Ethics in Psychotherapy and Counseling. Kenneth S. Pope
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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 to enrol at the all-White University of Mississippi” (Negro pastor pronounced sane, demands Mississippi apologize, 1958, p. 3). State troopers took him to a mental health institution where he was imprisoned against his will. Where he had been committed was kept secret from everyone for 48 hours. After being confined in the mental health institution for 12 days, he was released when a panel of 17 doctors declared him sane. He regained his freedom only to face charges of disturbing the peace by trying to enrol in an all-White university and resisting arrest. He said, “My only fear of jail is what might happen to me in that jail—the authorities are the only ones who have threatened me” (Negro pastor pronounced sane, demands Mississippi apologize, 1958, p. 3).
In the 1940s and 1950s, the government of Quebec falsely diagnosed 20,000 Canadian children as mentally ill and imprisoned them in psychiatric institutions to enable the misappropriation of government funds (Boucher et al., 2008; Clément, 2016; Duplessis orphans seek proof of medical experiments, 2004). The children became known as the Duplissis Orphans, named after Mauric Duplessis, who governed as Premiere of Quebec for five non-consecutive terms between 1936 and 1959. These are only a few of the countless examples in which the field of mental health and therapists have acted in unjust ways causing harm to vulnerable populations, and engendering distrust in the mental health system.
2. Power to Name and Define
We hold the power of naming and defining. To diagnose someone is to exercise power. In an ingenious study, Lam et al. (2016) showed clinicians a video of a woman describing how she experienced uncomplicated panic disorder. They then asked the clinicians to rate her problems and describe her prognosis. Research participants had been randomly assigned to three groups. One was given the woman’s personal details and background information, the second was also given a behavioral description consistent with borderline personality disorder, and the third was given one piece of additional information that included the label of a borderline personality diagnosis. The results showed the power of a diagnosis to affect perception and judgment. Their study found that “the BPD label was associated with more negative ratings of the woman’s