Power in Psychotherapy and Counseling
Re-thinking the 'power differential' myth and exploring the moral, ethical, professional, and clinical issues of power in therapy
By Ofer Zur, Ph.D.
To cite this page: Zur, O. (2014). Power in Psychotherapy and Counseling. Online Publication by the Zur Institute. Retrieved month/day/year from http://www.zurinstitute.com/power_in_therapy.html
- Rethinking the power differential in psychotherapy
- Re-evaluating the myth of therapists' omnipotence and patients' fragility
- Examining the idea: "once a client, always a client"
- Exploring the origin of the myth of the power differential
- Doubting whether clients who are CEOs, power attorneys, or therapists, are powerless and vulnerable
- Clarifying the different types and forms of power
- Discussing power relationships in psychotherapy in a complex and comprehensive way
- Reviewing the moral, professional and ethical implications of the different views on power
This article is also part of an online course for 6 CE Credits (CEUs) on Power in Psychotherapy and Counseling
Table Of Contents
The Myth of Power-Differential Direct Quotes
- Scholars, Texts, and Ethicists
- Codes of Ethics
- Feminist Therapy
- Psychoanalysis on Transference & Power
- Patients as "child-like"
Power in Perpetuity: Once A Client, Always A Client
- Scholars and Ethicists
- Codes of Ethics
- Licensing Boards and State Laws
Clients Come In All Shapes And Forms (of Power)
- Therapists as Clients
- Range of Clients
- Clients' Power as Portrayed in the Movies
The Origin of The Myth of "Inherent Power Differential"
- Source #1: Psychoanalytic Focus on Transference
- Source #2: Feminist Therapy Focus on Power
- Source #3: Prevention of Sexual Exploitation
- Source #4: Slippery Slope Hypotheses
Types of Powers in Psychotherapy
- Legitimate Power: Designated or legal power
- Expert-Knowledge power: Knowledge is power
- Professionalism power: Clout or aura of power
- Positional or Role power: Professional role as power
- Imbalance of Knowledge power: Knowledge of the other is power
- Coercive power: Forcing against one's will
- Reward power: The power to reward or withhold
- Reference power: The power of admiration
- Manipulative power: The hidden scheming power
How Psychotherapists Create Power Advantage
- Transparency, Disclosure, and power
- The one who gets to ask questions
- Maintaining therapists' anonymity
- Mystification of therapy
- Knowledge is power
- The power to name
- Isolating clients
- Setting the stage
- Perpetuate the slippery slope myth
- The misuse of the term "resistance"
- For your own good Beneficence principle
- Perpetuate the view of clients as helpless victims
- Meta Communications and Power Rituals
- Setting beginning and end time of sessions
- Note taking
- Patronizing touch
- Monopolizing the conversation
- Using jargon
- Scripted behavior
When Power-Differential Is Valid
- Inpatient psych. units
- Forensic: Sanity and Competency to Stand Trial Evaluations
- Child custody
- Foster care group homes
- Mentally retarded
- Recently traumatized
- Persons with dementia
How Power May Shift During Therapy
- As therapy progresses
- More Transparency
- Less mystery
- Client is more autonomous-empowered
- Multiple Relationships
- Informed consent
- Internet transparency-Google Factor
- Clients' Actions
- Not talking
- Not following advice
- Taking notes or recording sessions
- Coming late or leaving early
- Change sitting arrangements
- Provocative clothing
- Use of language
- Dominating the conversation
- Inappropriate touch
- Inappropriate gifts
- Offering incentive
- Acting seductively
- Home visits
- Clients who file false complaints against therapists
- Suicidal client
Modern Clients as Consumers
What Is Power?
Power in Psychotherapy and Counseling
- Denial of power issues by clinicians
- Exaggerated view of power by ethicists
- Theoretical orientations on therapist-client power issues
- Seldom discussed issues
The Ethical Way
- General ethical principles and power
- Beneficence and Nonmaleficence
- Fidelity and Responsibility
- Respect for People's Rights and Dignity
Towards a New View of Power in Psychotherapy
From the first day in graduate school in psychology, psychotherapists and counselors(1) in training have been instructed to pay great attention to the "inherent power differential" in psychotherapy, to be aware of the "imbalance of power between therapists and clients", and they have been repeatedly told to "never abuse or exploit our vulnerable and dependent clients." Generally, even though interns, graduate students and supervisees do not feel very powerful, the idea that they are powerful has been very appealing. As early as 1951, the prominent psychoanalyst Ernest Jones, raised a concern about the assumption of therapists' omnipotence, and labeled it as the "God syndrome." Nevertheless, the view of power as an attribute possessed exclusively by psychotherapists has been unchallenged in postgraduate training and continuing education workshops. Ethics texts and risk management advice columns in our professional newsletters have all presented a similar unified message about therapists' unilateral power and clients' inherent vulnerability.
While the universal assumption about the "power differential" is like an undercurrent in the fields of psychology, psychiatry, psychotherapy, and counseling, there is paradoxically a split between the ethicists, risk management experts and boards who over-emphasize the "power differential", and the clinicians and the theoreticians who largely avoid or ignore any reference to power (Heller, 1985). Clinicians tend to ignore the issue of power that is a reflection of the culture at large that often associates power with coercion, abuse, or injustice, in order not be perceived by themselves or others as controlling and dominating (Proctor, 2002). (The exceptions to the rule have been some feminist, humanist, narrative and postmodern psychotherapists.) As a result, the discussion of power has been primarily confined to ethics and risk management classes, licensing boards and court hearings. In these settings the emphasis has been on harm and on the supposed vulnerability of clients to therapists' immense power and influence.
Many psychotherapy or counseling clients are, indeed, distressed, traumatized, anxious, depressed and therefore vulnerable. Many others are also very young, impaired and vulnerable and can be easily influenced by their therapists. Then, on the other hand, other clients are strong, authoritative and successful. Many modern day consumers seek therapy to enhance the quality of their lives, improve their loving relationships or find meaning and purpose for their lives. They are neither depressed nor traumatized nor vulnerable. A more inclusive look at power reveals that the power differential in some instances is completely valid, but in many other instances it is a myth. The error is to see the power differential as always relevant - as if all clients are the same and all therapist-client relationships identical. Despite the evident fact that some therapists and counselors are successful and powerful while many others struggle financially and are, at times, emotionally fraught, the faulty belief that all therapists hold ultimate power over all their clients lives on. Throughout this paper, the context of the material will make it obvious when it discusses the valid power differential and when it refers to the myth.
While there seems to be a consensus on therapists' power over their clients, there are four views regarding this power. The minority group is composed of those who are highly critical of psychotherapy and counseling in general. These authors (i.e., Dineen, 1996; Laing, 1985; Masson, 1989; Spinelli, 1998; Szasz, 1997) view therapists' power as coercive and inherently abusive and generally damaging to clients. The majority of scholars and ethicists (i.e., Brown, 1994; Celenza, 2007; Gabbard, 1989; Gutheil & Brodsky, 2008; Rutter, 1989; Schoener, 1998; Pope & Vasquez, 2007) agree about the power inherent in the therapists' role but do not view it as necessarily abusive or damaging. They view it as potentially harmful if abused and warn against such misuse of power. The third group is composed of feminist, humanist, existentialist and postmodern scholars (i.e., Greenspan, 1986; Proctor, 2002; Rogers, 1978; Sutherland, 2007), who view the power differential as a given, emphasize the importance of attending to power issues, and want to see the imbalance of power reduced so that more egalitarian, authentic and mutually respectful relationships can be developed.
A fourth perspective was introduced by Lazarus in his 1994 ground breaking article titled "The illusion of the therapist's power and the patient's fragility: my rejoinder" and was expanded later by Williams (2000) and Zur (2005, 2007a), and more recently in Zur's short paper, "Re-thinking the power differential in Psychotherapy: Exploring the myth of therapists' omnipotence and patients' fragility" (2008c). This latter approach is the main theme of this paper. It looks at power as dynamic rather than static. It refutes the notion that power in therapy is exclusively possessed by therapists, and it equally rejects the simplistic notion that power is imposed by therapists exclusively on their clients. It claims that the dynamics of power and how it affects all the players involved can only be understood within the context of psychotherapy. It also identifies the many forms of power and elucidates how not only therapists, but also clients, often possess them or bring them into the therapeutic exchange. This paper expands on Lazarus' and Zur's original work and reviews the different approaches to power offering a detailed and inclusive view of the complexities and diverse forms by which power may manifest itself in the psychotherapeutic arena.
The goals of this paper are to bring the issue of power out of the clinicians' closet and to critically look at the ethicists' and legal experts' assumption of therapists' omnipotence and clients' inherent vulnerability. While the general topic of power obviously extends to economic, political, racial, gender and many other realms, the focus of this paper is on the therapeutic arena. The hope is that the paper will help psychotherapists, counselors, and clinicians review and discuss issues of power in therapy without being trapped in the two extremely unhelpful positions of denial or blind belief in the "power differential" myth. By exploring the complexity, variability and the intricacy of power relationships in psychotherapeutic relationships, therapists will be able to view their relationships with their clients in more realistic and helpful ways. Most importantly, by having a better understanding of the multiple types and forms of power, therapists are likely to increase their clinical effectiveness.
This paper presents, in all probability, the most extensive and up-to-date account of the myth of the power differential by providing numerous direct quotes from the most prominent scholars in the field, codes of ethics, court rulings, state laws, and other sources. It also provides direct quotes from those who have perpetuated the myth that all therapists have influential power over all their clients long after the termination of the professional relationship and those who claim that: "Once a client, always a client." After extensive documentation of the myth of therapists' omnipotence and clients' fragility, the paper explores the possible sources of such faulty beliefs. It then provides a rather complex view of power in therapy and details how therapists and clients are vested with different forms of power. Next, the paper looks at the diverse ways that therapists attempt to bolster their power over their clients. The last several sections of the paper discuss: those situations where the power differential is valid, applicable and helpful in understanding therapeutic relationships; how informed and knowledgeable modern psychotherapy clients view themselves as consumers rather than patients; and the ethical implications of the analysis provided by this paper. Finally, the paper proposes new ways to view power relationships in psychotherapy that are realistic to the field of therapy and counseling and are, at the same time, respectful to clients. And most importantly, how this new approach can help increase therapeutic effectiveness.
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The Myth of the Power Differential: From the Horse's Mouth
Following is a compilation of quotes that exemplify the prevalence of the message regarding the supposed power discrepancy between therapists and clients. The quotes below are from leading scholars, codes of ethics, different theoretical orientations, and mental health attorneys. This section closes with quotes from a renowned expert who likened the therapist-client relationship to that of parent and child. (Note: The lettering in bold in the following quotes was added to emphasize certain wording and does not appear in the original texts.)
Quotes from Leading Scholars and Ethicists on Power in Therapy
The message of therapists' power and clients' dependency comes from some of the most prominent scholars and ethicists in the field, from presidents of our professional associations and major organizations and citations gleaned from the most acclaimed ethics texts. All of these have helped to establish and perpetuate the notion of therapists' omnipotent power and clients' inherent vulnerability:
"A power differential is inherent in psychotherapy." (Pope & Vasquez, 2007, p. 43)
"The client is always to be considered vulnerable to harm relative to the therapist, and the psychologist is obligated not to use the power position inherent in the therapists' role to the client's detriment." (Koocher & Keith-Spiegel, 1998, p. 91)
"Abuses in therapy are, from the feminist viewpoint, abuses of the power inherent in the role of the psychotherapist . . ." (Brown, 1994, p, 29)
"Virtually all psychotherapy clients enter treatment with some impairment in their self-esteem and assertion skills, making the therapist's approval extremely important to the client . . ." (Borys, 1992, p. 449.)
"The power differential is inherent in such relationships, renders the patient vulnerable and thus unable to participate in such relationships as a truly consenting person." (Plaut, 1995, p. 264)
"The professional relationship represents a fiduciary contract - that is, an agreement between unequals in which one person has more power, and therefore more responsibility." (Schoener, 1998, Political & Philosophical Underpinnings section, para 4)
"But in all cases the therapist must recognize and handle in, a professional manner, the patients' dependence and vulnerability, the power differential, and the phenomenon of transference." (Gabbard, 1989, p. 42)
"Three factors contribute to this uniqueness: the special vulnerability of patients who seek mental health treatment; the power differential between therapists and patients, heightened by the phenomenon of transference, which makes it difficult for patients to resist therapists' sexual advances . . ." (Appelbaum &Gutheil, 2006, p. 122)
"Because of the power imbalance between the therapist and the patient, the patient is frequently not in a position to make informed decisions about what is in her/his best interest." (DeVaris, 1994, p. 592)
Even scholars who have presented a balanced and non-dogmatic view of ethics, a rather flexible view of therapeutic boundaries and were early to recognize that not all dual relationships are counter-clinical and unethical have taken a clear stance on the issue of power.
"The psychotherapy relationship, by its very nature, results in an imbalance of power. The psychotherapist is in a much more powerful and influential position than the client " (Barnett, 2007, p. 401)
"Clients, by virtue of their need for help, are in a dependent, less powerful, and more vulnerable position." (Herlihy & Corey, 2006, p. 13)
Quotes from Codes of Ethics on Power in Therapy
Some professional associations' codes of ethics also convey the message of the "inherent power differential." For example:
"We recognize the trust placed in and unique power of the therapeutic relationship. While acknowledging the complexity of some pastoral relationships, we avoid exploiting the trust and dependency of clients." (American Association of Pastoral Counselors Code of Ethics, 1994)
"The psychiatrist should diligently guard against exploiting information furnished by the patient and should not use the unique position of power afforded him/her by the psychotherapeutic situation to influence the patient in any way not directly relevant to the treatment goals." (American Psychiatric Association, 2010)
"Be acutely aware of the power relationship in therapy and, therefore, not encourage or engage in sexual intimacy with therapy clients, neither during therapy, nor for that period of time following therapy during which the power relationship reasonably could be expected to influence the client's personal decision making." (Canadian Psychological Association, 2000)
Feminist Therapy Institute code of ethics:
"Feminist therapists are accountable for the management of the power differential within these roles and accept responsibility for that power."
"A feminist therapist acknowledges the inherent power differentials between client and therapist and models effective use of personal, structural or institutional power. In using the power differential to the benefit of the client, she does not take control of power which rightfully belongs to her client."
"A feminist therapist is actively involved in her community. As a result, she is aware of the need for confidentiality in all settings. Recognizing that her client's concerns and general well-being are primary, she self-monitors both public and private statements and comments. Situations may develop through community involvement where power dynamics shift, including a client having equal or more authority than the therapist. In all such situations, a feminist therapist maintains accountability."
(Feminist Therapy Institute, 1999)
"Because a relationship begins with a power differential, I shall not exploit relationships with current or former clients for personal gain, including social or business relationships." (National Association of Alcoholism and Drug Abuse Counselors, 2004)
"Body Psychotherapists are aware of the differences in power that may exist in their relationships with clients, students and supervisees. Body Psychotherapists will be sensitive to the real and ascribed differences in power, be responsible for bringing potential issues into the awareness of those involved, and be available for reasonable processing with those involved." (United States Association for Body Psychotherapy, 2007)
It is important to note that some other major professional associations' codes of ethics do not mention the terms power or power differential in their codes. These include: American Counseling Association (ACA), American Psychological Association (APA), California Association of Marriage and Family Therapists (CAMFT), National Association of Social Workers (NASW) and National Board for Certified Counselors (NBCC). As will be discussed later in this paper, the fact that the term power does not appear in these codes does not mean that these codes deny the existence of a power differential in therapy.
Quotes from Feminist Therapy Literature on Power in Therapy
The issue of power in general has been central to feminist therapy. When it comes to therapist-client relationships, feminist therapy has struggled to balance two approaches. On the one hand, feminist therapy advocates that power will be shared between therapists and clients and egalitarian relationships must be achieved in order to promote healing. On the other hand, most feminist therapists subscribe to the power differential idea by emphasizing the positional, expert and legitimate power vested in therapists by society and a patriarchal culture. They often focus on how therapists' abusive power results in sexual abuse of vulnerable clients by domineering and exploitative therapists. Following are a few quotes from feminist therapists on the issue of therapist-client power relationships.
"Abuses in therapy are, from the feminist viewpoint, abuses of the power inherent in the role of the psychotherapist . . . " (Brown, 1994, p, 29)
"Power in therapy is an issue of great import. Feminist therapists work to create a relationship in which power is shared, and where mutuality is the goal. Yet denying power differentials in the therapy relationship may have deleterious consequences. Believing that feminist therapists are powerless or have no power relative to others may be one of the most important issues related to harm in therapy." (Veldhuis, 2001, p. 37)
"Sexual boundary violations are considered the most serious ethical infraction in the mental health profession, as well as in higher education and pastoral counseling. Recognized as unethical due to the power imbalance inherent in the structure of the therapist-patient and teacher-student dyads, erotic contact between therapists and patients has been revealed in prevalence studies to occur at an unacceptably high incidence rate (9 to 12 percent) among mental health practitioners." (Celenza, 2007, Back page)
"The feminist therapy literature has extensively explored the problems associated with the failure to acknowledge power differentials in therapy . . ." (Rave & Larsen, 1995, p. 92)
Quotes from Analytic Literature on Transference and Power
Psychoanalytic literature on power has focused extensively on the relationships between transference and power. The power differential argument is often based on the psychoanalytic construct of transference. According to traditional analytic literature, client transference and projection results in viewing the therapist as having unrealistic, immense power and, therefore, rendering the client powerless and vulnerable. Following are a few quotes from analytic literature on the construct of transference and power in analysis.
The therapeutic context (and this applies to psychopharmacological or so-called medical back-up relationships) contains a power imbalance inherent in the structure of the relationship. This imbalance derives from many sources but revolves primarily around the unequal distribution of attention paid to the client, patient, or student as compared with the therapist, analyst, teacher, or member of the clergy. Furthermore, the patient comes to therapy seeking help, guidance, support and self-knowledge, and he or she is usually in a state of emotional disequilibrium, distress, or need. Finally, the therapy process encourages unresolved, transference-based relationships in which the patient will begin to experience the therapist as an important and conflictual figure from the past. Usually, this takes the form of an intense yet unresolved mode of relating derived from early childhood, most often with a parent." (Celenza, 2008, Definition sec., para. 1)
"Neither transference nor the real inequality in the power relationship ends with the termination of therapy." (Herman, Gartrell, Olarte, et al., 1987, p. 167)
The discussion of transference and its relationship to power has not been limited to analytic literature. Many non-analytic scholars subscribe to the idea of the importance of transference. Following is an example from feminist scholars who refer to the important link between transference and power.
"Gonsiorek & Brown (1989) were the first to propose highly specific rules with regard to sexual relationships with former psychotherapy clients. They make a distinction between two types of therapy. Type A therapy is one in which the transferential relationship plays a primary role in the process. On the other hand, Type B therapy is short-term and offers little opportunity for transferential relationships to develop. Based on this distinction, they offer six rules. First, sexual contact with former clients who have received Type A therapy is always and forever prohibited." (In Gotlieb, 1993, p. 43)
It should not come as any surprise that civil or malpractice attorneys have readily adopted the idea of transference and the interpretation that results from it, which supposedly gives therapists immense power over their clients. Following is one example of this:
"The transference phenomenon is extraordinarily powerful and yet the patient does not realize it is occurring, since it is an unconscious process." (Winer, 2008)
Quotes from Attorneys on Power in Therapy
Several attorneys who have contributed significantly to the literature on mental health law have also supported the theme of psychotherapy clients' inherent vulnerability. Here are a couple of examples from prominent attorneys:
"Regardless of how lucrative a potential business opportunity seems to be, a therapist must weigh whether that opportunity is worth the potential destruction of his or her career. The heart of the problem lies in the inherent unequal bargaining power between the parties once the therapeutic relationship has been established." (Caudill, 2008, "Business Relationships with Patients" section, 1st para.)
". . . the therapist must handle the therapeutic relationship, with its power imbalance, inherent vulnerability of the patient and transference and countertransference reactions." (Strasburger, Jorgenson, & Sutherland, 1992, p. 544)
"The theme, as stated above, serves to highlight the power of the psychotherapist, the vulnerability of the plaintiff, and takes the focus away from the plaintiff, who may be unattractive to the jury, and puts the focus on the harm that the defendant has caused to all of us, not just the plaintiff." (Winer, 2008)
Quotes from Authors Likening Clients to Children
Leading ethicists and authors have likened the therapist-client relationship to the parent-child relationship, viewing clients as powerless, child-like beings. Correspondingly, they view therapists' power as similar to that of the parents of young children. They wrote:
"The sequelae (of therapist-patient sexual involvement) bear certain similarities both to Rape Response Syndrome and to reaction to incest and other forms of child sexual abuse . . . The shared similarities of therapist-patient sex, rape, and child sex abuse present a variety of scientific, clinical, and practical dilemmas to researchers and therapists." (Sonne & Pope, 1991, p. 175)
"An analogy is commonly drawn between therapist-client sex and incest because therapists (parents) can abuse their power and manipulate clients (children) who trust and depend on them for caring and safety. The power differential can remain after therapy is terminated, just as incest can still occur when children become adults and leave the family home." (Seto, 1995)
"Linda M. Jorgenson, one of the plaintiff's lawyers in the Riley case, also was aware of the Plymouth County award and predicted that more such suits will follow. The application of the Riley decision to child abuse is a logical one, she says, because of the 'power imbalance' that exists between therapist and patient as it does between adult and child." (Retrieved on Sept. 23, 2008 from http://www.speroandjorgenson.com/spero7.htm#ABA%2011/92)
"The transference phenomenon is extraordinarily powerful and yet the patient does not realize it is occurring, since it is an unconscious process. The therapist essentially becomes a parent in the patient's eyes." (Winer, 2008)
"The analogy [between client-therapist and child-parent] may be found in the fact that parents bear children who may grow up to become their friends, coworkers, the executors of their estates, even their caretakers in the parents' old age. . . As a society, we do not see the adulthood of the child as opening the door to sexual relationships with the parent. We acknowledge that there remains within the equal relationship between parents and their adult children some remnant of the enormous power imbalance that is the hallmark of early parent-child relationships." (Brown, 1988, p. 252)
"A man in the position of trust and authority (as a therapist, doctor, clergy, teacher, and other) becomes unavoidably a parent figure and is charged with the ethical responsibility of the parent role." (Rutter, 1989, p. 101)
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Power in Perpetuity: Once A Client, Always A Client
Many of those who subscribe to the idea that all psychotherapy clients are highly vulnerable to their psychotherapists' influence also view therapists' power as lasting long beyond termination and even forever - "once a client, always a client." Following are quotes from scholars, textbooks, codes of ethics, licensing boards and state laws regarding power in perpetuity.
Quotes from Leading Scholars and Ethicists on Power in Perpetuity
"Remember: Once a client, always a client." (Bernstein & Hartsell, 2004, p. 236 )
"In so many ways, the power differential and the patient's vulnerability persist, regardless of the termination of the therapy sessions." (Gabbard, 1989, p. 122)
". . . it should be remembered that in the unconscious mind, time has no relevance." (Epstein, 1994, p. 133)
"Neither transference nor the real inequality in the power relationship ends with the termination of therapy." (Herman, Gartrell, Olarte, et al., 1987, p. 167)
"The therapist-client power differential remains after formal termination of a psychotherapy relationship." (Brown, 1988. P. 249)
"The post-termination romantic or sexual relationship between a therapist and his or her former client may hold as much potential for harm as do those relationships where genital sexuality occurs during the therapy session. As such, it may be time to codify that potential for harm by explicitly defining these relationships as unethical." (Brown, 1988. P. 255)
"A former therapist-patient pair will never be in the equivalent situation of a couple who did not initially meet under the auspices of a structured power imbalance." (Celenza, 2007. P. 126)
"What should be done about social relationships with former psychotherapy clients? Even if the treatment course is short and termination is clear, it should be assumed that a power differential continues (especially if the former client reserves the right to return for further treatment), making such relationships very inadvisable." (Gottlieb, 1993, p.47)
"Gonsiorek & Brown (1989) were the first to propose highly specific rules with regard to sexual relationships with former psychotherapy clients. They make a distinction between two types of therapy. Type A therapy is one in which the transferential relationship plays a primary role in the process. On the other hand, Type B therapy is short-term and offers little opportunity for transferential relationships to develop. Based on this distinction, they offer six rules. First, sexual contact with former clients who have received Type A therapy is always and forever prohibited." (Gonsiorek & Brown (1989) in Gottlieb, 1993, p. 43)
"The therapeutic relationship always involves an imbalance of power. One person pays, the other receives. Vacations, time, duration of the session are all in the hands of one party. Only one person is thought to be an 'expert' in human relations and feelings. Only one person is thought to be in trouble." (Masson, 1989, p. 289)
One of the most telling statements is by the widely published and highly acclaimed scholars in the field, Gutheil and Brodsky, who ignore the debates on therapists' power and even the question of whether transference really exists, and, as late as 2008, arbitrarily and baselessly claim that:
"Although some professional organizations as well as some laws and regulations do provide for time-limited prohibition, "once a patient, always a patient" remains the consensus in the mental health professionals . . ." (Gutheil & Brodsky, 2008, p. 213)
A study by Mattison, Jayaratne and Croxton (2002) found that practitioners differed on the definition of ex-client or former client. 40.9% state that a client becomes a former client "at the time services are terminated." 46.8% define former client as still a client in a different sense, i.e., "once a client, always a client."
An interesting recent discussion on therapists' post termination power was provided by Sarkar (2009):
. . . why should a former patient always be personally less powerful in any future relationships, let alone with a professional? Some ex-patients may be more powerful than the professional, for example in status or personality. It is generally assumed that 'patienthood' is a role occupied only when one is actually ill or receiving treatment; it would be odd to say that someone who had their leg fracture pinned 2 years ago is still an orthopaedic 'patient'. If psychiatric and psychotherapy patients are always 'patients' in this sense, it suggests that they are being treated differently from medical patients in a way which sits oddly with anti-discriminatory practice. (p. 83)
Quotes from Codes of Ethics on Power in Perpetuity
Professional organizations' codes of ethics seem to fall into two categories in regard to their views of how long therapists' power lasts beyond the termination of professional relationships. While not always addressing the power differential directly, the obvious implication of the ban on sexual dual relationships with former clients is the concern with therapists' exploitative power or dominance. Very few codes state that therapists' power lasts in perpetuity and therefore sexual relationships with former clients are also prohibited in perpetuity. Most of the codes fall into the second category, which presents an ambivalent and ambiguous view of power as manifested in the codes' stance on post-termination sexual relationships between therapists and clients. While these codes may put a minimum mandatory post-termination (cooling off or distance) period where sexual relationships with former clients is clearly prohibited they also provide several additional restrictions and conditions on sexual relationships after the cooling period.
Examples of the first group of organizations' codes, which implicitly or explicitly implies power in perpetuity or "once a client, always a client," follow:
"Because a relationship begins with a power differential, I shall not exploit relationships with current or former clients for personal gain, including social or business relationships." (National Association of Alcoholism and Drug Abuse Counselors, 2004)
III-G: "All forms of sexual behavior or harassment with clients are unethical, even when a client invites or consents to such behavior or involvement. Sexual behavior is defined as, but not limited to, all forms of overt and covert seductive speech, gestures, and behavior as well as physical contact of a sexual nature; harassment is defined as but not limited to, repeated comments, gestures or physical contacts of a sexual nature."
III-H: "We recognize that the therapist/client relationship involves a power imbalance, the residual effects of which are operative following the termination of the therapy relationship. Therefore, all sexual behavior or harassment as defined in Principle III, G with former clients is unethical." (American Association of Pastoral Counselors Code of Ethics, 2004)
"The therapist-client power differential remains after formal termination of a psychotherapy relationship." American Psychological Association, Board of Professional Affairs, Committee on Professional Practice. (1987) [Note: APA Code of Ethics of 2002 (cited below), is different than the above statement by the APA Board of Professional Affairs of 1987.]
Most professional associations' codes of ethics belong to the second group and present ambivalent and ambiguous guidelines in regard to how long therapists' power over their clients last. On the one hand, they require an arbitrary minimum cooling period of two to five years before any post-termination sexual relationships may be ethical. On the other hand, they warn that even after the cooling period it still may be unethical for therapists to be involved sexually with their clients. Following are a few examples of such ambiguous guidelines regarding therapist-client post-termination sexual relationships:
A.5.b. Former Clients: Sexual or romantic counselor-client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. Counselors, before engaging in sexual or romantic interactions or relationships with clients, their romantic partners, or client family members after 5 years following the last professional contact, demonstrate forethought and document (in written form) whether the interactions or relationship can be viewed as exploitative in some way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering such an interaction or relationship. (American Counseling Association, 2005)
10.08 Sexual Intimacies with Former Therapy Clients/Patients
(a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.
b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client's/patient's personal history; (5) the client's/patient's current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the client/patient. (American Psychological Association, 2002)
1.5 Sexual intimacy with former clients is likely to be harmful and is therefore prohibited for two years following the termination of therapy or last professional contact. In an effort to avoid exploiting the trust and dependency of clients, marriage and family therapists should not engage in sexual intimacy with former clients after the two years following termination or last professional contact. Should therapists engage in sexual intimacy with former clients following two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client or to the client's immediate family. (American Association for Marriage and Family Therapy, 2001)
Should a marriage and family therapist engage in sexual intimacy with a former patient or a patient's spouse or partner, or a patient's immediate family member, following the two years after termination or last professional contact, the therapist shall consider the potential harm to or exploitation of the former patient or to the patient's family. (California Association of Marriage and Family Therapists, 2011)
Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers--not their clients--who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally. (National Association of Social Workers, 2008)
Quotes from Licensing Boards and State Laws on Power in Perpetuity
State laws and licensing boards' regulations are similar to professional organizations' codes of ethics in regard to their view of how long therapists' power lasts beyond the termination of professional relationships and seem to fall into two categories. While not always addressing the power differential directly, the obvious implication of the ban on sexual dual relationships with former clients is the concern with therapists' exploitative power or dominance. Very few statutes are clear that therapists' power lasts in perpetuity, and therefore, sexual relationships with former clients are also prohibited in perpetuity. Again, like the codes of ethics, most statutes fall into the second category, which presents an ambivalent and ambiguous view of power as manifested in the codes' stance on post-termination sexual relationships between therapists and clients. While these statutes may put a minimum, mandatory post-termination 'cooling period' where sexual relationships with former clients are clearly prohibited, they also provide several restrictions and conditions on sexual relationships after the cooling period.
Examples of the first group of statutes or licensing boards' regulations, which implicitly or explicitly imply power in perpetuity or "once a client, always a client", follow:
For the purpose of determining the existence of sexual misconduct as defined herein, the psychologist-client relationship is deemed to continue in perpetuity." (The State of Florida Chapter 21U-15.004)
"(2) A licensed marriage and family therapist, licensed mental health counselor, or licensed social worker shall never engage, or attempt to engage, in the activities listed in WAC 246-16-100 (1) [sexual misconduct with a current patient, client, or key party]." (Washington Administrative Code, 2008)
Most statutes belong to the second group. Many states clearly state that termination of professional relationships is not relevant when the therapeutic relationships were terminated primarily for the purpose of engaging in sexual relationships. Such sexual relationships are clearly illegal. Then, many states present an arbitrary period of time (often two years) in regard to how long, after termination, therapists are not allowed to engage in sexual relationships with former clients. One may infer that, by establishing a certain cooling period, therapists, supposedly, still have power over their clients for its duration. It is important to know that many states have adopted the professional organizations' codes of ethics as part of state law. In these cases, the ambiguity of the codes of ethics in regard to post-termination sexual relationships, discussed above, is carried into the states' laws. Following is a sample of California law regarding therapist-client post-termination sexual relationships.
California Statutes and Regulations Relating to the Practice of Marriage and Family Therapy, Educational Psychology and Clinical Social Work by Board of Behavioral Sciences (BBS), California (2008) and the Laws and Regulations Relating to the Practice of Psychology by Board of Psychology (BOP), California (2008) have similar language in regard to sex with former clients. The statue defines punishable unprofessional conduct as ". . .any act of sexual contact . . . when that act is with a patient or with a former patient when the relationship was terminated primarily for the purpose of engaging in that act. (§4982.26). CA law set the cooling period at two (2) years. "Engaging in sexual relations with a client, or a former client within two years following termination of therapy (§4982. Unprofessional Conduct, k). Then the statute continues, stating that "Sexual exploitation by a physician and surgeon, psychotherapist, or alcohol and drug abuse counselor is a public offense." The regulations spell out in detail the punishment for sex with current and former patients, which may include substantial financial fines and/or imprisonment (For more detailed information on California Laws and Regulations in regard to sex between therapists and clients, relevant to fulfillment of California law and ethics requirements, click here.)
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Clients Come In All Shapes And Forms (of Power)
The stereotype of the powerful and dominant therapist who has absolute power over vulnerable, dependent and easily influenced clients, neither fits with my view of myself as a client, nor with my extensive experience with my clients over the many years of conducting psychotherapy. I do not need to look far to know that, even though I have been a client of several therapists, I have never felt powerless, extremely dependent or at their mercy.
Therapists as Clients
I suspect that most of the therapists-readers of this article have spent some time in therapy and it is highly doubtful that they experienced their therapists as possessing some kind of inherent power and superiority. In fact, many of the therapists who have attended my workshops, taken my courses and sought my consultation have been very critical of the quality of their therapists and, in many instances, experienced them as inferior and, at times, incompetent.
I deeply doubt that all the knowledgeable and authoritative scholars cited above, who perpetuate the myth of therapist omnipotence and the client's inherent vulnerability, view themselves as meek, helpless, vulnerable, and dependent when they consulted with or are being analyzed by fellow psychotherapists. I suspect that several, if not most, of these redoubtable and influential psychiatrists, psychologists, counselors, social workers, and attorneys went through their own therapy without feeling extremely vulnerable, dependent, helpless or child-like.
Range of Clients
Looking back at my over 20 years of consultations, it has become clear to me that while some of my clients have been vulnerable and dependent, others could not have been further from that:
- While some clients seek my counseling when traumatized, confused and disoriented, others have been very centered and assured but needed a new direction in their, so far, generally successful lives;
- While some were young and vulnerable others were old and strong;
- While some patients were immature, dependent and helpless, others were mature and in reasonable control of their lives;
- While some clients were powerless and hospitalized against their will, others were powerful and came to see me of their own free will;
- Some clients were hopeless, depressed and suicidal, others were hopeful, enthusiastic and embraced life in its entirety;
- While some were homeless, poor and desperate, others lived in huge mansions and were searching for new ways to enjoy life;
- While some were clinically depressed and barely functioning, others were existentially depleted but still were highly functioning, powerful individuals;
- While some were poor, others were very wealthy;
- While some were unemployed, others were CEOs of huge corporations;
- And, most relevant to the issue of power: while some were weak, vulnerable, dependent, and helpless, others were powerful, dominating and controlling.
The renowned behavioral psychologist, Arnold Lazarus, described his clientele in similar terms:
Too many clinicians consider clients as malleable, defenseless, weak, and childlike, as easy victims in the hands of powerful, compelling, and dominant psychotherapists. I see the issue of power on a continuum where, at one end, you have clients who tend to feel dependent, gullible, suggestible, inconsequential, powerless, and feeble, and at the other end are clients who see themselves as more powerful than the psychotherapist, and indeed they often are (e.g., CEOs of large corporations, judges, powerhouse attorneys, master mediators, or successful entrepreneurs). (Lazarus, 2007, p. 406)
In a similar way, Wright (1985) argued in a rarely cited article that "The therapist is every bit as much in the power of the consumer, as the consumer is in the power of the therapist. In that sense, the relationship is no different from any other human interaction" (p. 117).
A few years ago I consulted with a high-strung, successful, ex-beauty queen. She was also an educated attorney, well read in psychology relating to the challenges of her arrival at middle age and motherhood, and was interested in the subject of power. One day she said to me:
You shrinks seem to think you are these powerful beings. Your literature paints images of clients as helpless, vulnerable, pliable, weak creatures at the mercy of you omnipotent people. Your ethics texts make it sound like you can snap your fingers and I will jump into your bed. Well, let me tell you something about power. With my J.D. and Ph.D., I am better educated than you, which gives me more power than you have with your Ph.D. As far as I can tell, I am much wealthier than you, which gives me another form of power over you. I have professionally achieved more than you have, which gives me another power advantage. Yes, you know more than I do about psychology, but this does not necessarily count for much. Additionally, I am an attractive woman, which gives me the undeniable power that sexy women have over men. Finally, I can destroy your career with one call to your licensing board. So much for your illusion of your power.
Obviously, she had made a valid and rather convincing argument. What we must see as obvious is that clients may fall anywhere on the line from weak to strong, as can therapists.
Very few authors, beside Dineen (1996), Fay (2002), Gutheil, (1989), Heller (1985), Lazarus (Lazarus, 1994; Lazarus and Zur, 2002), Proctor (2002), Williams (2000), Wright (1985) and Zur (2007a, 2008c), have reflected directly on clients' power or analyzed therapist-client relationships beyond the simplistic and unrealistic split of omnipotent therapists and helpless clients. Gottlieb (1993) and Kitchener (1988) created ethical decision models that also went beyond the simplistic generalization of the inherent power differential myth.
Gottlieb's ethical decision-making model regarding dual relationships was published in 1963. The model is based on three dimensions, of which the first is power. Gottlieb writes:
The first dimension is Power. It refers to the amount or degree of power which a psychologist may have in relation to a consumer. Power can vary widely. The psychologist who gives a speech at the local PTA on childrearing practices has relatively little power over members of the audience when compared with a therapist's influence over someone in long-term, insight-oriented psychotherapy. (p. 44)
Gottlieb differentiates among "low power", "mid-range power," and "high power." With "low power" there is little or no personal relationship between therapist and client, or therapist and client consider themselves as peers, or when therapy was brief. At "mid-range power", he includes "Clear power differential but relationships are circumscribed." At the "high power" end, Gottlieb refers to "clear power differential with profound personal influence," which is likely to take place in long-term, professional relationships. The weakness of this model is that it makes an assumption that long-term psychotherapy is likely to increase the power differential between therapists and clients. Such generalizations are not always valid, as some long-term therapeutic relationships may tend to level the playing field rather than increase the power differential. As this paper articulates below, this is due to increased familiarity between therapists and clients and the decreased mystery of the therapeutic process.
Kitchener (1988) addresses dual relationship problems where power is one of the three main focuses of her decision-making. She observes that when the prestige and power differential between the professional's and the consumer's roles increase, so does the potential for exploitation and harm, and she concludes that as the risk of harm (or power differential) increases, so should the ethical prohibitions against engaging in the relationships.
Clients' Power as Portrayed in the Movies
Movies have seemed to capture the diversity and complexities of power relationships in psychotherapy better than most therapy experts and scholars. Movies about psychotherapists present a wide range of situations, settings and behavior showing therapists' and clients' power. Following is a non-comprehensive list of movies, each of which directly depicts some form of power relationship in psychotherapy.
- Analyze This clearly presents a powerful patient who is also a legendary mafia boss. The therapist is obviously frightened, quite helpless and totally compliant. Client intrudes on his therapist's wedding, vacation, private home, and family. Through demands and threats, he receives 24/7 care.
- Basic Instinct 2 presents a sexy, possible psychopathic, murderer who likes to shock and manipulate people. The therapist who is evaluating her for trial is no exception. Just coming out of a divorce, he is slowly but surely sucked into the client's powerful web when he takes her on as a private therapy client. Day by day he realizes that she has infiltrated more and more of his personal relationships. Each time he is convinced that his client is guilty; she effectively diverts suspicion in another direction.
- Charlie Bartlett. In this comedy, teenaged Charlie becomes an underground shrink who listens to the private confessions of his schoolmates. He then describes and acts out each friend's symptoms in his own therapy sessions, confusing and manipulating (i.e., overpowering) his psychiatrist into providing a variety of treatments and medications that he then passes on to his friends.
- Deconstructing Harry presents a therapist who is in the midst of domestic conflict after discovering that her husband has had an affair with one of her clients. The home-office setting exposes her desperation, volatility and vulgarity to her clients who witness the therapist out of control, therefore, altering the power dynamic between the therapist and her clients.
- Don Juan De Marco, the protagonist of this comedy is convinced that he is Don Juan, the world's greatest lover. This is a movie about a client's power to transform his caregivers. When Don Juan De Marco ends up in a mental hospital, he completely overwhelms his assigned, rather conventional, psychiatrist, who in response washes his hands of the case. The inpatient psychiatric nurses fall into a form of romantic trance in the powerful presence of Don Juan De Marco. When Dr.
Mickler, his second psychiatrist, gives his patient 10 days to convince him of his sanity, the patient insists on elaborating his fantasies. Through his convincing stories, Juan, powerfully influences Mickler to dramatically transform his life, including his marriage.
- Dressed to Kill presents power issues in this thriller, twist-and-turn mystery. It appears, at various times, that the Dr. is at the mercy of manipulative and dangerous clients when, in fact, he is at the mercy of a dissociative aspect of his own personality that is a psychopathic killer.
- Frances. When the psychiatrist, Dr. Symington, meets the actress Frances Farmer, he is star-struck over having a famous movie star as a patient. The power differential is clearly tilted in the direction of the client. The psychiatrist demonstrates his insecurity by revealing to his patient that he needs her to admire and respect him.
- Good Will Hunting. In his therapy with Sean McGuire as Will Hunting, a working-class young math genius in attempting to heal him from his childhood trauma. Toward the end of their first session Will insults the therapist's painting which represents McGuire's loss and grief of his deceased wife. The client hit a vulnerable spot and McGuire angrily grabs him and pushes him against the wall. With this emotional outburst the therapist looses power and control. He regains the upper hand as he responds with "time's up" and leaves the office.
- Grosse Point Blank presents a client, a professional assassin, who informs his therapist that he knows his home address. The therapist appropriately acknowledges the explicit threat and discusses his fear of his client. Needless to say, the clients gain significant 'coercive' power in this exchange.
- House of Games presents a manipulative con artist who gains a lot of power over his therapist when the naive therapist tries to beat him in his own game. In a desperate attempt to regain power and control the therapist reaches for her gun and . . . shoots to kill.
- K-PAX is a film about a mental patient who claims to be an alien. During the course of treatment, the therapist begins to lose power as he begins to doubt his own context of reality and begins to move in the direction of believing that his client is from another planet. The patient also demonstrates an outlook on life that proves inspirational (i.e., powerful) for his psychiatrist who finds this helpful in his own personal relationships.
- Mr. Jones gets treated for Bipolar Disorder in a mental hospital by Dr. Libbie Bowen. When she falls in love with him and a romantic relationship ensues, the power dynamic between them shifts completely.
- One Flew Over the Cuckoo's Nest presents the ultimate brutal and ultimately deadly power of a treating psychiatric nurse over psychiatrically incarcerated men. Her shaming of one vulnerable young man motivates his suicide and, she makes an definitive power play by being instrumental in the lobotomy of another.
- Prince of Tides presents an example of a therapist's vulnerability to the power of the client's brother. The therapist is lonely and missing a 'manly' man in her life. The client's brother charms the therapist into a sexual relationship.
- Prime presents a shift in power as an obedient and compliant client becomes appropriately outraged when she realizes that her therapist is her boyfriend's mother. Eventually, the power is equalized as the therapist and former client transition to a social relationship relative to the client's romantic relationship with the therapist's son.
- Stay presents a client who announces that he will commit suicide at midnight on Saturday. The psychiatrist wants to save his client, and tries to do everything in his power to figure out why and where his patient wants to kill himself in order to prevent the suicide. The clients' threat seems to take over the psychiatrist's life and the haunted psychiatrist becomes an obsessed and determined detective.
- What About Bob. In this movie, Bob starts as a vulnerable, low functioning client, but the power shifts as he chooses to follow his psychiatrist to his vacation destination. This comedy presents a client's power to harass, impose upon, intrude on, stalk, and ultimately
drive his psychiatrist, literally insane.
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A Critical Look At The Origins Of The "Inherent Power Differential" Myth
The myth of therapists' power and clients' vulnerability has emerged from different sources. The main sources have been the psychoanalytic focus on transference, the concern with predatory therapists who sexually exploit their clients, feminist focus on power in society and therapy, and the faulty belief about the slippery slope. While this section expands upon these two primary sources, later on the paper explores the idea that the myth may also be a result of therapists' attempts to counter their own sense of powerlessness and ineffectiveness by creating such a belief and working at projecting an aura of power and superiority.
Source #1: Psychoanalytic Focus on Transference and Power
Transference is one of the foundations of psychoanalytic psychotherapy. It is defined as a phenomenon in psychoanalysis characterized by unconscious redirection of feelings for one person to another and it refers to the client's manifestation of unconscious, unresolved, and conflicted patterns of interpersonal relationships in the therapeutic setting (Lang, 1981). It often refers to redirection of feelings, which were originally directed towards a parent, to the current analyst. According to the analytic claim, because transference is largely unconscious and evokes feelings from early childhood, it renders the client powerless and vulnerable to the therapist's power and influence.
There are a number of aspects of transference that have relevance to our discussion of power. The first is the concern with the therapist's transparency and anonymity; the second is the client's supposed inevitable regression; and, last is the interpretive power that analysts assume in psychoanalytic and psychodynamic psychotherapies.
Maintaining anonymity and separateness is an important part of transference analysis. Too many psychoanalytically oriented therapists believe that self-disclosure, gifts, hugs, or dual relationships result in contamination of the transference, interference in the analysis of the transference, and the risk of inappropriate self-gratification on the part of the therapist (Johnston & Farber, 1996; Lang, 1981). For that reason, traditional psychoanalysis has issued the injunction against therapists' transparency, gift exchange, bartering, touch, home visits, etc. Familiarity that arises from self-disclosure, chance encounters or dual relationships has also been seen as compromising the projections necessary for the analysis of transference and counter transference and to the process of securing the consistent and neutral mode of therapy (Epstein & Simon, 1990; Lakin, 1991; Langs, 1982; Lewis, 1959; Simon, 1994).
Once transference is established, most analysts conclude, the patient is regressed to a child-like state and, therefore, is likely to feel young and vulnerable while experiencing the analyst as dominant and powerful. As several of the above quotes indicate, many analytic scholars not only believe that the transferential relationship renders the client vulnerable, but they also believe that transferential relationships are part of any and all therapeutic relationships. In other words, many analytic thinkers believe that the transferential relationship takes place in therapies that neither use nor think in terms of transference and, as a result, that the idea of clients' vulnerability to their 'powerful' therapists is equally applied to all schools of therapy.
Reflection & Critique:
Transference has emerged as a controversial term in the last couple of decades, especially in the ethics and forensic areas. The debate is about its universality and applicability. On one side of the debate are those who claim that transference is a universal phenomenon that inevitably takes place in and out of the consulting room (i.e., Celenza, 2007, Simon, 1994). It follows, they claim, that transference takes place in the consulting room regardless of the therapist's theoretical orientation, method of intervention or training. In the forensic area, transference has been used to support the claim of clients' inherent vulnerability to therapists' misuse of power. In this view, transference increases therapists' power and, therefore, their ability to exploit their clients. Several courts, convinced by expert witnesses and malpractice attorneys, have supported this view of the relationship between transference and power by accepting the supposed inevitability that transference feelings emerge in the course of therapy and the supposed inevitability of clients' powerlessness and vulnerability (Sarkar, 2009; Strasburger, et al., 1992). Similarly, "transference abuse" was introduced in malpractice litigation and administrative hearings and appears in court rulings synonymously with therapists' misuse of their inherent power (Williams, 1997, 2002).
On the other side of the debate are those authors and clinicians who view transference principally as a psychoanalytic psychodynamic construct rather than a universal phenomenon. They view it as a theoretical concept used mainly in psychoanalysis (Lazarus, 1994; Zur, 2007a). Williams (1997) accurately reflects on transference: "Transference abuse had been a problematic concept in malpractice litigation because of its overt theoretical linkage to psychoanalysis, causing the concept to be meaningless or offensive to numerous practitioners" (p. 7). Gutheil (1989), similarly points out, "It seems that professionals who belong to a school of thought that rejects the idea of transference, behaviorists or psychiatrists who provide only drug treatment, are being held to a standard of care they do not acknowledge" (p. 31). The fact in the real world is that many therapists are not in a position to use a blank-screen or emotionally neutral type of intervention. Those who practice in any kind of small community, such as rural, LGBT, church, minority, disabled or university campus, are highly transparent to their clients, which is not conducive to analytic work or transference analysis. Similarly, those who make home-visits, work with homeless people on the streets, or conduct adventure therapy, for instance, are widely known and transparent. Then there are several theoretical orientations, such as humanistic and feminist therapies, that emphasize the importance of transparency (Bloomgarden & Mennuti, 2009; Greenspan, 1986; Jourard, 1971; Pedersen, 2002; Stricker & Fisher, 1990; Williams, 1997; Zur, 2007a) and neither see value in anonymity and neutrality nor conduct transference analysis.
The universality, application and utility of transference is far from being settled. The fact that some expert witnesses and attorneys have convinced some courts of the universality of transference only reflects their persuasive capacity, not the truth of the matter. The overriding emphasis that psychoanalysis places on therapist neutrality and distance to preserve the purity of transference work should not be seen as a model or frame of reference for the entire field of psychotherapy and counseling. Most therapists do not practice psychoanalysis or devote extensive or any time or attention to the analysis of the "transference" (Lazarus, 1994; Zur, 2001, 2007a), yet the bulk of the therapeutic community is often expected by the few to adhere to its standards (Gutheil, 1989; Williams, 1997). It is obvious that both the standard of care and the most recent American Psychological Association (2002) Ethics Code have emphasized the importance of evaluating the appropriateness of therapeutic interventions and therapists' conduct within the context (which includes the theoretical orientation) in which they have taken place, rather than by an arbitrary, analytic or any other standard that fits all situations.
The concept of transference implies that therapists are in a position to interpret transference, which is an obvious position of power. As noted above, patients are viewed as unconscious and regressed in contrast to the analysts whose job it is to reveal the 'true' nature of the clients' feelings and thoughts. It is up to the therapists to differentiate between clients' appropriate and inappropriate responses or feelings and provide interpretations and insights. Spinelli (1994) wrote perceptively:
Analytic interpretations place therapists in a position of great power since they rely on abilities to understand and reveal the hidden meaning in their clients' statements and behaviors, before they are consciously acknowledged by the clients themselves. (p. 199)
The analytic belief that therapists know the 'truth' about the clients gives them significant power. The assumption that clients get better, according to many psychodynamic theories, only when they accept their therapists' truth, gives therapists even more power.
In summary, transference is an analytic construct. It is not an entity that can be observed, touched, or measured. Those who believe in the phenomenon of transference also believe that most or all clients are highly vulnerable to their therapists' power and influence. However, many of those who do not believe that transference actually exists view the power relationships between therapists and clients differently. It is unreasonable and, in fact, unethical (according to APA Code of Ethics of 2002) to hold therapists to the ideology of an orientation that they neither practice nor believe in.
Source #2: Feminist Therapy Focus On Power
The second source of the myth of power in therapy comes from the feminist therapists who focus on power issues as a core concern of the theory and ideology of feminist therapy. An important aspect of the original feminist therapy agenda was prevention of sexual and other exploitation of women, in general, and, more specifically, female patients by male therapists.
Feminist therapy has two agendas in regard to power.
On the one hand, feminist therapists work to create an egalitarian relationship in which power is shared between therapists and clients and where mutuality is the goal (Rave & Larsen, 1995). Brown wrote:
A feminist therapy perspective has as one of its most central tenets the concept that therapy should strive to create an egalitarian relationship between client and therapist. The movement toward a relationship of greater equality of power and greater symmetry of roles is seen as part of the normal development of the therapy process. (1988, p. 251)
On the other hand, many feminist therapists claim that denying power differentials in the therapy relationship may have seriously negative consequences. The latter argument asserts that ignoring the power differential or believing that feminist therapists have no power relative to others may be harmful by itself (Brown, 1988; Veldhuis, 2001).
This dual focus seems to create a subtle theoretical split on the issue of power and its application among feminist scholars who may focus on either aspect of power relationships.
The first, and the more vocal and politically and professionally active faction, focuses on issues of male power and dominance and cultural dominance over minorities, which, in their view, all stem from patriarchic cultural values of power and dominance. Predictably, this group focuses on the protection of, what they see as, vulnerable female clients who have been sexually exploited by powerful male therapists (Borys 1992; Bouhoutsos, 1985; Brown, 1994; Sonne & Pope, 1991). They view power primarily as unitary, monolithic and unidirectional.
The second group, a much smaller faction of feminist therapists (i.e., Greenspan, 1994; Heyward, 1994) and other scholars (i.e., Dawes, 1994; Dineen, 1996; Proctor, 2002; Tavris, 1993, Zur, 1994, 2007a) focus on essential issues of mutuality, equality and, most relevant to power issues, responsibility. They view power dynamically, as being neither directional nor as held by one powerful group (i.e., therapists) over another powerless group (i.e., clients). They view power in a more dynamic, interactive and mutually complementary way.
Reflection & Critique:
Feminist therapy focuses on power relationships, and its commitment to fight the abuse of power by male therapists is, undoubtedly, a very important and commendable professional, sociological and political agenda. Identifying the cultural values of dominance and abusive power has been as important as the revelation that sexual exploitation of female patients by male therapists is real and is not an imaginary invention of hysterical or neurotic women, as was often alleged by the early psychoanalysts. However, as often happens with professional and political agendas, they go too far in the right direction and at times become extreme and/or self-serving. The focus on power by most feminist scholars often ignored the importance of personal responsibility. As a result, feminist therapy scholarly texts inadvertently end up portraying women as generally "helpless females," "innocent victims" and "child-like creatures" who do not have the capacity to withhold consent or the power to make personal decisions.
Miriam Greenspan (1986, 1994), Carol Tavris (1993) and Tana Dineen (1996) are some of the few feminist authors who challenge the feminist mainstream view of women's vulnerability, irresponsibility and innocence. Similarly, Zur (1994) provides an alternative and a systems view of victims-victimizers relationships. Viewing women clients as always innocent and pure victims, completely vulnerable to male, sexual predators, is very far from a comprehensive view of the interplay of power and sex. This view becomes irrelevant as we learn that sexual misconduct is as prevalent in the lesbian community as it is in the heterosexual community.
In response to past tendencies to blame the victim, present time political correctness and some mainstream feminist scholars have turned the tide. Now, it is politically incorrect to explore the role of women and victims in violent or exploitative systems. The third approach, endorsed by the author of a systems approach, which explores the mutual contributions of victim and victimizers, males and females, therapists and clients, has been often wrongly equated with "blaming the victim." In an extensive analysis of the psychology of the victim, Zur (1994) emphasized the importance of shying away from blame when exploring the familial and cultural origins of victimhood. Zur documents how the "do not blame the victim" approach has stopped the exploration of victims' characteristics, victim typology and the complex system of victims and perpetrators. In fact, the "do not blame the victim" stance has perpetuated the continuation of victimization of women and others. In contrast to most feminist writers, he writes, "As we move from blame to a more complex understanding of violent systems, the perpetuation of these systems in our culture and the role victims play in these systems, we provide ourselves with better tools to predict and prevent further victimization" (p. 15).
Consistent with mainstream feminist literature's view of power is the idea that 'once a client, always a client' and the understanding that post-termination sexual relationships are always prohibited. This stance, in fact, is highly demeaning to women as it presents them as incapable of making consensual and informed decisions regarding their sexual behavior even years after termination of therapy. It is a paradox that some feminist therapists, on the one hand, uphold women's respect and strive for egalitarian relationships but at the same time treat them as psychological invalids, incapable of making rational decisions about their sexual behavior. Women, in this rather common view, are ultimately viewed as helpless victims, easily influenced, indeed, like children.
Source #3: Prevention of Sexual Exploitation of Women in Therapy
After a long history of denial of the sexual abuse of women by predatory male therapists, and soon after the Human Potential Movement and its "free-love" message in the 1970s, professional and political winds changed direction. Following a number of highly successful malpractice suits against prominent psychologists and psychiatrists in the late 1970s and 1980s, the issue of therapist-client sexual relationships came to the forefront of our awareness. Bouhoutsos (1985), Gabbard (1989), Guthiel (1993), Pope (Pope &Vasquez, 2007), Rutter (1989), Schoener (1998), Simon (1991), and Sonne (Sonne & Pope, 1991), among others, have been instrumental in bringing these professional violations to a high profile position in our professional consciousness. Obviously, the concern with sexual exploitation of clients was associated with the misuse of power by predatory therapists. The obvious focus in these inquiries is that such therapists take advantage of vulnerable clients for their own sexual gratification, as well as other benefits.
It is a completely valid assumption that many clients start therapy in a state of crisis, confusion and vulnerability and there is often a power differential in such situations. This is even more valid vis-à-vis women clients who were sexually molested and traumatized as young girls. Obviously, these clients can be highly vulnerable to and dependent on their therapists, at least at the earlier stages of therapy. The power differential and clients' vulnerability are certainly often relevant in these situations with these clients.
As a result of the successful malpractice suits and an increased number of publications on the issue of sexual abuse, the field significantly changed its attitude toward the issue of therapist-client sexual relationships. Across the board, all professional organizations have made it unethical for therapists to be sexually involved with current or recently terminated clients. Many states and licensing boards have made therapists' sex with current clients a crime. One of the assumptions behind many rules, laws, regulations, codes of ethics, and professional guidelines is that therapists have the power to influence, coerce or impose their will or desires on their clients in various ways, including the power to elicit sexual acquiescence. Of course, therapists have the fiduciary responsibility not to harm or exploit their clients, sexually or otherwise. As cited above, the professional literature, courts and many codes of ethics have extended the idea of the sexual exploitation of clients by predatory therapists and generalized it to the entire field, concluding that all therapists have omnipotent power over clients, who are generally presented as vulnerable, dependent and powerless.
Reflection & Critique:
What started as a legitimate and important inquiry and professional attempt to protect clients from predatory therapists has resulted in misunderstandings around the issues of power in therapy. From the denial of sexual abuse of women in Freud's time, all the way to the exposure of exploitation of women clients in the 1980's and 1990's, the pendulum has swung to the other extreme. Because of the pronouncements of certain analysts, ethicists, feminists, and attorneys since the 1980's proclaiming the inherent power differential, suddenly all therapists seem to be possessed of great power over their clients and all clients are viewed as vulnerable, passive, helpless, and child-like. Gutheil and Brodsky (2008) describe the swing between an era where the boundaries were "too loose" to the "rule of simplicity," which consists of the "list of forbidden acts," (p, 247) such as gifts, touch, bartering, or dual relationships.
This is obviously a case of what Zur (2000a) called "going too far in the right direction" where scholars apply words such as "always" or "all" to a phenomenon that sometimes exists and sometimes does not exist. As noted above, prominent ethicists, such as Koocher & Keith-Spiegel stated, "The client is always to be considered vulnerable to harm relative to the therapist . . ." (1998, p. 91). Similarly, Borys stated, "Virtually all psychotherapy clients enter treatment with some impairment in their self-esteem . . ." (1992, p. 449). Even scholars who have been advocating for flexible clinical application of boundaries, surprisingly, came up with absolute statements. Barnett stated as late as 2007 that, "The psychotherapy relationship, by its very nature, results in an imbalance of power." (p. 401) and Herlihy and Corey in their 2006 book stated, "Clients, by virtue of their need for help, are in a dependent, less powerful, and more vulnerable position." (p. 13).
Almost all feminist therapists agree on the power differential idea and within this understanding they try to prevent sexual abuse of women in therapy. Greenspan (1986) captures the paradox that is presented by feminists and other therapists in regard to power in therapy and sexual abuse when she discusses the fact that sexual and power abuse are inevitable in a system so steeped in unquestioned assumptions about power and hierarchy.
Obviously, these definitive statements to the effect that all clients are vulnerable and all therapeutic relationships involve a power differential are incorrect due to the fact that the power differential statement does not capture the complexities of the therapeutic relationships and the multidimensionality of power. As was mentioned above, it demonstrates that not all clients are dependent and vulnerable to their therapists and some therapeutic relationships have a power differential that is clearly tilted in the direction of the client.
Source #4: The Slippery Slope Argument
The slippery slope argument is the fourth source fueling the idea of the inherent power differential and therapists' power over their patients. The slippery slope process is described by Gabbard (1994) as "the crossing of one boundary without obvious catastrophic results (making) it easier to cross the next boundary" (p. 284). It refers to the idea that crossing therapeutic boundaries that are seemingly harmless is likely to lead to boundary violations and harm to clients (Pope & Vasquez, 2007; Simon, 1991). The idea of the slippery slope is closely tied to the idea of the power differential (Zur, 2007a). In this view therapists, who supposedly possess overwhelming power over their clients, are likely to go, undeterred and unstopped, down the slippery slope from minor deviations from abstinence and neutrality all the way to full, exploitative sexual relationships. Following a similar line of thought, several other writers describe certain behaviors undertaken by therapists with their clients (e.g., self-disclosure, hugs, home visits, socializing, longer sessions, lunching, exchanging gifts, walks, playing in recreational leagues) that can be precursors to sexual or other violations or the first step on the slippery slope toward harm and exploitation of their clients, sexually or otherwise (Bersoff, 1999; Borys & Pope, 1989; Koocher & Keith-Spiegel, 1998, 2008; Lakin, 1991; Rutter, 1989; Sonne, 1994; St. Germaine, 1996; Strasburger et al., 1992).
On the basis of the idea of the slippery slope, an "exploitation index" was developed by Simon and Epstein (Epstein & Simon, 1990; Epstein, Simon, & Kay, 1992) consistent with Simon's (1994) belief that therapists must "Maintain therapist neutrality. Foster psychological separateness of patient. . . . Ensure no previous, current, or future personal relationships with patients. Minimize physical contact" (p. 514). Simon and Epstein developed an index that identifies common, helpful and widely practiced interventions, such as nonsexual touch, gifts and dual relationships, as behaviors that are likely to lead to exploitation of clients by their therapists.
If one accepts the slippery slope and the power differential hypotheses, it readily leads to a conclusion such as that of Strasburger, et al. (1992), who stated, "Obviously, the best advice to therapists is not to start [down] the slippery slope, and to avoid boundary violations or dual relationships with patients" (pp. 547-548). Similarly, Woody (1988) asserted, "In order to minimize the risk of sexual conduct, policies must prohibit a practitioner from having any contact with the client outside the treatment context and must preclude any type of dual relationships" (p. 188). The slippery slope solution to the power differential 'problem' is for therapists to focus on risk management and stay neutral and emotionally distant from their clients and to avoid even clinically beneficial interventions, such as self-disclosure, bartering, gifts, appropriate non-sexual touch or benign or clinically beneficial dual relationships.
Reflection & Critique
The claim that research supports the slippery slope idea is based on statistical findings that almost all harmful boundary or sexual violations were preceded by minor boundary crossings, such as hugs, gifts or self-disclosure (Borys & Pope, 1989; Koocher & Keith-Spiegel, 1998; Lakin, 1991; Rutter, 1989; Sonne, 1994; St. Germaine, 1996; Strasburger et al., 1992). The problem with this argument is that it draws causal conclusions from statistical correlations. As most undergraduates are aware, sequential relationships and statistical correlations cannot be equated with causal relationships. Therefore, we cannot say that boundary crossing causes boundary violations just because a boundary crossing happened to precede a boundary violation. Arnold Lazarus (1994) called this slippery slope argument, "an extreme form of syllogistic reasoning" (p. 257). Zur (2000a, 2005, 2007a) argued that to assert that boundary crossings are likely to lead to harm and sex because they statistically precede them is like saying doctors' visits cause death because most people see a doctor before they die.
National surveys document that most therapists exchange inexpensive gifts, engage in appropriate, nonsexual touch and almost all self-disclose (e.g., Borys & Pope, 1989; Johnston & Farber, 1996; Pope, Tabachnick, & Keith-Spiegel, 1987). Some of the same surveys also report that between 0.9% and 12.1% of male therapists and between 0.2% and 3% of female therapists have engaged in sexual acts with clients. The discrepancy between the majority of therapists who use boundary crossing to increase effectiveness of treatment and the small minority who commit boundary violations does not lend support to the slippery slope idea that boundary crossings are likely to lead to boundary violations.
In contrast to the slippery slope idea, it has been widely documented that nonsexual therapeutic touch, self-disclosure, small gifts, home visits, and other appropriate boundary crossings can have high clinical utility and a positive effect on the therapeutic alliance and therapeutic outcome (Bennett, et. al., 2006; Gutheil & Brodsky, 2008; Lazarus, 1994; Lazarus & Zur, 2002, Pope & Wedding, 2007; Sonne, 2006, Vasquez, 2007; Williams, 1997; Zur, 2007a). These activities can also reduce any power differential, if there was one to begin with, as they create more egalitarian relationships. It is important to remember that following the slippery slope rationale and banning or avoiding some appropriate boundary crossings because they may lead to boundary violations, may undermine important tenets of humanistic, existential, feminist-based, group and cognitive-behavioral therapies and would abolish body psychotherapy. For similar reasons, it would eliminate home visits, adventure or outdoor therapy, treating the chronically mentally ill homeless population, and military psychology, where dual relationships are mandatory.
The slippery slope construct is unscientific and professionally precarious. Accordingly, the generalization about the power differential, which lies at the core of the slippery slope idea, has no scientific base and results in conclusions that threaten the health and stature of the psychotherapeutic profession.
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Types of Powers in Psychotherapy
The literature on power relationships has proposed several typologies to identify different types of power. Brody (1992) in his book, The Healer's Power, separates power into three categories of Aesculapian, Social, and Charismatic power. Proctor (2002), in her thorough book, The Dynamics of Power in Counseling and Psychotherapy, proposes a typology of three types of power: role power, societal power and historical power. Perhaps the most cited typology was offered by French and Raven (1960), who differentiate between expert power, legitimate power, referent power, reward power, coercive power, and informational power. Pope and Vasquez (2007) focus on therapists' power and have identified several types of power that pertain to them. These include power conferred by the state, power to name and define, power of testimony, power of knowledge, and power of expectation. Starhawk (1987), Arendt (1986) and other feminist authors differentiate between power-over and power-with, and also between power-over and empowerment, a distinction that will be further elaborated upon in the last part of the paper.
Following are descriptions of nine types, sources or categories of personal power. This typology is partly based on the classical work of French and Raven (1960) and also on the summary by Devries (1994) and Douglas (1985) and conceptualizations of Proctor (2002), Zur (2007a) and others. These nine categories, described below, are not mutually exclusive (e.g., legitimate and coercive types of power overlap significantly). This section is focused exclusively on sources of power that are most likely to play a role in the psychotherapeutic arena and, therefore, do not include discussions of power issues, such as weapons and war, domestic violence, economic warfare, or technological power.
This article identifies the following nine sources of power and discusses their relevance to psychotherapy and counseling. Let us recall that these sources of power are not mutually exclusive:
Each type or category will be described and its relevancy to therapists and clients detailed.
1. Legitimate Power: Designated Or Legal Power
Legitimate power refers to the power of individuals based on the legally designated positions they hold and the resulting power that they have over others. This type of power derives from a formal, legal, official or elected position that a person holds. Kings, judges, prison guards, and policemen are classic examples of people who have legitimate power or occupy an official position in our society that is also associated with power. Many argue that this is the most obvious and also the most important kind of power. Zimbardo's (1972) famous prison experiment and the recent abuse at Abu Ghraib exemplify how potentially easy it is to abuse this kind of power.
- Therapists' Legitimate Power: Psychiatrists, psychologists and other designated psychotherapists in many settings have the legitimate power to detain clients against their will, to force clients to take medication or undergo psychiatric treatment (Dawes, 1994; Proctor, 2002; Szasz, 1997). Therapists in inpatients units and correctional institutions often have the same legitimate power as prison guards. The enormous or even deadly legitimate power of therapists who work in inpatients units was exemplified in the movie, One Flew Over the Cuckoo's Nest. Some therapists have the legitimate authority to effect whether a client may live or die if they are conducting sanity (forensic) evaluations, capacity to stand trial assessments or intellectual disability evaluations, when conviction for the crime may carry a death sentence. Therapists' legitimate power is generally based on state or federal laws and also on licensing laws that define and protect the professional titles of psychiatrists, psychologists, counselors, social workers, and other therapists. Inherent in the role of a psychiatrist, psychotherapist or counselor is a form of power that is given by the state in the form of a professional license. License confers specific powers beyond the above mentioned to detain, medicate or treat patients without consent. Psychotherapists also have legitimate power to diagnose, report child abuse to the authorities, or alert police or other institutions or people if therapists perceive the clients as being a danger to self or others. Undoubtedly, this legitimate form of power and authority to control, detain and coerce elevates the psychotherapists' power relative to their clients.
- Clients' Legitimate Power: Generally, clients do not have legitimate power over their therapists unless on those rare occasions when they hold certain positions in society that may have a bearing on the power dynamic in therapy. However, a patient uses legitimate power in working out a contractual agreement with the therapist. All clients have the legitimate power to complain to the state licensing board if they believe that the therapist has behaved unethically, operated below the standard of care, if they wish to take revenge, or for any other reason. Similarly, all clients have the legitimate power to attempt to file a civil lawsuit and claim that they were harmed by the therapists' negligence or substandard care. By simple acts, such as filing complaints with licensing boards or lawsuits, clients have the power to negatively effect or potentially destroy therapists' careers and livelihood.
Sources of Power Index
2. Expert-Knowledge Power: Knowledge Is Power
Expert power relates to the individual's knowledge, information, proficiencies, mastery of techniques and skills that are generally acquired through education, training and experience. The famous phrase, scientia potentia est, is a
Latin maxim, "For also knowledge itself is power", stated originally by Sir Francis Bacon. Similarly, in Proverbs 24:5, it says: "A wise man has great power, and a man of knowledge increases strength." In modern times, it is paraphrased simply as "knowledge is power." The statement implies that through education, training and experience one acquires knowledge, which readily translates into power. With greater expertise and knowledge one's potential or abilities in life will certainly increase. Foucault (1980), like many other philosophers, has emphasized the fact that power and knowledge are inseparable.
- Therapists' Expert-Knowledge Power: Therapists' expertise in behavioral health is derived from their professional education, training and experience in psychiatry, psychology, social work, counseling, etc. It has also been referred to as "Aesculapian power," which is gained through training in the discipline, skills and art of physical health or mental health (Brody, 1992). For the most part, therapists have more expertise, knowledge and information in the field of human behavior than their clients. They often also have higher degrees, more formal education in the mental health field and more information about behavioral health assessment and interventions (DeVries, 1994; Heller, 1985; Proctor, 2002; Sutherland, 2007). Therapists have expertise in identifying the strengths and weaknesses of their clients, are knowledgeable about ways to affect people in general, including their clients' behavior, cognition and emotion. They also can educate and inform their clients about the nature and meaning of certain situations and propose new ways of viewing, reacting and responding to situations. In summary, "knowledge is power" is highly relevant to therapist-client power relationships. At times, therapists use professional or obscure jargon as a way to further establish or enhance their expert power. Back in 1973, Frank wrote his classic book, Persuasion and Healing, which appropriately and realistically viewed therapists' expertise as the capacity to persuade and convince.
- Clients' Expert-Knowledge Power: Patients' general expertise and knowledge may affect the power relationships with their therapists. Many clients, but by no means all, are less educated, have less expertise and knowledge about psychology and mental health, and are, therefore, in a less powerful position in relationship to their therapists. When clients are more educated and knowledgeable in psychology or psychiatry than their therapists, the power balance shifts their way. This is likely to be the case when therapists are in their own personal therapy with fellow professionals. In this "informational age", where almost unlimited information is readily available online, some informed consumers come to sessions with a significant amount of information about mental health in general and about their condition in particular. When clients do their homework and conduct extensive research on their condition, they may be leveling the playing field with their therapists. Highly skilled, motivated and capable clients, technically and otherwise, may even obtain more recent and more extensive information about their treatment issues than their therapists have. In certain situations, clients' expertise and knowledge on financial, real estate, computers, law, art, etc. may play a role in balancing the power relationship.
Sources of Power Index
3. Professionalism Power: Societal Respect For The Healer's Role
Professionalism power is inherent in one's professional role. This power derives from the respect - and consequent influence - engrained in many societies for the professional role itself, as well as the expectations, capacities, 'rights,' and liberties that come with certain professional roles. This is sometimes referred to as 'clout' in the vernacular. While this kind of power can be closely related to legitimate power (type #1) and expert power (type #2), it differs from these in that it emphasizes the universal perceptions, expectations and the professional aura of the healer's role, beyond the actual legitimacy provided by the established authorities or the actual knowledge or academic degree that the therapist may possess. Witch doctors, indigenous healers and priests, who many consider the predecessors of modern psychotherapists, all have a "healing presence." There is a mystical trust engendered by the healing professions in the general populace (Dawes, 1994; Proctor, 2002; Zilbergeld, 1983). There are many ways that therapists may augment this professional presence or enhance their professional influence and aura. Generally, the more professionally one presents oneself or one is perceived by others, the higher the professional esteem, which, in turn, is most commonly associated with more prestige, income and power, i.e., clout.
Milgram, more than any other researcher, has shown the power of professionalism. In his famous 1963 experiment, authoritative-sounding and looking men, in professional settings, dressed in professional attire (i.e., lab coats) who exuded a professional aura, got most ordinary people and research subjects to comply with immoral and nonsensical orders and to perform brutal and unjust acts on innocent people. Milgram's work provided the most powerful illustration of the enormous power of professionalism and the power that is held by those who are influential due to public respect or possess an aura of professionalism.
- Therapists' Professionalism Power: Professionalism power, or power emanating from one's role, is based on the ability to influence, on one's aura, or the general perception of the professional role of the psychotherapist. Beyond the actual professional license, the role of a professional projects a certain aura and mystique. As mentioned, psychotherapists and counselors are often viewed as descendents of witch doctors or medicine men, which adds a mysterious and magical element to the concept of aura populace (Dawes, 1994; Proctor, 2002; Zilbergeld, 1983). Langs (1989) observed accurately, "Psychotherapy is a service, a business, an industry, yet the mystique of psychotherapy endures beyond all reason" (p. 5). As discussed later in this paper, there are many ways therapists can increase their professional 'look.' They can place graduate degrees or certificates on the office walls, take notes, configure the seating arrangement in certain ways, 'dress the part', or use professional or obscure jargon.
- Clients' Professionalism Power: Most clients are not likely to have power over their therapists derived from their professionalism unless they hold certain positions in society that may have a bearing on the power dynamic in therapy.
Sources of Power Index
4. Positional Or Role Power: Professional Role As Power
Positional, or role, power refers to the power of an individual because of the relative position he/she has in the professional-hierarchical relationships (i.e., doctor-patient, therapist-client) or in hierarchical relationships in an organization. This type of power is also closely related to above-mentioned legitimate (type #1) and professionalism (type #3) types of powers. It differs from legitimate power as it is not necessarily nor always related to the legally sanctioned role, and it differs from professional power as it draws power from the professional roles and hierarchical relationships, not only from professional influence. As articulated below, as part of one's position or role, one is likely to have a wide array of powers.
Ways Therapists May Use Positional Power
- Set the time and place: In their professional capacities, therapists are in charge of setting the beginning and end time of sessions. They can choose to extend the time, finish strictly on time or finish even earlier than schedule, if they wish to. Similarly, they choose, and can change, the venue of therapy. All this gives them power over their clients who, as part of the clients' role, must play by the rules that are determined by the therapists.
- Set the stage: Therapists have the capacity to organize the seating arrangement in any way they wish. They can elevate their power by either sitting physically higher, sitting behind a desk, having a bookshelf behind them, putting a tissue box next to client, etc.
- Right to ask questions: Therapists' roles give them the right to ask questions but not necessarily to answer questions. This discrepancy elevates therapists' power compared to their clients.
- Maintain anonymity: The fact that most therapists know much more about their clients than the reverse gives them a significant power advantage. "Unknown" therapists can easily become mysterious and powerful in the eyes of their clients.
- Power to name: The authority to label, name and diagnose is another form of power that therapists have over their clients. This also involves the power to suggest or interpret unconscious or conscious motivations. As part of the therapists' authority to name or label mental illnesses is the enormous power to define that which is normal and that which is not. As will be articulated below, the power to define what is normal gives therapists social power and control and is reserved to very few others in our society.
- Authority to determine the rules of the relationships: In their role, therapists can determine the rules of therapy almost any way
they wish. Some therapists choose to impose strict rules about many aspects of therapy, such as strict prohibitions against physical touch, gifts or bartering. Others are open to more flexible therapeutic boundaries and welcome appropriate gifts, fair bartering arrangements or healing touch. Yet, others may impose the "only in the office" rule of therapy, resulting in greater isolation and in increased risk of exploitation.
- Clients' Positional/Role Power: Most clients are not likely to have power over their therapists derived from their professionalism unless they hold certain positions in society that may have a bearing on the power dynamic in therapy.
Psychotherapy clients occupy the role of the one who seeks, needs or is required to receive psychiatric help. Very often they assume the stigma or label of being "mentally ill," "mentally deficient" or "mentally impaired." As such, they are, almost by definition, in a lesser position of power. While most clients accept and internalize the role of the broken or ill, some do not. While most clients accept the role and comply with the rules of therapy, as established by the treating clinicians, some do not. Many modern clients view themselves as consumers rather than patients. They are often highly informed, educated and well-established and do assume the role of the 'sick ones.'
Following is a short list of ways that clients may not follow the rules and act in ways that may balance the power in therapy:
Ways Clients May Use Positional Power
- Time: Clients may come to sessions late or leave early as a way to actively or passively gain control of the beginning and end of sessions. Some clients can stretch the end of the sessions by continuing to talk or being slow or actually refusing to leave. Other clients may show up at the therapists' offices when they are not scheduled.
- Set the stage: Therapists have the capacity to organize the seating arrangement in any way they wish. They can elevate their power by either sitting physically higher, sitting behind a desk, having a bookshelf behind them, putting a tissue box next to client, etc.
- Space: While therapists can set up the office in any way that they choose, some clients may elect to move their chair or seat to another place other than the place designated by the therapist. Some clients may make a power move and sit in the therapist's chair.
- Answer therapists' questions: Clients may exercise their power and prerogative to answer therapists' questions or not to answer them. They can also answer the questions truthfully or not.
- Ask questions: Some clients choose to ask their therapists a variety of questions. These can range between very personal to professional questions. Asserting themselves by asking questions can be a way to level the playing field in therapy.
- Maintain anonymity: Clients may elect not to answer therapists' questions, and remain elusive. The power behind anonymity and mystery is equally applied to therapists and clients.
- Naming and labeling: Clients may choose to accept or reject therapists' diagnoses or naming of their conditions and some more assertive or aggressive clients may even label or diagnose their therapists.
- Playing by the rules: While therapists have the professional right to set the rules of therapy, patients have the choice to play by these rules or not. In power moves, they can bring gifts, refuse to pay the fees or touch the therapists without the therapists' consent.
- Draw attention to higher status: Clients who are extremely wealthy, socially or politically well connected or are famous in some high profile way, may use their special status to subtly demean the relative status of their therapists.
- Fear: Clients who have a history of violent, criminal behavior may use threats to decrease their sense of vulnerability and attempt to dominate the therapist. The movies Analyze This and Grosse Point Blank, cited above, present clients who instilled fear in their therapists, and by that they gain significant power over them.
- Intrusive boundary violations: Clients can do extensive Internet investigation, as well as using other means to obtain personal information about their therapist or therapists' family members. They can try to join therapists' social and civic organizations. They can actually stalk the therapist.
- Sexual seduction: A client may dress, speak or behave in a manner that is intended to be sexually enticing to the therapist.
- Legal violation: The client may make false accusations against a therapist and file inappropriate malpractice suits or complaints to the local governing board.
Sources of Power Index
5. Imbalance (Or Inequality) Of Knowledge Power: Knowledge Of The Other Is Power
When one person has more knowledge and information about another, it gives him/her an obvious power advantage over the other person. This section discusses the issue of knowledge as knowledge of the other rather than scientific, or academic knowledge. This lack of mutuality in regard to personal information creates a tilt in the power differential in the direction of the one with the information. Knowing a person's vulnerabilities, history, patterns, reactions and sensitivities gives a person a potential power advantage. The idea of "knowledge is power" is not only applied to people's general or academic knowledge, as discussed in type #2 above, but also to knowledge about other people.
- Therapists, ordinarily, know more about their clients than vice versa: In most psychotherapeutic situations, therapists have much more information and knowledge about their clients than vice versa. This discrepancy in knowledge is readily translated to a power advantage as therapists often have extensive information about their clients' vulnerabilities, shameful, or even criminal, behaviors, personalities, impairments, etc. For that reason, feminist therapists encourage therapists' self-disclosure as an important way to reduce the power differential (i.e., Brown, 1994, 1998; Greenspan, 1986, 1994; Heyward, 1994). Similarly, humanistically oriented therapists emphasize the importance of therapists' transparency as the foundation for engaging in authentic relationships between therapists and clients (Jourard, 1971; Proctor, 2002; Williams, 1997; Zur, 2007a, 2008b). The idea of "knowledge is power" is aptly applied here as therapists' general knowledge of psychology, as well as of their clients, can compound itself when it comes to power relationships. Therapists have many ways to enhance or display their knowledge-based power. They may use professional jargon, display certain books on the bookshelves or directly discuss their knowledge or understanding and experience on certain topics.
- When client have significant knowledge about their therapists:
Most clients, as a rule, do not have as much information about their therapist as their therapists have about them. Generally, such a discrepancy is likely to shift the power in the direction of the therapist. When clients reveal shameful thoughts or behaviors, criminal activity, fears, etc., they are likely to feel vulnerable to their therapists. There are a number of strategies that clients may follow in order to avoid 'losing power' in regard to their therapists around the issue of discrepancy of knowledge:
- Withhold information: Clients may consciously or unconsciously withhold shameful or other information that would make them vulnerable to their therapists.
- Ask questions: Clients may ask their therapists probing and personal questions in order to level the (power) playing field.
- Make inquiries about their therapists: There are many ways that clients may inquire about their therapists. They may inquire about their therapists in the community or even stalk them.
- Search for information online: In this Internet era, clients can easily access a significant amount of information about a therapist with a simple click of a mouse. A Google search can often reveal information about the therapist's professional training, professional activities, articles, teaching, etc. It can also reveal information about the therapist's family, home address, hobbies, sexual orientation, spiritual practices and much more. More intrusive or illegal searches, or what has been called cyber stalking, can reveal therapist's credit reports, debts, divorce records, law suits, and even cell phone records. In his article, Zur (2008b) called this phenomenon "The Google Factor" and articulated the following five levels of client-initiated searches:
- Basic review of therapists' professional web pages.
- Simple 'curiosity' Google search.
- More intense and 'due diligence' search.
- Intrusive search or paying for online investigators to conduct highly intrusive but legal searches of their therapists.
- Paying for online investigators to conduct an extensive and highly intrusive illegal search of a therapist.
Clients can collect this information without the knowledge of the therapists, which, depending on the information they collect, can give them significant power over their therapists.
Sources of Power Index
6. Coercive Power: Forcing Against One's Will
Coercive power is the capacity to force someone to do something against his or her will. The source of coercive power varies widely. People can coerce others by employing threat of physical force or actual physical force, by invoking their legal status or authority, or by blackmail, intimidation and other forms of manipulation. Parents, for example, have coercive power over their children, as do teachers over their students. Obviously, officers of the law, judges, federal officials, and the like can compel people to do things against their will. This form of power also includes those who can coerce others using their physical strength and psychological intimidation. It also includes, basically, any weapon or threat of physical harm, as exercised by bullies, Mafioso, gangs and others who specialize in extortion or blackmail, relying on coercive power. Craziness or erratic behavior also presents a form of coercive power, as acting 'crazy' can have an intimidating effect on others. This source of power overlaps with the first source of legitimate power, as parents, judges, police officers and other authorities possess both, legitimate and coercive powers.
- Therapists' Coercive Power: Psychiatrists, psychologists and other mental health workers in certain settings have the power to detain, hospitalize, treat, and medicate clients against their will (Law Project for Psychiatric Rights v. State of Alaska, 2008). Coercive power is obviously closely related to legitimate power (see Type #1). The power to detain, treat and medicate people against their will is tied to therapists' legitimate and professional power to define what is healthy, normal or adaptive in our society. Szasz (1997) and The Citizens Commission on Human Rights (CCHR) have been the most vocal critics of therapists, primarily psychiatrists' coercive and abusive power. The movie, One Flew Over the Cuckoo's Nest, presents the brutal and ultimately deadly coercive power of a treating psychiatric nurse over psychiatrically confined men. Some may argue that therapists, in certain settings, have the power to kill, such as when they conduct fitness to stand trial assessments or insanity assessments of those who have committed crimes that may carry a death penalty. Also, therapists have the legal right to use coercive power to stop clients from hurting themselves by calling the police or intervening in other ways.
- Clients' Coercive Power: Some clients are physically stronger than their therapists; others can be highly intimidating, therefore possessing a coercive power over their therapists. Some clients are psychopathic, sociopathic, mafia-related (as in the movies, Analyze This or Grosse Point Blank) and threatening. Others may stalk their therapists (as in the movie, What about Bob) and yet others are very litigious. Borderline Personality Disorder (BPD) clients represent a special group who are highly litigious, erratic and persistent and can be frightening and intimidating to therapists (Welch, 2000). The acclaimed ethicist, Gutheil (1989), writes about the borderline rage coercive force:
Borderline rage is an affect that appears to threaten or intimidate even experienced clinicians to the point that they feel or act as though they were literally coerced -moved through fear- by the patient's demands; they dare not deny the patient's wishes. Such pressure may deter therapists from setting limits and holding firm to boundaries for fear of the patient's volcanic response to being thwarted or confronted. . .
At other times, therapists who would ordinarily reflect back personal inquiries about themselves may feel actually trapped or pressured by the patient's potential rage into unusual and inappropriate degrees of social interaction with the patient or of self-disclosure, such as discussing their own marital difficulties. Intimidation may be further reinforced by latent and implicit or overt suicide threats. (598)
Sources of Power Index
7. Reward Power: The Power To Reward Or Withhold:
Reward power is the ability to give or withhold what people want and, hence, get them to do or not do certain things. Rewards may be financial, physical, emotional, spiritual, etc. and can include payment, promotion, gifts, praise, appreciation, acknowledgment, or love. Similarly, one may withhold love, praise, payment, gifts, etc., as a way to have people comply and submit. Obviously, one does not need to be a revered teacher, beloved priest or adored actor to have reward power. Students, parishioners and audiences of movies or plays have equal power to reward or withhold praise and appreciation or turn to other people.
- Therapists' Reward Power: Clients often desire therapists' approval and love and therefore imbue the therapists with reward power. Therapists can reward clients by give them approval, commending them on their progress, stating that they love them, lowering their fees, extending the length of sessions, increasing frequency of visits, giving gifts, or accepting bartering proposals from clients. A predatory and exploitative therapist may sexually abuse a client by 'rewarding' him or her with special attention and sexual love. Therapists also have the power to reward clients by writing a favorable custody or probation report. In extreme situations, therapists may reward clients with life itself if they find them incompetent to stand trial for a crime where the death penalty may be involved. Therapists can reward their clients by positively mirroring the clients' worth. They can write letters of recommendation or agree to testify in the clients' favor in various kinds of legal proceedings. They can also reward clients by attending celebrations such as graduations or weddings.
- Clients' Reward Power: One of most obvious ways that a client can assert reward power is by withholding payments, but there are others. Many therapists seek their clients' approval or appreciation of their services. Psychotherapy and counseling are not necessarily high paying jobs, and clients' appreciation and satisfaction has been reported as a significant element for therapists' sense of job satisfaction. Other ways for clients to assert power is by resisting therapists' suggestions, interpretations and interventions, not improving, or not acknowledging the help they receive or progress they make. Clients may use reward power by referring friends and family to their therapists, rewarding them with professional and financial rewards. Sex is one way that some clients, using their sex appeal, reward their therapists (however, needless to say that it is the therapist's legal and ethical responsibility to hold the line, avoid temptation and never to sexually engage with current or recently terminated clients).
Sources of Power Index
8. Referent Power: The Power Of Admiration
Referent power derives from people's liking, admiring, being attracted to, or desiring to be like another person and results in them being willing to follow that person and obey his or her requests, wishes or orders. Referent power is often fueled by the person's charisma, social or economic status, or capacity to persuade, influence and manipulate. Individuals' sex appeal or other attractive, personal characteristics may enhance their referent power. Referent power overlaps with reward power as the person that is being admired or liked has the power to reward or withhold love, praise, attention, etc. Psychological research has found that people tend to imitate those they admire, wish to be like, can relate to, and perceive as superior to themselves.
- Therapists' Referent Power: Many clients admire, respect and look up to their therapists, which gives therapists referent power. Therapists who seem to be wealthy and successful may also command more referent power. Some therapists are highly charismatic or authoritarian, which is likely to give them even more power over their clients. Therapists use referent power clinically when they model or self-disclose in order to promote certain attitudes or behaviors. Obviously, some of the most renowned clinicians (e.g., Beck, Ellis, Erickson, Freud, Haley, Jung, Minuchin, Perls, Rogers, and Sullivan) have been highly charismatic and/or authoritarian.
- Clients' Referent Power: Some clients are charismatic, successful, famous, or adventurous and, as such, may elicit therapists' admiration and respect. Therapists may find their clients sexually or otherwise attractive or admirable for their artistic or entrepreneurial or other capacities or skills. Clients' social or economic status may also engender respect and admiration, thus giving clients referent power.
Sources of Power Index
9. Manipulative Power: The Power To Control Deviously
Manipulative power is an important source of power that may relate to most of the above eight sources of power. It refers to the conscious or unconscious attempt to deceptively, deviously or unfairly convince, subtly coerce, and influence someone to do something, often against their will or conscious knowledge. Con artists are archetypal examples of manipulative power. The source of manipulative power varies widely. People can manipulate others by employing deceit, trickery, subtle threat, charm, seduction, or sex appeal. They can also manipulate others by being insistent, persistent, acting in an irrational or 'crazy' manner, or via emotional blackmail. Pretending to be an innocent victim, when one is actually not, may also constitute emotional manipulation (Zur, 1994).
- Therapists' Manipulative Power: Looking at the broadest definition of manipulation, one may claim that many forms of effective therapy involve manipulating clients to act in ways that therapists determined as healthy. Similarly, paradoxical interventions, such as punishment and rewards, can also be viewed as manipulative as they often involve covert actions that clients are not aware of. Obviously, exploitative therapists manipulate their clients for their own benefit, sexual or otherwise.
- Clients' Manipulative Power: Some of our clients' problems in the world may stem from their attempts or capacity to manipulate. There are several groups of clients most notable in this regard:
- Child custody: In the last couple of decades, we have seen a rise in the number of clients who come to therapy as a strategic (manipulative) move to advance their claims in their custody wars over their children. These clients' ultimate goal is not to get mental health treatment but to elicit the therapists' support in their custody battles. They may come to therapy on their own initiative or on the strategic advice of their attorneys. Many therapists are unwittingly manipulated into taking sides in these conflicts, which can be detrimental to the therapists. In recent years, licensing boards' complaints against psychotherapists have mushroomed as more therapists get wittingly or unwittingly caught in the middle of the custody battles because they were manipulated into writing letters or making statements that support one side in the conflict without the proper information and custody evaluation training.
- Borderline Personality Disorder (BDP): Some patients with Borderline Personality Disorder, as most therapists know, manipulate through rage, persistence, erratic actions, and bizarre behavior. At times even experienced therapists can be intimidated and frightened by the Borderlines' rages and may succumb to their demands, regardless of how bizarre, extreme, unethical or illegal they are. Similarly to Gutheil (1989), quoted above, Welch (2000), a psychologist and renowned attorney, states in his "Borderline Patients: Danger Ahead" article:
In fact, therapists may quickly find themselves in a "damned if you do, damned if you don't" position. If therapists try to meet the borderline's demands, they are pursuing a bottomless pit and facilitating regression by feeding the underlying fantasy that is untempered by reality. But any other treatment may enrage the patient, threatening the treatment alliance. (p. 2)
Borderline rage cannot only turn psychotic but can also translate to false accusations and manufactured complaints to licensing boards. Like Williams (2000) and Welch (2000), Gutheil (1989) explains the threatening and manipulative power of the borderline when he states what most attorneys and ethicists know well: "Patients with borderline disorder apparently constitute the majority of those patients who falsely accuse therapists of sexual involvement" (p. 597).
- Psychopathic and con-artist clients: Not surprisingly, psychopathic or con-artist clients are likely to try to manipulate, lie, cheat, and scam their therapists. The movie, House of Games, provides an excellent example of manipulative power where the con-artist client cons the therapist who thinks she is helping her client.
- Litigious clients: Litigious clients, who manipulate therapists, often file several lawsuits against different health care providers or other people or organizations. The motivation can be financial and/or to satisfy their vindictive impulses. Williams (2000) provides some of the few accounts of such a group of people in his breakthrough article, "Victimized by victim: A taxonomy of antecedents of false complaints against psychotherapists."
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How Psychotherapists Create Power Advantage:
Rituals, professional posturing and meta-communications
Psychotherapy or counseling often includes numerous rituals, actions and meta-communications that subtlety, yet significantly, enhance therapists' power relative to their clients. Many of these meta-communications, which can be considered as professional posturing to augment power, are deeply ingrained in therapeutic routines and professional rituals. These meta-communications may involve verbal or non-verbal communications. In fact, almost all clients and therapists take them for granted and are not even aware of their significant implications for power in relationships.
Following are brief descriptions of several of these rituals, posturing and other forms of communication that enhance therapists' power relative to their clients.
Transparency, Disclosure, and Power
The issues of transparency, self-disclosure, and the privilege of therapists to ask but not necessarily answer questions have a few significant ramifications in regard to the therapist-client power dynamic
- The One Who Gets To Ask Questions: Therapists' professional role gives them the right to ask questions but not necessarily to answer them, which automatically elevates their power position relative to their clients. Asking probing, detailed, and, what may seem, intrusive questions definitely further elevates therapists' expert and positional power. Refusing, evading, or avoiding answering clients' questions is another way to create and maintain the power differential, because it creates a clear hierarchy between therapists and clients. Regardless of their theoretical orientations, many therapists have been trained and professionally socialized to respond to clients' questions with, "I wonder why you asked that?" or "We are here to talk about you, not me." In an interesting double standard, it seems that the therapists' have a "professional right" not to answer clients' questions, but when the client does not answer questions, he or she is often negatively viewed as non-compliant or "resistive."
- Maintaining Therapists' Anonymity: Graduate school courses, supervisors and risk management literature have often emphasized the importance of therapists minimally self-disclosing and limiting their transparency. Combining analytic and risk management orientation, the forensic expert, Simon (1994), advocates that psychotherapists, at all times, "Maintain therapist neutrality. Foster psychological separateness of the patient . . . Preserve relative anonymity of the therapist" (p. 514). As noted by feminist (Greenspan, 1986, 1994; Rave & Larsen, 1995) and humanistic (Jourard, 1971) psychologists and other texts on self-disclosure (Milioni, 2007, Bloomgarden & Mennuti, 2009; Zur, 2007a, 2008b), the discrepancy in transparency creates a power differential. This is why humanistic, feminist therapists and those who work with ethnic minorities emphasize the importance of therapists' self-disclosure as a way to create more egalitarian relationships and level the (power) playing field between therapists and clients.
- The Mystique of Therapy: "Unknown" therapists, or those who do not self-disclose and as a result are not transparent or known, inevitably become mysterious to clients. Such mystery often translates into power in the eyes of their clients. Facing unknown, non-transparent, mysterious therapists, clients are more likely to idealize them and project a more generalized power "authority" onto them. Like Dawes (1994), Proctor (2002) emphasizes that "False authority can be set up for therapists through mystification of their activity" (p. 14). The idealization and projection that develops towards mysterious therapists have partly to do with the clients' desire to believe that their money and time are well spent and partly to do with the aura that the therapists and their settings project. What may intensify the idealization of therapists besides their lack of transparency is that the process of therapy and counseling is often not clearly defined and is mysterious and confusing in itself. The cumulative effect of entering an ambiguous situation and encountering a non-transparent therapist results in a greater chance that the client will perceive the therapist as possessing unusual, magical or mysterious powers.
Knowledge is Power
There are a couple of ways that the common phrase, "knowledge is power", is relevant to our analysis of power in psychotherapy and counseling.
The first application of this statement was discussed above in the "expert power" section. In this context, knowledge referred to psychological knowledge. Such knowledge often involves understanding what motivates or inhibits people and how to influence people's emotions and thoughts and control their behaviors. Obviously, the knowledge and capacity to influence can be employed to help people heal and grow and can also increase therapists capacity to dominate, manipulate, control, or exploit.
The second application of the statement, "knowledge is power", refers to the idea that when one person has much more extensive knowledge about another person, it is likely to give him or her power over that person. As noted above, the nature of psychotherapy and counseling is that, in most cases, therapists have significantly more knowledge and information about their clients or patients than the reverse. This fact gives therapists a significant power advantage. In fact, being privy to personal information is one of the most basic power positions in human relationships. Therapists, in general, are likely to know about clients' histories, including frightening, traumatic or shaming experiences; they know about their clients' present time vulnerability, fears, anxieties, and trepidations; and they are aware of their clients' strengths and weaknesses. Undoubtedly, such personal knowledge easily translates to power.
The Power to Name
The authority to label, name and diagnose is another form of power that therapists have over their clients. Part of therapists' expertise-based responsibility is to name conditions, diseases, disorders, dynamics, or processes. Regardless of the scientific or non-scientific basis of these assessments and psychiatric labels, the fact that the expert therapists identify and name the "mental disorders," "developmental problems" or "family dynamics" gives them power that derives from expertise and knowledge of the clients' so-called diseases (Caplan, 1995; Zur, 2008a; Zur & Nordmarken, 2007). Proctor clarifies, "The power of the psychiatric system is not just in treating people against their will but also in the power to define distress in terms of illness" (2002, p. 5). Similarly, Rowe writes, "In the final analysis, power is the right to have your definition of reality prevail over other people's definition of reality" (in Masson, 1989, p. 16-17).
Naming what is healthy or sick, normal or abnormal, or adaptive or maladaptive gives therapists a form of social control. It becomes therapists' role to interpret or, even worse, define social values and social structure. The fact that therapists can detain, medicate and treat people against their will is probably one of the most profound powers that are assumed by therapists. However, social control is also gained from the sheer capacity to define what is normal or healthy. Proctor (2002) correctly states, "However, despite the inadequacies of explanation inherent in the medical model, particularly in mental illness, it serves a function of social control by individualizing society's sickness and diagnosing it to be treatable by the medical profession" (p. 16). By 'medicalizing' social distress or individualizing social ailments, therapists contribute to the social dysfunction by preserving and authenticating the status quo. Empowering clients, in this context, can be viewed as helping them to adapt to an unhealthy culture rather than empowering them to change the sick culture or social dysfunction.
In an attempt to shed light on how subjective and ethnocentric the Western mental health diagnostic system is, Zur (2000b) contrasts the views and values of Western cultures of diversity and mental health with those of other cultures. He writes:
Resurrecting the Village
My first experience of a true village was in East Africa in 1970 where, as a young scientist, I was attempting the interesting and ultimately impossible task of getting the villagers to eat fish from a nearby lake and thus to enrich their protein poor diet. I was swept up by the strong current that flowed through and around this group of families, uniting them in a circle of interdependence, acceptance and mutual support. This current embraced the strong and the weak, the good and the not so good, the healthy and the frail and the so-called normal and the different. And what a plethora of roles were to be found in this small village: the Grouch, grumbling and complaining and annoying everyone; the Clown who joked and mocked and brought laughter to every face, finding the ridiculous in any circumstance, teasing me mercilessly about my odd accent; the Witchdoctor who allowed me to observe him for days on end as he ministered to the villagers and conducted the rituals; the Man-who-Talked-to-Trees; the Medium who communicated and interceded with the villagers' ancestors; and the young warriors, self-consciously leaning on their new spears, spending hours beautifying their hair and skin with red mud. Each was a treasured and colorful piece of the mosaic that made up this vital community. And, to be sure, there were those
who also occupied common basic roles, equivalent to our butcher, baker and candlestick maker.
There were villagers who needed to be carried everywhere. There were villagers who needed to be constantly protected from harming themselves. Yet, the traditional village not only tolerated such diversity but, in fact, truly embraced and often celebrated the differences, offering a wide network of support for all. The village respected the roles and functions of the village shaman, the fool, the warrior or whomever, and provided them with food and shelter. Whether strong and healthy or frail or handicapped, all were supported physically, emotionally and spiritually. When necessary, special healing rituals focused on the mentally or physically frail. (Zur, 2000b)
Therapists in Western cultures seem to assume the authority to determine who should be considered normal, and therefore allowed freedom, and who is mentally ill, and therefore may be incarcerated, detained, hospitalized, and treated, even against their will.
Giving a client a certain diagnosis, whether it is depression, anxiety or addiction, automatically places the client in the role of a sick person or one having some other form of deficiency or brokenness. In fact, any DSM (Diagnostic and Statistical Manual) diagnosis automatically implies that the client is actually mentally ill (Caplan, 1995, Zur & Nordmarken, 2007). Therapists' approach to healing, which includes their theoretical orientation, is likely to determine whether they will employ a DSM type diagnosis or not. Humanistic therapists and those who align themselves with Positive Psychology are less likely to use DSM diagnoses as they seem to seek a more compassionate and less "medical" understanding of patients' suffering. Similarly, many feminist therapists attempt to create more egalitarian, rather than hierarchical, relationships by avoiding the hierarchical consequences of medical diagnosis. Existential therapists may rephrase or re-define depression as "existential depletion" or "lack of meaning" rather than "major depression," "clinical depression" or "biologically-based depression." Those who work with ethnic, disabled or other disenfranchised minorities are more likely to understand the suffering of their clients within the social, political and economic context of their lives rather than by interpsychic disorders. While the existential and developmental-based understanding attempts to normalize clients' experiences, a DSM-based diagnosis implies that the client is genetically deficient, biologically unbalanced or mentally flawed. While the general role of naming and labeling may create some power differential, the use of DSM diagnoses is likely to create a substantially greater discrepancy in power.
Labeling clients conditions in pathological or DSM terms creates a clear hierarchy of power and health between therapists and clients as it sets up a situation where a healthy, knowledgeable and powerful expert provides a name for the condition from which a defective, suffering client suffers. The humanistic, developmental or existential form of assessing suffering views clients' conditions as a normal part of human existence and therefore does not promote such a discrepancy of power between therapists and clients. Therapists, in the existential-humanistic mold, often view their own emotional and other struggles and difficulties in the same way that they view their clients' struggles, which definitely helps level the playing fields between therapists and clients.
The private and confidential nature of psychotherapy has been known to enhance clients' openness and disclosure as it can reduce feelings of shame and increase their sense of privacy, trust and safety (Zur, 2007a). However, the same private or isolated nature of therapy may also significantly increase the power of therapists over their clients. In the isolation of the office, clients are left to rely on their imaginations regarding their therapists and, as a result, many tend to unrealistically idealize their therapists and attribute great social and intellectual power, wisdom, beauty, or sex-appeal to them. In his book, The Transparent Self, Jourard (1971) discusses how lack of therapists' transparency leads to mystification and idealization of the therapists by the clients. Such an idealization or projection without any real life corroborative references or support is likely to give many therapists, not only the gratification of being adored, but also power over their unrealistically adoring clients.
Psychoanalysis has emphasized the importance of therapy in isolation and anonymity of the therapists not only for the purpose of privacy and a way to increase self-disclosure but also for transferential-clinical reasons. While isolation and non-transparency of therapists may apply to psychoanalytic and psychodynamic techniques, for some reason the "blank screen" and lack of transparency is erroneously viewed as an industry-wide standard (Williams, 1997). The combination of analytic dogma and risk management practices has led scholars to instruct therapists to "Maintain therapist neutrality. Foster psychological separateness of the patient", Simon (1994, p. 514). Similarly, Strasburger, et al. state, "The slippery slope of boundary violations may be ventured upon first in the form of small, relatively inconsequential actions by the therapist . . Violations can involve excessive self-disclosure by the therapist to the patient" (Strasburger, Jorgenson, Sutherland, 1992, p. 547).
Another aspect of isolation that has long been known is that it is as one of the most effective ways to achieve mind-control. Military basic training and cults (Singer & Lalich, 1995) are examples of institutions that systematically and deliberately use isolation to increase influential power and conduct brainwashing. Although there are several compelling reasons for therapy to be conducted in a private and confidential environment, the obsession with therapists' lack of transparency, the rigid avoidance of out-of-office encounters or interventions, and the historically negative attitudes towards dual relationships have all resulted in increased isolation and increased power differential.
The increased isolation and increased power differential may ultimately be more damaging than enhancing to the clients' welfare as it separates therapists and clients as fellow human beings, creates an unrealistic power differential and increased chance of exploitation (Zur, 2000a). This self-serving obsession with isolation has been unfortunately translated into laws, ethics codes and guidelines that imbue therapists with undue power. Even a brief review of traditional healing practices throughout the history of humankind does not support the idea that isolation promotes healing. Shamans, wise women and medicine men, the antecedents of modern psychotherapy and counseling, did not work in isolation. On the contrary, they often performed their healing practices and rituals in the midst of the community where the community members were the witnesses and participants in the healing rituals.
Setting the Stage (Office)
The way the office is set up is one form of meta-communication that is likely to have a significant impact on the power relationships between therapists and clients. Following is a list of office arrangements and office decor that are likely to enhance therapists expert and positional or role power.
Office Settings That Effect Power Relationships
- The therapist is sitting on a higher or more comfortable chair than the client.
- The therapist has framed diplomas and certificates from universities, honor societies and professional organizations on the wall, enhancing his/her expert power.
- There is a professional library of textbooks on the bookshelves, implying that the therapist has derived knowledge and wisdom from these resources.
- Behind the therapist are bookshelves stocked with professional publications, as well as pictures of Freud or Jung, while no such background is behind the client.
- While therapists have notebooks next to them, clients have tissue boxes next to them and a blank wall behind them. Milioni (2007) identifies the impact of this setup in her, "Clients' constructions of power and metaphor in therapy" article, ". . . by having a bookcase behind the therapist (knowledge and power) and a box of tissues and a bin (a receptacle perhaps for emotional rubbish) next to the client. The client describes this as a dictation of the role she is expected to take ('I'm supposed to sit there and cry')" (Section C, 1st para.).
- Medicating psychiatrists, testing or evaluating psychologists and other therapists often signified their power by sitting on a large leather chair behind a large executive oak desk while interviewing a client who sits in a simple straight back chair.
- Some therapists position the clock in such a way that they can see it but it is difficult for clients to see it, signifying their control of time.
- Therapists tend to be the one who both opens and closes the door to the treatment room.
Perpetuating the Slippery Slope Myth
To revisit the 'slippery slope' mentioned earlier in this paper, one of the main arguments supporting isolation and therapist anonymity and detachment is the snowball effect described by Gabbard (1994) as " . . . the crossing of one boundary without obvious catastrophic results (making) it easier to cross the next boundary" (p. 284). Many scholars, primarily in the 1990s, have promoted this myth, which asserts an imaginary causal link between non-sexual and sexual dual relationships. In a classic example, Sonne - who by 2006 had changed her view on the topic - wrote in a1994 article that a therapist and client who play tennis together can easily begin to carpool or drink together. But it is Pope who has been a one-man juggernaut in popularizing the slippery slope idea and transmogrifying it into something like a professional ethical standard. In 1990, Pope wrote, ". . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships" (p. 688). (Like, Sonne, Pope seems to view boundaries in a more flexible way in a more recent article (Pope & Wedding, 2007).) Along the same line, Simon declared, "Self-disclosures by therapists have a high correlation with subsequent therapist-patient sex." The idea behind the slippery slope concept is that therapists have an immense power to lead clients down the slippery slope regardless of clients' intentions, will, desires, state of mind, and social status, and regardless of the context of therapy (Lazarus, 1994; Zur, 2007a).
The myth of the slippery slope has not only contributed to the justification of isolation of clients but also perpetuated the illusion of the power differential and therapists' omnipotence. In reflecting on the slippery slope argument, it seems illogical that a handshake between a therapist and client is likely to lead to sex, self-disclosure to extensive [intimate] social relationships, or a gift to exploitative business relationships. It is worthwhile repeating here what was stated earlier, that many scholars who supported this myth have found support for their dogmatic stance in the fact that generally a boundary crossing (i.e., gifts, bartering, non-sexual touch, dual relationships) always precedes sexual exploitation of clients. To confuse such sequential relationships with causal ones is like saying that doctors' visits cause death because most people see a doctor before they die. To assert that hugging a child, touching a dissociated patient or visiting an elderly client are likely to lead to harm, exploitation or sex is clearly paranoid (Lazarus & Zur, 2002). Zur (2005) views this myth as one of the most prominent ways that our professional standards have been, what he called, "dumbed down."
In an encouraging development, in recent years even Pope (Pope & Wedding, 2007), Sonne (2007) and Vasquez (2008) have all presented a more reasonable, realistic and flexible view of boundaries and the slippery slope idea. While not directly denouncing the slippery slope theory, they nevertheless more readily acknowledge that many boundary crossings and dual relationships do not necessarily lead down the path towards exploitation but can be ethical and even clinically beneficial.
Contrary to the slippery slope belief that dual relationships and other boundary crossings increase the chance of exploitation, I argue that exactly the opposite is often true. Gifts, bartering, attending weddings, appropriate self-disclosure, and appropriate dual relationships are likely to reduce the power differential as they tend to make therapists more transparent and more personally engaged with their clients as fellow human beings. Self-disclosure and dual relationships significantly increase transparency, reduce idealization and reduce the chance of exploitation rather than increase it. Similarly, appropriate dual relationships are likely to reduce the power differential as therapists and clients are less isolated and therapists may be involved with clients' spouses, children and fellow community members. In summary, the slippery slope dogma that imposes greater anonymity on the therapist and increased isolation is likely to increase the power differential and exploitation rather than decrease it.
The Misuse Of The Term "Resistance"
In the isolation of the office, without dual relationships and with lack of transparency and visibility in the community, therapists can easily blame clients for their own ineffectiveness. This is often done by using the famous and widely used "resistance" charge. Therapists not only get to name or label clients' so-called mental disorders and conditions but also get to lay the blame for lack of therapeutic progress at the feet of their clients. While it may be unflattering to the psychotherapy profession, the fact is that whole ideologies and theories focusing on the construct of "resistance" were developed partly to justify ineffective therapies or, even worse, to justify continuing treatment and payment even when there is no therapeutic progress (Zur, 2005). While resistance to change or difficulties in adapting are real problems facing many of our clients, some therapists have given the term an extra self-serving spin by blaming the client. I do not claim that there is no resistance amongst psychotherapy clients. However, I do believe that therapists must function like any other professional. Pilots, plumbers, mechanics, teachers, heart surgeons - all face "resistance" in their line of work, whether it is wind, water, engines, students, or luck, etc. They do not seem to use it as an excuse to be paid without performing their duties effectively. Many therapists, instead of stopping ineffective treatment, shifting to a different modality or referring out, continue it for long periods of time under the justification of clients' resistance. Dozens if not hundreds of books and articles have been devoted to the elusive and self-serving construct of "Resistance" (e.g., Langs, 1981; Stark, 2002). The "resistance excuse" not only absolves therapists from any responsibility for therapeutic failures but also puts them in a position (again) of labeling or naming clients' "dysfunction". In summary, with the resistive idea, many therapists have developed yet another self-serving ideology that gives them the power to blame clients for lack of progress and collect fees while not delivering the goods.
"For Your Own Good"
Several moral principles have been repeatedly referred to by most ethicists and professional organizations' codes of ethics. Of these principles (i.e., respect for patient autonomy, non-malfeasance, beneficence, justice, and respect for clients' rights and dignity), detailed by Beauchamp and Childress (2001), the beneficence principle refers to an action done to benefit others. Under the guise of "therapists know best" and "for your own good", therapists have gained enormous amounts of power to lead, direct and force clients to go in the direction determined by the therapists (Breggin, 1991; Dawes, 1994; Proctor, 2002, Szasz, 1997). (See further discussion on the beneficence principle in "The Ethical Way" section, below.) Under the guise "for your own good", therapists have detained clients, force them to take powerful medication against their will, or have taken their children away.
Perpetuating The View Of Clients As Helpless Victims In Need Of Rescue
At the heart of the power differential is the illusory split between powerful, benevolent therapists and helpless, child-like, victim-clients. Like the general medical model, psychiatry, psychology, social work, and counseling generally view clients as victims. While psychiatrists are likely to see clients as victims of their biology and genetic makeup, social workers and feminist therapists are likely to focus on economic, racial or gender politics. In the new millennium, more clients than ever are diagnosed with Post Traumatic Stress Disorder (PTSD). Regardless of the source of distress, most clients are often viewed as victims of some sort (Zur, 2004). Obviously, some clients are, indeed, innocent victims; these include young children, victims of random crime, or disabled or mentally disabled clients
Many therapists, like many attorneys, have contributed to a victim industry that sustains their professional standings and, of course, income. These two professions have been reaping the benefits of the victim culture by perpetuating the "rights industry" and the culture of victims. Labeling clients as victims is likely to create a power differential between a therapist-rescuer and a client-victim in need of rescue. In her book, Manufacturing Victims, (1996) Tana Dineen details how the victim industry has been fueled by psychotherapists and outlines the direct economic and professional benefits that psychotherapists derive from perpetuating the idea of victimhood. In his book, A Nation of Victims, Sykes (2002) detailed how clients are often viewed and referred to as innocent victims by psychotherapists, which means that they bear no responsibility for their suffering. While clearly acknowledging that some clients are truly helpless victims (i.e., abused children, traumatized adults), Zur (1994) discussed how many other clients are encouraged by therapists to accept the victim identity. Zur identified the victim stance as: he or she is not responsible for what happened, is always morally right, is not accountable, is forever entitled to sympathy, and finally is justified in feeling moral indignation for being wronged. In short, the stance is one of an innocent and helpless victim in need of rescue by a powerful therapist. Obviously, victims mean good business for psychotherapists and the resulting power differential helps maintain that business. (For a more complete analysis and literature review of the psychology and politics of victims, go to Zur, 1994, Rethinking "Don't Blame the Victim: Psychology of Victimhood")
Meta-Communications And Rituals Of Power
There are several meta-communications and rituals in psychotherapy that subtly convey the message of therapists' power and superiority over their clients. Non-verbal behavior has long been known to play a crucial role in power communications between people. Besides the messages that are expressed in the office setting, discussed above, following are descriptions of other behaviors that convey or attempt to convey the power differential message to clients and therapists alike.
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When a Power Differential Is Relevant and Valid
The idea of powerful and influential therapists working with vulnerable, dependent clients is applicable to some situations. This paper critiques the idea that the power differential is applicable to all situations and to all clients but does not deny that this idea is applicable and relevant in some relationships. While this paper provides many examples where clients are neither vulnerable nor therapists are omnipotent, it is important to list situations where the power differential is valid and real.
In a most general sense, many clients seek therapy at times of distress or soon after experiencing traumatic events in their lives. Many clients are anxious or depressed when they finally seek therapy or counseling. Generally, the more distressed, anxious, depressed, traumatized, or dissociated the clients are, the more vulnerable they are and the more dependent on their therapists. While some scholars assess that long term therapy is likely to increase therapists' power, there is also evidence that as therapy progress over time, clients are less likely to be mystified by the therapeutic process and their therapists, and they are likely to get to know their therapists better. Both of these factors are likely to increase clients' power.
The question of how much power psychotherapists who employ hypnosis have over their clients has been debated for many decades. Hypnosis is viewed by many as a technique that evokes an undue power differential between patient and therapist. Images of Svengali, the fictional character in George du Maurier's 1894 novel Trilby, controlling his helpless victims, of walking zombies, and individuals unwittingly exposing their darkest secrets are common among therapists, the popular media, and the public. Research (i.e., Baker, 1990) has consistently debunked the myth of the all-powerful hypnotist controlling his helpless subjects by hypnotic suggestion. A more detailed discussion of hypnotherapy and power is provided later on in this paper.
Following is a list of settings and populations where therapists have a significant measure of power over their clients.
- Inpatient Psych. Units
- Forensic: Sanity and other Forensic Evaluations
- Child Custody
- Mentally Retarded
Inpatient Psych. Units: Psychotherapists in inpatient psych. wards and psychiatric hospitals are likely to have significant power over their clients as they often determine if clients may be released or freed or given psychiatric medication against their will. The coercive and legal power to detain clients against their will is one of the most potent forms of power that therapists have over their clients. As was noted above, the movie, One Flew Over the Cuckoo's Nest, presents the ultimately brutal and deadly power of a treating psychiatric nurse over psychiatrically incarcerated men.
Corrections: Psychotherapists in prison and jail settings often have legal and coercive power to determine inmates, detainees, and prisoners access to medical and psychiatric care, housing arrangements, eligibility for probation or parole, safety arrangements, and many other crucial aspects of clients' lives.
Forensic: Sanity and Competency to Stand Trial: Forensic evaluations, such as sanity or competency to stand trial, can be literally life and death type decisions. Clients who have committed a crime that can carry the death penalty are often at the mercy of the forensic evaluator who can indirectly determine their fate.
Child Custody: Psychotherapists who provide child custody evaluations are often in a powerful position to make very important recommendations regarding children and parents. Many divorce and custody cases that end up with custody evaluations are often bitterly contested and volatile. The power to recommend to the judge, arbitrator, mediator, or parent certain custody arrangements places the parents and the children in an extremely vulnerable and dependent position vis-à-vis the therapist/evaluator who holds that power.
Foster care group homes: It is common for psychiatrists and, at times, other therapists to decide if and how to medicate minors in foster care settings. The conservators for many of these minors are often not involved with the day-to-day care and are rarely involved in medicating decisions. Just as in inpatient units, some minors may be medicated or subdued so they can be managed better rather than because they suffer from diagnosable mental illness.
Children: Without a doubt, when working with children, therapists have enormous power over their clients. Not only do they have legal, expert, coercive, and other forms of power, they also have the adult advantage, the reward, legal, coercion, referent, and other powers that almost all adults have with children.
Mentally Retarded and Other Mentally or Developmentally Challenged: Like young children, clients who are retarded or developmentally challenged are often at the mercy of their therapists and others who are selected to take care of them. Due to their emotional or cognitive impairment, these clients are highly vulnerable to their caregivers.
Recently Traumatized: Many clients seek psychotherapy or counseling after they experience a traumatic event that has affected them in some significant way. These clients may present with intense anxiety, immobilizing fears, dissociation, insomnia, or other debilitating symptoms. Due to their posttraumatic stress response, some of these clients are likely to be highly vulnerable, as they feel unsteady, helpless and dependent. At such vulnerable times, such clients often seek directions and reassurance from authority figures, such as therapists. Therapists, in these situations, have significant expert, professional, positional, and referent power.
Persons with Dementia: People with dementia are most often unable to cognitively participate in treatment decisions and are also at the mercy of medicating psychiatrists and other therapists who have wide control over their lives.
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How Power May Shift During Therapy
The reason that a term like 'power differential' is generally not helpful to understand therapist-client relationships is because power is not only multidimensional, it is also dynamic. The balance of power can and often does shift during the course of therapy and may fluctuate during treatment. This section reviews the different factors that are likely to affect a shift of power where clients may gain more power in relation to their therapists
As Therapy Progresses
There are several situations and reasons that many clients are progressively more empowered, less dependent, and feel more equal to their therapists, or even superior in some areas, as therapy progresses. Some factors that contribute to this shift are:
More transparency: As therapy progresses, therapists are likely to be more transparent. As therapy progresses, clients inevitably learn more about their therapists due to therapists' unintentional or intentional and conscious or unconscious self-disclosures. Clients learn about therapists' reactions, moods and reasoning, different habits, choices of clothing and jewelry, etc. Of course, if therapists choose to self-disclose, the relationship may become even more egalitarian and power is shared more equally.
Less mystery: Clients often enter therapy, especially for the first time, without much understanding of the nature of the process and dynamics of psychotherapy. As therapy progresses, they learn the rules of the game, their therapists' style, rationale for interventions, or, at times, therapists' theoretical orientation.
Client is more autonomous-empowered: Clients' state of mind, sense of self, self-esteem, or sense of personal effectiveness may improve as therapy progresses. As clients are empowered and feel more autonomous, powerful and secure, the power imbalance may change. Bannister (1983) reflects on this dynamic: "'Cure' can be defined as reaching a level at which the client can effectively contest the psychotherapist's view of life, i.e., the level at which the client does not need psychotherapy or the psychotherapist" (p. 139).
Multiple relationships in psychotherapy are defined as those occurring when therapist and client are engaged in relationships other than that of therapist-client. Multiple relationships, or what are often called dual relationships, may be social, business, professional, or sexual (Younggren & Gottlieb, 2004; Lazarus & Zur, 2002). While many forms of multiple relationships are neither unethical nor avoidable, sexual dual relationships with current or recently terminated clients are always unethical and illegal in most states (Zur, 2007a).
Non-sexual Multiple Relationships: When clients and therapists have connections other than clinical, counseling, or evaluation relationships, they get to know and interact with each other in different ways than those of the consulting room. If the additional relationships are social, clients get to know their therapists in the community and see them in 'real-life' situations. This is likely to level the playing field and to create less hierarchical relationships. Similarly, the power playing field is likely to be more level if clients and therapists attend a conference together, co-author a book, work out in the local gym, attend church together, sit on a committee together, teach in the same institution, or get involved in a business venture together.
Sexual dual relationships: When clients and therapists are engaged in sexual relationships during or after therapy ends, the power relationship often shifts drastically. Because all sexual dual relationships with current clients are unethical and illegal in most states, when such relationships are consummated, clients often gain enormous power over their therapists. Schonner (2000), who has worked extensively with clients and therapists who were engaged in sexual relationships, discusses how when a professional engages in sexual or other misconduct, the power may shift when the client realizes that he/she can make a complaint against the therapist. Once sexual relationships between therapists and current or recently terminated clients have been consummated, clients may hold their therapists hostage if clients are aware that such relationships are unethical and illegal and can be the grounds for licensing board complaints and medical malpractice civil lawsuits.
Informed consent is a legal and ethical term and in the context of this article is defined as the consent by a client or patient to a proposed psychotherapeutic or counseling treatment or evaluation. In order for the consent to be informed, the client must first achieve a clear understanding of the relevant facts, risks, benefits, and available alternatives involved (Lidz, Appelbaum, & Meisel, 1988; Younggren & Gottlieb, 2004).
The concept of informed consent originated with the idea that individuals have rights: to freedom, autonomy, and human dignity. True informed consent can be empowering to clients as they can make informed decisions about who may treat them and how they may be treated. Many scholars have argued that a simple document, regardless of how detailed and informative it is, often does not do justice to the informed consent process. They argue that a true informed consent takes place where clients have true choices about their treatment, and it emerges from a dialogue between therapists and clients, which discusses treatment options, risks, benefits, therapists' expertise and limitations, etc. Obviously, when clients are detained, medicated, and treated against their will, their individual rights are suspended, and they are neither viewed nor treated as autonomous people (Dawes, 1994). Obviously, an informed consent has neither meaning nor significance when clients are detained against their will or are forced to comply with treatment. Similarly, Szasz (1997) and others have pointed out that the many legal exceptions to the process of securing informed consent, such as when clients are a danger to self or others, make a mockery of the idea of informed consent, and the commitment to protect and respect clients' autonomy and dignity. Informed consent may have meaning when clients are informed that their civil liberties would be compromised if their therapists make the determination that they may be in danger to self or others. Informed consents come in different forms and types. They can be expressed or presumed, explicit or implicit, verifiable or conjecture, written, verbal, or nonverbal.
Internet Transparency-Google Factor:
The Internet has transformed the nature of self-disclosure in psychotherapy. Clients can now access considerable amounts of information about their therapists (Zur, 2008b). In addition, many clients now view themselves as consumers as much as patients, and these clients have increased expectations and demands for psychotherapists' transparency. As was discussed above, therapists' transparency is one of the main ways that power in therapy can be equalized. For example, if clients find out in their web search that their therapists are or have been engaged in criminal activities, they do gain a lot of power vis-à-vis their therapists. Clients' search for information about their therapists may vary between normal curiosity and criminal stalking (Zur, 2007a). Following are five different categories under which clients' behavior may fall.
How and What Clients Can Learn About Their Therapists from the Internet
Following are the different ways that clients may inquire about their therapists online.
- Level 1 - Reviewing Therapists' Professional Web sites: In this day and age, it is very common for a client or informed consumer to review his or her therapist's or potential therapist's web page. The client may learn about the therapist's web pages from therapist's business card, marketing material, online directories, or other sources. Reviewing a therapist's web page may reveal the therapist's educational background, professional experience, family status, hobbies, and recreational preferences.
- Level 2 - Curiosity: Many clients are appropriately curious about their therapists and will go beyond therapists' own web sites and conduct a simple Internet search (i.e., Google) focused on their therapists. Even the most basic Internet search is likely to yield information regarding the therapists' professional lives, such as education, training, credentials, and personal information that can vary from very minimal to very extensive and detailed.
- Level 3 Due Diligence: Some clients are better-versed in the use of the Internet and are looking more seriously for information about their therapists. A client may employ more specialized searches, such as searching the licensing board's web site, to see if a potential therapist has had any complaints filed against him or her, or what other professionals or clients have posted about that therapist. In our modern era of consumer rights and consumer power, it is not uncommon for some clients to want to learn about the people in whom they will place their trust and from whom they hope to learn.
- Level 4: Intrusive Search: Some clients may 'push the envelope' and intrusively search for information about their therapists due to intense curiosity or for obsessive reasons. Some may do it as a game they often play, seeing how far they can get, as well as how much they can get away with. Intrusive searches may target home addresses, marital status, family members, church affiliations, sexual orientation, community disputes, and court records. An intrusive search may also include disguising one's identity and joining social networks (e.g., FaceBook or LinkedIn), listserves, chat rooms, etc., in order to find out more information about therapists' professional and personal lives. Online services may legally gather information not readily available online. This may include divorce, criminal, or other court records, and it is sometimes possible to locate online cameras that televise at public places where the therapists may visit. Many therapists are neither aware of how common such cameras are nor realize that some clients may be able and willing to access them.
- Level 5: Illegal Search Cyber Stalking: At the most intrusive levels, a client can hire online services that may illegally gather information about the therapist. Clients can obtain information about their therapists' credit reports, banking information, cell phone records, tax records, email accounts, and other highly personal information.
Clients may use various strategies to resist therapists' power and influence and to assert their own. Following are some examples of such behaviors.
Ways That Clients May Assert Their Own Power in Therapy:
- Not talking: Some clients may choose to stay completely silent during therapy or an evaluation session. For some clients, keeping silent is a way to maintain control and power over the situation. Adolescents, young adults, inmates, those who were detained in psych. wards, and certain clients with character disorders have been reported to be selectively mute or use the 'silent treatment' against their therapists, especially if they were coerced or were mandated to enter therapy against their will.
- Not following advice or suggestions: Some clients may maintain autonomy and control by not following the therapists' ideas, suggestions or homework.
- Non-disclosure [Selective disclosure] or not answering questions: An obvious way for clients to maintain control over what the therapists know about them is by disclosing very strategically and discriminately. By limiting their self-disclosure, clients limit therapists' knowledge-base power. Non-disclosure is more overt and is apparent as when clients do not answer therapists' questions and inquiries or can be more passive and covert when clients do not disclose important or relevant information.
- Taking notes or recording sessions: Some clients take notes during therapy or insist on recording sessions as a way to gain more power or, at least, match therapists' power.
- Coming late or leaving sessions early: One of the many ways that clients may control the beginning or end of sessions is by either coming late to sessions or leaving early. While leaving early is more likely to be a more overt way to gain power over the time and length of session, arriving at appointments late is a more passive way of such time control.
- Non-payment: One of the more common ways for clients to assert control over their therapy and their therapists is by deliberately withholding agreed upon payments or fees. Like non-disclosure and timing, clients may choose to withhold payment more passively by making up excuses or more overtly by stating their intention of withholding payments.
- Stalking: Clients who successfully stalk their therapists are likely to gain a lot of information about the therapists, which may translate to a power position. Therapists who are stalked are often frightened for their own safety and the safety of their family or pets. Therapists are often hesitant to report criminal stalking to the authorities because they either are (needlessly) concerned with confidentiality issues or are afraid to aggravate their clients. This is especially true with psychopathic, violent, and Borderline Personality Disordered clients. Stalking clients are often intimidating and therefore often command significant power in the relationships with their therapists. Cyber-stalking, which was discussed above, can be performed without a therapist's knowledge and can also yield vast amounts of personal information about the therapist, which can give the client significant knowledge power.
- Change seating or other office arrangements: Some clients, in a 'power move', sit in places that were not assigned by the therapists or even sit in the therapists' chair themselves. Similarly, a client may turn the clock in the office so it faces him or her and faces away from the therapist. Another client may move his/her chair closer or further from the therapist or turn it in away from the therapist. In a fit of rage, some hostile, psychopathic, and Borderline Personality Disordered clients were reported to reorganize the office furniture.
- Provocative or threatening clothing: Clients may gain power by dressing in certain ways that may be sexually or otherwise provocative, seductive, or intimidating. Sexually revealing clothing or garments that bear gang insignias or symbols like swastikas may be intimidating and so are certain violent, sexist, or racist tattoos. Depending on the gender, ethnicity, age, culture, race, or class of the therapists and the clients, clients can dress in ways that can give them power.
- Use of language: Violent, vulgar, or threatening language can definitely affect the power relationships between therapists and clients. Therapists may be intimidated, frightened or simply distressed by the use of certain expressions and intonations by certain clients. Borderline clients have been reported to throw tantrums or fits and use language that intimidates and threatens their therapists.
- Rage: Rage-filled clients can be highly intimidating to therapists who may feel frightened and powerless in the face of raging patients. This is especially true in a private practice setting when therapists are isolated and often are not trained to deal with clients who are extremely hostile or violent. Gutheil has written about Borderline rage:
Borderline rage is an affect that appears to threaten or intimidate even experienced clinicians to the point that they feel or act as though they were literally coerced -moved through fear- by the patient's demands; they dare not deny the patient's wishes. Such pressure may deter therapists from setting limits and holding firm to boundaries for fear of the patient's volcanic response to being thwarted or confronted. . . Patients with borderline personality disorder who are dysfunctional in many areas of life may still preserve intact powerful interpersonal manipulative skills. They may still be capable of getting even experienced professionals to do what they should know better than to do or -all too commonly- what they do know better than to do. (Gutheil, 1989, p. 598)
- Dominating the conversation: Another way that clients may gain the 'upper hand' is by dominating the conversation, talking excessively and incessantly, or simply taking all the airtime.
- Inappropriate touch: The professional literature has described several situations where clients surprised their therapists with a kiss on the cheek or lips, sexual embrace, or even reached out and touched the therapists' genitals. Needless to say, any of these actions, when they catch the therapists by surprise or unprepared, can cause a power shift in the relationships.
- Inappropriate gifts: Clients may give very expensive gifts (i.e., season tickets, a car) or symbolically inappropriate gifts (e.g., sex toys, a dozen roses, weapons) in a power move over their therapists.
- Offering incentives: Clients may offer their therapists a promising business contact, lucrative business deals, investment tips or promise to give them referrals as a way to level the playing field or even to gain the upper hand.
- Acting seductively: Clients can act seductively in many ways. It can be the content of their dreams, description of their private behavior and, of course, the way they talk, move, or dress. Clients can gain significant power if they get the sense that their therapist is attracted to them and their seductiveness is effective.
When a therapist conducts home visits, some power is inevitably relinquished as well as control over a number of factors. Unlike in the therapist's office setting, in the home office, the therapist is not in control of who is present, who may join in mid-session, phones ringing, neighbors coming in, televisions blaring, etc (Knapp & Slattery, 2004; Zur, 2007a). The therapist does not have control over whether alcohol is being served with hors d'oeuvres or a meal. Slattery captures the dynamic of this change of power when she writes:
Being a host often has a fair amount of associated power. One advantage of this power is that it can give some families who feel little control in their lives a greater sense of control . . . Although the guest cannot go anywhere within the home, the host can. They may do things that they would never expect to do in other settings, including watching TV, talking on the phone, or getting up and leaving the room. Because their home is often their castle. . . . these actions might be acceptable in the presence of another visitor. (2005, p. 389)
Clients Who File False Complaints Against Therapists
In his 2000 article entitled "Victimized by Victims: A Taxonomy of Antecedents of False Complaints against Psychotherapists," Williams lists a group of clients that may file false complaints against their therapists. Different clients may file such false complaints for different reasons. Regardless of the reasons or motivations, clients gain a lot of power over their therapists when they threaten or file complaints with licensing boards or file civil malpractice suits. He lists the following groups:
Malingering: Clients who malinger may file false but seemingly credible reports or complaints against their therapists. Williams writes:
Malingering and fraud are well known to play a significant role in the civil justice system (Rogers, 1997). Plaintiffs seeking financial gain may intentionally simulate or exaggerate symptoms of illness in the hope of defrauding an insurance company or other defendant. A plaintiff may fraudulently simulate a specific personal injury scenario for the purpose of winning a financial award or increasing the size of such an award. In many cases, fraud and malingering are difficult to detect because the plaintiff does a convincing job of manifesting credible symptoms. In other cases, damages need not be confirmed for a damage award to be made. (2000, p. 78)
Vengeful: Clients who feel resentful or hold a grudge against their therapists may gain a lot of satisfaction and power if they file a complaint or lawsuit. Williams (2000) elaborates:
Revenge can serve as motivation for a former patient to file charges against a psychotherapist. The individual who files a complaint based on a wish for vengeance is distinct from the individual who commits fraud for financial gain. While the latter is driven by a wish for compensation that might be unrelated to that plaintiff's relationship with the psychotherapist--the psychotherapist may be little more than an innocent bystander who happens to be harmed by the plaintiff's quest for money—the former files the complaint in reaction to the perception of harm the psychotherapist has done to him, her or a family member. Along these lines, one hears anecdotes about complaints based on revenge following child custody evaluations. (p. 78)
Severe psychopathology: According to Williams (2000), some groups of clients suffering from severe mental disorders are more likely to file false complaints. Besides the Borderline Personality Disordered clients mentioned above, he also lists those who suffer from other personality disorders and those who are paranoid or suffer from schizophrenia. He writes:
A variety of emotional disorders can lead a patient to perceive the psychotherapist as his or her tormentor. In some cases, the patient will carry such feelings all the way to filing a civil suit or board complaint. Commonplace examples of the sort of psychopathology, which could bring about a complaint, are schizophrenia, borderline or other personality disorder, paranoia or various types of dementia. The schizophrenic or demented patient, while perhaps inclined to file a complaint, might not pose a credible threat to a psychotherapist, since he or she might impeach the credibility of the complaint by blending whatever could have happened with situations, which are very unlikely to have occurred. Such a patient would file the complaint because the psychotherapist had unwittingly entered the patient's delusional system, becoming one more tormentor, generally, in a long line. (p. 78)
Clients who express suicidal ideation to their therapists are mostly likely to draw attention to themselves and, depending on the situation, may gain the power to have their therapists' attention, time, and focus (Gutheil & Brodsky, 2008). Manipulative clients have been known to threaten suicide as a form of power play.
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Modern Clients as Consumers
Over the last decades, and clearly in the 21st century, a new consumer culture has emerged characterized by clients' different expectations about their relationships with their medical and mental health providers. Managed care organizations, which proliferated in the 1990s have popularized the idea that clients or patients are, in fact, consumers of medical and mental health services. As consumers, they have numerous rights and, of course, power (Sarkar, 2009). Unlike most medical subspecialties, most psychotherapists have failed to recognize this shift; that many of those whom psychotherapists have habitually called 'clients' or 'patients' consider themselves to be consumers first. As consumers, they want to know what they are getting for their money, whether it is a car, a house, a cruise, jewelry, or a psychotherapist. They are often well informed about their treatment options and range of providers. With the aid of the Internet, they learn about their conditions and what treatments are available. These modern, informed consumers take increased interest, responsibility, and control of their wellbeing. In terms of psychotherapy, this shift often results in many modern day consumers demanding in-depth information, i.e. transparency, about those providing them with care and expecting to be presented with a range of treatment options from which to choose. Obviously, the Internet is the well from which they draw most of their information in the 21st century (Zur, 2007a; 2008b). Needless to say, in the identity shift from patient or client to informed and entitled consumer and from psychotherapist to provider, the client has gained a significant amount of power. In light of these profound shifts, seeing many modern clients as helpless, dependent, or powerless is, at best, out of touch.
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What Is Power?
We have spoken about power from the beginning of this article, but what exactly is it? The word power is rooted in the Latin posse, which means "to be able" or "to have power." The word 'potential' is related also. Power in its essence has to do with potential. Potential is a capacity; a capacity to grow, develop, change, effect self, others, or the environment, thus the power to develop, change, etc.
In the context of this paper, power refers to any ability to effect, direct, influence, change, or exert control over self, people, situations, or courses of events. It can be viewed as people's capacity or ability to affect, control, or manipulate their environment, including the attitudes, emotions, and behavior of other people or themselves. Power, obviously, can be just or unjust, fair or unfair, direct or indirect, or it can be referred to as holy or evil. It may or may not involve force or threat of force and can be employed consciously or unconsciously, overtly or covertly, and the recipients may be aware or unaware of the impact of power on them.
This paper neither covers the philosophical contributions of modern and structural theories (i.e., Machiavelli, Hobbes, Weber, Luke), who generally view power as "monolithic, unidirectional and oppressive" (Proctor, 2002, p. 41) nor reviews the post-modern, post-structural philosophers and deconstructionists (Foucault, Deleuze & Guattari), who question the modernists' assumptions and their views of knowledge, truth, or rules and challenge the myth of objectivity. Foucault, for example, does not see power as a property or possession but a strategy and analyzes the multiplicity of power relationships. He carefully analyzes the relationships between knowledge and power and discusses how knowledge is used to justify the just and unjust use of power. (For a summary of these philosophers' ideas on power, see Proctor, 2002.)
Ernest Becker (1975) has paid extensive attention to the issue of power. He views the prevalence of the denial of death in our culture with a sense of powerlessness. This sense of powerlessness is encountered in a variety of maladaptive ways. Along these lines, he assesses that most people live with this paradox, i.e., a "lie in the face of reality." From childhood, most people use all kinds of repressions and denial to pretend that they aren't going to die. Like many cultures and societies, much of modern society's effort to deny death is based on symbolic systems allowing people to feel heroic, because when we achieve heroism, we feel that we have transcended our mortality. Whether it is on TV, news media, war, or, these days, the Internet, much of this heroism is in fact false, even disempowering. Most pointedly with entertainers and athletes, we often, in fact, project our need for heroism onto them.
Starhawk (1987), like many feminist scholars, distinguishes between "power-over" and "power-with." She associates power-over with coercion and domination. She links power-with to the influence of a strong individual in a group of equals and to types of power that empower rather than control or dominate. She suggests that power-with is realized through the other's willingness to follow and be led rather than being compelled to comply. Power-from-within relates to the roots of the term power as "potential" and often refers to one's power over one's own life, relying on one's inner strength to 'become' rather than the exertion of power over others.
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Power in Psychotherapy and Counseling
The psychotherapeutic community's attitudes towards power present a paradox. While clinicians have a tendency to obscure or deny it, ethicists tend to exaggerate it and researchers to minimize it. All three groups have a tendency to avoid some of the most basic issues about the social role that therapists play when they exercise their power in psychotherapy and wield social-control. Additionally, there is no agreement about the definition and meaning of power.
Alfred Adler, back in 1927, discussed power as power-over and synonymous with domination and control. Harry Stack Sullivan (1953) defined human power in interpersonal terms and viewed power as dualistic and in a less negative light than Adler. French and Ravin (1960), whose work has been extensively cited by sociologists and psychologists, describe power as the potential of one person to get another person to do something that she/he might not have otherwise done. They developed a widely used typology of social power that included the six types of power listed and defined earlier: Expert power; legitimate power; referent power; reward power; coercive power; and informational power.
The next section summarizes the current stances of modern therapists in regard to power. It discusses the denial of power by most of those who provide direct services, the exaggeration of therapist power by ethicists, attorneys, and risk management experts, the different attitudes towards power among different theoretical orientations and, finally, provides a summary of the most seldom discussed power-related issues in therapy.
Denial of Power
Within the psychotherapeutic community, there is a tendency to deny or obscure issues of power. While ethicists have incessantly propounded the power differential idea, clinicians seem to naively deny the relevance of power to therapy as it is supposedly regarded as a benevolent process. When pressed, clinicians take the naïve and simplistic view that power in therapy is merely applied by therapists to heal their clients or to help their clients heal or better themselves.
The ambivalence, or avoidance, of deep exploration of the role of power in therapy is probably the result of the generally negative view of power in our culture, where power is viewed as part of political, legal, business, or criminal enterprises.
Power is often associated with abuse of power and therefore seen as irrelevant to clinical work (Heller, 1985). When power is mentioned in connection with psychotherapy, evaluation, or counseling, it either negatively refers to the few "bad apple" therapists who misuse their power to exploit their clients sexually, or otherwise, or is positively referred to in terms of therapists' capacity to heal their clients.
Under the guise of science and "for the good of the client", most clinicians, ethicists, instructors, and scholars deny the power premise upon which psychotherapy is based, i.e., that a knowledgeable and healthy practitioner is in the business of guiding a broken or sick patient back to the road to health, adaptation, and wellness. The question of what is health or what constitutes adaptive behaviors is rarely asked in graduate school, training institutions, postgraduate training, or in the professional literature.
One of the criticisms of conventional psychology, raised by critical psychology, is the inattention to power differentials between different groups - examples include between psychiatrists and patients, psychologists and clients, wealthy groups and the less financially well-off, or industrial lobbyists and the general public. This inattention to power has resulted in conventional psychology tending to assume that how things are is how they should be, that the current state of affairs is the natural state of things. As a result, conventional psychology has a tendency to uphold the status quo, blame the victim, and situate problems within individuals rather than the social context in which they are embedded.
The Exaggerated View of Power by Ethicists
While clinicians may tend to avoid discussing or to minimize power issues in therapy, ethicists, risk management experts, and attorneys seem to be focused on them. As the quotes at the beginning of the paper illustrate, the general theme among many ethicists is that all therapists are extremely powerful in all situations and have a far-reaching capacity to harm clients; that in order to reduce the harm that can be caused by "powerful" therapists, clear professional guidelines must be developed and detailed codes of ethics must be established. Ethicists have often cited the beneficence principle - which refers to an action done to benefit others - as a way to assert that therapists "know best" and, furthermore, to justify therapists controlling their clients and using, or misusing, their power for the clients' "own good."
Consistent with the dozens of quotes regarding therapists' superior power that were cited above, Pope and Vasquez (1998) write: "In licensing therapists, the states invest them with the power of state-recognized authority to influence drastically the lives of their clients." (p. 43) These two influential authors reiterated Freud's idea that "therapy is similar to surgery." Freud (1968) compared psychoanalysis and surgery in his lecture entitled, "The Analytic Therapy", when he commented that psychoanalytic suggestion works "surgically" (p.458) and that "psychoanalytic treatment is comparable to a surgical operation…" (p.467). If therapy is like surgery, clients are indeed highly vulnerable to their therapists. The question then becomes whether the analogy of therapy and surgery is correct or valid. Is it valid to compare a surgical patient who is indeed helpless, unconscious, unaware, and anesthetized to a fully awake, conscious, aware client in the therapy room?
For the many reasons articulated in this article, the comparison of surgery and psychotherapy is ludicrous, faulty and pretentious. While such a statement is nonsensical to any mildly informed person, it is nevertheless likely to boost the egos and professional esteem of psychiatrists, analysts, psychologists, social workers, therapists, and counselors who may need such a boost.
Whether comparing clients to children (i.e., Brown, 1988; Seto, 1995; Sonne & Pope, 1991) or claiming that "once a patient, always a patient", there is a wide-spread self-serving mythology that is perpetuated by therapists, scholars, and ethicists.
The most updated outcome research has clearly supported what Szasz (1997), Zilbergeld (1983), and others have asserted; in fact, therapists and their techniques count for very little when it comes to therapeutic outcome. Duncan and Miller (2004), whose outcome research has dominated the field for the last decade, point to the existence of four factors common to all forms of therapy despite theoretical orientation (dynamic, humanistic, feminist, cognitive, etc.), mode (individual, group, couples, family, etc.), frequency, presenting problem, or professional discipline. They found that one factor dominates the lion's share of change, extra therapeutic or client factors, accounting for 87% of change. The remaining 13% of change, according to many research findings, can be attributed to therapeutic effects. These therapeutic effects include therapeutic alliance factors (8%), allegiance factors (4%) and finally the actual model or technique used by the therapists (1%).
The above findings, which have been replicated in several studies, clearly discount the notion of therapists' overwhelming power over the treatment outcome or over their clients.
Theoretical Orientation on Power In Therapy: A Critical Look
Different orientations have different relationships to power (Zur, 2008c). Following are brief descriptions and critiques of different theoretical orientations' attitudes to therapist-client power relationships.
Psychoanalytically oriented ethicists focus on the power of transference and the resulting power of analysts over their clients. The premise of psychoanalytic methods is that a client's suffering can be alleviated only through gaining insight into their unconscious distortions. This implies that human suffering is an interpsychic phenomenon, devoid of external factors, such as poverty, racism, sexism, or political corruption. The interpsychic focus gives therapists a sense of power as they can help clients gain insights. A limitation of this approach, and the therapist's actual realm of power, is that it excludes overarching societal issues, which clearly affect the individual, the therapist, and the treatment, as well. Psychoanalysts' illusion of immense analysts' power has contributed more than any other influences to the power differential myth.
Feminist scholars have emphasized the relevance of gender, ethnicity, and class to our understanding of the general concept of power. They have stressed the importance of differentiating between "power over" and the "power to empower" or, what has also been called "power with". They also contrasted "power over" with "power-from-within." As noted above, the issue of power in general has been central to feminist therapy. When it comes to therapist-client relationships and power, feminist therapy is deeply ambivalent concerning these two different approaches.
On the one hand, feminist therapy advocates that power will be shared between therapists and clients and that egalitarian relationships must be achieved in order to promote healing. The focus is often to empower the clients and avoid exerting "power over." An important goal of feminist therapy is to respect women's autonomy, honor the choices they make, and accept them as autonomous, mature beings who are capable of making informed decisions. Accordingly, the role of the therapist is to empower the client to develop the capacity to make such informed decisions. Some feminist scholars assert that therapy is not complete for most women until they challenge the basic structure of therapy, which essentially refers to the attribution of false power to the therapist, the hierarchical nature of it, and the fact that if it works the relationship ends.
On the other hand, most feminist therapists subscribe to the power differential idea by emphasizing the positional, expert, and legitimate power vested in therapists by society. At the heart of feminist therapy is the awareness of power differential in the areas of gender, economic, and racial relationships. They often focus on how therapists' abusive power results in sexual abuse of vulnerable clients by domineering and exploitative therapists. As the quotes above exemplify, most prominent feminists believe that "once a client, always a client" or the idea that the therapists' power exists in perpetuity. Therefore, they advocate that women and men therapists should never sexually engage with former clients, regardless of how much time has passed since termination. This clearly implies that women cannot become autonomous and evolved enough to consent to sexual relationships with certain people, a notion that is inconsistent with feminist philosophy.
Regretfully, there is no reconciliation between these two positions within the feminist literature.
Cognitive and Cognitive-Behavioral (CBT) therapists focus on faulty thinking. These modalities view healing as a process of guiding people to change their misguided views or their negative cognitions of the situations and people that have caused them distress, anxiety, fear, or depression. These modalities of therapy are based on the claim that the causes of distress and suffering lie in the individuals' maladaptive thinking rather than in the situations they are in or the people with whom they interact. Cognitive-Behavioral therapists, who compose the majority of therapists in the 21st century, are armed with a multitude of empirically based research to support their expert-based power and authority. There is an inherent flaw in an orientation that unilaterally excludes and, therefore, perpetuates the injustices of biases such as racism, sexism, ageism, and homophobia that are so prevalent in our culture. One may argue that cognitive and cognitive-behavioral therapists are involved in social control and maintaining mainstream values rather than healing or growth. Proctor (2002), echoing Foucault (1980), summarizes her critique of CBT with "It is necessary for CBT to look realistically and honestly at the dynamics of power in therapy relationships. Without this, CBT therapists are in danger of obscuring their power and not taking an ethical stance to avoid domination and abuse" (p. 83).
Humanistic psychotherapists readily acknowledge the importance of power relationships in therapy and are committed to promoting authentic relationships and minimizing the power differential between therapists and clients. Humanistic therapists view the idea of "being with" clients rather than controlling or directing them as a crucial element for effective therapy and healing. Rogers (1978) challenged the position of the expert therapist with respect to power in the therapy relationship by his emphasis on a 'person-to-person' encounter and demystifying the process of therapy. He opposed the notion that is promoted by most psychotherapeutic orientations that clients cannot be trusted but must be guided, directed, rewarded, punished by those who are of a higher status, such as their psychotherapists. For humanistic therapists, avoiding the use of their power and not deciding what is in the clients' best interests is an ethical commitment based on the belief that clients' autonomy must be honored and respected (Proctor, 2002).
Family therapy: The training of family therapy practitioners focuses on the effects of "family systems" and includes analysis of the power relationships between individuals and between sub-systems. This approach includes attention to every aspect of the system. Practitioners face the complicated task of being constantly observant of how they may be consciously or unconsciously entering the power dynamic of the system. Unless the practitioners have significant insight regarding their own family dynamics, they may be vulnerable to unwittingly getting entangled in the power dynamics of the families they treat. Unless they bring a moralistic bias or their own unresolved issues to the treatment process, most family therapists are often invested in compassionate and empathetic understanding of the family dynamics rather than some subjective judgments of right or wrong. Family therapists, generally, do not find the DSM useful as they attempt more to identify patterns and dynamics in the family system rather than individual pathologies.
Narrative therapy, Solution focus and other 'deconstructing psychotherapies': Several orientations and practitioners have paid close attention to the subject of power. Narrative therapy (White & Epston, 1990) is aimed at helping clients narrate their lives consciously and reflectively and, if necessary, to rewrite a more helpful narrative. Narrative therapy is an example of applying deconstruction to the theory and practice of psychotherapy, where therapists are collaborators and facilitators of a process, the questioning of assumptions and what (and how) clients know what they know, rather than assuming the roles of guides, directors, or mentors. Solution focused therapies (e.g., Berg & de Shazer 1993; O'Hanlon & Weiner-Davis, 2003) also seem to focus on clients' stories, biographies, agendas, and context rather than therapists imposing their own. It is based largely on the theoretical insights of Milton Erickson and the researchers at the Mental Research Institute, such as Gregory Bateson, John Weakland, Jay Haley, and Paul Watzlawick (Sutherland, 2007). This approach challenges many established and unproven assumptions of traditional therapies, asserts that assessment of the problem is not a prerequisite to finding a solution, and discards the question of "why this problem", instead focusing on themes that perpetuate the problem and those that diminish it.
Hypnotherapy: The power of hypnotherapists over their clients has been debated for a long time. On one side of the debate is the popular but unsupported view of hypnotherapists as all-powerful practitioners who have undue influence and can control their client's thoughts and behavior. An example of this view is the image of Svengali, the fictional character in George du Maurier's 1894 novel, Trilby, controlling his helpless victims, walking zombies, and people who unwittingly expose their darkest secrets at the command of the hypnotic master. This view of hypnotherapists' power not only lends itself to a colorful and dramatic story, it is also quite common among therapists, the popular media, and the public. On the other side of the debate is the most scientifically controlled research which has consistently shown that the so-called "hypnotized" individuals will not do anything they would not do when they are wide awake (sample reviews by Baker, 1990; Walling & Levine, 1997). The most convincing proof, however, of the fact that people who are hypnotized are not robots or automatons under the control of the hypnotist comes from the efforts of the CIA, who carried out over a decade of research to determine if it was possible to create a "Manchurian Candidate"--i.e., to use hypnosis to program a man to turn, after the appropriate signal, into a mindless robot killer. All of the CIA's efforts proved this to be impossible (Thomas, 1989). While not supporting the entire myth of the power of hypnotherapists, Walling and Levine (1997) nevertheless wrote in their article, "Power in the hypnotic relationship: Therapeutic or abusive?", "The unique relationship between hypnotist and subject has been theorized as one explanation for the effectiveness of hypnosis. This relationship carries a power differential, present in most therapeutic relationships, but accentuated by hypnosis" (p. 67).
Seldom Discussed Issues
- Therapists infrequently tend to engage critical thinking skills with relation to their powerful role in determining what is best for their clients, nor do they routinely do so with issues regarding their own objectivity. Therapists generally view themselves benevolently and complacently as promoting clients' health and adaptive behavior but rarely question, specifically, how they came to their conclusions or on what assumptions they based their assessment of what is adaptive behavior.
- The power differential myth is embedded in the perception that all therapists are healthy and knowledgeable and all clients are broken and lost. Even though the field of therapy proudly holds itself to be a scientific endeavor, it has never attempted to scientifically test or validate this myth.
- Since the inception of psychotherapy, therapists have been seen as powerful guides, teachers, and mentors. Some have even referred to them as secular priests. This creates an aura of omniscience and wisdom, leading clients to highly value what therapists dictate regarding what is normal or abnormal and what is healthy or disordered. In contrast, it can be noted that therapists are informed by scholarly literature that gives very little systematic attention to what constitutes what is normal or abnormal, what is healthy or not, or the cultural relativity of these terms.
- The Diagnostic and Statistical Manual, known as the DSM, is considered by many to be the "Bible of Psychotherapy." There is a pervasive and generally unquestioned myth that the DSM is a scientific document. It is not. Its reliability and validity is highly questionable, even by the people who developed it. Instead, it is a powerful political document that guides therapists in determining who is normal or abnormal, who is healthy and who is mentally ill, or who should be hospitalized or remain free in our society. It is also a self-serving 'bible' as it enables psychotherapists to charge insurance companies for their services. Most therapists and clients alike are unaware that the DSM is designed to increase psychopharmacological company profits rather than to identify mental health conditions and that there are minimal objective scientific findings to support the ever-increasing diagnostic categories that compose the "ever-revised" DSM. (For information, see Zur (2008) and Zur & Nordmarken's (2008) extensive critique of the DSM.)
- Therapists fail to view their knowledge about mental health as highly subjective and culturally bound. Cross cultural values and individual differences are given lip service as the profession doggedly strives to develop unifying principles, values, and rules rather than being truly devoted to seeking perspective, diversity, and objectivity.
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The Ethical Way
Once we have defined power and have identified and analyzed the many forms of power in therapy, it is time to look at the ethical implications of this analysis. Partly based on the formulation of Beauchamp and Childress (2001) the Code of Ethics of the American Psychological Association (APA) provides general principles that are intended to inspire therapists to act in accordance with the very highest ethical ideals of the profession. These principles include:
Principle A: Beneficence and Nonmalfeasance
Principle B: Fidelity and Responsibility
Principle C: Integrity
Principle D: Justice
Principle E: Respect for People's Rights and Dignity
Other codes, such as those of the California Association of Marriage and Family Therapists (CAMFT), the
National Association of Social Workers (NASW), the
American Counseling Association (ACA), the National Association of Alcoholism and Drug Abuse Counselors (NAADAC), the
National Board for Certified Counselors (NBCC), and others have incorporated the above principles in their codes in one form or another. For example, CAMFT's Ethical Standards Part I have sections on integrity, responsibility, cultural sensitivity, accountability, honesty, etc. NASW's Code of Ethics has sections on justice, dignity, integrity, responsibility, etc. Similarly, codes of ethics of other professional organizations (e.g. AAMFT, AAPC, ApA, ASPPB, CCA, CPA, USABP) have paid attention directly or indirectly to the issues of beneficence, non-malfeasance, fidelity, responsibility, integrity, justice, and respect for people's rights and dignity.
Following are descriptions of the general ethical principles, listed above, and a review of their relevancy to power relationships in psychotherapy and counseling.
Principle A: Beneficence and Nonmalfeasance
This first principle asks that therapists strive to benefit those with whom they work and take care to do no harm. The beneficence principle refers to an action done to benefit clients and assumes that therapists have the knowledge to know what is beneficial for clients, whether it is to think differently about their situations, leave a bad marriage, to be less shy, to detain them so they are "safe," or medicate them so they get "better." Under the guise of "therapists know best" and "for your own good", therapists have gained an enormous amount of power to lead, direct, coerce clients to go in the direction determined by the therapists as best for the clients (Breggin, 1991, 1994; Law Project for Psychiatric Rights v. State of Alaska, 2008; Proctor, 2002; Szasz, 1997). This moral principle infers that therapists know or can make the judgment of what is best for clients. C. S. Lewis reflected on the rhetoric of medicine and the 'know it all' attitudes of psychiatry saying, "Of all tyrannies a tyranny sincerely exercised for the good of its victim may be the most oppressive" (quoted in Breggin, 1993, p. 3). Based on the illusion that they know best, therapists are ethically mandated to do what is necessary to guide clients towards this goal. The moral principle and ethical mandate of beneficence not only implies that therapists know best, but it obliges them to guide clients in the way that is 'best for them.' Rowe also reflected on the "for your own good" theme:
Many people who wish to impose their definition of reality would deny they are involved in gaining power. They would say that because of their great knowledge, wisdom, training, and experience they know what is best. The most dangerous people in the world are those who believe they know what is best for others. (In Masson, 1989, pp. 16-17)
Principle B: Fidelity and Responsibility
This principle asks that therapists strive to establish relationships of trust with clients and be aware of their professional responsibilities to clients, communities, and society. This principle also encourages therapists to be concerned about the ethical behavior of their colleagues. The issue of trust is closely related to power. Armed with legal, professional, and other forms of power, therapists often are trusted by their clients. The question that this paper has explored is not so much how to engender trust but, more so, how not to abuse it. As trust and power go hand in hand, it is the therapists' responsibility to abuse neither. That may mean respecting clients' autonomy (see Principle E, below), their capacity to make informed decisions, and their right to determine a course in life that may or may not correspond to therapists' values or world view.
Principle C: Integrity
The principle of integrity seeks to promote honesty and truthfulness in the practice of psychotherapy and counseling. This principle brings up the overarching question of what is truth and what constitutes honesty? When it comes to power, very few therapists acknowledge or admit the complexities that surround power relationships in therapy. Most therapists do not comply with this principle, which would require open discussion and transparency when it comes to power. As this paper avers, therapists tend to ignore or obscure the issue of power and rarely discuss it openly and honestly among themselves or, even more importantly, with their clients. Such denial and avoidance is in contrast to the integrity principle that asks therapists to strive to present themselves and their essence of therapy with all honesty. This principle also invites therapists to inform clients of the potential risks and benefits of therapy. While not very easy to articulate, not too many therapists meaningfully discuss the potential negative outcome of therapy or power relationships with clients. One of the goals of this paper is for therapists to become more aware of power issues. They can then act with more integrity by facing them themselves, exploring these issues with colleagues, and discussing them with their clients, when relevant.
Principle D: Justice
The justice principle recognizes the importance of fairness and justice issues in therapy and calls for therapists to do their best to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to unjust behavior or the disregard of unjust practices. As was discussed, therapists' subjective and, at times, tyrannical judgment of what is normal or healthy can lead to clients being hospitalized, imprisoned, treated, or medicated against their will. Most therapists have not been professionally socialized to explore power issues or their own biases. As a result, they often do not realize the power they have in certain situations and its potential impact on their clients. The hope is that this paper will raise awareness and encourage meaningful exploration on the issues of justice, fairness, and subjectivity, with an equally comprehensive dialogue about therapists' unspoken assumptions about what is normal, healthy, or adaptive.
Principle E: Respect for People's Rights and Dignity
Finally, the last principle focuses on respecting the dignity and worth of all people and the rights of clients to privacy, confidentiality, and self-determination. Therapists' legal and coercive power, when abused, is definitely a breach of this principle. Obviously, clients who are detained, medicated, and treated against their will are neither respected nor are their rights and dignity upheld (Dawes, 1994; Szasz, 1997). For example, therapists are often mandated by codes of ethics, the standard of care, or state or federal laws to prevent clients from harming themselves. The right to die may be looked upon as a crime by the state or a person's right to self-determination, as defined it principle E. Therapists' biases and moral and spiritual convictions about assisted suicide are likely to come into play. Additionally, they have legal and coercive power to prevent clients from pursuing their right to die. One way to follow the aspirational goals of these principles and to handle the ethical, legal, and clinical complexities is to have an open, truthful, and honest discussion of the therapists' moral convictions, cultural biases, and legal and ethical mandates so that clients, if they even have a choice, can make informed decisions regarding their treatment.
This principle also asks therapists to strive to be aware of and respect cultural, individual, and role differences, including those based on age, gender, identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status. As this paper discusses, this aspirational principle is an immense challenge for many therapists and to the field of psychotherapy as a whole. Whether it is CBT therapists who presume to know what are adaptive or maladaptive thought, or analysts' almost exclusive focus on interpsychic dynamics, the field of psychotherapy and counseling is largely focused on individuals' dynamics, suffering, or problems. Family therapists attend to the broader system of the family; feminist therapists do pay close attention to gender, economic, cultural, and minority issues; and some social workers attend closely to community issues. In general, the field of therapy has only paid lip service to issues of diversity and individual differences. The repeated warning by ethicists and risk management experts to avoid dual relationships, minimize touch, gifts, self-disclosure, bartering, etc., just illuminates the white, middle class, western ethnocentric values that dominate the field. By no means does it offer respect for diversity nor does it honor individual and cultural differences.
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Towards a New View of Power in Psychotherapy
Power is an exceptionally complex construct that has been discussed by many philosophers, sociologists, political scientists, and, obviously, psychologists; however, in this paper we can only view limited aspects of this vast and fascinating subject. The term power means a potential or capacity to touch or influence those around you, or sometimes, populations distant and unknown. Power can elicit the noble or the despicable, positive or negative actions or feelings. It is an ability to move others for good or for ill. Power can be employed in just or unjust, fair or unfair, direct or indirect ways. It can be referred to as holy or evil. The use of power may or may not involve intellectual coercion, physical force or threat and can be employed consciously or unconsciously, subtly or blatantly, overtly or covertly. The recipients may be aware or unaware of the fact that they are under the influence of some form of power.
Power analysis can be done at the individual, institutional, communal, national, or international levels, or it may include economic, cultural, and gender perspectives, as well as the complex interactions between all these levels or perspectives. All are highly relevant to our understanding of the nature and manifestation of power.
Applying power analysis to psychotherapy and counseling is very complicated and far-reaching. The focus can vary between looking at the nature of the therapist-client dyad all the way to the role of psychotherapy in maintaining the societal and cultural status quo in regard to racial, gender, economic, or cultural power relationships.
Within the context of therapy specifically, therapies can create an environment that will increase the possibility of clients living up to their potential, or they can create an environment that is detrimental to them. Similarly, therapists themselves may directly or indirectly support or oppose the status quo in regard to social injustices, including racism, sexism, homophobia, etc, by focusing on individual difficulties and naming pathologies while ignoring the social context of individual challenges.
This paper attempts to take the discussion of power beyond the idea that power is always employed by one person (i.e., the therapist) upon another (i.e., the client) in a unidirectional and often coercive, manipulative, or negative fashion. Instead, power is viewed as a multidimensional, dynamic presence in relationships, influenced by forces outside the relationships, and having the potential to be positive, negative, or even both, depending on the perspective from which it is viewed. The interactions of power are inevitable and so are the multiplicity of its forms, types and the ways that power is employed, the way it functions or is perceived.
In the context of psychotherapy and counseling, there are many types of power possessed by therapists, clients, institutions, and the culture at large. This paper pays special attention to the therapist-client dyad and identifies nine (non-mutually exclusive) types of power that are relevant to this context: Legitimate power; Expert-Knowledge power; Professionalism power; Positional or Role power; Knowledge-Discrepancy power; Coercive power; Reward power; Reference power; Manipulative power. Most of these types of power can be employed by therapists and clients, which makes the psychotherapeutic process complex, intriguing, and often unpredictable. For example, therapists may have ultimate power to detain clients against their will, and clients may have the power to file licensing board complaints and/or file malpractices suits, potentially destroying therapists' careers and livelihood. Therapists may withhold empathy, attention, or love, while clients may withhold appreciation. Therapists often know more about their clients, which gives them some form of power, but clients can gain such power by accessing general information about their therapists online or intrusively snooping into their personal or professional lives, e.g., via the Internet.
What seems clear from the above review of forms of personal power is that reducing the power relationships in psychotherapy and counseling to the "power differential" and incessantly discussing "clients' inherent vulnerability" is neither valid nor helpful, nor does it, by any means, hold true for all psychotherapeutic situations. While some therapists possess or are invested with some kinds of power, clients may possess the same kinds of power or other kinds. What it comes down to is personal power, which derives from a wide array of sources, including a person's position, education, personality, physical strength, physical attractiveness, sex appeal, charm, charisma, force of personality, and ability to manipulate or elicit guilt or gratification, to reward or threaten, etc. In the context of this paper, the measure of power is ultimately a person's capacity for direct, indirect, or subliminal persuasion - the ability to bring about change in one's environment, impose his/her will on others; to bring about change and to control or influence others.
Power in psychotherapy is traditionally and most commonly viewed as being unidirectional and as being a quality possessed by (all-powerful) therapists and employed on (highly vulnerable) clients. Alternatives to the power-over view are the power-with and power-from-within views. While power-over is associated with coercion and domination, power-with is linked to the exchange between individuals as equals and to the type of power that empowers rather than controls or dominates. Power-with is realized through cooperation and mutual receptivity rather than through any coercion to comply. Power-from-within relates to the roots of the term power as "potential" and often refers to one's power over one's own life, relying on one's inner strength to 'become' rather than exerting power over others.
Professional training generally ignores the issue of power, except as it is mentioned in ethics and risk management classes under the mandate that therapists should not abuse their supposedly superior power over their clients. While therapists may not pay direct attention to issues of power, they often indirectly and unconsciously enhance their aura and power in numerous subtle ways. These may be part of the therapeutic-professional rituals, customs, and habits or may involve meta-communications. They may involve: the way therapists organize the office seating arrangements, furnish the room, put a tissue box by a patient's chair, take notes, talk with an authoritative tone, touch in a patronizing way, use professional jargon, monopolize the conversation with long sermons, etc.
As a dynamic, relational, and multifaceted force, power may shift during and between sessions and over time. Power imbalances that may take place at the beginning of therapy may disappear as clients feel empowered, get to know their therapists better, and perceive the therapeutic process as less mysterious and more tangible. Informed consent can also facilitate the leveling of the power playing field as it can provide clients with information and knowledge that can help them attain more control over their treatment or their lives by making informed decisions. Additionally, there are many ways that clients, directly or indirectly and consciously or unconsciously, may enhance their power in the relationships. Clients may come late or leave early, they can monopolize the conversations, ignore therapists' suggestions, refuse to pay, record sessions, persuade the therapists to engage in dual or multiple relationships, search for information about their therapists online, etc. Sexual dual relationships between therapists and clients can give clients enormous power over their therapists. The fact that clients can file a licensing board complaint and possibly destroy their therapists' professional careers or file civil malpractice suits and attempt to collect large amounts of money, give them significant power. In these situations, the therapists are the vulnerable parties and, at times, are held hostage by their clients.
The Internet era has introduced new ways for clients to access considerable information about their therapists. Clients can easily Google their therapists and, with the click of a mouse, find professional and personal information about them. Modern day consumers often use such searches to check out their therapists and the methods or techniques their therapists employ. While basic searches are appropriate, highly intrusive searches may be inappropriate and even illegal. Regardless of how and where clients find information about their therapists, such information gives them the power of knowledge, which can translate to power-over if they use it against their therapists or power-with if it increases camaraderie, empathy, compassion, and/or trust.
In the 21st century, a new consumer culture has emerged characterized by clients and patients who view themselves as consumers of mental health services. As such, they have numerous rights and, of course, power. As consumers, they want to know what they are getting for their money and, therefore, are often informed about their options for mental health treatments and types of providers. With the aid of the Internet, they learn about their conditions and become aware of their treatment options. These modern, informed consumers take increased interest in, responsibility for, and control of their well-being. In terms of psychotherapy, this shift often results in these consumers demanding transparency of those providing them with care, and they are expecting to be presented with a range of treatment options for them to choose from. Needless to say, as part of the identity shift from patients or clients to informed and entitled consumers and from psychotherapists to service providers, clients have gained significant power. In the light of these profound shifts, looking upon many modern clients as helpless, dependent or powerless is, at best, out of touch.
Different theoretical orientations have different interpretations of power. Traditional analytical therapists focus on the importance of transference analysis and lack of transparency and, as a result, view the power differential as inherent in the psychotherapy. Feminist therapists have paid close attention to the topic of power and raise the concern that psychotherapy may uphold the societal status quo in regard to race, gender, sexual orientation, and other power concerns. Generally, they struggle to balance two approaches. On the one hand, feminist therapy advocates that power will be shared between therapists and clients, and egalitarian relationships must be achieved to promote healing. On the other hand, most feminist therapists subscribe to the power differential idea by emphasizing the positional, expert, and legitimate power vested in therapists by society and a patriarchal culture. Cognitive behavioral therapists rarely discuss issues of power directly. However, at the heart of this orientation is the assumption that therapists have the knowledge and capacity (i.e., power) to determine what are adaptive or maladaptive cognitions. In that regard, they are likely to support and maintain cultural norms, morals, injustices, etc. Family therapists often focus on power dynamics in families and are apt to explore their own relationships to power as manifested in their dynamic with the families. Most narrative and other deconstructionist, postmodern therapists readily admit to their subjective experience of power and how it may manifest and affect the therapeutic relationships.
On a broader scale, The Diagnostic and Statistical Manual, known as the DSM, is a very powerful document as it supports therapists' power to name and to decide what and who is normal or abnormal. It gives therapists the power not only to collect insurance reimbursements but also to detain, hospitalize, medicate, and treat people against their will, or to allow them to live freely in society. There is a pervasive, and generally unquestioned, myth that the DSM is a scientific document. It is not. Its reliability and validly is highly questionable, even by the people who developed it. Most therapists and clients alike are unaware that the DSM is a political document primarily designed to increase psychopharmacological company profits rather than to identify mental health conditions, and there are minimal objective scientific findings to support the ever-increasing diagnostic categories that compose the "ever-revised" DSM. (For information, see Zur & Nordmarken's (2008) extensive critique of the DSM).
This paper emphasizes the importance of going beyond the simplistic, over-generalized, and often inaccurate and unhelpful myth of therapists' "inherent power" and the "power differential" and viewing the therapeutic relationships in a more complex way. Equating or inferring the close relationship between power and exploitation in psychotherapy further distorts the understanding of power in psychotherapy, inflates therapists' egos and, most harmfully, indiscriminately demeans clients as it always identifies them as helpless, fragile, powerless beings. The illusion of therapists' power also flies in the face of the findings that therapeutic effects account for only 13% of change in clients' behavior.
At the heart of the problem is the dominant view of power as "power-over" rather than power to empower. As therapists, we want to maximally employ our expertise, as well as our reward and referent powers, to empower our clients to heal, grow, and help them achieve their goals. This may involve overcoming fears, improving the capacity to relate and love, dealing effectively with anxieties, learning to live with voices, facing death, etc. As therapists, we must realize that admitting our sense of powerlessness, when true and appropriate, can be helpful and effective as it humanizes the relationships and presents us in a realistic and authentic way.
One must wonder why therapists so readily believe in the power differential myth and how the belief in therapists' omnipotence has persisted so long with very little challenge. One potential explanation may be because many therapists feel less than powerful and often do not feel effective at all. Psychotherapeutic change is sometimes hard to observe, and very often therapists have no idea of the very long-term effects of their treatment. Therapy and counseling can be very slow, frustrating, and, at times, stalled. Perhaps this view of therapist omnipotence was also born out of, or was readily embraced due to, therapists' feelings of frustration, powerlessness, and a need to boost therapists' professional self-esteem.
While the generalized ideas about therapists' power over their clients are often exaggerated, there are still situations in which these generalizations are valid. When clients are young children, cognitively impaired, physically disabled, traumatized, dissociated, or psychotic, the power differential is indeed valid and real and therapists must factor it in and act accordingly. There are several settings in which therapists are likely to have significant power over their clients. These settings include prisons, jails and other detention facilities, inpatient psych units and hospitals, and forensic evaluations, such as custody, insanity, etc. In these instances, therapists must remember that many relationships with a significant differential of power, such as parent-child or teacher-student, are not inherently exploitative. Parental power facilitates children's growth and teachers' authority enables students to learn. Therapists' power, like that of parents, teachers, coaches, politicians, attorneys, or physicians, can be used or abused. The Hippocratic Oath's mandate to "first do no harm" refers exactly to such dangers. The problem of abusive or exploitive power in therapy stems from some therapists' propensity to exploit their power for their own selfish gain. It is not the power itself that corrupts; it is the propensity to corruption and lack of personal integrity that results in abuse of power (Tomm, 1993.)
From the mid-1990s to the present time, the field of psychological ethics has significantly changed its rigid stance of therapeutic boundaries of the 1980s and early 1990s. Barnet and Barnett and Yutrzenka (1994) and Lazarus (1994) led the way and Williams (1997) and Zur (2000a) followed. This change is also illustrated in the 2002 revised code of the American Psychological Association (APA) and the 2005 revised code of the American Counseling Association (ACA). While the initial change was on multiple relationships, the focus broadened towards the end of the 20th century and the beginning of the new millennium to include issues of non-sexual touch (e.g., Fosshage, 2000; Hunter & Struve, 1998; Smith, Clance, & Imes, 1998, Zur, 2007a), home visit (e.g., Knapp & Slattery, 2004; Slattery, 2005; Zur, 2007a), self-disclosure (e.g., Barnett, 1998; Bloomgarden & Mennuti, 2009; Gutheil, & Brodsky, 2008; Knox, Hess, Petersen, & Hill, 1997; Pedersen, 2002; Zur, 2007a), gifts (e.g., Hahn, 1998; Knox, Hess, Williams, & Hill, 2003; Zur, 2007a), and bartering (Hill, 1999; Thomas, 2002; Zur, 2004). Without a doubt the most significant change has taken place around the issue of multiple relationships. The earlier consensus that dual relationships are unethical, harmful, and are likely to lead to sexual relationships was replaced with the understanding that some dual relationships are unavoidable and normal in small and rural communities and in fact can be beneficial (e.g., Herlihy & Corey, 2006; Knapp & VandeCreek, 2006; Lazarus & Zur, 2002; Pope & Wedding, 2007; Sonne, 2006; Younggren & Gottlieb, 2004; Zur, 2007a).
In the bigger scheme of things the most important changes in the late 1990s and in the beginning of the new millennium have been a less dogmatic approach to therapeutic ethics. This evolving approach appreciates individual and cultural diversity and, most importantly, is context based. Shying away from the 'one rule fits all', the new approach is incorporating clients, therapy, settings, and therapists' factors into the ethical decision-making. Some of texts that exemplify these more complex, more flexible, and more humane views of therapeutic ethics have been Barnett and Johnson (2008), Bennett, Bricklin, Harris, Knapp, VandeCreek, and Younggen (2006). Gutheil and Brodsky (2008), Herlihy and Corey (2006), Knapp and VandeCreek (2006), and Zur (2007). The hope of this paper is that it will continue the momentum of change in therapeutic ethics and apply the new, more complex, more inclusive analysis to power relationships in psychotherapy.
Finally, it is important to emphasize that regardless of clients' and therapists' respective power, the fiduciary relationship is the foundation of the therapist-client relationship and must be preserved at all times by the therapist. Ultimately, the buck stops with the therapist. It is the therapists' responsibility to do their best to avoid harm and exploitation. Accordingly, a therapist must avoid any interventions that are likely to harm a client, such as a sexual relationship or financial exploitation. The fields of psychotherapy, counseling and ethics would benefit from a more complex view of power and its many permutations. An essential understanding of when the power differential is valid and when it is not can help therapists to be, not only more realistic and less bound to pretentious forms of professionalism, but also will uphold clients' dignity and respect while simultaneously helping therapists to be more credible, authentic, and, most importantly, effective.
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- The word "power" comes from the Latin root posse or to be able from which we also get potentia. Power, at its heart, is about potentiality.
- Power can be employed in just or unjust, fair or unfair, direct or indirect ways. It can be employed or perceived as positive or negative.
- The use of power may or may not involve intellectual coercion, physical force, or threat and can be employed consciously or unconsciously, subtlety or blatantly, overtly or covertly.
- The recipients may be aware or unaware of the fact that they are under the influence of some form of power.
- Unlike the common view of power as unidirectional and exclusively possessed by one party in the relationship, power is multidimensional, dynamic, almost always present in relationships, and influenced by forces outside the relationships. It is a dynamic, multifaceted, and relational force.
- Evaluating the balance of power is very complex as power has many faces and can manifest itself in a variety of ways and forms, some of which are subtle and covert.
Power in Therapy:
- There is a basic but flawed assumption within the field of psychotherapy, counseling, and psychiatry that all psychotherapists are significantly more powerful than all their clients.
- The power differential view of power in therapy, where all therapists are viewed as all-powerful and all clients as dependent and vulnerable, is incomplete, misleading, disrespectful to clients, and unhelpful to therapists.
- The myth of therapists' omnipotence is rooted in analytic therapy's understanding of the nature of transference, in ethicists' attempts to reduce abuse and exploitation of clients by predatory therapists, and in the faulty belief in the slippery slope.
- Therapists can facilitate the creation of an environment that will increase the possibility of clients living up to their potential (i.e., their power), or they can create an environment that is detrimental to clients or patients.
- This paper identifies nine (non-mutually exclusive) types of powers: Legitimate power; Expert-Knowledge power; Professionalism power; Positional or Role power; Knowledge-Discrepancy power; Coercive power; Reward power; Reference power; and Manipulative power.
- Therapists and clients are likely to posses some aspects of each and every one of these nine forms of power, with the exception of legitimate power.
- There are many types of clients with whom the power differential is valid and real. These clients are likely to be either young children, cognitively impaired, physically disabled, traumatized, dissociated, or psychotic.
- There are several settings where therapists are likely to have significant power over their clients. These settings include prisons, jails, and other detentions facilities, inpatient psych units and hospitals, and forensic evaluation, such as custody, insanity, etc.
- There are many ways that therapists, directly or indirectly, enhance their aura and influence. These may involve: the way therapists organize the seating arrangements, furnish the room, put a tissue box by patients' chair, take notes, talk with an authoritative tone, touch in a patronizing way, use professional jargon, monopolize the conversation with long sermons, etc.
- An initial power imbalance may shift as clients feel empowered, get to know their therapists better, and perceive the therapeutic process as less mysterious and more tangible.
- There are many ways that a client, directly or indirectly and consciously or unconsciously, enhances his or her power in the therapist-client relationship. The client may come late or leave early, he/she can monopolize the conversation, fail to follow the therapist's suggestions, refuse to pay, record sessions, persuade the therapist to engage in dual or sexual relationships, search for information about the therapist online, etc.
- Power in therapy can only be understood within the context of therapy. The context involves looking at different aspects of therapy. This includes who the client is, what orientation is employed, the quality of the relationship between therapist and client, the setting of therapy, and the therapist.
- Power in psychotherapy is traditionally and most commonly viewed as being unidirectional, a quality possessed by powerful therapists and employed on vulnerable clients. Alternatives to the power-over view, which is associated with coercion and domination, are power-with, which is linked to the cooperative and respectful exchange between equal individuals and to the employment of power that empowers rather than controls or dominates, and power-from-within, which views power as "potential" and often refers to one's power over one's own life, relying on one's inner strength to 'become' rather than the exertion of power over others.
What Therapists Should Pay Attention To:
- While one can assume that power almost always plays a role in therapeutic relationships, do not assume that there is always a power differential between therapist and client.
- Pay attention to how different settings, clients, and therapies may affect the power differential between therapist and client.
- Differentiate between clients who are more vulnerable (e.g., young children, highly anxious, recently traumatized, dissociated, forensic evaluation patients) and clients who are not likely to be vulnerable to therapists' influence (e.g., high functioning and mature, sociopaths, litigious clients).
- Recognize settings and situations where clients are highly vulnerable to therapists' evaluations, assessments, and recommendations. These may include insanity evaluations, inpatient units, custody assessments, and other forensic evaluations.
- Be aware of ways in which therapists subtlety or unconsciously enhance their power vis-à-vis their clients.
- Realize that many modern day consumers are well-informed, demand transparency, and are very far from being meek, dependent, or vulnerable as so many ethicists characterize patients.
- Be aware of the meaning and relevance of theoretical orientations to power issues in therapy.
- Realize that the DSM is essentially not a scientific document; it has poor validity and reliability. However, it gives therapists the power to name and identify what is normal or not and detain people against their will.
- Be aware of your own sense of vulnerability and powerlessness. As fallible human beings, therapists must consciously and humbly accept that there are times when they are powerless and their efforts ineffective while maintaining faith in their basic desire, ability, and determination to help their clients achieve their goals/achieve a positive therapeutic outcome.
- It is important to emphasize that regardless of clients' and therapists' respective power, the fiduciary relationship is the foundation of the therapist-client relationship and must be preserved at all times by the therapist. It is the therapists' paramount responsibility to try to avoid harming or exploiting their clients.
- Use your knowledge, expertise, and all other forms of power that you may have to create an environment that honor clients and gives them the best opportunity to grow and heal.
(1) This paper uses the terms psychotherapy and counseling interchangeable. It also uses the terms clients and patients interchangeably, and clinicians, psychotherapists, and counselors, also interchangeably.
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