Dan Sankowsky: from the inside
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Essays/Articles :: Counseling
Therapy and Theoretical Abuse (pdf version)
Individuals who seek counseling are immediately at a huge power disadvantage with respect to their therapists. In choosing to seek that kind of help, clients tacitly typically grant therapists not only the status of possessing superior knowledge about human behavior and emotions, but they also assume these individuals have the capacity to apply that knowledge so as to understand (what's best for) clients more than the clients do themselves. This is a model of expertise that extends assumptions about doctors and lawyers, who would claim they know what is wrong with the patient/client and can probably fix it as well.
The difference between those contexts and the therapeutic setting is the totality of knowledge — it's not limited to a gall bladder or a civil suit. Therapists are presumed to know — or have the capacity to do so — the whole person, in terms of "who s/he is," again, more than the client him or herself. To avoid manipulation of that advantage is an awesome charge. Many therapists fail to do so. Besides the egregiously "overt" unethical instances of therapist using client vulnerability for personal gain, e.g. sexual favors, a much more subtle, widespread, often inadvertent and even well-intentioned form of taking advantage of the power differential is readily available. Following Michael Basseches, I will refer to a phenomenon called "theoretical abuse," for which the focus is the meanings ascribed to various aspects of both the client's personal experience as well as of shared events in treatment.
Theoretical abuse occupies center stage in this writing. Briefly, I want to explore some aspects that often go underground. Defined as the therapist's putting his or her sense-making needs ahead of the client's, or as using his or her presumed knowledge superiority at the expense of the client, it speaks to the therapist's failure to provide the resources necessary for the client to grow in terms of increasing self-awareness, surfacing restrictive assumptions, and finding new behavioral choices. In some cases, a therapist will cling to a diagnosis, pigeonholing a client who has signaled however fleetingly a need for "further review. " When treatment founders, therapists always have the out that the client "resisted." If the therapist communicates that to the client, far more often than not, the latter will accept that explanation, out of deference to the therapist's status as expert psychological sense-maker.
Theoretical abuse, then, focuses on the meanings attached to events rather than other sorts of manipulations of power. Having sexual relations with a client, for example, would invariably be an abusive act within the relationship, but it only becomes theoretical abuse when the therapist tries to convince the client of its mutual benefit ("this is good for you too!"). More commonplace would be rigid adherence to a belief system, e.g. practitioners of the 70s revolutionary primal therapy who were convinced that every client at a certain stage of treatment should seek out and undergo a cathartic release related to any event that triggered painful emotions. On the other hand, a therapist practicing behavior modification in a rigid way would have an entirely different way of understanding the client's plight and would offer a different direction to pursue.
The rest of the essay seeks to make distinctions about the type of theoretical abuse, about client response, and about psychological consequences for clients so abused. Examples will help to clarify the issues.
Active versus passive abuse
When therapists advocate for a point of view without nurturing or inquiring into their clients‚ this is likely to be theoretical abuse of the active kind. Such an apparently anti therapeutic stance occurs more frequently in clinical settings than we would like to think. One reason for pushing an explanation to a client about his or her woes is a strong, and often closed, attachment to theory. It may satisfy the therapist's sense-making if he or she can fit the client issues neatly into a theoretical niche. Rarely is the therapist doing this out of malice: he or she is enthusiastic about the treatment protocols and excited when a scenario appears to fit in.
For example, at a clinic that emphasized working directly on body "armor," a rather loquacious client struggled to connect to the therapy. His counselor was particularly enamored of terse utterances and seemed to feel it necessary for clients to struggle with and be frustrated by having to channel their words into physical movement. When the therapist did speak, it generally involved a metaphor. Explanations or directives were withheld, for the theory indicated that they provided an intellectual escape from the real work that had to be done. This therapist seemed to take pride in coming up with pithy synopses of situations, often reiterating general aspects of the theory that clients already knew.
In another context, a client seemed to involuntarily assume a posture consistent with being battered from behind. Her therapist was a woman who liked to explain and generally had fairly credible explanations. This time, she suggested to the client that her body might be remembering an act of rape at a young age. Horrified by this notion —which in fact turned out to be true — the client pulled back, away from the therapist and therapy. This breach lasted several months until finally she found a new therapist who created a nurturing therapeutic environment. That led to the client's realization that she had been molested by her father at age 4. It also turns out that the original therapist had also been raped as a child, by an older brother, accounting perhaps for some of her zeal in pushing that kind of trauma explanation onto her client.
Sometimes, a therapist can abuse by being supportive when the client needs him or her to be investigative. In general, theoretical abuse occurs when the therapist fails to elicit, elucidate, and explore the client‚s sense making — how he or she understands what has happened and what is now happening, and the link between them. This definition helps clarify passive abuse which most often occurs in the absence of therapist advocacy or intervention.
Passive abuse is best exemplified in the stereotypic reflexive reflecting back, "and how does that make you feel?" often associated with psychoanalysis. By trying not to take a stand at any point, therapists run the risk of failing to explore the client's world. By trying not to impose, therapists end up creating conditions whereby clients resort to and/or regress to self-doubt, self-recrimination, and self-blame. For example, in the absence of significant therapist feedback and inquiry, lack of progress becomes increasingly likely. Then clients will more often than not attribute that lack to themselves— more later— assuming it can't be the therapist's fault because the therapist knows what's best. Free association, for example, tends to self limit with the client needing a push and a probe from time to time. If sufficiently motivated and with the right balance of exploration and support, clients are likely to be receptive of therapist intervention, and as a result, discover not only their sense of the world, but connect to a greater set of possibilities.
Three fertile arenas that possess an innate degree of interpretive ambiguity are client personal events, either past or present, client-therapist interaction, and client progress. Often, the two parties diverge when explaining the meaning of events in these contexts. For instance, a client may be in denial of the impact of certain childhood based parental behaviors; a therapist may reject a client's request for an extra session or for some support; a therapist might suggest the need to supplement the sessions with medications, ready and willing to refer the client to a psychiatrist; or the client may decide that he or she is getting nowhere in treatment.
Either party, as is evident from the above examples, can bring a point of view to the table. The other responds. If the client has the initial say, we are interested in his or her response to the therapist's reaction. If the therapist advances an idea first, we again seek to catalog client response.
Three broad categories are contesting, complying with, and colluding with the therapist's sense-making— whether this sense-making represents theoretical abuse or a benign position reflecting his or her general knowledge and experience. The therapist may initially be innocent of all charges and yet later lapse into abuse in response to client response.
Obviously, this typology is presented in ascending order of vulnerability to the abuse: the contesting client sees the differences and maintains his or her own view, whether rightly or wrongly, persistently or stubbornly; the complying client sees the differences, but then is persuaded to "come around" to the therapist's apparently superior meaning making; and the colluding client sees only the therapist's position. It should be noted that in each case, we are assuming that theoretical abuse has already taken place, either by active "assault" or by failure of omission, to elicit, elucidate, and explore client meaning making. For example, when we indicate a client is complying, this is not to say that the therapist has engaged him or her in a dialogue and then facilitated an internal move from one sense making schema to another. Rather, having already attempted to impose a point of view with no such dialogue, no such elicitation, the therapist's "weight" finally wins out— the client is "forced" to agree, in the face of superior reasoning, wisdom, or assumptions to that effect.
(Whether the therapist's pronouncements are "accurate" or useful is not the issue. Under scrutiny is his or her capacity to do the 3 Es for clients: elicit, elucidate, and explore their meanings. If the therapist ultimately seeks to convince a client of an explanatory point of view, that in itself does not constitute abuse, provided an adequate delving into client thinking has been performed and the therapist remains open to being convinced of that point of view as well.)
When the client contests the therapist meaning, he or she openly argues against it, trying to persuade the therapist to come around to his or her way of thinking. Often, the client's sense-making is dubious: denial when it comes to personal history, unrealistic expectations when it comes to the interaction with the therapist and around progress in treatment. But the therapist of course needs to work through all this by using the 3Es. Otherwise, theoretical abuse is the likely result.
Of course, there are times when therapist issues get in the way and bias his or her judgment. A contesting client's accuracy and self-awareness, however, will not prevent theoretical abuse— only the therapist's honesty, openness, and discipline will, coupled with use of the 3Es.
Some clients are particularly vulnerable to theoretical abuse and some therapists wield various personal powers so effectively as to induce compliance and even collusion. These powers are the TEA, i.e. transference, expertise, and advocacy (this refers to how persuasive the therapist is in presenting an explanation). Charismatic therapists have high TEA power and thus have the ability to induce compliance in most clients. Collusion results when clients' vulnerability is also high. We will proceed to look at the consequences when clients either comply or collude, understanding that they are more severe and more insidious in the case of collusion.
Generally, the complying client loses confidence in his or her meaning-making capacity. And the lack of a dialogical process, the undiscussability of these concerns within the relationship, diminishes trust— but this loss of trust is also internalized, so that the client loses trust in him or herself (the therapist is always "right" when they disagree).
The most critical psychological consequence of a colluding response to theoretical abuse is the internalizing of various relational decrements within the self— that is, the colluding client turns it all inward and suffers false ownership of the shortcomings of the relationship and of the therapist as well. For example, the therapist is in a position to hide his or her issues, including fears, needs, and hurts; the colluding client in effect picks them up, absorbing them as if they were his or her own to start with. In effect, the client doubles his or her pain.
As a result, the client's experience of self is significantly diminished and his or her probability of failure to progress is enhanced. Further sense making then takes place on the level of attribution (for the poor performance). Typically, lack of ability, lack of effort, task difficulty, and random noise are offered as reasons for poor performance in many venues. Having made the effort and having seen others succeed, implying that the "task" is doable, colluding clients fix on lack of ability. In this context, this means having a sense of being inherently flawed as a human being with no prospects of growing/changing in the future. Summarizing, theoretical abuse in this context— a therapist with high TEA power and a colluding client— often leads to unsuccessful treatment for which the client takes all the blame, leaving him or her with a rock bottom self concept.
The previous paragraphs should caution both therapists and their prospective clients of some typically concealed dangers inherent in the treatment process. Add to the above scenario the disclaimers made by most therapies that often clients feel the worst just before they make significant breakthroughs. This only exacerbates the abused colluding client's plight, for he or she is not only suffering, but is also left hanging with no way of distinguishing between different kinds of bad feelings. This is not a community-minded sharing; theoretical abuse not only serves the therapist, but also saddles the client with the therapist's emotional garbage. Buyer beware!