Power Dynamics in Therapy: Symbolic Relationship

Feminist therapy does not formally utilize the construct of a transference relationship as conceptualized by psychodynamic psychotherapies. However, feminist therapy, as a biopsychosocial/spiritual model, affirms the reality that each person in the psychotherapy relationship represents both the real here and now and also symbolizes something to the other person. “When and where I enter, there and then the whole race enters with me,” said Anna Julia Cooper, the 19th-century African American suffrage activist (Giddings, 1996). This is true for all human beings: When we enter an exchange, we bring with us the unspoken meanings of our personal experiences, our cultural experiences, and, as importantly, the meanings of the context of psychotherapy itself. Feminist therapy urges its practitioners to notice how symbolic phenomena evoked by representations can affect the balance of power in the relationship. This question goes beyond usual constructs of transference and countertransference because feminist practice explicitly integrates the effects of current social context on these symbolic shared meanings rather than construing symbolic processes as fixed unconscious dynamics. Thus, for instance, when events in the world outside of therapy affect the meaning of therapist to client or vice versa, feminist therapy posits that the symbolic relationship will be affected and power will shift at that moment. The therapist bears responsibility for attending to this potential effect of external realities and raising the matter in treatment as a component of the ongoing analysis of power in the relationship and for each person.

THE INVITATION TO TRANSFORMATION

A metaphor for the relationship of client and therapist in an egalitarian dynamic is that of invitation of the honored guest to partake in what is offered by the host. The construct of an invitation is used to denote an offering of something valued by the therapist to a client whose presence in relationship to the therapist is desired. An invitation is something that can be accepted or rejected with no negative consequences. By inviting consideration of alternatives, the therapist does not denigrate or dismiss the client’s own current strategies toward empowerment, nor does the therapist knowingly set up a dynamic in which a client feels frightened to say no or complies because this is her or his usual interpersonal strategy.

This metaphor of host, guest, and invitation acknowledges several other important components of the egalitarian relationship: honor of clients for their willingness to step through the difficult and often frightening door to transformation, respect for their autonomy and rights to make choices about what is offered, and value on the work of the therapist. Feminist therapists take seriously that our clients, no matter how much they are suffering, have devised means by which to arrive alive, albeit in deep psychic pain, in our offices, and that those strategies have been their ways of self-empowerment. Therapy is not the only means of empowerment, a fact frequently forgotten in the business of therapy as usual.

In the egalitarian dynamic of feminist therapy, the heartfelt offer of deep respect for clients’ capacities and abilities can make it possible for clients to then consider other means of surviving, or even thriving, offered to them by the therapist. The atmosphere of respect does not require the disempowering process of disowning the client’s previous attempts to care for self; it conveys, instead, the message, “That was a good tool then, and it might be again. And it might be useful to have another tool or two available to remodel life today.”

A therapist working with an individual who is frequently dissociative in the face of painful or difficult stimuli might, for instance, invite that person to reframe these experiences, not as evidence of pathology, but instead in terms of a talent for dissociation that allowed him to escape painful experiences even when he was physically trapped in them and could not safely use a more visible or active strategy. The feminist therapist would similarly invite this person to frame current problems related to dissociation not as a sign of failure, but rather as the evidence that this strategy may have outlived its usefulness for the client’s current life or may need to be applied judiciously rather than as the default option. After all, there are many valuable uses for dissociation such as increasing pain tolerance at the dentist’s office or being able to become deeply absorbed and resist distraction in a task. By consciously constructing the process as one in which the therapist offers invitations to a client with the right to choose, the unspoken power dynamic in which the client is named disturbed by means of a diagnosis, and the therapist anointed as normal, and the one handing out the diagnosis, is also challenged, again leading to a more egalitarian distribution of power within the therapy relationship. This continuing challenge to the construction of distress as pathology conveys the message of value, respect, and welcome so central to feminist therapeutic practice.

Feminist therapists also utilize a number of structural and ecological strategies in their practices to systemically decrease imbalances of power and increase similarities of access to resources in therapy, although none of these are prescribed or required strategies for a feminist therapist. Consistent with research on positive effects of self-disclosure (Hill & Knox, 2002) and with its roots in humanistic models valuing therapist genuineness (Rogers, 1957) and in the powerful shared experiences of consciousness-raising, feminist therapy has long supported therapist self-disclosure in the client’s interest (Brown, 1991; FTI, 1990, 2000) as one available strategy for empowerment of clients. Feminist therapy asserts that there is no such thing as a neutral or objective psychotherapist, noting that so-called objectivity is what the person with the most power calls her or his own subjectivity. The therapist who disowns the reality of being known and knowable to clients is at greater risk of abusing power, which is left unexplored and unexamined by that therapist. Thus, a therapist may choose not to overtly disclose, for example, his sexual orientation or social class background, but he must be attentive to how that information may be transparent to a client even when not overtly disclosed. The therapist must also consider what it communicates to that client that this personal information can be hidden, while the client’s, for the most part, cannot be concealed.

“You never mention a partner,” said Isabella, an upper-middle-class woman whose parents had come to the United States from Chile, to her therapist, Paz, who had grown up poor in Puerto Rico. “But I can tell that you have one by how you talk with me about the struggles people have in relationships. It’s not just theory, is it?” Paz, who had been psychodynamically trained, was not in the habit of disclosing details about her life, although their shared cradle language of Spanish was the reason for Isabella having chosen Paz from her insurance company’s list of providers. When Isabella initiated the discussion, Paz affirmed that in fact she was partnered and then asked Isabella what that meant for her. She also disclosed that it was challenging for her to be asked about personal details by clients, thus balancing the power dynamic by disclosing genuine vulnerable emotion in the moment, while maintaining the privacy boundaries that were important to her personally.

An interesting validation for this assumption of feminist therapy about the disempowering effects of disowned privilege and bias can be found in Dovidio and colleagues’ (Dovidio, Gaertner, Kawakami, & Hodson, 2002) construct of aversive bias. Aversive bias can best be understood as the presence of bias that is unacknowledged by the individual who holds it. Such bias leads to problematic and disempowering interactions between more powerful and less powerful persons when those powerful people are affected by aversive, unconscious bias. Bias owned is, conversely, less disempowering to its targets who, when able to see and know such bias clearly, become empowered to develop strategies for dealing with it.

Beverly was the fourth generation of women in her family to attend Spelman College. As the daughter of a physician and an attorney, she had never doubted her abilities nor her goal of becoming a psychiatrist. She had a strong sense of ethnic identity as an African American woman and consequently was surprised to find herself having harshly negative reactions to Lakeisha, a young African American woman who had struggled mightily to be the first person in her family to graduate high school. Lakeisha was now floundering in college because of the lack of adequate academic preparation afforded to her in her resource-poor high school. She was depressed and anxious and thrilled to find an African American psychiatrist. The relationship was not progressing well, however, because the dynamics of aversive bias were unacknowledged in the room. Beverly was taken aback by her reactions. In her consultation with her feminist peer group, she came to realize her powerful, unacknowledged aversive bias toward poverty-class African Americans. “I was raised to mock their names,” she told them, “to feel embarrassed by hearing someone say ‘aks’ for ‘ask.’ Here’s this impressive young woman who’s doing everything she can to succeed, and I’ve been sitting in sessions cringing at her name and her accent.” Once Beverly was able to identify her aversive bias, her responses to Lakeisha changed, which the latter noticed and commented on. At that juncture, Beverly invited Lakeisha to know why and told her that “I was doing something that embarrasses me. I was judging you for being poor.” This, in turn, opened the door to a powerful discussion that pervaded the remainder of the therapy as Lakeisha encountered aversive classism elsewhere in the community of highly educated African American women. Having Beverly become aware of and, when appropriate, disclose the realities of her aversive biases empowered Lakeisha to name the dynamics that were problematic for her in her interactions with others and cease to ascribe them to some unknown personal deficit.

Similarly, therapists’ disownership of power or privilege may disempower clients by creating a dynamic in which the therapist’s power is operative but cannot be named and challenged because that same power is used to deny its existence and presence. A conscious awareness and ownership by a therapist of her or his power and privilege, even if never discussed or disclosed to the client, will subtly shift the power dynamics in the direction of greater client empowerment and more equality in the relationship because the unspoken message conveyed is that this power differential may be addressed.

The centrality of the egalitarian relationship to feminist therapy practice leads feminist therapists to consider how they and their clients have power and privilege differences not only in the office, where a therapist is powerful by virtue of role, but outside in the larger social milieu, where clients may possess more of certain kinds of social location powers than therapists. Feminist therapists also consider how the details of their business practices, including where their office is situated, how they are addressed (e.g., “Am I Dr. Brown, or am I Laura, and who decides?” “Is my client Ms. Hernandez or Anita, and who decides?”), and how they set the fee, are consistent with a message to clients about equality of value and empowerment (Brown, 1991, 2007; Luepnitz, 1988). I, for example, ask clients to call me what they are comfortable calling me, saying that my personal inclination is to be called by my first name. I tell them that I’m fine with whatever I’m called so long as it’s in the ballpark of my name. In my forensic practice, where assertion of authority is core to empowerment, I always use my formal title; as a teacher and supervisor, I similarly encourage the use of my first name by my junior colleagues, which is how I conceive of the role of those receiving training from me.

Alexander, in his book on the psychology of spaces, A Pattern Language (1977), noted that how space is organized conveys to people whether or not a space is welcoming, safe, or intimate. Feminist therapists are less likely than architects to attend to questions of spatial patterns and what they communicate, but in developing an egalitarian dynamic, feminist therapists will think about how a space creates a message of equality of worth of all parties who inhabit it. A feminist therapist aspiring to an egalitarian and empowering practice setting considers the message that her office conveys about who is welcome there and who might be out of place. Is it in a setting that shouts of social class privilege in a fancy office building? Is it physically located in a part of town where people of color might feel uncomfortable? Is it so far from bus lines that someone who cannot drive or afford a car must struggle to reach the office? Once there, will the construction worker coming off the site know that his muddy boots are welcomed on the therapist’s floors? Are the chairs wide enough for a fat person to fit into comfortably? Consider the images of psychotherapists’ offices prevalent in today’s popular media. They are all lovely, full of expensive art and furniture. They convey a message about which people are welcome—and which are not. Even if this sort of office is a norm for nonfeminist peers, the ecology of such an office setting will have begun to set a nonegalitarian tone that will potentially permeate the therapy and undermine feminist goals. A feminist therapy office creates an empowering physical setting for the work of feminist therapy.

“Setting the fee as a feminist,” in Luepnitz’s (1988, p. 83) words, is another component of creating a relatively seamless web of empowerment and egalitarianism in all aspects of the therapy process. A feminist therapist must make a living and place value on her or his work. The therapist must also be mindful of what it means that a person coming to see her or him may have to work 2, 10, or 20 hours, or a quarter of an hour, to pay for the 1 hour of therapy time. Discussions about money and business are rarely easy for psychotherapists of any theoretical orientation. Feminist therapy provides a conceptual framework for the therapist to consider how to set fees, with the question being about how communications about money and fees disempower neither party to the transaction, while acknowledging differences in privilege that each one brings to the relationship (Brown, 1990). Wolfe and Fodor (1996) have, for example, discussed the challenges for feminist therapists working with wealthy clients; feminist principles guiding a therapist toward an egalitarian relationship with a client thus do not assume the specifics of any given client’s circumstances, but rather function as an epistemology of empowerment in which analysis of the financial aspect of the transaction is folded into the mix.

In my own psychotherapy practice I have attempted a wide range of strategies in relationship to money. These have included having a fully sliding fee scale practice, having a fixed number of slots reserved for low-fee clients, and most recently, opening a feminist therapy training clinic (http://www.therapyproject.org) where low-fee clients are seen by trainees and my pro bono hours go to supervision time. I have designated two conditions under which I will do forensic work pro bono and train and mentor more junior feminist forensic practitioners so that lower-cost services are available. I continue to discuss the meanings of my fees with the people who come to me and consult with other feminist therapists about their strategies for achieving this component of an egalitarian relationship. Some feminist therapists work only in agency settings, so as to be available to all comers regardless of cost. While no one fee-setting decision rule is the correct way for a feminist therapist to implement egalitarian relationships, thoughtful consideration of the meanings of the costs of psychotherapy and willingness to make one’s own decisions about fees transparent to clients in an open way is always an expression of egalitarianism.

In egalitarian relationships clients are also seen as worthy of the therapist’s trust, which is a form of giving power to someone. Therapists, conversely, are not construed as trustworthy per se, which is a form of reducing the power of the role. In fact, many feminist therapists will overtly discuss this reality, which is that they are a stranger to a new client, have not yet earned trust, and do not need the client to uphold the privilege of the therapist’s role by proffering trust too readily. Instead, in the egalitarian model, therapists are charged with the responsibility of acting in such a manner as to earn clients’ trust, thus offering to clients the power to decide as to the therapist’s trustworthiness rather than having the therapist declared trustworthy simply by virtue of occupying that role in the exchange.

Trystyn, a mixed race middle-class transman (individual who has transitioned or is transitioning from female to male), was seeing Callie, an African American poverty-class transwoman (individual who has transitioned or is transitioning from male to female), as a therapist at an agency for LGBTQ (lesbian, gay, bisexual, transgendered, queer) people. Trystyn’s identity as a transgender person was not immediately knowable to Callie, as he had gone through his transition over a decade previously and he was “read” as unquestionably male by everyone who met him. When he asked her what he could do to earn her trust, she told him that it was very uncomfortable for her, biologically a man, to be working with a male therapist. “Would it help you to know that I’m trans myself?” he offered. She averred as how that would help some, but given her feelings about being male, not as much as he thought. Trystyn then invited Callie to not need to trust or feel comfortable with him, which surprised her: “I thought I was supposed to just trust my therapist.” The ensuing discussion about trust had the effect of engendering Callie’s deepened trust in Trystyn, who she later described as a “no-bullshit kind of guy” when referring a friend to treatment a few years later.