What happens when people talk to their therapists about conspiracy theories? It’s tricky.

The internet is awash in conspiracy theories. No matter how major tech companies like YouTube, Facebook, and Google belatedly try to throttle or ban such content, people sharing misinformation and disinformation find loopholes to spread what they understand as the truth.

Thanks to algorithms that reward engagement over facts and a global pandemic that sent anxious people in search of answers, numerous conspiracy theories about COVID-19 have burrowed their way into American life. In some surveys, about half of respondents endorse one or more popular theories about the virus and vaccine. These beliefs have become so ubiquitous and emotionally consuming that some people are talking about them in therapy.

Therapists and psychiatrists know that conspiracy theory beliefs aren’t a mental illness. At the same time, their clients and patients may obsessively focus on those ideas, neglecting work, sleep, or relationships for online research. Conspiracy theories may prompt people to retreat from loved ones who don’t share their views, leading to disconnection and isolation.

Depending on which mental health provider you ask, they may have seen no change or observed a sudden, significant shift in which their clients or patients are preoccupied by conspiracy theories. Either way, for many of them, this is murky territory. If they push someone to defend their beliefs, it could ruin the delicate trust that therapists forge with their clients or patients. If they say nothing, it could make them complicit while hobbling their ability to address how fervent belief in conspiracy theories can make people miserable by increasing feelings of paranoia and anxiety.

The American Psychological Association and American Psychiatric Association, key professional organizations for mental health providers, told Mashable they do not have guidance related to responding to conspiracy theories as they arise in treatment. It’s easy to imagine why professional groups would be hesitant to tackle the subject. Members may not be pushing for such guidance, which must be informed by evidence-based research. Additionally, since many COVID-19 conspiracy theories are associated with conservative politics or movements like QAnon, professional organizations weighing in could create the perception that certain partisan beliefs are pathological.

So therapists and psychiatrists encountering conspiracy theories in their practice have to develop their own approach. A roundup of strategies published earlier this year by the nonprofit educational organization Psychotherapy Networker focused on the importance of curiosity, compassion, empathy, and patience. In other words, therapists summon an emotional generosity that many non-believers exhausted long ago. Surely it helps that they’re being paid for their time and work, but such an approach holds valuable lessons for people who’ve lost loved ones to the thrall of conspiracy theories and don’t know how to bridge their divergent realities.

How conspiracy theories come up in therapy

For Allen Lipscomb, Psy.D., a licensed clinical social worker who specializes in treating Black men grappling with trauma and grief, conspiracy theories have become a reoccurring theme of his sessions since the pandemic began. In the Before Times, they never came up. Instead, his clients talked about race-related microaggressions, fulfilling their roles at work and home, stress management, and self-preservation practices. Those subjects remain central to his clients’ concerns, but they’re also suspicious of what authorities say about the pandemic.

Drawing on debate over the origins of the novel coronavirus, they wonder why the Chinese government would try to create a virus that could kill millions of people. (U.S. intelligence agencies concluded COVID-19 wasn’t developed as a biological weapon.) Once the vaccine became available, Lipscomb’s clients told him the injection could monitor or track its recipients. Some suspect the vaccine is a Trojan horse with the capacity to kill its recipients, particularly Black people, once the government decides to flip the proverbial switch, some years into the future.

While there’s no evidence to support either of these theories, the Black men in Lipscomb’s care generally distrust the government. Their worldview is shaped not only by daily reminders of how American institutions fail them and their loved ones, but also historic acts of betrayal. They recall experiments conducted on Black people, like the physicians who purposely withheld treatment for men infected with syphilis and the researchers who studied cells taken from Henrietta Lacks without her consent before she died of uterine cancer. They don’t believe public health officials will protect them from harm, and in fact, may intentionally hurt them instead.

Lipscomb sees how his clients’ conspiracy theory beliefs are fueled by historic and ongoing oppression, as well as general uncertainty and anxiety. But rather than provide relief, conspiracy theories tend to heighten their sense of distrust and paranoia.

Conspiracy theory beliefs, says Lipscomb, are “priming them in such a way where they’re more susceptible to anxiety, and then because of the level of anxiety or paranoia it becomes debilitating.”

As a mental health provider, this dynamic matters a lot to Lipscomb. He aims to help clients heal, teach them coping skills, and improve their well-being. Left unaddressed, conspiracy theories can delay or impede that progress.

“Honoring allows me to go with it versus putting them in the position to teach, prove, and educate [me], which is a lot of labor.”

Lipscomb tries to strike a careful balance. He doesn’t ignore or interrogate conspiracy theories when they’re affecting a client’s well-being. His tactic is to “honor” them by acknowledging that the client feels angry, anxious, and distrustful. He invites the client to describe how their views shape their day-to-day experiences. They might find it difficult to sleep after reading disinformation on social media, or feel lonely because they refuse to get vaccinated but also continue to stay distant from others in order to avoid contracting COVID-19. These insights help Lipscomb know how to support his clients.

“Honoring allows me to go with it versus putting them in the position to teach, prove, and educate [me], which is a lot of labor,” he says.

Lipscomb developed the BRuH Approach to Therapy, which rests on four principles: bonding, recognition, understanding, and healing. While emphasizing the role of broken economic and political systems that contribute to his clients’ trauma and grief, Lipscomb also introduces coping skills like mindfulness, grounding techniques, and cultural and spiritual practices that foster resilience. Through narrative writing, he helps clients explore their experiences, putting them in the context of oppressive systems and policies, so they don’t reduce complex feelings to self-blame.

Overall, the idea is to help his clients function well so they’re not knocked off balance by incidents like racial profiling at a grocery store or encountering an alarming conspiracy theory online. As his clients’ coping strategies multiply, Lipscomb says they become less anxious and suspicious, even if they don’t disavow or abandon certain conspiracy theories. He believes that guidance on how to work with clients who express belief in conspiracy theories from professional organizations like the American Psychological Association would be “extremely helpful” provided it’s “critically racially conscious” as well as “antiracist and anti-oppressive.”

Understanding the spectrum of beliefs

Dr. Ziv Cohen, founder and medical director of Principium Psychiatry in New York City, says that it’s common for his practice’s patients — of which there are more than a thousand — to casually mention conspiracy theory beliefs. The trend he’s observed started after the Sept. 11 attacks. Patients often reference misinformation suggesting that the U.S. government orchestrated the events.

In Cohen’s experience, there’s a spectrum of belief. On the most mild end are people who believe, or partially believe, various conspiracy theories. They’re open to the idea that the “official narrative is not the real narrative,” but typically treat such skepticism as a form of entertainment. They don’t think much about conspiracy theories at the end of the day.

In the middle is a group of people who become obsessed. They might stay up late to solve QAnon riddles with others on Parler or wait for messages from conspiracy theory influencers to pop up on Telegram. They become consumed by wanting to know the latest theories and begin to exhibit conspiratorial thinking, which Cohen describes as holding a fixed belief they’re unwilling to change based on evidence.

“The problem here is they’re skeptical of everything except their conspiracy theories,” he says. Additionally, those in the first group who dabble in such beliefs can become fixated on them with enough exposure, joining the ranks of the obsessed.

The third cohort comprises people who become radicalized by a conspiracy theory. Perhaps already prone to violence, they’re eager to act when a conspiracy theory — like the Big Lie that the 2020 election was stolen — is used to justify an armed or paramilitary response. Cohen, a clinical and forensic psychiatrist, both treats patients and evaluates convicted criminals and those accused of crimes. Though he hasn’t evaluated anyone who participated in the Jan. 6 insurrection, Cohen has conducted mental health assessments of right-wing extremists who cite conspiracy theories as a defense of their actions.

Loosening the grip of conspiracy theories

In Cohen’s experience, some people with pre-existing mental health issues are at much higher risk of centering their lives around conspiracy theories. Their focus on those beliefs can aggravate conditions like anxiety and depression partly by fueling feelings of insecurity and reinforcing negative perceptions of others. When a conspiracy theory has minimal, if any, impact on a patient’s life, Cohen says it makes sense not to focus on it in treatment.

“Other times it can be squarely getting in the way of what’s important for that patient in terms of their goals,” he says.

Cohen says therapists must be careful about aggressively questioning patients’ conspiratorial views and thinking. Otherwise, they might become suspicious of the therapist, seeing them as if they’re just another sheep in the flock. Instead, Cohen recommends that therapists identify how conspiracy theory beliefs might help someone by creating a sense of certainty in an unpredictable world, providing secret knowledge that others don’t possess, and offering access to a community of like-minded people.

“Conspiracy theories initially make people feel safe, because they think they know what’s really going on, and it gives them that illusion that quote-un-quote knowledge will protect them,” he says.

Cohen might start with supportive therapy, with an emphasis on empathizing with a patient’s loneliness, depression, or anxiety, while also exploring healthy behaviors that help them cope. Once the patient is better able to handle their emotions, Cohen turns to psychodynamic therapy or cognitive behavioral therapy, which involve identifying thoughts and influences that shape people’s choices. These approaches often yield insights about what led a patient to embrace conspiracy theories in the first place.

“We really need to treat conspiracy theories as a public health problem.”

As treatment progresses and his bond with the patient deepens, Cohen notices that their demeanor shifts. The patient becomes more secure and less defensive. They’re no longer in the tight grip of conspiracy theory beliefs. In some cases, patients spontaneously realize “they’ve been had” and want help “regaining control of their mind,” says Cohen. They feel ashamed of their beliefs and want psychotherapy to help process the experience.

Whatever a patient’s trajectory, Cohen believes that the mental health profession needs to develop new paradigms for recognizing conspiracy theories as a potential threat to people’s well-being and then create appropriate treatment approaches. He would like to see the field’s professional organizations become more active in educating the public and mental health providers about the way conspiracy theories can affect people’s psychological and emotional well-being, but understands they may be worried about the perception of partisanship.

“The world has become so complicated that that’s created a lot of anxiety in individuals,” says Cohen, referencing the destabilizing effects of climate change, the pandemic, globalization, and other social and economic forces.

“We really need to treat conspiracy theories as a public health problem.”