Female doctor has discussion with female patientOn February 16, 2016, police in West Palm Beach, Florida arrested Malachi Love-Robinson, 18, for allegedly setting up a medical practice, posing as a doctor, and examining patients without a medical license. Amazingly, this was not the first time the teen had been arrested for operating without a medical license. On his website, Love-Robinson listed his qualifications to provide psychotherapy, phototherapy, electrotherapy, and physiotherapy, among many other professional services; however, licenses or certifications to provide such services were never disclosed.

It is frightening to consider that the person you turn to for physical or mental health care may not be who they say they are, let alone able to safely and effectively perform the procedures they say they can.

This sensational story sounds like just that, a story; however, stories of actual health professionals acting outside of their scope of competence occur only too often. As can be seen on popular cosmetic surgery shows such as E!’s Botched and Lifetime’s Atlanta Plastic, it is not uncommon for individuals to discover their health professional was incompetent or unqualified to perform a medical procedure. Unfortunately, this discovery typically happens after a surgical or cosmetic procedure has taken place and the person is left with a physical or psychological issue. Afterward, the person discovers their doctor was not a specialist, not licensed, or worse yet, not a doctor at all.

[fat_widget_right]

On reality television and with the Love-Robinson case, it is easy to blame victims for placing themselves in situations that caused physical or mental harm. In regard to Love-Robinson, social media posts have commented, “They (patients) should have known he wasn’t a real doctor by how young he looked” and “I congratulate the young man; it’s the patients’ own faults if they fell for it.” In hindsight, it is always easier to judge things differently, to believe all the information we know now was obvious in the beginning. But the reality is, when people visit health professionals, they typically trust them to be credible, vetted, and experts.

Many (perhaps even most) of us do not take time to really explore who our health professionals are. How much time did you spend investigating your primary care doctor before your first visit? When you were referred to a specialist, how much effort did you expend in reviewing their credentials? When you found a therapist, did you ask questions to determine the best fit or did you schedule with the first person who returned your phone call?

How much time did you spend investigating your primary care doctor before your first visit? When you were referred to a specialist, how much effort did you expend in reviewing their credentials? When you found a therapist, did you ask questions to determine the best fit or did you schedule with the first person who returned your phone call?

Additionally, unethical health professionals may target vulnerable populations, including individuals with low socioeconomic status, ethnic minorities, sexual and gender minorities, children, the elderly, and people with disabilities. We have seen this with the U.S. Public Health Service (USPHS) Syphilis Study at Tuskegee in which African-American research participants were purposely left untreated for syphilis despite there being a cure for the disease (Northridge, 2011); the continued practice in some states of conversion therapy, which attempts to change the sexual orientation or gender identity of gay, lesbian, bisexual, and transgender individuals, even with research indicating such practices cause psychological harm (APA, 2015); or the St. Louis Veterans Affairs dental clinic exposing more than 1,800 veterans to HIV and hepatitis. Subjugation to societal discrimination or biases can leave vulnerable populations feeling powerless to assert their rights or question those in positions of power.

It is not helpful to blame the victims when health-related crimes or injustices occur, as it is possible that any of us could be misled by a seemingly legitimate professional. Having said that, there are steps we can take to educate ourselves as consumers and to investigate the credentials of health professionals.

Consider the following:

References:

  1. American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832-864.
  2. Northridge, M. (2011). Toward the ethical conduct of science and a socially just world. In R. Katz & R. Warren (Eds.), The search for the legacy of the USPHS Syphilis Study at Tuskegee (pp. 49–58). New York, NY: Lexington.

Women working in store“I feel like I am not listened to and that what I say doesn’t count.” “I feel humiliated for speaking up.” “I’m afraid of losing my job if I am critical.” “I’m expected to take care of things that are not my responsibility.” “I feel used and taken advantage of.” “My supervisor can’t change. It’s just the way it is, and I have to accept it.” “It’s hopeless! I’ve tried, and nothing changes.” “Every time I do the right thing, it feels like I get punished.” “I can’t believe my boss doesn’t get how we feel about him and what kind of harm he’s causing.” “My therapist says she wants all kinds of feedback, but when I give her negative feedback, she just turns it around on me.” “My feelings and opinions just aren’t taken seriously.” “It’s just not safe.” “It’s really unjust, but it is more peaceful to just let it go.” “I feel like it is just hopeless to have an effect, so I don’t invest myself.” “I can’t believe it. She just said no. And she’s my friend.” “He’s always too busy.” “There’s no acknowledgement, no follow-up from what I say.” “She must be right.”

Sound familiar?

These are feelings and experiences frequently expressed by people when they are in what I call a down-power role. People in therapy, students, supervisees, employees, medical patients, and parishioners, among others, are in roles with less power and influence than their up-power therapists, teachers, supervisors, employers, doctors, and clergy. This greater power is an automatic accompaniment to professional or positional power and, in fact, is embedded in the up-power role. Role power is earned or assigned. Role power is an add-on to the personal power we all have and need in our lives. Think of it like a scarf or mantle of additional power and responsibility that one puts on when one is in an up-power role.

Often without recognizing it, we may move between up- and down-power roles multiple times in a day. At the dentist, we are down-power. As a teacher, we are up-power. With a police officer, we are down-power. This power difference, although it has vital functional and emotional value, creates relational dynamics that, when misused, are reflected in the italicized statements above.

[fat_widget_right]

Therapist, supervisor, teacher, director, clergy, doctor, police officer: these are the positional power roles that carry an especially strong power difference. The stronger the power difference, the greater the vulnerability and risk for those who are down-power. The strength of the power differential is directly related to the amount of risk.

I use the terminology up-power roles and down-power positions because they are simply directional words, not necessarily evaluative words. By the way, there are other up-power roles in which the power difference is not very great (although still present), or the power difference is temporary—waiter in a restaurant, committee chair, lecturer. Virtually all jobs have some up-power responsibilities for assessment and final decision-making.

The power-differential effects that I want to describe are the relational dynamics that are most potent in high-difference roles, such as teacher, therapist, clergy, supervisor, and director. This information may be useful to you when you are in a challenging down-power position and want to have some positive influence but not get hurt or feel put down. It may also be useful when you are in an up-power role and things aren’t smooth, or you’re getting a lot of pushback, shutdown, passivity, or anger. Reviewing these dynamics can help you make self-corrections that can shift the relationship for the better.

The dynamics are as follows:

  1. All power/no power
  2. Skewed impacts
  3. 150% principle
  4. Power blindness
  5. Power with heart

Let’s explore these dynamics in greater depth.

1. All Power/No Power

There is a misconception, based on witnessing or experiencing abuses of power, that up-power means “all power” and down-power means “no power.” This is a self-reinforcing dynamic. The more the up-power person over-identifies with the increased power accompanying their role, the more the down-power person feels powerless and disempowered; meanwhile, the more the down-power person experiences or assumes no power, the more the up-power person experiences or assumes they have all the power.

Without understanding the difference between role power and personal power (and also status power), it is easy and natural to think of role power as if it were personal power. As a therapist, it is not healthy to take a person’s suffering home. Better to leave it at the office. As an airline pilot, it is not healthy to treat your partner and children as if they were staff or passengers under your command.

There are also ways in which people get stuck in an up-power role even when they have taken off their role mantel. A member of the clergy, for example, may not be able to go to a meeting without being expected to hold up-power role responsibilities. We are generally unaware of how frequently we change from up-power roles to down-power positions.

2. Skewed Impacts

In the relationship between up-power and down-power, it is acceptable and a responsibility of the up-power role to give feedback—both positive and challenging. For those in a down-power position, it is fine to give positive feedback, but it can be risky to give negative feedback or even suggestions for what would work better. Challenging feedback can be met with humiliation, putdown, demotion, or even loss of a job.

3. 150% Principle

The 150% principle is an important concept. The up-power role is weighted toward responsibility, while the down-power role is weighted toward risk. One of the responsibilities that goes with the up-power role is what I call the 150% principle. While all are 100% responsible for the health of the relationship, the ones in the up-power roles are even more responsible—hence the 150% metaphor.

On a day-to-day basis, this attitude means the person in the up-power role needs to be 50% more active in tracking for and resolving working-relationship problems and issues, earning trust, holding the big picture, demonstrating listening and responding to feedback (especially challenging feedback), attending to safety, and being fair and respectful. This is a tall order, but it is part of using role power wisely and well.

4. Power Blindness

The socially dominant concept of power as force, exploitation, and manipulation often leads people in up-power roles to disown, deny, or downplay their increased power and influence by virtue of their role. This power blindness causes much harm, albeit harm that is subtle, confusing, and difficult to address.

Power blindness is particularly a problem for people in the helping professions: teachers, supervisors, therapists, and clergy, all of whom are often trying to help people heal from the wounds of power abuse and thus should be particularly sensitive to misuses of power. They don’t want to cause harm, yet they frequently fail to understand how their up-power roles heighten their influence, just as turning up the volume on the television increases the sound.

5. Power with Heart

The core of “right use of power” is the ability to stay connected. Staying connected involves standing in your strength while staying in your heart. Both strength and compassion are necessary aspects of power.

When in a down-power position, you can be wiser and less victimized by misuses of power. When you are in an up-power role, you can be more sensitive and responsive to your impact.

Many shadow aspects can interfere with a leader’s ability and even interest in staying in a relationship. Here are two of them: social distance and the ability to take action without interference. Both of these conditions have leadership value. Social distance helps give a leader a view of the whole person or organization that is essential for good care and decision-making. The ability to take action without interference allows the leader to take charge and make difficult decisions that move things along and are for the good of the whole even though not everyone affected agrees. However, in seeing the forest, one’s connection to individual trees can get lost or distorted. Compassion is lost when individuals become cogs in the wheel of progress and financial success.

An unfortunate but natural result of being able to take action without interference is that leaders begin to be more impulsive, more self-oriented, and less respectful in their relationships. Helping professionals and leaders need to understand this dynamic in order to be alert to ways they may unconsciously be losing compassion and connection.

It might be interesting now to go back to the beginning of this article and look at the statements. Can you relate each statement to one or more of the relational dynamics described? Do you have personal experiences with any of these role-power issues? To repeat, understanding and working with these relational dynamics may be empowering, whatever role you are in. When in a down-power position, you can be wiser and less victimized by misuses of power. When you are in an up-power role, you can be more sensitive and responsive to your impact. Staying connected is key. Maybe it’s not so hopeless, after all.

I am so very sorry that this is how the relationship with your therapist has ended. You mention feeling angry, hurt, confused, and even abandoned. Given the scenario you presented, I can certainly understand why you would feel these things.

[fat_widget_right]

There is a phase of therapy called termination that happens as treatment is winding down. Termination serves as an opportunity to reflect on the work that has been done and the progress, growth, and change that has resulted. It is also a time for therapists and people in therapy to say goodbye to one another and process the end of the therapeutic relationship. The absence of this phase of treatment can absolutely leave you feeling a need for closure—especially because it was your therapist’s decision to end treatment so abruptly, not yours.

Despite your request for a final session, it sounds like you are not going to be able to engage in the termination process with your therapist. Letter writing can be a helpful tool when you have a lot of thoughts and feelings about a person and the person is not available to have a conversation. Perhaps you could write a letter to your former therapist telling her how you feel and asking the questions you are left pondering. You could even write a response to your letter in your former therapist’s voice. You could process this kind of letter-writing exercise with your current therapist in order to get the most out of it. It can be a surprisingly powerful exercise. Your new therapist may have some other helpful ideas, of course.

As far as your questions about ethics and potential recourse, it’s a little less straightforward than it may seem.

As far as your questions about ethics and potential recourse, it’s a little less straightforward than it may seem. According to the American Counseling Association’s Code of Ethics, there is a prohibition against abandonment and neglect: “Counselors do not abandon or neglect clients in counseling. Counselors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, illness, and following termination.” However, there is also a section of the code on impairment that states, “Counselors monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired.” It sounds like your former therapist has just gone through a lot—the death of a parent, returning to her home country, and then retirement. It does seem possible that she might feel too impaired to work.

At this point, it does not seem like you can count on any assistance from your previous therapist in coming to terms with the end of the relationship, but you do have a new therapist who can partner with you to gain the closure you seek. I hope that process brings you peace.

Sincerely,
Sarah

Thank you for reaching out with this honest question. I commend you for having the courage to admit this is happening and to seek counsel for it.

You may be surprised to know that what you are experiencing with your therapist isn’t uncommon. In fact, what you are likely experiencing is a phenomenon known as “erotic transference,” which is when a person experiences feelings of love or fantasies of a sexual or sensual nature about his or her therapist.

[fat_widget_right]

It is easy to see why you might have developed these feelings. Your therapist may embody many, if not all, of the qualities you may desire in an ideal mate. The therapist is accepting, attentive, kind, and nonjudgmental and, for at least an hour every week, fully engaged with you. One of the problems with this sort of situation is that you are falling for an image you have of the therapist, not for who the therapist actually is. You know very little about him, and you have used your imagination to fill in the rest. You have created a fantasy of sorts of your unmet needs and have imagined that the therapist is that person.

It is not “nuts” to share this with your therapist—in fact, it can actually become a significant turning point in your relationship with him. In many cases, this deepens the therapeutic work and allows you to process things on a much deeper level. It will take courage and trust for you to share this with your therapist, but taking that kind of risk in therapy is necessary for growth.

It is not “nuts” to share this with your therapist—in fact, it can actually become a significant turning point in your relationship with him. In many cases, this deepens the therapeutic work and allows you to process things on a much deeper level.

There are a number of ways in which your therapist might respond. Ideally, he will be able to help you recognize what is going on beneath the “crush” in order to get to the deeper material. Many times, therapists in this situation are able to work with the person in therapy and generate meaningful transformation.

Of course, if he is not comfortable with continuing work with you, he may refer you to another therapist. Unfortunately, there is no way I can offer a definitive answer as to how he might respond.

What he ought not do is share that he has similar feelings or act on any feelings. As you mentioned, there are rules in every state that forbid romantic relationships between therapists and the people they help for a certain time period after termination of the therapy (it depends on your state). Regardless of state regulations, the ethics code of the American Counseling Association (2014) specifies that there must be a five-year period between the end of the counseling relationship and the start of a sexual or romantic relationship. It would be highly inappropriate, unprofessional, and, yes, illegal for your therapist to do anything other than work with you through this or refer you to someone else.

I hope you can navigate this with grace and recognize that what you feel can be and often is a part of the therapeutic relationship. In fact, I can’t think of one therapist I know who hasn’t experienced this, so please don’t feel as though you are an anomaly. It’s very normal, but the important thing is how you handle it; be honest, sit with his response, and most of all, treat yourself with the deepest level of care and compassion you can muster.

Best wishes,
Lisa

Oppressed man talking with psychologistThere is something special and unique about the relationship between a person in therapy and his or her therapist. It is a professional relationship, one in which the therapist is providing a service. However, it is also an intimate relationship, one in which secrets are shared, tears are shed, and moments of joy are celebrated. It is an open relationship in that, with consent, your therapist will communicate with other health professionals on your behalf. But it is also a very private relationship, as your confidentiality is held sacred.

A bond and trust are formed in therapy, yet the therapeutic relationship is a bit one-sided; while your therapist learns a great deal about you, he or she is less likely to engage in reciprocal sharing. This is different from a friendship, in which both parties mutually share who they are.

The complexities of the therapeutic relationship are distinct from other relationships, but it is these same complexities that make psychotherapy work. For therapy to be successful, your therapist must maintain healthy boundaries in the relationship and cannot develop a friendship with you.

Because of this, it could seem like your therapist is being fake or disingenuous with you. There have been multiple occasions in which a person in therapy has stated to me, “You don’t care about me, you are only here because this is your job.” It is true that your therapist is doing a job, but this does not mean he or she does not care about you. I rather like and enjoy the people I help. I have had the pleasure of meeting funny, intelligent, successful, and down-to-earth women and men who, had we met outside of therapy, likely would have made good friends. But for therapy to do what it’s supposed to do, your therapist simply can’t be your friend.

[fat_widget_right]

One of the first rules therapists learn is they cannot provide therapy to friends or family. It is too challenging to remain unbiased in friend and family relationships, which is why many people have great difficulty staying objective when it comes to those closest to them. Your therapist developing a friendship with you would ultimately serve to interfere with your therapeutic relationship. Additionally, therapists who become over-involved in the lives of those they help experience higher rates of burnout and decreased efficiency.

This does not mean a deep connection isn’t developed between you and your therapist. Authenticity, warmth, and support are desirable characteristics for any therapeutic relationship. In fact, the relationship between you and your therapist is one of the most important factors in creating a successful therapy experience. The better the fit between you and your therapist, the more likely you are to reach your therapy goals. It just so happens that the relationship remains safely protected from a level of personal involvement that would distract from your therapy goals and success.

Admittedly, it’s odd to share great detail about your life and get little in return from the other person. Fortunately, your therapist (hopefully) is not robotic or an emotionless blank slate. Although you do not have a friendship with your therapist, he or she does not have to be a mystery to you.

This is also not to say you cannot have a friendly relationship with your therapist outside of counseling. Your therapist is unlikely to accept your social media requests or attend social functions you invite them to; however, there are many cases where therapists and the people they help have more than one relationship. For example, a therapist working at a college counseling center could be an adviser for a campus organization in which a person they help is a member. Or a therapist and person in therapy could attend the same church and see one another at church functions. But even though friendly exchanges occur, your therapist is still operating within boundaries to protect your confidentiality and maintain the therapeutic relationship.

Admittedly, it’s odd to share great detail about your life and get little in return from the other person. Fortunately, your therapist (hopefully) is not robotic or an emotionless blank slate. Although you do not have a friendship with your therapist, he or she does not have to be a mystery to you.

As mentioned earlier, your relationship with your therapist is a predictor of therapy’s success; therefore, you and your therapist need to be a good fit. When appropriate, your therapist can voluntarily share personal information, but it is also fair to ask your therapist certain questions. You can ask professional questions about your therapist’s educational background or style of therapy. You can ask personal questions that seem relevant to you. Your therapist has the right to decline to answer any question. There are times when I refrain from answering questions if I believe that, regardless of my response, any answer I give will have some sort of unnecessary impact on the relationship. But often I answer personal questions, as they are not generally meant to be invasive—people are just curious about people sitting across from them.

Curiosity, about ourselves and about our relationships with others, is an important element of therapy. Honoring that curiosity is a good thing. Your therapist is there to help guide that curiosity where it is most needed. So, while you and your therapist can’t be friends, you can be part of a rewarding relationship!

“GoodTherapy | The Power Differential and Why It Matters So Much in TherapyI’m trying to imagine ethics without an awareness of power. That would be like trying not to step on anyone’s toes, without an awareness of one’s feet.” —Susan Mikesic

The power differential is the inherently greater power and influence that helping professionals have as compared to the people they help. Understanding both the value and the many impacts of the power differential is the core of ethical awareness. Written codes for ethical behavior are based on the strong positive and negative impacts of this power differential.

People seeking help are in a position in which they must trust in the knowledge and guidance of their caregiver. This results in a greater-than-ordinary vulnerability. Consequently, people are unusually susceptible to harm and confusion through misuses (either under- or overuse) of power and influence.

Examples of Power Inequality

“The impact of the role, control, and power difference between client and therapist is very strong and also very subtle, and thus demands a strong ethical stance. In brief, your role as the therapist [or any helping professional] is to create a safe space, empower your client, protect your client’s spirit, and to see a wider perspective.” —Hakomi Institute Code of Ethics preface

[fat_widget_right]

Stated another way, there is a power inequality whenever you take on a role that gives you authority over another or creates the perception that you have authority. Power differential roles include: supervisor, clergy, body worker, healer, lawyer, coach, group leader, therapist, counselor, doctor/nurse, mediator, teacher, social worker, massage therapist, guide, and social worker.

Personal Power and Role Power

In talking about the power differential, it is necessary to clearly describe and distinguish between two kinds of power. This distinction is important because it makes clear that the increased power that accompanies a position of authority is role-based and not the same as personal power.

I like to show the difference between these two powers with scarves. When I am a therapist, I have my personal power, of course, but I wear my added-on role power as if it were a scarf. When I leave my office, I take my role-power scarf off. My personal power stays with me. It’s like my scarf has access to and stores information related to the enhanced power that belongs to my role. With my scarf on, I can remember multiple details about my clients’ processes. When I take my scarf off, I can and need to leave those details and responsibilities behind.

This is not a purely black-and-white thing. Of course I continue to have concern about the people I work with in therapy, and I am known as a therapist or teacher even when I am not in these roles. But many misuses of power are a result of the person in the up-power role over-identifying with his or her role power, forgetting that this is a role-based add-on power.

My friend Nancy’s husband, Daniel, is a commercial airline pilot. Until they understood this dynamic, their marital relationship was quite compromised each time Daniel came home and acted as if he were still the airline pilot—a commanding position. Things changed when Daniel ritually took off his hat with the symbolic words, “I’m hanging the pilot on the hook now.”

Up-Power and Down-Power

I refer to those in positions of increased role power as having “up-power” and those in corresponding positions of lesser power as having “down-power.” These are simple and directional terms not intended to indicate disrespect, disempowerment, exploitation, manipulation, better, worse, power over, or power under. Instead, these terms are intended to denote role differences in responsibility and vulnerability.

Up-power and down-power positions have cognitive, emotional, and somatic differences. As an exercise, I ask my students to walk around the room imagining walking with someone up-power to them. My students notice a variety of things—feeling smaller, more cautious, protective, turned inward (or, for some, feeling relaxed, eager, relieved). Then, when imagining walking with someone they are up-power with, they notice feeling more spacious, focused on the other, taller, kind, caring, and alert. It is very clear to them that the two roles are experienced differently. For most, this is a surprise. A student described the difference in this way: “When I’m a practitioner, my personal needs and ‘stuff’ are behind me resting against my shoulders, and when I’m a client, my personal needs and ‘stuff’ are sitting right there in a huge ball on my lap, visible and available.”

We move back and forth daily between being in up-power positions and down-power positions.

We move back and forth daily between being in up-power positions and down-power positions. (Like putting on a scarf or robe when in a role and taking it off when leaving the role, we move from up-power therapists to a down-power supervisee, or up-power doctor to down-power patient, for example.) We are usually unaware of the shift. This unconscious shifting of roles makes it more difficult to clearly understand the dynamics and impacts.

Some up-power roles carry a stronger differential—and, therefore, a stronger risk of harm—than others. For example, the president or a police officer or a therapist has a greater power difference than the chair of a committee or a clerk in a store. But all up-power roles have impacts and dynamics.

Value of the Power Differential

In the helping professions, the power differential has great value. Used wisely and appropriately, it creates a safe, well-boundaried, professional context for growth and healing. More specifically, when used ethically and effectively, the power differential offers people in therapy, students, supervisees, and patients some important assurances:

These values can be reduced to six categories:

  1. Safety, kindness, and boundaries
  2. Larger frame
  3. Expertise
  4. Assigned responsibilities
  5. Accountability
  6. Assessment and productivity

Think about it. When you go to a therapist, doctor, or teacher, you want to be in an environment where you can get what you need. You want the environment to be different than just talking to a friend. When you get on a plane, for example, you want and need the pilot to look and act competent. Wearing jeans and a T-shirt just won’t do. You need him or her to be skilled, to embrace his or her role, and treat you with respect.

Understanding and Owning Your Power and Influence

Because the power differential is role-dependent, it is easy to over-identify with (or get inflated by) this increased or enhanced power. However, it is just as easy to misuse this increased power by under-identifying with it. The central idea here is the necessity to understand and own your role power so that you can be conscious and informed.

Here are several misunderstandings that illustrate the multiplicity of the impact of the power differential for both helping professionals and people who seek help:

The power difference between therapist and person in therapy, or other similar pairs, is the dynamic that creates down-power vulnerability. Down-power vulnerability, based in a role, is what creates the need for ethical guidelines to protect people from harm.

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?

[fat_widget_right]

1. Gather Information: The Informed Use of Power

2. Engage Compassion: The Conscious Use of Power

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:

Questions for resolving difficulties and repairing harm:

4. Resource Yourself: The Skillful Use of Power

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:

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.

Hands and heartIt should go without saying: conversion therapy is an outdated mode of treatment for an issue that is not, and has not been, a mental health diagnosis for quite some time. GoodTherapy.org does not endorse conversion therapy —also known as reparative therapy or sexual orientation change efforts (SOCE)—for homosexuality, nor does it permit mental health professionals to advertise those services to website visitors.

On March 3, 2015, The Huffington Post published an article in which Human Rights Campaign, a leading LGBT rights group, condemned Psychology Today, an online therapist directory, for allowing its therapist members to advertise conversion therapy on its profile pages. A representative of Psychology Today told The Huffington Post that the company did not intend to begin removing or refusing membership to therapists who offer conversion therapy. The backlash and criticism from health professionals, human rights advocates, and others was immediate.

Within 24 hours, Psychology Today had changed its position. In a statement issued March 4, the company asserted that it does not condone conversion therapy, and has notified therapist members that they would be de-listed if their profiles advertised this practice. Their updated stance is in line with what the majority of the mental health community has come to believe: conversion therapy has no place in mainstream mental health care.

Flaws in the Conversion Concept

Conversion therapy, also known as reparative therapy, is a controversial type of treatment aimed at changing a homosexual person’s sexual orientation on the assumption that homosexuality is an inherent flaw or disorder that must be altered. While homosexuality was once listed in the Diagnostic and Statistical Manual (DSM) as a mental health diagnosis, it was removed from the DSM by the time the third edition was published in 1980 with support from the professional mental health community.

In addition to rejecting conversion therapy as a useful treatment, GoodTherapy.org does not acknowledge homosexuality as a mental health disorder. The American Psychiatric Association (APA) agrees; a statement issued by the board of the APA in 1998 states: “The American Psychiatric Association opposes any psychiatric treatment, such as ‘reparative’ or ‘conversion’ therapy, which is based upon the assumption that homosexuality per se is a mental disorder, or based upon a prior assumption that the patient should change his/ her homosexual orientation.”

GoodTherapy.org takes this stand based on mounting evidence that conversion therapy causes harm; leading mental health organizations do not view it as ethical; and it requires the therapist to operate from a fundamentally pathology-based understanding of the person who is seeking therapy.

The APA isn’t the only organization to reject conversion therapy, as research over the course of years has affirmed concerns over conversion therapy as a treatment modality. The American Association for Marriage and Family Therapy, the National Association of Social Workers, the American Psychological Association, and the American Medical Association, among others, have issued statements against reparative therapy. Many cite research that suggests conversion therapy is likely to lead to harmful outcomes, such as contributing to anxiety, depression, relationship problems, self-loathing, and other issues. According to the Pan-American Health Organization (PAHO), “Services that purport to ‘cure’ people with non-heterosexual sexual orientation lack medical justification and represent a serious threat to the health and well-being of affected people.”

Several states consider conversion therapy detrimental enough that they have enforced or are considering bans on it. California, New Jersey, and Washington, D.C. have banned the use of conversion therapy on minors. Other states that have pending legislation to ban reparative therapy include New York, Massachusetts, Illinois, Iowa, Minnesota, Michigan, Ohio, Vermont, Pennsylvania, Colorado, and Hawaii.

Given a lack of research that supports the effectiveness or safety of conversion therapy, the American Psychiatric Association “recommends that ethical practitioners refrain from attempts to change individuals’ sexual orientation, keeping in mind the medical dictum to ‘First, do no harm.’ ”

GoodTherapy.org Philosophy of Membership

GoodTherapy.org is founded on a mission and vision to reduce harm in therapy by educating consumers so they can be equipped with resources and services that will help them achieve their mental and emotional health goals.

When mental health professionals sign up to be listed in the GoodTherapy.org therapist directory, applicants are required to certify that the services they provide accord in orientation and attitude to its Elements of Healthy Therapy Statement. A peer-review team verifies each clinician’s credentials and screens his or her profile content to ensure the person’s practice is in line with elements of good therapy. Profiles are reviewed for questionable content, such as homophobic, sexist, racist, or other discriminatory or harmful practices or beliefs. GoodTherapy.org does not list conversion therapy or reparative therapy as a type of therapy that members can select.

[fat_widget_left]Because the review process for inclusion in GoodTherapy.org’s therapist directory is done on a case-by-case basis by human beings, and because members are able to update their listings at any time, it is possible that an inappropriate listing could appear for a period of time in its directory. However, GoodTherapy.org addresses any such listing as soon as it becomes aware of it and takes action to remove the individual from its directory. Since GoodTherapy.org was founded in 2007, situations like this have been extremely rare.

It is important to note that there are people who seek therapy as part of an effort to change their sexual orientation. GoodTherapy.org’s position is in no way an invalidation of these individuals’ desires to work toward their chosen goals in therapy. GoodTherapy.org respects individuals’ rights to identify their treatment goals and choose treatment modalities that appeal to them for any reason.

It is perfectly acceptable for individuals to discuss, explore, and evaluate their sexual orientation in the context of a therapeutic relationship. Trained therapists should be equipped to support people in these efforts without prejudice or discrimination. GoodTherapy.org works to ensure that it offers people seeking treatment quality choices so they can find a therapist who meets their unique needs.

GoodTherapy.org was founded in 2007 with the mission of:

Toward this end, GoodTherapy.org makes every effort to avoid and remove from its site any content—including blog material and therapist listings—that contains a homophobic, sexist, racist, ableist, or otherwise discriminatory message. Dan Fajans, director of member services at GoodTherapy.org, explains, “Everything we do, from our therapist directory, to our Continuing Education Program, to The Good Therapy Blog, to our GoodCause program and beyond, is first and foremost an effort to put this mission into action. Providing an advertising platform for conversion therapy would be directly at odds with our mission.” GoodTherapy.org takes this stand based on mounting evidence that conversion therapy causes harm; leading mental health organizations do not view it as ethical; and it requires the therapist to operate from a fundamentally pathology-based understanding of the person who is seeking therapy.

Noah Rubinstein, GoodTherapy.org’s founder and CEO, stands behind GoodTherapy.org’s position on conversion therapy both professionally and personally. As a licensed marriage and family therapist who has worked in the mental health field for over 25 years, Rubinstein elaborates:

“In general, any psychotherapy that focuses on trying to depreciate, banish, or exile a psychological aspect of a person at the expense of curiosity, appreciation, and compassion is not in the best interest of the individual. Even with issues such as depression, anxiety, addiction, anger, self-criticism, and nearly every other symptom which motivates a person to seek help, the only agenda ever set by the therapist, in my opinion, should be to help the individual understand the purpose, function, and existence of such an aspect. The decision to help a person change some aspect of themselves should be made by the person in therapy only when he or she is in a psychological state of calm and self-compassion.

“I can only imagine how difficult it is in this culture for some individuals to recognize, accept, and explore their sexuality when it differs from the majority. I assume that those who want to change their sexual orientation are under enormous pressure internally and/or externally to assimilate and that any desire to alter their sexuality does not originate from self-compassion, unless their sexual practices are harmful to self and others—which homosexuality in and of itself is not. The only way to tell, I imagine, would be to first work with an individual to access the internal resources to transcend any internal or external pressures. At that point, one could reach a place of understanding, acceptance, and self-compassion for his or her own sexuality.”

As an organization, GoodTherapy.org reiterates its support for individuals experiencing any type of mental health challenge, in any stage of their mental health journeys. No person should be made to feel inadequate or broken because of a psychological concern, and all people are worthy of healing and love—especially self-love. If you feel discouraged or troubled, or if you feel you have been treated unfairly in therapy, there is hope and help available.

We invite you to share your thoughts or comments in the “Leave a Reply” section below.

References:

  1. APA Board of Trustees. Position Statement on Issues Related to Homosexuality. March 2000. Retrieved from http://www.aglp.org/pages/LGBTPositionStatements.php#Anchor-55000
  2. Herek, Gregory M. Facts about Homosexuality and Mental Health. Retrieved from http://psychology.ucdavis.edu/faculty_sites/rainbow/html/facts_mental_health.html
  3. Millar, Katharine S. The Myth Buster. February 2011. Retrieved from http://www.apa.org/monitor/2011/02/myth-buster.aspx

tidy-work-spacePopular wisdom suggests that a messy work space is the product of a creative and unique mind. At least one study has found support for this claim, noting that a messy space can be a source of creativity and inspiration. If you’re concerned about promoting an ethical environment, though, it might be time to rethink your work space. According to a collection of three different Rice University studies, the feelings of disgust associated with an unclean work space might give rise to unethical behavior.

How Disgust Changes Behavior

Disgust helps protect people from dangerous or questionable situations. The disgust you feel when looking at rotten food, for example, prevents you from eating a potentially toxic meal. The study’s authors speculated that disgust might make people more self-interested, decreasing their willingness to help or notice others. After all, disgust can be an overpowering emotion that provokes an immediate desire to escape the disgusting situation. 

Ethics and Disgust

To test their hypothesis about how disgust affects behavior, researchers induced disgust in nearly 600 participants. In one trial, participants contemplated “disgusting” products such as cat litter, incontinence products, and anti-diarrhea medication. Researchers asked a second group to write an essay about their most disgusting memory, and a third group watched a toilet scene from the movie Trainspotting.

After inducing feelings of disgust, researchers administered a series of tests to evaluate participants’ willingness to lie and cheat for financial benefit. Those who reported higher levels of disgust were also more likely to lie, cheat, and engage in other self-centered behaviors. [fat_widget_left]

In a second trial, researchers induced a state of disgust, then asked participants to contemplate various household cleaners. Participants who evaluated the cleaners were no more likely to engage in dishonest behavior than those who did not experience disgust.

The study’s authors believe their results point to the value of a clean environment. When people feel disgusted by their surroundings, they’re less likely to behave ethically. But when that disgust is “cleaned”—either metaphorically, by thinking about cleaning products, or literally, by removing the source of the disgust—people may behave more ethically.

A 2008 sociological experiment made a similar observation after evaluating the effects of urban disorder, such as litter and graffiti, on people’s behavior. Researchers found that passersby were more likely to participate in vandalism and other minor infractions in environments where these kinds of activities were already taking place. This study was based on the “broken windows theory,” introduced in the early 1980s by Dr. George Kelling to explain how dilapidated areas, like abandoned buildings with broken windows, inspire further vandalism.

Of course, an unclean environment that doesn’t promote disgust, such as a slightly disheveled desk, is unlikely to lead to unethical behavior. For managers, parents, and other people who perpetually ask others to clean up their mess, though, this study provides one more point in favor of a clean work space.

References:

  1. Can the can. (2008, November 20). Retrieved from http://www.economist.com/node/12630201
  2. Falk, J. (2014, November 13). Rice U. study: Disgust leads people to lie and cheat; cleanliness promotes ethical behavior. Retrieved from http://news.rice.edu/2014/11/13/rice-u-study-disgust-leads-people-to-lie-and-cheat-cleanliness-promotes-ethical-behavior/

Thanks for the letter and your thoughtful questions. I am very pleased that you reached out, seeking advice on what to do.

You ask if it’s possible to become dependent on therapy, and as much as I would like to offer a simple answer, the honest answer is much more complex. Many people come to rely on the insight of their therapist and the relationship they foster in the safe confines of the therapy room. However, it is the responsibility of the ethical therapist to create conditions that do not foster or encourage dependence, and to do his or her part in helping a person in therapy learn to function and perhaps even thrive without the therapist.

The point of therapy is not to keep people in therapy indefinitely; if a person is not getting better or otherwise seeing desired results, the therapist has an ethical obligation to stop working with that person. Therapists are also bound by an ethics code that does not allow them to benefit financially if the person isn’t benefiting therapeutically. Additionally, you are always free to choose when you end therapy, unless you are court ordered to attend. On the other hand, many people maintain a relationship with a therapist long term and go in for “tune-ups” when needed—which, of course, is not the same as being “dependent.”

[fat_widget_left]

Beyond any ethical obligations, please know that good therapists thrive off of people getting better. If it was about making money, most therapists would chose a different profession. Most therapists truly care about the well-being of the people they work with. That’s why they do what they do.

As for medication, yes, some meds can be addictive after long-term use. I am not a psychiatrist, so I can’t speak to which medications specifically. There is certainly a lot of fear about becoming dependent on medication, and I understand that fear. However, if you were to seek out therapy and/or medication, the clinician or physician you work with can discuss with you, at length, which medications might work best without being addictive. Also, you have a say in your treatment, so if you want to change or eliminate medication (should you decide to use it), that is always your choice. It is imperative to remember to only make changes under a doctor’s supervision, however.

You ask whether you can get better on your own. That is a question I can’t really answer. There are anecdotal accounts of people who defeated depression without the use of therapy and/or medication, but there are a lot more who did it with the assistance of a mental health professional and/or medication. I believe the best and fastest healing of the things that ail us comes through relationships. Research has consistently shown that people who go to therapy and use medication have better and long-term recovery from their mental health/emotional concerns.

I’m curious, though, whether your desire to avoid therapy has less to do with cost and more to do with stigma. There’s nothing wrong or bad about needing therapy; many people do, including therapists themselves. Even just a session or two of therapy often yields insight and healing that can help a person move forward. I challenge you to view the possibility of therapy in such a light.

I suggest that you interview some therapists; ask them about their methods, how they feel about the use of medication, and how long the people they see usually remain in therapy. The foundation of a good therapeutic relationship is trust, and trust is fostered through honest communication. You can begin building that bridge immediately simply by openly expressing your concerns and sharing your fears. You have every right to ask as many questions as you have, and a good therapist will do his or her best to address and alleviate your concerns. Even if you decide ultimately not to pursue therapy, at least you will have explored all your options.

Sincerely,
Lisa

Video chat communicationIn the Showtime series Web Therapy, Lisa Kudrow plays a narcissistic therapist who administers questionable therapy over the Internet. Life often imitates art, and web-based therapy is no exception, though the therapists engaged in web therapy—also known as distance therapy—are nothing like Kudrow’s character. They’re qualified professionals who want to help people.

Several large and well-respected websites now offer web-based therapy or provide advertisements for therapists who do. The advent of online therapy raises important ethical issues that online therapists may not be fully ready to address.

Skype Therapy: Risks and Benefits

At first glance, online therapy might seem like little more than another way technology makes life easier and more convenient. After all, a therapist who doesn’t have to maintain a brick-and-mortar office can probably afford to charge less. People concerned about being seen going into and out of a therapist’s office may feel more comfortable with web-based therapy, and the easy accessibility of the service means that people can choose from therapists across the country rather than being limited to a specific geographic location.

The problem is that the technology has not caught up to the ethical and legal demands of therapy. Skype and similar technologies may retain records of conversations and calls, but therapists have little control over what happens to this information. The Health Insurance Portability and Accountability Act, better known as HIPAA, mandates that mental health professionals protect client privacy and data, but even the best therapists can’t guarantee that their Skype conversations are private or safe.

[fat_widget_right]

The American Psychological Association weighed in on this issue in an April 2014 practice update. The APA explained that “liability for failure to comply with HIPAA is now shared equally by covered entities and business associates—third parties that provide services to covered entities and may have access to [protected health information]. So it is critical for practitioners to have business associate agreements in place. Yet Skype does not offer business associate agreements for health care professionals who want to use it for telehealth purposes.”

The ongoing controversy about government use of Internet records compounds the concern. The National Security Agency (NSA) may review Skype metadata, and some privacy advocates have expressed concern that government entities have access to everything a user does on the Internet—even web therapy.

At a time when it can be more challenging than ever to protect client privacy, ethical norms are placing an increasing premium on such privacy. The American Counseling Association’s 2014 Code of Ethics requires therapists to protect the privacy of both current and prospective clients. This means an email asking about therapy or a brief online conversation with a prospective client are now forms of health care data that professional ethics mandate must be protected.

Virtual therapy such as Skype poses some other, more tangential concerns as well. For example, it can be harder for a therapist to read body language over a video call, and the environment in which people seeking therapy conduct video chats could be anything but relaxing. Such challenges could reduce the effectiveness of therapy, particularly among therapists who don’t actively work to prevent these problems.

What Could Possibly Go Wrong?

We live in a world where video cameras can be seen on every corner and employers regularly snoop through employees’ email, so privacy can feel like an increasingly remote concept. But confidentiality is a cornerstone of ethical and effective therapy. Marlene Maheu, PhD, an expert in online therapy, has repeatedly argued that Skype can pose serious challenges to professional ethics. “Ultimately, my strong suggestion is that providers proceed with great caution when using Skype or similar non-HIPAA-compliant platforms,” Maheu told GoodTherapy.org.

Consider the following ways Skype therapy can compromise a client’s well-being:

Balancing Privacy and Convenience

The challenges posed by Skype don’t mean that mental health professionals have to give up on web-based therapy altogether. Maheu argues that there are other options. “The beauty of Skype is that it is easy and free,” she said. “The truth is that several HIPAA-compliant platforms are also free and/or low cost, as well as easy to use.” Maheu maintains a list of HIPAA-compliant platforms on her website.

People who want to give online therapy a shot should ask their therapists the following questions:

There’s no denying the convenience offered by Skype, but the consequences of poor privacy standards can vastly outweigh the convenience of distance therapy. Both therapists and people seeking therapy should proceed with caution before sharing personal information via Skype.

References:

  1. Huggins, R., LPC, NCC. (2014, April 2). Initial client contact by email & the 2014 ACA Code of Ethics. Retrieved from http://www.personcenteredtech.com/2014/04/initial-client-contact-by-email-the-2014-aca-code-of-ethics-vs-hipaa-1st-in-a-series/
  2. Maheu, M. M., and McMenamin, J. (2013, March 28). Telepsychiatry: The perils of using Skype. Retrieved from http://www.psychiatrictimes.com/blog/telepsychiatry-perils-using-skype
  3. Practitioner pointer: Does the use of Skype raise HIPAA compliance issues? (2014, April 24). Retrieved from http://www.apapracticecentral.org/update/2014/04-24/skype-hipaa.aspx
  4. Zur, O. (2014). Utilizing Skype and VSee to provide TeleMentalHealth, E-Counseling, or E-therapy. Retrieved from http://www.zurinstitute.com/skype_telehealth.html#debate

Thanks for your thoughtful question. I’m going to do my best to answer it and to alleviate some of the concerns you have expressed.

The most important thing to address here is your statement that if your personal issues were to get out, it would be damaging to your reputation. I’m not sure how much you know about the ethics of counseling and therapy, but one of the most important guidelines is that anything that a person shares with his or her therapist is confidential (with the exception of imminent risk to self or others or in the case of child/elder/dependent abuse). There are other, less common situations where confidentiality is not protected, but those are very rare. Also, the laws may differ by state, but by and large those are the two most common cases where confidentiality isn’t guaranteed. With that said, I understand your concern about privacy and your desire to be sure that you are protected as best as you can be. I hope that this knowledge will help you to feel safer as you consider whether to seek a therapist.

[fat_widget_left]

As for the next aspect of your question, it is not uncommon for people to seek out therapists with similar belief systems, especially when it comes to religion or spirituality. After all, some people tend to feel more comfortable with someone who shares those beliefs. There are some therapists who have no problem sharing their beliefs with a person considering therapy, and even those who specify their spiritual or religious affiliations up front. The other aspects you’re looking for (political, social) in your therapist might be more challenging to find, as many therapists might not feel comfortable discussing those views so early in the therapeutic relationship, if at all. It is quite likely, in fact, that a therapist will not discuss those issues, as they are intensely personal and private matters. Ethically, the therapist is not prevented from discussing personal views so long as it is in service to a person’s progress, but I would venture that many would feel that answering those questions prior to an appointment might be out of bounds.

As you already mentioned, therapy is not about your therapist but rather about you and your process. While you might feel more comfortable with a therapist who has similar views, it is quite possible that you may not find someone who meets your expectations. I do wonder why you feel that you can work only with someone who shares your beliefs. Given the laws and ethics governing confidentiality in therapy, whatever you tell the therapist (outside of the rare exceptions I outlined above) will remain confidential. Unless what you are sharing with the therapist is putting you or others in imminent danger or involves abusing others, you are protected. Regardless of political, social, or spiritual beliefs, ALL therapists are bound by this code of conduct. Not only is violating the confidentiality of a person in therapy unethical, it is illegal. That protects you far more than a shared belief system.

Your letter also mentions that you live in a small community. That factor alone makes it more difficult to find a therapist in your area who will share your beliefs because there are likely to be fewer therapists to choose from. If that is the case, I would hate for you to not seek therapy as a result. I wonder if your desire for your therapist to share your beliefs isn’t a way to limit the possibility that you will seek help if you can’t find the “perfect” fit. I hear that you feel vulnerable, and I want to acknowledge that this process can be very scary and feel risky. Indeed, it is risky to trust someone with your deepest secrets, and I applaud you for considering taking this journey.
I would also like to invite you consider your other possibilities. There are therapists who may not share your beliefs but who can be great catalysts for change nonetheless because what facilitates change in a therapeutic relationship is not shared values or similar beliefs—it’s the relationship between the therapist and the person in therapy. That je ne sais quoi of the healing relationship is not something that can be predicted by anything other than a mutual willingness to engage in the process.

I encourage you to reconsider your position given the information I have shared and to at least explore some of your options. Call and make some consultation appointments. Go meet some therapists and see how you FEEL when you are with them. Talk about your concerns about confidentiality and how you feel vulnerable undertaking this process. Give them a chance to see you and be seen. You might be pleasantly surprised to find that even someone whose belief systems are unknown to you can be very welcoming, accepting, nurturing, and can be a great agent of change.

Best wishes,
Lisa

Important Notice

GoodTherapy is not intended to be a substitute for professional advice, diagnosis, medical treatment, or therapy. Always seek the advice of your physician or qualified mental health provider with any questions you may have regarding any mental health symptom or medical condition. Never disregard professional psychological or medical advice nor delay in seeking professional advice or treatment because of something you have read on GoodTherapy.