form of tokens that can be exchanged for goods or privileges); the power of the therapist and staff is used to control, or at least influence, the client’s behavior.
Psychologist Laura Brown (1994) describes another domain of the therapist’s power:
The therapist also has the power to engage in certain defining behaviors that are real and concrete. She sets the fee; decides the time, place, and circumstances of the meeting; and determines what she will share about herself and not disclose. Even when she allows some leeway in negotiating these and similar points, this allowance proceeds from the implicit understanding that it is within the therapist’s power to give, and to take away, such compromises (p. 111).
7. Inherent Power Differential
Power differential is inherent in psychotherapy. Although some approaches emphasize egalitarian ideals in which therapist and client are equal, such goals are viewed only within a narrowly limited context of the relationship. In truly equal relationships, in which there is no appreciable power differential, there is no designation of one member as “therapist” in relation to the other member, there is no fee charged by one member to the other for the relationship itself, there is no designation of the activity as “professional” (and falling within the scope of a professional liability policy), there is no license possessed by one member allowing initiation of a 72-hour hold on the other, and so on. A defining attribute of the professional is the recognition, understanding, and careful handling of the considerable power—and the personal responsibility for that power—inherent in the role. Regardless of how mutual, genuine, or egalitarian a therapist may choose to be, often utilizing humanistic, feminist (e.g., relational), multicultural orientations, some degree of power difference is unavoidable.
CARING AND HEALING
Both the individual client and society recognize the diverse powers of the professional role and place their trust in us to use those powers to help—never to harm, oppress, or exploit. We must match with our caring the trust that society and the individual client invest in us. Only within a context of caring and healing—specifically, caring about the client’s well-being, and working to not just help cope or adjust to intolerable circumstances but actually helping clients heal their pain—are our professional status and powers justified.
Historically, professional status was not created or defined by charging high fees, spending long years in training, or reaching a high level of skill. The professional’s defining characteristic was an ethic of placing the client’s well-being foremost and not allowing professional judgment or services to be drawn off course by one’s own needs and wants. A major purpose of professional ethics codes is to help us use our knowledge, skills, status, and other forms of powers to help our clients and not to take advantage of, endanger, cheat, undermine, abuse, or otherwise mistreat or harm them. “Professional ethics protect the public against the abuses of professional power, specialized knowledge, and prominent positions. They place protecting the public interest above advancing the profession’s self-interest” (Pope, 2019, p. 186). Professional ethics help keep us from being biased or blinded by our own self-interest so that we can no longer see clearly or care about our clients, their legitimate interests, and our responsibilities to them.
The touchstone for the approaches discussed in this book is caring for and about our clients. This book’s concept of caring avoids passive, empty sentimentality. Caring includes responding to a client’s legitimate needs and recognizing that the client must never be exploited. Caring also includes assuming personal responsibility for working to help and to avoid harming or endangering our clients. Caring involves learning to contextualize experiences and realities that may be completely different from our own so that we do not pathologize, misdiagnose, or misattribute behaviors that may be culturally congruent or blaming our clients for their reactions to oppression. Furthermore, caring means that we work on addressing our biases and prejudices as a way to ensure that we are able to treat all of our clients with the same level of respect and dignity. Caring is being a healing presence in the lives of those we serve.
Unfortunately, the concept of caring may not receive adequate attention in graduate training programs. As Seymour Sarason (1985) wrote:
On the surface, trainees accept the need for objectivity—it does have the ring of science, and its importance can be illustrated with examples of the baleful consequences of “emotional over-involvement”—but internally there is a struggle, as one of my students put it, “between what your heart says you should say and do and what theory and your supervisor say you should say and do.” Many trainees give up the struggle but there are some who continue to feel that in striving to maintain the stance of objectivity they are robbing themselves and their clients of something of therapeutic value. The trainee’s struggle, which supervisors gloss over as a normal developmental phase that trainees grow out of, points to an omission in psychological-psychiatric theories. Those theories never concern themselves with caring and compassion. What does it mean to be caring and compassionate? When do caring and compassion arise as feelings? What inhibits or facilitates their expression? Why do people differ so widely in having such feelings and the ways they express them? It is, of course, implicit in all of these theories that these feelings are crucial in human development, but the reader would be surprised how little attention is given to their phenomenology and consequences (positive and negative) (p. 168).
Sarason made some excellent recommendations for how to encourage and develop caring, compassion, and empathy in clinical training programs, and more recently other innovative approaches have begun to emerge (see, for example, Condon & Makransky, 2020; Fragkos & Crampton, 2020; Han & Kim, 2010).
We still have a long way to go in ensuring that clinical training programs, internships, professional organizations, clinics, hospitals, and other settings are doing all they can to support caring, compassion, and empathy among clinicians. Unfortunately, there is evidence that such qualities may actually decline in some settings (see, for example, Hegazi & Wilson, 2013; Hojat et al., 2004, 2009). In “Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents,” Neumann and her colleagues noted that the evidence of declines of empathy over the course of medical training, they describe:
Some of the studies included in our review reported significant increases in cynicism among medical students. Crandall et al. also found students’ commitment to caring for medically underserved patients to be greater when they entered medical school than at graduation. This result was independent of gender and curriculum type (problem-based versus traditional; Neumann et al., 2011).
Caring about clients and what happens to them is at the heart of the formal rules and regulations that are society’s attempt to hold us accountable, of our professional ethics codes, and of our personal ethical responsibilities to each patient.
Chapter 6 COMPETENCE, HUMILITY, AND THE HUMAN THERAPIST
When patients seek our services, they hope we know how to help them. Ethical practice hinges on competence, including our ability to use our skills effectively to help our clients heal and cope with the challenges they face. Society gives us the power and privileges to help our clients, while holding us accountable for competence through the courts and licensing boards.
Cynthia Belar (2009) discusses our ethical responsibility to train competent psychologists and to maintain our own competence as our “social contract.” She emphasizes that a central question for our training programs
is whether we are producing what we say we are producing—a psychologist competent for entry to practice. This question comes from prospective students, prospective employers, and the public. Indeed our social contract with the public as an independent profession requires that we self-regulate in these
