Increasing trust was also important to clients concealing mistreatment in relationships and even for those lying about self-harm” (p. 3203–3204).
Our ethical responsibility includes respecting our clients’ trust that we will do nothing that places them at risk for harm. When we betray the client’s trust, they may lose hope in the system and profession we represent and not just in us as individual providers. When we betray our clients’ trust, we can sometimes cause deep, pervasive, lasting damage. The poet Adrienne Rich wrote a vivid description of the effects of shattered trust:
When we discover that someone we trusted can be trusted no longer, it forces us to reexamine the universe, to question the whole instinct and concept of trust. For awhile, we are thrust back onto some bleak, jutting ledge, in a dark pierced by sheets of fire, swept by sheets of rain, in a world before kinship, or naming, or tenderness exist; we are brought close to formlessness (1979, p. 192).
Research by psychology professor Jennifer Freyd and her colleagues (e.g., Freyd, 1998; Freyd et al., 2005; Gobin & Freyd, 2014; Platt & Freyd, 2015; Smith, 2017) has explored and described how betrayal trauma can result when our trust is violated. Freyd emphasized:
Psychologically, betrayal is toxic to the mind and body. We know this from decades of research on betrayal trauma. People who are betrayed are likely to suffer mentally and physically. This is true whether the betrayer is a trusted person—like a psychotherapist or supervisor—or a trusted institution—like a clinic, hospital, or university. In the case of institutional betrayal, the harm can be particularly acute and even associated with increased thoughts of suicide (personal communication, August 7, 2020).
We all face the challenge of understanding what inspires and validates trust and what misreading, misunderstanding, or mishandling trust can mean for the client. For some of us, advanced degrees from prestigious universities, diplomate status and other certifications (often framed in the office), awards and honors (often framed even more prominently in the office), publications in respected journals on topics related to what we want to work on in therapy, fame, and even an office in an impressive building may inspire our initial trust in a therapist. Surely someone with all those accomplishments must know what they’re doing, some of us might think, rightly or wrongly. For others the realities of intergenerational trauma and institutionalized forms of oppression experienced many times at the hands of those deemed experts rightfully detract from our ability to trust us. Clients may think that we may not know what to do with them. Others know that we too have biases that affect how we treat them; yet, despite these valid concerns, clients hope to be proven wrong. They hope we can be of help so they can feel better.
But for some prospective patients, these markers may be warning signs and even barriers to trust (Alire, 2019; Okun et al., 2017; Sue et al., 2019). These markers may suggest to members of historically oppressed communities that the therapist is a member of the establishment that has inflicted prejudice, discrimination, hate, oppression, and injustice. For instance, some BIPOC may understandably assume that a White therapist holds the same racist views and practices that so many White people have held for generations, given the many ways in which systems and institutions provide unearned advantages (privilege) to White people. Some of these privileges include: hiring and promotion practices favoring Whites; juries less likely to convict White defendants or, after conviction, to impose the death penalty on White defendants for comparable crimes; and traffic stops being much less risky for White drivers than for Black drivers. BIPOC may believe that White therapists have accepted those views and enjoyed those benefits without acknowledging the taint, wrongness, and injustice of such unearned advantages, let alone working to dismantle racist or other oppressive systems.
A White therapist who reacts defensively to a client holding a version of such views—an extreme version might be “Why, there’s not a racist bone in my body. I have no racist views”—or tries to block or shunt side dealing with such trust issues honestly and openly, is on the wrong track. A well-intentioned response to an experience about discrimination, such as “Oh, I am sure they didn’t mean it that way” invalidates the reality and perceptions of the BIPOC client.
Many minorities may perceive that the therapist cannot be trusted unless otherwise demonstrated. Again, the role and reputation that the therapist has as being trustworthy evidenced in behavioral terms. More than anything, challenges to the therapist’s trustworthiness will be a frequent theme blocking further exploration and movement until they are resolved to the satisfaction of the client (Sue et al., 2019, p. 109).
Similarly, not talking or addressing issues related to racism, anti-Semitism, sexism, heterosexism, cis-sexism, gendered-racism and other forms of oppression may signal to the client that the therapist does not see these social problems as significant, real, or important to how they impact clients who are members of various minoritized groups. This lack of attention to the lived experiences of BIPOC and those who experience other forms of oppression may further negatively impact a client’s ability to trust that the therapist will hear, understand, and respect their experiences. The heart of trust is not about our telling clients to trust us, the credentials on our walls, or the buildings where we practice—the heart of trust is about who we are, about whether we treat our clients with dignity and respect, and about our actions and inactions.
POWER
The trust that society and individual clients give to therapists is one source of power—for example, the power to respect and value that trust or to abuse and betray it. The role of therapist holds power ranging from superficial to profound, from fleeting to lasting. The following sections look at seven forms of power including: (1) power given by the state; (2) power to name and define; (3) power of testimony; (4) power of knowledge; (5) power of expectation; (6) power created by the therapist; and (7) the inherent power differential.
1. Power Conferred by the State
State and provincial licensing confers power. Licensed professionals can do things that people without a license cannot. With patients’ consent, surgeons can cut human beings wide open and remove internal organs, anesthesiologists can drug clients until they are unconscious, and some therapists can recommend or administer mind or mood altering drugs to clients, all with the law’s authorization. People will take off their clothes and willingly (well, somewhat willingly) submit to all sorts of indignities during a medical examination. They let physicians to do things to them that they would not dream of letting anyone else do.
Similarly, clients will open up and allow us as therapists to explore private aspects of their thoughts, feelings, and social lives, including their history, fantasies, hopes, and fears. Clients will tell us their most guarded secrets, material shared with literally no one else. We can ask questions off-limits to others. States and provinces recognize the importance of protecting clients against the misuse of this power to violate privacy. Except in certain instances, we are legally required to keep confidential what we have learned about clients through the professional relationship. Holding private information about our clients gives us power.
Through licensing, governments also invest us with the power of state-recognized authority to affect our clients’ lives. We have the power to make decisions (subject to judicial review) about our clients’ civil liberties. In some cases, we have the power to determine whether a person constitutes an immediate danger to the life of someone else and should be held against their will for observation or treatment. Alan Stone (1978), professor of law and psychiatry at Harvard University and a former president of the American Psychiatric Association, noted that in the 1950s the United States incarcerated more of its citizens against their will for mental health purposes than any other country, and that the abuse of this power later led to extensive reforms and formal safeguards.
The state has sometimes used the power of involuntary hospitalization to enforce social injustice. For example, in 1958, Black pastor and civil rights activist Clennon King “tried in vain
