Ethics in Psychotherapy and Counseling. Kenneth S. Pope

of BPD ‘symptoms’” (p. 253).

      In one of the most widely cited psychological research studies, “On Being Sane in Insane Places,” Rosenhan (1973) wrote, “Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophesy. Eventually, the patient himself accepts the diagnosis, with all of its surplus meanings and expectations, and behaves accordingly” (p. 254).

      Caplan’s description (1995) of psychiatrist Bruno Bettelheim’s analysis of student protesters reveals the potential power of diagnosis and other forms of clinical naming to affect how we view people:

In the turbulent 1960s, Bettelheim … told the United States Congress of his findings: student anti-war protesters who charged the University of Chicago with complicity in the war machine had no serious political agenda; they were acting out an unresolved Oedipal conflict by attacking the university as a surrogate father (p. 277).

      The power of naming and defining has been particularly harmful to BIPOC and members of other oppressed social groups. For instance, naming “homosexuality” as a mental illness, being gatekeepers of gender-affirming terms for transgender people, over-diagnosing Black children with externalizing behavioral disorders and Black adults with more severe forms of mental illness (e.g., bipolar disorder, schizophrenia) has contributed to the pathologizing of communities who are already suffering as a result of discrimination and hatred.

      3. Power of Testimony

      We possess authority to change the course of lives when we testify as experts in the civil and criminal courts and through similar judicial or administrative proceedings. Our testimony can help determine whether someone convicted of murder is executed. It can be the deciding factor in whether a parent gains or loses custody of a child. It can shape a jury’s view of whether a defendant was capable of committing a crime, was likely to have committed it, was legally sane at the time the crime was committed or is likely to commit similar crimes in the future. It can lead a jury to believe that an uncle sexually abused a young child or that the child either imagined the abuse or was coached as part of a custody dispute. It can help immigrant and asylum-seeking individuals regularize their status in the United States so they can live and work free from the fear of being separated from their families or deported to countries where their lives may be at risk. Our testimony can convince a jury that the plaintiff is an innocent victim of a needless trauma who is suffering severe and chronic harm or is a chronic liar, gold digger, or malingerer.

      4. Power of Knowledge

Our role as therapist holds power beyond the power that a license creates. We hold power that comes from knowledge. We study human behavior, mental processes, and the intrapsychic and social factors that affect motivation, decision, and action. We learn methods to bring about change. Our research, writing, and our very words have the power of providing language and validation to experiences that have been marginalized, made invisible, silenced, and disregarded. Maintaining a constant, respectful awareness of the power flowing from knowledge and expertise is essential to avoid the subtle ways of manipulating and exploiting clients through our interaction with them or through our clinical documentation (treatment plans, progress notes, assessment report) and scholarship.

      5. Power of Expectation

      The process of psychotherapy itself creates and uses different forms of power. Most therapies recognize the force of the client’s expectation that the therapist’s interventions will be able to induce beneficial change. One aspect of this expectation is the placebo effect, a factor that must be considered when studying the efficacy and effectiveness of interventions. The client’s investing the therapist with power to help bring about change can become a significant part of the change process itself. Conversely, the therapist’s expectations, including optimism and belief in the client’s capacity to change, are powerful as well. Miller et al. (1995) reviewed the research and noted that

      As a factor in outcome, technique matters no more than the “placebo effect” … The creation of such hope is greatly influenced by the therapist’s attitude toward the client during the opening moments of therapy. Pessimistic attitudes conveyed to the client … are likely to minimize the effect of these factors. In contrast, an emphasis on possibilities and a belief that therapy can work will likely counteract demoralization, mobilize hope and advance improvement.

      On the basis of their research, Connor and Callahan (2015) reported:

      Psychotherapists were found to hold significantly higher expectations for client improvement than anticipated, based on existing literature, and these high expectations were found to be positively correlated with clinically significant change in clients. Moreover, psychotherapists’ expectations were found to explain 7.3% of the explainable variance in whether or not clients experienced clinically significant change during psychotherapy (p. 351).

      Similarly, research conducted by Swift et al. (2018) found that student therapists’ expectations were a “significant unique predictor of change. These results suggest that therapists should be aware of their own expectations when working with clients in order to make sure that any negative beliefs do not impact the quality of care that they provide” (p. 84).

      6. Therapist-Created Power

In some approaches, the therapist works to create specific kinds of power. A family therapist may unbalance the equilibrium and disrupt alliances among family members. A behavior therapist may create a hospital unit or halfway/transitional house in which desirable behaviors bring a rewarding response from the staff (perhaps in the 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.