A Brief Reflection on Impartiality in Psychotherapy

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There has been a lot of debate in the UK recently about "impartiality." The issue was played out in front of us when the BBC suspended Gary Lineker from presenting Match of the Day after he tweeted against the Government’s proposed immigration policy, only to have to do a humiliating U-turn when other sports commentators boycotted the programme in protest. Lineker’s suspension was widely believed to be in response to pressure from the Government, although this was denied. The BBC are now committed to revising and clarifying its impartiality guidelines. Well, good luck to them.

I have always mistrusted the idea of impartiality, and similar concepts such as objectivity and neutrality, particularly when idealised and presented as a virtue. I grew up in a vicarage where my Dad’s driving ethic was to ensure the church was welcoming to everyone, whatever their dodgy politics. This meant avoiding "taking sides." To my mind, fighting for justice was more important.

As medical students, we were taught to treat everyone the same, however much we might have reason to dislike them. During psychiatry training, we were taught the idea of "unconditional positive regard" whilst also admitting and treating patients against their will using the Mental Health Act. It was getting more and more complicated! What’s more, a night in the Accident and Emergency Department very quickly put an end to any illusion that all patients were treated the same, particularly if they had mental health problems. Judgments about patients’ being deserving or not were made all the time, and labels such as "manipulative" were bandied around without much thought or care.

My training in psychoanalytical psychotherapy reified the concept of "neutrality." It seemed our job was to understand the world from the patient’s point of view to help them gain insight into the deeper levels of their minds. To be free from our own prejudice and judgments, we had to undertake our own therapy (rightly so), but some believed in the concept of being "fully analysed"–a dangerous illusion, to be sure. Free from our passions, we could then confidently make "interpretations" about the meaning of what we were observing. Sadly, in insensitive hands, these interpretations could be anything but neutral and judgment-free. They were sometimes confusing or even cruel.

In CBT, the worrying idea was that working with behaviour and cognitions was somehow a more "objective" project than working with emotions, and therefore free of the subjective pitfalls that troubled psychoanalysis, interpersonal and humanistic psychotherapies. It was a matter of learning skills. Personal insight and knowledge of their own psychopathology were not a requirement for CBT therapists. At its worst, patients who didn’t improve were blamed for not working hard enough on their homework. The relationship with the therapist was not considered an issue.

I do, of course, have lots of respect for a great number of both psychoanalytic and cognitive behavioural psychotherapists–and even a few psychiatrists! My point is to show how unhelpful it can be to encourage the idea that one can or should be free of passion. We all take sides, day-in-day-out, often without even noticing. Indeed, colluding with the status quo and the powers that be is no more impartial than taking oppositional attitudes.

Naturally, our relationship with people with mental health problems and the situations that can arise are complex. There are times when I’m grateful for the discipline of treatment models that hold me back and stop me from identifying unthinkingly with the patient's plight. Like so many healthcare workers, I am prone to rushing in and wanting to rescue people, to colluding with the victimised aspect of the patient. The discipline of stepping back and attempting to think objectively can be all important. But this should always be in tension with stepping in to empathise. This is the dialectic at the heart of our work. To idealise the former at the latter's expense is to diminish our humanity.

I think it is no accident that I ended up working in therapeutic communities where balance is expressed by encouraging multiple voices in the group. A patient who had harmed himself could be on the receiving end of angry challenges and criticism, sympathetic reassurance, pressure to change their behaviour, and interpretations about the underlying meaning of their behaviour–all in the space of one group. But beware of simplistic idealisation! Even in therapeutic communities, any sense of group therapy as a forum where the balance would organically emerge was very quickly quashed by the reality of the harm that could be done in the short term if destructive scapegoating and bullying were allowed to dominate. Our job as staff was to make sure that everyone felt safe enough to make their voice heard, but this was easier said than done and required constant vigilance.

To return to the BBC, Andrew Marr, an ex-BBC journalist, recently wrote:

After attending innumerable BBC teach-ins on the subject, I have concluded that it (impartiality) has become a damaging way of thinking about modern politics. Fairness and openness are much more useful.

Like journalism, mental health work is saturated with values. Let’s talk about these in all their rich complexity and contradiction. And treat the concepts of impartiality, neutrality, objectivity, and the like, with caution.