C o nclusio ns: so w h a t can w e

do a b o u t p o w er?

Each of the models of therapy I have considered, and probably all models of
therapy, work with the implicit assumption that mental wellbeing is associated
with a feeling of control and power over one’s life. It is generally accepted
that experiencing and feeling powerless are associated with psychological
distress. So, how can therapy best empower the client? Does the power
dynamic inherent in the therapy relationship hinder this, and if so, how can
this effect be ameliorated? Chamberlain (2013) proposed a working definition
of empowerment, particularly for use in the psychiatric setting. She suggests
that it has several dimensions, includes individual and group components, and
comprises access to information, ability to make choices, assertiveness and
self-esteem’. She points out that it is a complex and multidimensional concept,
and describes a process rather than an event. Empowerment goes beyond the
interpersonal therapy relationship and connects with the much wider political
environment. However, the distribution of power in the therapy relationship
is a very important template for the distribution of power in the wider context.

Summary
Three aspects of power in the therapy relationship have been considered: the
power arising from the roles of therapist and client (role power), the power
arising from the structural positions of therapist and client (societal power),
and the power arising from the personal histories of therapist and client with
respect to experiences of power and powerlessness (historical power). I have
presented the literature on power in therapy, and have argued that most of

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this literature is based implicitly on structural models of power. Thus, the

literature assumes that power is unidirectional, is a possession, is monolithic
and is necessarily negative. I have also presented post-structural concepts of
power, arguing that these concepts of power broaden our understanding of
power in the therapy relationship by enabling us to see it as something that
is present in the relationship, rather than being the possession of one person;
as bidirectional and influenced also by outside relationships; as inescapable,
and as potentially both negative and positive. I have discussed three different
models of therapy and pointed out the gaps in the analyses of power in these
models.
Cognitive behaviour therapy (CBT) fails to analyse and problématisé the
position of the therapist as expert, as ‘objective scientist’, and thus is at risk of
abusing a position of power, while obscuring the therapist’s powerful position
within the rhetoric of collaboration. It fails to address any of the three aspects
of power in the therapy relationship, primarily because of its lack of focus on
the therapy relationship per se.
Person-centred therapy addresses all aspects of power in the therapy
relationship. This theory provides a radical alternative to the dominant medical
model of the ‘ill’ and untrustw orthy client. The person-centred therapy
relationship is set up to reduce the potential for domination and control by
the therapist. However, sometimes the focus on the therapist as a person risks
obscuring the power inherent in the role of therapist, and there is potential
for therapists to miss levels of oppression resulting from structural positions,
unless the socially positioned person is acknowledged.
Psychodynamic therapy has addressed some issues of power in the
relationship by examining the various aspects of the therapy relationship. I
have presented the model of relational psychoanalysis, which aims to address
most aspects of power in the relationship and aims to protect the client from
dom ination and the therapist’s authority. Psychodynamic therapists range
widely in how much they use the real relationship to address issues of power in
the transference relationship and how much they acknowledge the limitations
of the therapist’s authority because of a lack of objectivity in perceiving a
dynamic unconscious.
In both person-centred therapy and psychodynamic therapy, where role
power is considered, mutuality in the therapy relationship is promoted. This
concept is referred to in several ways, using Buber’s (1970) concept of I-Thou
relations, the person-centred concept of a person-to-person relationship, the
notion of connected knowing and the psychoanalytic concepts of ‘mutuality’

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and ‘intersubjectivity’. In all these concepts, the therapist’s authority is

questioned, with the emphasis on the therapist’s own subjectivity, and the
client’s view is emphasised. The importance of the therapist’s openness and
‘realness’ is stressed. Acknowledgement of the therapist’s authority based on
their role is seen as inescapable, and the need to consider the responsibility for
using this power positively is highlighted.
In considering societal power, recommendations are made for considering
the socially positioned individual, in order to acknowledge structural positions
in society, while noting the interaction with individual subjectivity and agency.
Both psychoanalytic and person-centred models of therapy theorise
historical power. Integral to the analysis of this aspect of power is the emphasis
on self-awareness for the therapist and on supervision as a check on the
therapist’s feelings and motives for their behaviour in therapy.

Themes
The following them es recur throughout this book and sum m arise the
conclusions.

1) Power is dynamic and relational. The dynamics of power in

relationships are ever-changing and are constantly to be explored.

2) Power is ubiquitous. The dynamics of power are in every

relationship and cannot be dissolved in a utopia of transparency.

3) Post-structural concepts of power remind us that all subjects

have agency and that there is resistance to the operations of
power. However, structural theories of power remind us that
the effectiveness of resistance is determined partly by structural
positions. It is essential that resistance is not used to justify
oppression and domination.

4) Three types of power to consider are power-over, power-from-

within and power-with. The aim in exploring dynamics of power is
not to erase or obscure power, but to minimise the negative aspects
(particularly domination) and to maximise the positives (such as
collective power and using power to resist structures of domination
and to maximise the power-from-within of both the client and
therapist).

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A w ay forward
It is rare to find discussions about power that do not rest on structural models
of power as m onolithic, unidirectional and necessarily negative. Either
power is ignored, or concealed by rhetoric of equality or collaboration, or,
at the other extreme, use of structural models of power leads to a radical,
environmentalist behaviourism, in which people are treated as ‘black boxes’, as
‘docile bodies’ upon whom structural forces act. The challenge for therapists
is to take seriously issues of power in all their complexity without reducing
all these aspects and the complex dynamics between people to obscure either
structures or individual agency. O f course, theoretically, balancing these
concepts requires a m ultidisciplinary approach. It means that psychology,
counselling and therapy training must take seriously what has been discovered
and explored by sociologists, political theorists and philosophers.
Issues of power raise ethical questions, and values are an inescapable
part of the consideration of power (see Proctor, 2014). In ethical frameworks
for therapy, the ethical codes of beneficence and non-maleficence are clear,
although the balance between these and autonomy is left to the individual
therapist. Heath (1992) suggests that our need to believe in benevolent
intention prevents us addressing issues of misuse of power. However, one of
the aims of therapy is to try to help clients take more control of their lives. We
need to consider carefully how our roles as therapists help or hinder this aim,
particularly with respect to the internal consistency of the means and the end.
If we take control, and do not think carefully how to avoid domination during
therapy, how can we expect clients to walk away feeling more in control?
Both psychodynamic therapy and person-centred therapy provide ideas
and ways for therapists to consider responsibly the issues of power that are
summarised here. CBT is still far behind at the moment (see Proctor, 2008b),
and seems to be prevented from serious consideration of the issues by the myth
of the objective scientist and expert. As CBT is the main model advocated in
psychological therapy services in the NHS and by NICE in the UK, it urgently
needs to develop a clear model of ethical behaviour and underpinning values,
to challenge or supplement the scientist practitioner model (see Proctor, 2017).

Checklist for consideration of pow er in therapy

W hatever m odel of therapy is being used, this book should provide a
framework to enable practitioners to analyse and explore the dynamics of

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power in therapy. The following checklist summarises how to analyse power

in therapy.

7. Consider each of the three aspects of power in the therapy

relationship.
(a) Role power. This refers to the power arising from the roles of therapist
and client. The therapist can inform their analysis of this by listening to what
people who have been clients of therapists say about the roles with regard to
power. There is now a large body of literature addressing this issue from the
service user movement (for example, Ward, 1993; Bates, 2005; France, 1988;
Heyward, 1993). Therapists need generally to examine their model of therapy
and the position this places them in with respect to power and their attitude
to the client’s autonomy. How does the therapist conceptualise their position
in terms of expertise and responsibility (see Johnstone, 2000)? How is this
expressed in the therapist’s attitude towards the client? Then, with each client,
the therapist can also consider the client’s position and attitude towards their
own role and towards the therapist’s role. How does the client see themselves?
Do they see the therapist as the expert? How clear has the therapist been
about what they can provide and their own limitations? Has the therapist been
clear about their own ethical position (particularly with regard to autonomy
or beneficence)? Has the client had a choice to work with someone using a
different approach or for this therapist to take a different approach? How much
should we be involved in state-controlled therapy and accept the roles given
to us in this context? At what point do we decide that the ethical benefit of
providing free therapy is outweighed by the obligations of our role within such
systems as IAPT (see Proctor & Hayes, 2017)? We need to seriously consider
the impact of contexts on our work and the possibility of us having enough
power-from-within to not take power-over our clients.

(b) Societal power. This refers to the power arising from the structural positions
of therapist and client. Awareness of the social and political context is essential
for therapists to consider the socially positioned individual, and to address the
interaction of the individual with their environment and avoid pathologising
them. In particular, the social causes of distress need to be considered and
understood. For therapists to consider this issue with each client, it is essential
that they should have already explored their own structural positions with
regard to power and oppression and the effect of these positions on them and
others in relationships. Then they can consider the structural positions of each

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individual client, although it is im portant not to make assumptions about

which positions clients occupy or how those positions affect them. However, it
is useful to be aware of the structural positions of power held by therapist and
client in relation to one another, which can magnify the inequality set up by the
power in the roles of therapist and client. For example, a middle-class therapist
working with a working-class client cannot assume what the clients attitude
will be towards them purely because the client is working class. However, an
awareness of these positions and the history and current manifestations of class
oppression will enable the therapist to be open to considering the positions,
attitudes and differences within that individual relationship. Attenborough and
colleagues (2000) stress the necessity for therapists to be aware of the social
and political context and suggest areas that need to be considered. Williams
and Watson (1994) suggest a checklist for therapists learning about the effects
of social inequalities on the lives of women, which includes learning from
women service users, from theory and research, from women-centred mental
health projects and from our own experience of power and powerlessness.
A similar checklist can be devised for each social inequality. Newnes (2014)
and Holmes (2010) emphasise the importance of the social context and give
examples of how to work in a way that takes these concerns seriously.

(c) Historical power. This refers to the power arising from the personal histories
of therapist and client with respect to experiences of power and powerlessness.
Again, awareness of this aspect of power requires therapists to be aware of their
own history and experiences and how it affected them. This could include an
awareness of particular dynamics in relationships that trigger certain responses
in the therapist with respect to feeling powerless or powerful. Particularly
important would be an awareness of triggers that may provoke feelings of
powerlessness in the therapist and lead them to react by exerting power over the
client to try to regain their own sense of power. Awareness of the power arising
from the personal history of the client will lead to a gradual understanding
between therapist and client of these issues as the client discloses more about
their life. It would also be useful for the therapist to have an awareness of
some general issues in terms of the likely effects of particular experiences - for
example, the possible effects of experiencing childhood sexual abuse - on a
survivor’s sense of power or powerlessness. Again, as with structural positions,
it is essential that these generalisations are not used to assume particular issues
with any individual, but that, by being aware of the possibility, the therapist is
open to considering the dynamics with a particular individual.

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2. Cromwell and Olson's (1975) domains of power

Another useful way to conceptualise the relations of power in the therapy
dyad is to consider Cromwell and Olson’s (1975) domains of power. They
conceptualise power in families as a construct incorporating three analytically
distinct but interrelating domains: power bases, power processes and power
outcomes. Power bases are the economic and personal assets (such as income,
economic independence, control of surplus money, sex-role attitudes, desire for
intimacy and physical and psychological aggression) that form the basis of one
partner’s control over the other. Power processes are interactional techniques,
such as persuasion, problem-solving or demandingness, that individuals use in
their attempts to gain control over aspects of the relationship. Power outcomes
determine who has the final say - who determines the outcome in problem -
solving or decision-making. Power bases comprise all the above three aspects
of power. Consideration of power processes within therapeutic interactions
offer a way to apply Foucault’s concept of ‘normalising discourses’. Power
outcomes make explicit who holds the power in the therapy relationship:
however collaborative a therapist purports to be, if they still determine the
outcomes, the collaborative process’ taken to arrive at that point is a nonsense.

Politics
This book has mainly considered power relations in the therapy dyad, from
within the therapy relationship. However, there are also power relations in
organisations and in institutions such as training organisations and professional
bodies that affect the therapy relationship at a political level. In addition to an
analysis of power relations at the micro level within the therapy relationship, an
analysis of power at these wider political levels is also necessary, as is political
resistance. At this level, democratic debate, transparency and the enhancement
of the rights of clients and therapists to object and litigate all contribute to the
analysis and changing of damaging power relations.
At the personal level, Foucault’s stance of scepticism and constant
questioning is a necessary and useful position to take with respect to power in
therapy. We need to question anything that seems to be taken as self-evident,
to free up knowledge and open up new possibilities for thought or action. Here
we can learn from the service user movement and its questioning of so many
principles that have been taken for granted for far too long in mental health
services. Foucault (1984) advises: ‘Problematisation and apprehension go hand
in hand; inquiry is joined to vigilance’ (p239).

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Resistance and change can occur at several levels. Political resistance can
challenge and change institutions and make a difference at structural levels of
power (see the campaign group Psychotherapists and Counsellors for Social
Responsibility (PCSR)).1 Research and theory can inform and continue the
democratic debate and bring power relations out in the open. Resistance at
the level of individual practice, by analysing and changing how individual
clinicians work, not only changes and challenges the individual therapy
relationship, but also contributes to more pervasive changes in theory and
organisations.
Williamson (1992: 190-191) exhorts us to live our lives with authenticity
and conviction and realise our power-from-within for the benefit of all. This
can be understood without the reference to God, but from the perspective of
the unique potential within us all.

Our deepest fear is not that we are inadequate. Our deepest fear is that
we are powerful beyond measure. It is our light, not our darkness, that
most frightens us. We ask ourselves, ‘Who am I to be brilliant, gorgeous,
talented, fabulous?’ Actually, who are you not to be? You are a child
of God. Your playing small does not serve the world. There is nothing
enlightened about shrinking so that other people won’t feel insecure
around you. We are all meant to shine, as children do. We were born to
make manifest the glory of God that is within us. It’s not just in some of
us; it’s in everyone. And as we let our own light shine, we unconsciously
give other people permission to do the same. As we are liberated from our
own fear, our presence automatically liberates others.

We must not be afraid of trying to make a difference.

1. See http://pcsr-uk.ning.com/ (accessed 22 February, 2017).

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