by Julie Diamond, Ph.D.
When I was working as a therapist, I often asked myself about the future of psychotherapy. I even wrote an article about it in 2000, called Five Predictions on the Future of Psychotherapy. In it, I said that the paternalistic doctor-patient model will be replaced by a partnership model. I wasn’t exactly looking into a crystal ball. My prediction simply iterated research emerging at the time about the role and value of the therapeutic (or helping) alliance. Studies suggested that it was the quality of client-therapist relationship, and not any one model of therapy, that was the most reliable predictor of positive outcomes. And it’s not just therapy. In other health care fields as well, the patient’s own participation and initiative in the treatment program yields more positive results than a passive or compliant role in the treatment process.
But there’s a long and sticky history to the old doctor-as-expert model. We need to use expertise to help others, but it’s hard not to fall prey to the trappings of the role of expert. Knowing how to be an expert and a partner in an alliance is not easy nor is it commonly taught. Thus, the helping profession is a field fraught with danger: the emotions and vulnerability of the client, coupled with the expertise of the practitioner, creates a power imbalance that can easily be abused. This is why the helping professions have such extensive and well-enforced ethical guidelines and oversight. But ethics isn’t enough. Ethics is vital, but doesn’t take into account the subtle changes of awareness and feelings that being in a power role creates.
In my new book, Power: A User’s Guide, I analyze the elements of this imbalance. First, there is a one-way disclosure of personal, private, and sensitive information from the client to the therapist. Second, the therapist has expert knowledge to which the client is not privy. The client places her or his trust in the therapist and agrees, tacitly or explicitly, to follow the therapist’s expertise without the knowledge or insight to judge good from bad advice, except for (thankfully) gut feelings. The third is the intimacy and deep emotional bond between the therapist and client that comes from placing your trust in someone to help you with vulnerable states and feeling. Finally, there is the work context itself. Therapy is often done in private, without a supervisor or colleagues present. Not only does this give the therapist unfettered freedom, but makes his or her sense of rank lopsided. In most other organizational settings, we have a steady mix of roles and rank—we interact with bosses, subordinates and peers. But therapists spend almost every minute of their working hours with clients, i.e., solely in the expert, high ranking role. Think about it. Your expert role—along with your perceptions, analysis and decision making—is seldom challenged, ultimately skewing your perspective of yourself. It takes a lot to work against this power imbalance, and mitigate its inherent potential for misuse.
Given this innate imbalance, what can we do to create more of a partnership model, to be experts, but partners at the same time?
Stand outside yourself
When you are an expert relative to someone who is not privy to the theory upon which your expertise is based, it’s not enough to be proficient in your theory; you have to know about your theory. You need to be able to stand outside your knowledge, and look at it—and yourself—with a critical eye.
Here’s why. When authority rests on expertise that others can’t challenge, our power is absolute. We can use the theory to justify our actions. And if we’re dispensing expertise based solely on our own knowledge base, then we are simply asking others to act on faith, to uncritically follow our methods.
To engage with the client as a partner, we need to constantly critique our theory and methods, by drawing on knowledge from outside our paradigm. And we need to encourage our clients to do the same, to bring their questions, critical thinking, and their way of knowing, into the work itself.
We also need to recognize that we are not only, as Marshall Goldsmith says, “mission neutral.” We have a preferred way of thinking, and we need to know what it is. I wrote about this recently in this post, that our personal orientation defines progress and success. We come into our work with personal proclivities, with innate interests, cultural values, temperament, and the like. And this creates a bias, an unconscious preference for some methods, some types of clients, and even some issues more than others. Knowing ourselves from the outside in is critical to relativizing the expert role.
What’s your own power story?
When we step into a role of authority, we don’t step in as blank slates. We bring our own personal rank history with us. Our relationship to power, from earliest childhood, is a part of how we show up. In my work as a supervisor and in training, some of the more difficult problems I saw stemmed from practitioners who were unaware of their own power story and had “wood to burn,” as Arnold Mindell calls it, unfinished issues relating to their early experiences of marginality, centrality and power.
For instance, if we are unaware of our dominant identity, or high social rank, it’s easy to make assumptions about our clients from our position of privilege. Conversely, feeling low social rank could be challenging for us, stepping into a role of expertise, feeling fraudulent or inferior, having difficulty identifying with our expertise. How our own power stories intersect with our expert role is unique and individual. There is no one way this happens, and it takes constant self-awareness and personal work to unravel our power story, to see how our rank identity plays into how we view and relate with others, and to make it useful to our work.
Know your needs
Unfulfilled personal needs create a powerful vacuum that attracts the admiration, vulnerability, and dependency of those over whom we have influence. Knowing your needs is not easy, but in a power role we have an obligation to do so. We have to ask ourselves tough questions, regularly, and keep our self-interest in check. We need ask ourselves:
• How much do we enjoy the positive projections of our client?
• Can we support our clients’ independence? Can we encourage them to seek help elsewhere? To question our view? To bring in an opinion from another source, such as a course, book, or previous therapist?
• How fulfilling are our own relationships? Do we have areas of intimacy outside of work?
• How do we react when someone challenges our knowledge or authority? Do we ever feel hurt or aggrieved if our clients disagree with us? Are we open to feedback, even critical feedback?
It’s important to ask yourself these questions and others, and ever better: ask yourself how your clients would answer these questions. And what would your colleagues say? Discuss your insights with someone else, your own coach or supervisor, someone outside your work who can give you impartial feedback. Find out where you might be tempted, where you may have underlying need or weakness that tempt you to use your power role to get them filled.
I look forward to diving into these issues and more next month, on Friday, April 1, , at my discussion on power at KPACT, the Kink & Poly Aware Chicago Therapists, network event, and on Sunday, April 3, at a workshop at LifeWorks Psychotherapy Center in Skokie, Illinois, BEYOND ETHICS: Power in the Helping Relationship. Hope to see some of you there!