Ethical Decision-Making in Therapy: The Power Spiral Process

SpiralThe power spiral is a guide to using role power wisely and well, and is of particular use to therapists. There are four aspects to the power spiral for use with ethical decision-making: gathering information, engaging compassion, resolving and repairing, and resourcing.

As a mental health professional, when you have any kind of ethical decision to make, consider the questions that guide you through the power spiral process. This process may also be helpful when you would like to harvest some learning by reflecting back on a decision or mistake you may have made.

Start by focusing your thoughts on the situation you want guidance on. Then imagine this situation in the center of a power spiral surrounded by the four aspects described next. Now imagine sitting in each of the directions of the spiral and consider questions such as the ones listed here. What insights emerge?

1. Gather Information: The Informed Use of Power

  • What does your code of ethics say about this issue?
  • What is the impact of the power differential?
  • What other objective information is relevant?

2. Engage Compassion: The Conscious Use of Power

  • How does this issue affect you personally?
  • Is shame de-resourcing either you, the person you’re working with in therapy, or both?
  • What kind of transference or countertransference may be operating?

3. Prevent or Repair Harm: The Caring Use of Power

Some ethical decisions are involved with how to be in service to the person you’re working with and prevent harm, while others are related to how to resolve difficulties and repair harm.

Questions for being of service and preventing harm:

  • What are the response options?
  • What will be the short- and long-term impact of each of these options?
  • What additional factors might be important to consider? For example, you might take into account other family members, the life circumstances and abilities of the person in therapy, any risks to the person or therapist, or the spirit (versus the letter of the law, cultural norms, and spiritual beliefs).

Questions for resolving difficulties and repairing harm:

  • Is there a difference between intention and impact?
  • How do you feel toward the person you’re working with? Toward yourself?
  • Because of your role, what are you responsible for?
  • What is the best strategy for: (1) compassionately understanding the experience of the person in therapy and communicating this understanding along with genuine concern; (2) ascertaining what kind of repair is needed; and (3) following through in the most appropriate way?

4. Resource Yourself: The Skillful Use of Power

  • How will you take care of yourself and use the resources and support available?
  • How can you use this situation to self-correct and/or be more skillful in the future?
  • When you have done all you can, how can you best let it go?

Example of the Power Spiral Process in Action

One of my students told me about an experience that usefully illustrates this process. Names and identifying information have been changed to protect confidentiality.

A colleague referred someone to Elena, who works for an agency. The written notes about this man, David, said he wanted to get disability payments. When Elena met with David, he said he didn’t want disability assistance. Hearing that and feeling some reticence from David, Elena began working with him on feeling less shame and personal failure at needing to apply for public assistance.

This process went nowhere. David stopped coming to appointments and even filed a complaint with Elena’s boss. He said he had quit his appointments because she wasn’t giving him any help with his communication skills and managing his anger. Elena was quite surprised to hear this.

Using the power spiral process, Elena got some insights:

  • That the power differential might have been interfering with David’s ability to tell Elena the truth—that he wasn’t getting what he needed. Based on her notes, she had not actually asked David what he wanted help with, assuming his reticence was his discomfort with needing assistance.
  • That she was likely projecting her sense of shame about needing public assistance onto David, and that she wasn’t checking in with her gut sense of what was going on.
  • That she needed to take responsibility for being insensitive to David’s real needs and relying too much on the referral notes. She decided her best choice was to make an authentic apology to David and invite him back to work with her on anger and communication skills. Elena also understood that she needed to do some follow-up work with her boss to let him know how the complaint had been successfully handled.
  • Elena took the action she decided on. David came back to work with Elena on communication and anger, and was satisfied with their work. Elena learned to focus on the relationship rather than the referral notes. She was glad she had taken responsibility for her mistake and reached out to David to resolve and repair the situation.

This is a fairly simple example of how to use this process and the many insights and guidance the focused questions can provide, and demonstrates how the process can be used in supervision or with a group of peers. It is also a humbling example of how quickly and innocently we can get off course. Further, it underscores how easy it is to be rule-bound (in this case, referral notes-bound) when we most need to be attuning to ourselves and being in right relationship with the people we serve—ethics from the inside out. Finally, it is an example of how simple and straightforward it can be to work out a problematic issue.

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  • 3 comments
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  • lizzy

    lizzy

    May 6th, 2015 at 1:24 PM

    I really don’t know all the much about this, but I presuming that this means that all 4 of these things need to be taken into account before acting or making an irrational decision?

  • Kendra

    Kendra

    May 9th, 2015 at 10:52 AM

    This really does give you some insight into how all of this is such a process, that it is a way to learn and to grow as a person, and how to become a better person in the end.

  • focused

    focused

    May 13th, 2015 at 1:55 PM

    The thing that I like about this is that not one thing is shown to be more important than the other.
    they are all equally important to the therapist as well as to the patient.

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