The Vulnerable Therapist

Practicing Psychotherapy in an Age of Anxiety

Helen W. Coale

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780789004802
• eBook ISBN: 9781317790990
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

A passionate, proactive stance on the present state of psychotherapy, The Vulnerable Therapist: Practicing Psychotherapy in an Age of Anxiety picks the brains of contemporary mental health professionals and finds a common symptom--fear. You'll see why litigation, market forces, and ethical confusion have raised a dark umbrella of angst over psychotherapy practices and discover what therapists can do to restore the profession to its former good self.The Vulnerable Therapist will capture your interest with its broad systemic approach, contextual analysis, fascinating case studies, and anecdotal material. You'll see the need for improvement at the institutional and individual levels of the psychotherapy professions. Specifically, you'll read about:

• social, cultural, and contextual aspects of the crisis of meaning in psychotherapy
• professional responses to the crisis of meaning which create ethical dilemmas for individual practitioners
• the power of language to construct and control mental health beliefs
• psychotherapy's core constructs and ethical "buzzwords"
• psychological and legal risks in practicing psychotherapy today
• specific problems with licensing boards and other complaint channels
• problems with rule-based ethics
• alternative models for creating ethical therapist-client relationships Today, more and more, excessive litigation and market-driven forces are imposing standard ethics decisions on psychotherapists, forcing them to see their clients through the clouded lenses of risk management and liability instead of through the lens of therapeutic need. Much like the symptomatic children whose dysfunctional family stops blaming them and starts shouldering part of the "problem," distraught therapists need the psychotherapy profession to address its own psychopathology at the institutional level. The Vulnerable Therapist shows how you can contribute to a total revamping of the mental health professions in a way that facilitates rather than impedes ethical functioning.

Chapter 1

Introduction: Ethical Contexts, Ethical Rules

… [W]e ask of a proposition not whether it is true or false, but in what kind of possible world it would be true.

—J. Bruner Actual Minds, Possible Worlds

… [W]e do not relate to life “itself” but to our understanding of it.

—T. Andersen “Reflections on Reflecting with Families”

This book is an exploration of therapist and client vulnerability in a professional context that is increasingly (and unethically) rule-based. While giving lip service to client protection, the mental health professions are equally concerned with risk management, i.e., with protecting the therapist from threats of litigation and ethics complaints by clients. This pits clients and therapists against one another and exacerbates the vulnerability of both.

What we need is a total revamping of our basic premises about ethics. We must move from rule-based ethics, which minimize rather than maximize healing possibilities in therapy relationships, to context-based ethics, which encourage ethical thinking, feeling, and behaving that are relevant to the uniqueness of each client and each client-therapist relationship. Context-based ethics facilitate ethical decision making as a process, not as a regulation, and rely on therapist use of self in relationships. Attention to the uniqueness of each client-therapist situation and the capacity of the therapist to facilitate an ethical process is the focus.

WHAT IS CONTEXT?

By context, I include not only the system of people involved in any therapeutic endeavor—the clients, their families, the professional helpers, their behaviors and interactions--but also the collective meaning in each system. This is consistent with constructivism’s emphasis on the problem-determined or linguistically-determined system, the system of meaning, rather than people (Epstein and Loos, 1989; Goolishian and Anderson, 1988; Hoffman, 1985, 1990). Thus, context is how people talk, think, and believe about a problem.

To illustrate, take the simple example of a behavior such as drinking wine. Drinking wine has different meanings depending on the context. In a communion service it has a spiritual meaning. At a wedding celebration it has a ritual meaning. At a cocktail party it has a social and, perhaps, a business meaning. At an AA meeting it has a deviant meaning. In a therapy office it has an unethical meaning. In every context the meaning varies. And even within one context the meaning is different for each individual participant.

There are certain consensual meanings inherent in any therapy context. Therapy is a process in which one or more persons meet with a professionally trained therapist to solve a problem that they have been unable to solve, usually because they have become demoralized about the chances of doing so (Miller, Duncan, and Hubble, 1997). The therapist has expertise and power along with caring and compassion. The client gives up some power and trusts the therapist to work in her best interests, not exploiting her sexually or in any other way. Hopefully, by the end of therapy, the therapist will have helped her solve the problem.

Beyond this very general meaning, each therapy relationship--depending on therapist theoretical orientation, person of the therapist, practice setting, and individual client—varies in the meanings cocreated between therapist and client. The problem definition and resolution plan will be different in each situation. The same symptom can be defined in a myriad of ways. The same resolution behaviors between therapist and client can have many different meanings depending on the context of the therapist-client relationship.

The symptom of bedwetting, for example, can be viewed by the therapist as a physiological problem, a behavioral problem, a family organizational problem, a stuck problem/solution/problem cycle, a developmental crisis or delay, or a product of symbiosis in the parent-child dyad. From the child’s perspective, bedwetting may be a nonproblem, a physical discomfort, an anxiety-provoking scene because it upsets his parents, a barrier to spending the night with other children, a way of getting back at perfectionistic parents, or a mysterious force that visits him in the night. From his parents’ perspective, it may be something he will outgrow, a hostile rebellion, an ordeal, a sleep disturbance, a sign of parental deficiency, or a hereditary problem.

Putting together everyone’s beliefs in a consensual meaning that conveys a plan for problem resolution, is the task of the therapist and clients together. Each situation will be different. The same behavior bedwetting—can be resolved in a multitude of ways depending on how the clients and the therapist together define the problem’s meaning.

If the resolution plan is taken out of the context of consensual meaning, it is useless. Hence, therapists who “apply” interventions “to” clients usually find that the solutions do not work because the therapist’s meaning about the problem does not fit the client’s meaning. A therapist who, for example, understands bedwetting as a symptom of cross-generational coalitions in the family, paired with parents who insist that the child will outgrow it, will encounter only resistance in trying to strengthen the marital bond and detriangulate the child. She has to first build some bridge between her meaning of the symptom and the parents’ meaning that can then evolve into something with which the parents can agree. Many therapy failures occur because the therapist intervenes with her meaning before building such a bridge with the client. When the therapy fails, the client is then labeled resistant.

Perhaps, in the above example, the child’s meaning will assist the therapist in building the bridge between her meaning of the symptom and the parents’ meaning. Let’s say that the child understands bed-wetting as a kind of monster that overtakes him in the night. The therapist can combine her organizational theory and the parents’ developmental beliefs with the child’s monster theory. If a monster is disrupting the family by causing troubles upon which the parents must focus, keeping them from getting a good night’s sleep in the marital bed (therapist’s organizational theory), do the parents have hope that as the boy gets older (parents’ developmental theory), he will have the strength to kick the monster from his bed (child’s theory)? How old do the parents feel the child must be to do this? Do think it is time to him in this endeavor now?

If the parents agree with this meaning, then they, the therapist, and the child can begin developing a solution. Perhaps their strategy will be to establish ways of kicking the monster out of the child’s bed (White, 1984). Perhaps they will make friends with the monster and “tame” it. The possibilities are endless; they all emanate from the consensual meaning that therapist and clients create together.

Suppose the therapist, in talking about the case, presents only the solution behaviors to her colleagues. She tells them that her latest solution for bedwetting is to ask the family to get up in the middle of the night and talk to the monster that causes the bedwetting. Depending upon theoretical orientation, the listeners might interpret this as a kind of ordeal therapy or as an exaggeration of the parental detour of marital problems through the child’s symptomatic behavior and, hence, an attempt to restore appropriate hierarchy in the family. They might see it as a pattern disruption, or perhaps delusional thinking on the part of the therapist for accepting, rather than trying to correct, the child’s primitive thinking. Unless the therapist explains the meaning context of the bedwetting cure, her approach cannot be understood by the listening therapists.

THE RELEVANCE OF CONTEXT TO PROFESSIONAL ETHICS

Because the nature of the therapist-client relationship—and the meanings that evolve within it—are, by necessity, ambiguous, the context in which ethical decision making occurs is also ambiguous. What is ethical in one situation is not ethical in another. Ethical meanings vary. The imposition of the therapist’s ethics on the client, without an attempt to build bridges to the client’s ethics, does not work any more than the imposition of any therapist meaning on the client. Ethics are shaped in the context of the client-therapist relationship.

To continue with the bedwetting example, suppose that the monstertaming idea works and, at the end of the therapeutic relationship, the child and parents request closure through a ritual honoring the monster’s retirement. The child, with the parents’ full support, wants to have a ceremony by his bed to ban the monster from soiling his sheets. The therapist is invited to be a part of the ceremony and agrees to consider it. In the ethics of parents and child, inviting the therapist to their home for such a ritual is congruent with the therapist’s involvement in taming the monster. For them, it is a healing way to terminate the therapy relationship.

In considering the family’s request, the therapist takes into account the appropriateness of it from their point of view and decides that the ritual will be an important part of everyone’s closure. She discusses with the family some of the possible complications regarding how the family will experience shifting from her office to their home and, in this conversation, realizes that the family is totally comfortable with this shift. She makes the home visit, participates in the monster’s retirement ceremony, and celebrates the family’s success.

Later, the therapist describes the termination session in a conversation with colleagues. Without understanding the entire treatment context created between therapist and clients, several colleagues challenge her on the appropriateness of her boundaries in shifting from office to home. They suggest the possibility that she was participating in a social, not a therapy, agenda with the family. They express concern that she could be accused of creating an unethical dual role with the child and his parents.

This is the kind of thinking that is prevalent in the mental health professions these days. Behavior taken out of context can be framed as unethical. The same therapist, working with a different kind of client, would not consider a home visit as part of the treatment. With the monster-taming family, however, a home visit was congruent with the treatment frame and was inherently ethical. To refuse to participate in the monster’s retirement, based only on the profession’s paranoia about the ethics police and without regard for the family’s genuine and appropriate wish for this kind of closure, would be unethical.

Ethics are contingent on context. There is no way, given a few exceptions such as sexual or business exploitation of clients, that ethics rules can be legislated. What is ethical in one situation may not be ethical in another. As discussed in the following section, rule-based ethics circumscribe ethical thinking.

PROBLEMS WITH RULE-BASED ETHICS

There is a saying, tu puedes saber muchas cosas, you can know about things, but it is not the same as sentido, possessing sense. (Estés, 1992, p. 188)

The problems with rule-based ethics include the following: their lack of attention to the variability of human need; their use as a substitution for ethical thinking; their privileging of professional over client voices; their ethnocentric representations of reality; their hidden agendas; and their legal, risk management emphasis.

The Variability of Human Need

As illustrated in the monster-taming case, rule-based ethics do not fit every situation. A home visit that is appropriate in one client-therapist relationship may be intrusive in another. Self-disclosure, touch, boundaries, and all of the other buzzwords in our current codes vary in their ethicality in each individual client-therapist relationship. Uniform truths simply cannot be applied to human relationships because they do not take into account the immense variability of human need, emotion, cognition, and meaning. Rule-based ethics rest on the assumption that clients are basically alike and therefore require uniform therapeutic responses. They also ignore legitimate variations in therapist theoretical orientations and personal characteristics that inform treatment decisions.

The Privileging of Professional Truths

The uniform application of rules to different therapist-client relationships is unethical because it favors the professions’ needs and definitions of reality over the client’s. It assumes that the various professional institutional bodies know the “truth.” Not only does this disempower clients, but it is also problematic because professional “truths” have been responsible for grave harm done to many people. In the name of truth, psychiatry created tardive dyskinesia. In the name of truth, psychology proclaimed racial differences in intelligence. In the name of truth, marriage and family therapy blamed poor marriages for all schizophrenic offspring. In the name of truth, all of the mental health professions have contributed to pathologizing and disempowering the individuals and families they are purported to serve. As discussed in Chapters 5 and 6, nowhere is this pathologizing and disempowering more evident than in the traditional gender bias of many of the professions’ beliefs.

The mental health professions have traditionally had a one-sided view of power, authority, and expertise (Marmor, 1983). A therapist-as-expert mentality disempowers the clients we serve.

The “rights” may be the client’s, but the therapist holds the power to define the client’s reality and to set the tenus of the therapeutic relationship… . Nowhere is the concept of shared power encouraged, or even discussed. (Ballou, 1990, p. 240)

In the real world of psychotherapy, clients do have power. They are not simply passive recipients of services given to them. Power imbalances beg to be rectified. Clients can “refuse” to get well, prematurely terminate treatment, or file an ethics complaint against the therapist as a way of doing so.

I was in the hospital for some diagnostic tests a couple of years ago, sharing a room with a woman who was scheduled for major back surgery the following morning. I listened as her surgeon brusquely reviewed the litany of things that could go wrong in her operation and then closed his monologue with “I’ll see you in the morning,” thereby staving off any conversation with her. While he was functioning according to the basic rules of informed consent, his whole manner screamed of protecting himself from malpractice claims; there appeared to be no genuine concern for the patient. When he left the room, I noticed that the woman was crying and asked if she felt like talking. With tremendous relief, she sobbed out her fears about the surgery and her pain in being treated like an object by the surgeon.

This example is from a medical, not a psychotherapeutic, setting. But all of the psychotherapy ethics codes are headed in this dehumanizing, rule-based direction. Even where there have been attempts to change ethical principles in ways that would enhance the healing potential of the therapist-client relationship, they have been absorbed into the rule-based approach. Feminist therapists, for example, challenged the hierarchical ordering of knowledge in psychotherapy and called for a more mutual process in which women’s “knowing” is as privileged as therapist “knowing.” One of the natural outcomes of this recommendation was an emphasis on talking with female clients, indeed with any clients, about all of the choices and ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• About the Author
• Table of Contents
• Preface
• Acknowledgments
• Chapter 1. Introduction: Ethical Contexts, Ethical Rules
• Chapter 2. The Crisis of Meaning in Psychotherapy and the Vulnerable Therapist
• Chapter 3. Social Constructionism and Its Implications for the Mental Health Professions
• Chapter 4. Language: Some Theoretical Considerations
• Chapter 5. Diagnosis: The Power to Name
• Chapter 6. Social Constructionism’s Challenge to Traditional Mental Health Beliefs: Some Additional Examples
• Chapter 7. The Language of Professional Ethics: Some Buzzwords
• Chapter 8. Legal Vulnerabililty: Context
• Chapter 9. Licensing Boards, Malpractice Actions, and Profiles of Complaints
• Chapter 10. Psychological Vulnerability
• Chapter 11. Alternatives to Traditional Models
• Chapter 12. Toward an Ethic of Multiplicity and Mutuality
• Chapter 13. Toward an Ethic of Care, Compassion, and Character
• Chapter 14. Toward Transformation
• References
• Index