UCPR, it's a matter of it being for a different purpose such that it takes on an almost strictly behaviorist aim. By letting their bx knock you off your post, it's just going to reinforce their hostility. Instead, while one is likely (and rightfully so) thinking up a way to refer them elsewhere, the response should simply be a calm "It seems like he feel very strongly about this. Has something happened in your life to make you feel this way? Or is it merely a general belief? I'd like to talk about it with you more so that I can understand you better."

Physical attacks are obviously a whole other level, but the point is the same--UCPR in these cases means not taking it personally or reacting against the person instead of the behavior. I've been punched in the face, held up against a wall and choked out, bitten, spit on, and more, and I learned very quickly that if I didn't react to their behavior, their behavior would burn out pretty quickly. Now, this doesn't rule out defending yourself-clearly you have the right to and should exercise it within whatever bounds are appropriate to your settings, but that still needs to be done wearing the clinician's jacket, as opposed to throwing that jacket off and getting steeped in the personal reactions you're feeling in that moment. Maintaining one's composure in this way, and employing your professional faculties, is not "blaming the victim" nor is it validating the aggressive bx. It's simply doing your job.

 

[PsyDr]

uhm,

1) You interpreted my post incorrectly. You used this misinterpretation to criticize my reaction to an assault. You used your experience of going to work with your prison guard father as justification of victim blaming. You opened the door on criticizing.

2) Your profile pictures clearly reads, "unidentified special needs child" with a picture of an cartoon adult character who has never been identified as special needs. Explain how that is not,".... I in no way (or anything close to it) made fun of special needs kids."

3) Kid, you have a long way to go.

 

[smalltownpsych]

I have done a pretty good job in inpatient settings and jail settings developing rapport with dangerous people, but that does not mean that I am not still at risk for attack and more importantly it does not mean that someone who is attacked did anything wrong. The psychological need for perceived control over dangerous situations is what can lead to the "blame the victim" phenomena.

 

[dale.gribble]

uhm,

1) You interpreted my post incorrectly. You used this misinterpretation to criticize my reaction to an assault. You used your experience of going to work with your prison guard father as justification of victim blaming. You opened the door on criticizing.

2) Your profile pictures clearly reads, "unidentified special needs child" with a picture of an cartoon adult character who has never been identified as special needs. Explain how that is not,".... I in no way (or anything close to it) made fun of special needs kids."

3) Kid, you have a long way to go.

I'm sorry if you felt that I was invalidating your experience or blaming you as the victim. That was not my intent, and I in no way alluded to such a notion. If there's something that could have been worded better--fine, I'll accept that, because I'm sure writing thoughts without the scrutiny of something I'd submit to a journal is more liable to misinterpretation. But, to be sure, I actually wasn't addressing you directly. I was quoting your post as a means of illustrating how it was a springboard that got me to thinking about what I posted, which has nothing to do with you. I was engaging in a conversation regarding the OP, not a whodunnit investigation devoted to you. You're taking this way too personally.

The rest of your post(s) are pure ridiculousness and refusal (or, perhaps, inability) to engage intellectually and/or appropriately. I'll forgo any further wasting of my time responding to them.

I hope you get a better handle on your emotions/narcissism sooner than later. Or, at least, that you don't interact in such a manner in real life.

 

[CheetahGirl]

Ok, Kids, let's try to get along here and elevate the level of conversation to more than just lowly pop shots. After all, we're commenting on a "Women & LGBT clinicians" thread....where's the love?

Blaming the victim is never the solution, but we do have a tendency to consider the roles of all parties involved in any altercation. In my sexual assault work & training protocol, we generally ask: "If a woman is walking down the street naked, is she asking to be sexually assaulted?" Immature folks who lack empathy and sometimes awareness will generally say "yes," but the correct answer is a resounding "NO." Walking down the street naked is not an invitation for sexual assault, and one should not blame the victim. However, we must consider her mental state, physical state, emotional state, circumstances, acute and long-term history...but we should not blame her....blame lies solely with the assailant's lack of impulse control and lack of prosocial behavior. *Edit* And the real work begins when we deal with the consequences of these behaviors if primary and secondary prevention programs/interventions were unsuccessful.

I edited out my original response to PSYDR asking his role in the originally stated altercations because I noticed I was doing the same - blaming him as the victim by implying perhaps there is an air of entitlement that some practitioners give off to their patients that may create a disparity. But, I edited it out because AA clarified that there are just instances where people are determined to go forth with their intended actions regardless of whatever skilled, pleasant, positively regarding clinician walks in the room. It is another example of solipism, and just illustrates the complexity of the work we do when dealing with another individual's thoughts, behaviors, and subsequent actions.

 

[dale.gribble]

I agree that it's unfortunate this thread became weighed-down by hardly-passive aggression and the like; for my part, I was earnestly trying to further the thread.

AA's point is precisely what I've been attempting to illustrate all along.

To be sure I'm clear, I assumed it was simple common sense to understand that, especially if you are assaulted for no reason, then their behavior is not about you or your relationship with them. Clearly that doesn't excuse it or make it any less traumatic; I felt that this, too, was a basic understanding we all had, so I didn't explicitly mention it.

I also assumed that I was responding to/quoting a contribution to the OP's question/conversation, not an attempt to put the brakes on the conversation, and therefore didn't feel that the conversation must be halted until I apologized for their experience and expressed other warm-fuzzies. My contribution was an attempt to bring it back to the question at hand, regarding the importance of unconditional positive regard, to emphasize that the whole point of unconditional positive regard is that it's unconditional, even if that manner of regarding the patient is not paralleled in your personal feelings about the them.

Ok, now I'm truly done with such dead-end hooks and digs.