It matters that people have a way to use the latest findings in psychology beyond buying a pill for depression. It matters that people have a way of looking at their lives that lets them ask the big questions and determine how they want to live – and that this is supported by therapists and mental health professionals.

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Power, Influence and Will

Posted on 03 Jan | 0 comments
We all have to make our own choices
We all have to make our own choices

Question: is someone good if they do good because they are forced to?

Imagine I find a Bernie Madoff in the act of stealing millions. Imagine I force him at gunpoint to phone up his investors and come clean, and wire the money back. Would this hypothetical Bernie then be a good, ethical business-person

Imagine I find a person in the act of killing another person. I force them to stop by physically pulling them away and removing their weapon. Have I made them less murderous? Are they a better person now than when they had the weapon in their hand?

In examining the nature of power in the therapy relationship, we have to examine first the nature of freedom. Nobody is really very free; we are at least mostly determined. We have not chosen our families, we have not chosen the circumstances of our birth, we have not chosen our childhoods, we have not chosen our genes or our society. As we mature, we are increasingly capable of choosing these things, or at least how to respond to them and how to influence them. How much we are able to be conscious of and choose these things is largely a matter of chance, until we become more conscious, and then largely a matter of will.

When a person enters therapy, it is generally because they have problems. This has been less true in the past, and hopefully will be less true again in the future, but for the present time the statement stands. We can see many of these problems as problems of freedom. Existential psychology as conceived of and described by May and Schneider (1995) sees the fundamental process of therapy as one of liberating people by increasing their awareness of the things that influence them and of their own process. (With apologies to both gentlemen for a nutshell analysis that by definition cannot do the work justice).

But at the beginning of the work, the person is surrounded by determining factors – things that control them, make them this way or that way, make them do this thing or that thing. And as Herbert (1965) understands, a beginning is very delicate. We need to attend to balance now because it will be very difficult to make corrections later. If we accept humans as complex and the relationship between humans as dynamical, then the initial conditions are very important. The end result of therapy will depend heavily on the initial conditions.

Now the therapist is someone with a great deal of power. The therapy-goer has come to the therapist looking for help or for answers. The therapist is cast into the role of expert or teacher or mentor – all precarious positions. It would be easy to act in that role, setting the initial conditions such that the therapist is powerful and the client a mere learner, advice-taker, student; they are not as good, not as accomplished, not as wise; they must ever-after come seeking advice and wisdom.

Perhaps just as importantly, the therapist may not disregard this role entirely. The will of the therapy-goer is to find comfort and wisdom and an expert. A complete denial of this role might be counter-productive. And it may even be impossible in many contexts. The therapist is educated and accomplished, perhaps, with many publication credits, letters behind their name, and respect in the community. Moreover, the job of the therapist might be to diagnose and treat some mental illness, or else forego support from insurance, grants, or the regional system in which they operate.

Unto this come the therapy-goer, problems in hand, ready to get help. How do we begin? What balance must we strike to help the outcome be a good one?

Recall the opening lines about the nature of goodness and coercion. One cannot coerce goodness into another person or evil out. At best, one can prevent the evil actions. When we enter the therapeutic relationship, there is a power differential, and we must be careful how much of the will that is enacted in that relationship comes from the therapist, beginning with what the therapy-goer wants from the therapy.

If we begin from the metanarrative that difficult feelings are dysfunctions and they must be eliminated, it is relatively easy to convince most people that this is the truth. We will then embark on a course of therapy that minimizes symptoms. Has the client chosen this, or have we chosen this for them? One might hope the decision was mutual, but how much mutuality is there really? The person has come asking for help and readily believed that this is what help looks like. They are convinced because a) they are suffering and ready to reach for any balm for their wounds and b) the unavoidable authority of the therapist makes their arguments more readily believed and c) any decision made in absence of all the facts is not a free decision.

Imagine the outcome of a therapy of this nature. The client comes to ‘manage’ their feelings like employees on a production line, a “101 days since last breakdown” sign in the background. They feel better – at least for a while – and they may not care why or what it costs.

What if, instead of offering only one balm, the therapist offered a menu of balms, with the costs written clearly? Here we have CBT. It makes you feel better fairly quickly, and is not very interested in really deep life change in most cases. Here we have a depth therapy. You might feel better fairly quickly – a lot of folks do – but that is unlikely to be enough to sustain you. Once you feel better, the goal is often something much more difficult, some more core life change.

It is a fairly simple matter to not sell one’s brand of therapy too hard, as long as one is conscious of this. A complicating factor is that belief in one’s model is a key ingredient to success, and belief in the model leads to the temptation to sell it or convert others, but this is another story.

More difficult is to avoid other kinds of influence. Say the person is presented with a form to fill out. At the top, it says “symptoms inventory.” The questions all ask for how many times a day, week or month the person has felt a certain way (say, anxious) or had a certain kind of thought (say, worry). Now most people are smart. It is very easy to see the inference that anxiety and worry are symptoms, and we all know that symptoms need to be eradicated. A lot of the work has already been done here – by the time someone arrives for therapy, they have seen dozens of television advertisements with lines like “depression is a serious medical condition,” or “if you are taking an antidepressant and still feel depressed, talk to your doctor about adding Pharmacon.” The list of side effects, by the way, implies that being depressed is worse than being diabetic, having an involuntary movement disorder, or possibly dying.

Maybe we are taking insurance money for therapy. We begin with the disclosure that their insurance will pay for about 10 sessions. Without some attention to this detail, we may be implying that therapy should work in 10 sessions or so. Depending where we work, there may even be pressure to make this true.

I once worked at a site where the process was to ask the person for their symptoms on first meeting them. We would chart how much the symptoms bothered them and tuck that data away. Next we would ask how well the person thought they were functioning, and tuck that data away for later. Then we would plot a course to treat that symptom, and every week ask those same questions: how much does the symptom bother you, and how well are you functioning?

In this model, the important things appear to be that symptoms are reducing and functioning is improving. Now this is a fine model that works for many people, but without very full disclosure and education about this at the beginning, has the person chosen a course of symptom reduction and improved functionality? Might it be they would make a different choice in the face of a fuller menu, such as a more meaningful life and increased consciousness?

The big ethical question for me is this: if the person has made life change at any level and this change partially or wholly at the direction of another person, involving practices that intentionally or unintentionally reduce the freedom of the changer to choose… under these circumstances, if the change in life real, meaningful and wholesome? Or have they been coerced into goodness in the sight of the therapist?

-- Jason Dias

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