By Sam Knapp, Ed.D., ABPP
Director of Professional Affairs
Director of Professional Affairs
Some patients will request a psychologist of a particular gender, and psychologists will usually try to accommodate those concerns. For example, a female patient with sensitive sexual or gender-related issues might not feel comfortable raising them with a male psychologist, and an effort will be made to find a woman psychologist. However, is it possible to implicitly accept or endorse discriminatory practices by agreeing to other similar requests? For example, should psychologists respect the preferences of prospective patients who want to have Christian psychologists? Some conservative Christians fear that psychologists will mock their religious beliefs or try to blame their problems on their religion. Consequently, having a Christian psychologist may be very important for them. Most non-Christian psychologists I have spoken to have received phone calls from prospective patients who ask them if they are Christian. One psychologist commonly responds, “no, but I am very respectful of Christian beliefs and will help you formulate goals consistent with your beliefs.” So far, no prospective Christian patient has ever failed to make an appointment after that conversation.
How should a psychologist respond if asked to provide a referral for a Christian psychologist? Perhaps one response would be to anticipate the concern of the patients, which is to have someone who respects their beliefs, without necessarily restricting the referrals to a psychologist who happens to be a Christian. It could be possible to respond by saying, “Psychologists are expected to respect the religious beliefs of their patients. I don’t have a list of Christian psychologists, but here are psychologists whom I know to be respectful of Christian beliefs.”
Should race, ethnicity, or sexual orientation be a factor in making a referral? On the one hand, it seems reasonable that some patients may want assurance that the psychologist they have will understand their racial or cultural background or respect their sexual orientation. It is possible to imagine a prospective patient who has not had a history of positive experiences with European Americans, or who has had a background with issues or struggles that even a sensitive European American would have difficulty understanding. Or, consider the case of a European American family who adopted an African American child who generally did well in school and at home. However, as a teenager he struggled to consolidate his racial identity and asked to speak to an African American psychologist. It appears that race would be a relevant factor in making that referral.
On the other hand, psychologists who defer to patient preferences for race may inadvertently reinforce racist attitudes. So, the perception of the clinical relevance of the request appears important. Psychologists can decide how to respond to these requests by looking to three overarching ethical principles. First, we generally want to respect patient autonomy, including respecting their preferences in a health care professional. Second, we typically want to give patients a referral based on beneficence and nonmaleficence; that is, we want to provide a referral based on who we think can help the prospective patient. Finally, we are also guided by the overarching ethical principle of justice wherein we refuse to engage in unfair discrimination based on race, religion, gender, national origin, or other factors. Often justice is sufficiently important to trump other ethical principles.
I once had a patient who wanted a referral to a different psychiatrist because he said the one I had sent him to was not a “real American” (the psychiatrist was an American citizen of Filipino descent and highly competent). I refused to give him a new referral, and he stayed with the Filipino American psychiatrist, who was of benefit to him. In this case, the overarching ethical principle of justice trumped the other ethical principles. However, I might have responded differently if this patient were highly suicidal or homicidal. Then I would have made inquiries about his concerns, but ultimately deferred to his wish if doing so substantially reduced the risk of death.
