Manifestation Of Power Imbalance In The Therapeutic Relationship: Essay Implications And Impact.

Difference between mental health care and other health care programs

Question:

Discuss about the Power and its impact on therapeutic relationships of psychology.

Mental health care is critically different from the other health care programs or genres, and the most profound difference in the two different types of health care services is the extreme dependence of the patients or clients on their clinical therapists. A mental patient is not just depended for his or her health care benefits, but they are also extremely dependent on their clinical therapist for their basic wellbeing as well. It is common knowledge that in case of health care the dependence in most cases is necessary and inevitable, however this extreme dependence often paves way for power imbalances in the therapeutic relationships that the patients have with their health care provider. Many authors have discussed the implication of power imbalance and its manifestation in the therapeutic relationship that the patients have with their mental health care provider. The unwarranted manifestation of this power in between the client and the health care provider is often the onset of response issues within the care program. This essay will discuss the manifestation of power in the therapeutic relationship and its impact (Kelly et al., 2012).

In the history of mental health care, there have been many transitions, each of the transitions has helped more or less in enhancing the effectiveness, and the safety of the care provided to the patients. In addition, the most important of the innovations that have occurred in the mental health care is the diagnosis based and patient centred care. The onset of a therapeutic relationship can be the one change in the mental health care that positively revolutionized the mental health delivery and the quality of the care. On an elaborative note, a therapy can be defined as any care practice or technique that is employed in order to treat or support a mental patient. The most important difference between a conventional care technique and therapy is the fact that a therapy requires enhanced active involvement of the patient rather than letting the patient be a passive participant in the process (Kelly et al., 2012). A therapeutic relationship on the other hand is the amalgamation of growing comfort and compassionate co-operation in between the mental patient and the care provider giving him or her therapy. By definition, a therapeutic relationship in general is the engagement of the therapist with the patient, which helps forge a mutually respectful and collaborative connection between the patient and the therapist.

Importance of therapeutic relationship in mental health care

The therapeutic relationship between the therapist and the patient has a number of variables that define the dynamics of the therapeutic relationship that the individuals have. One very important aspect within the same is the fact that the mental patients and their family member bestow a lot of power to the therapist; hence, the onset of an inherent imbalance in term of power is inevitable in case of therapeutic relationships. On a more elaborative note, the clients, or mental patients that are engaged in the therapy provides the therapist with power which the therapist in turn uses for the benefit of the patients in care planning and critical  decision making so that the patient can recover fast and can revert back to their regular lifestyle. However, the power invested on the hands of a psychologist is often accused to be mis- exercised and abused in case of the mental patients. However, in order to analyse or elaborate the factors that define the unequal or unjustified manifestation of power in the therapeutic relationships with the mental patients, it is crucial for individual pathways of the power manifestation to be critically analysed (Zuroff et al., 2010).

According to the most of the research, the differential power gradient in the therapeutic relationships with the mental patients is critically associated with the assumption in the patients that the psychotherapists have more psychological strength, emotional control and stability than the mental patient involved in the therapy, hence entire decision-making and judging responsibility falls upon the therapists. Although, this understanding is completely flawed. According to the theories of Foucault, knowledge and power are inseparable, and in case of post modern narrative therapy. the sensibility and relevance of the therapy is based on the theory of Foucault, that the human beings utilize power and knowledge in an intricately linked manner, and it is reflected in case of the psychotherapists as well (Gough, McFadden & McDonald, 2013). In order to provide the optimal care experience and helping them to recover faster, the therapists exercise the decisive power completely and in certain cases, it is helpful as well.

For instance, in case of a mental patient with severe disconnection with the reality will depend completely on the therapist. According to the Hjelm (2014), in such cases the mental patient will have a sense of comfort in giving away the power led by the perception that their psychotherapist has a special psychological might or power. However, this frequent misperception in the patient-client relationship is based on the Freudian dogma or psychoanalytical therapy; where the concept of transference is the most important and deciding element of the therapy. In case of transference, the patient is coerced redirect the feelings of trust and dependency, that humans generally feel during childhood, is persuaded to transfer that power to the therapist. Although a little trust and dependency is required from the mental patient so that there is enough co-operation with the therapist in the activities that is going to be performed during the therapy. Although there is a significant drawback of phenomenon is the fact that the excessive dependency of the patient on the therapist bestows them with a power that is easily exploited (Zur, 2014).

Dynamics of power in the therapeutic relationship

It has to be mentioned in this context that exceeding dependency is not always present in the therapeutic relationship, whereas, for the mental patients dealing with severe social rejection and abandonment anxiety, the dependency is often the only means of comfort for these patients. The only drawback in this case is the fact that this absolute transference of power makes these patient very vulnerable to the exploitation, which in most cases is not even deliberate from the clinical therapist (Perlman, 2012).

It has to be mentioned in this context that the psychotherapists and counsellors understand the inherent power differential in the therapeutic relationship with a distressed client as a part of a job responsibility. In addition, it is critically ingrained within the psychotherapists’ perception is the fact that the considerable power imbalance must never be exploited under any circumstances. However, in the most of the scenarios, the power imbalance is manifested as an undercurrent within the practice. For instance, it has been reported frequently that the power imbalance is most of the times unnoticed by the therapists where the controlling and dominating stance in the care approach of the therapists is perceived as a part of the therapeutic relationship. Furthermore, in case of the patients, the patients facilitate the manifestation of the power imbalance as well. For instance, it has to be considered in this discussion that most of the psychotherapy or counselling clients is mostly distressed, traumatized, agitated and helpless; which in turn elevates the vulnerability that these patients are accustomed to feeling (Zuroff et al., 2010). Along with that the mental patients are often subjected to immense discrimination and social rejection. The stigmatization adds to their helplessness and increases the need for anyone reliable or compassionate in their life. In case of psychotherapy, the therapists and the compassionate and understanding care approach that the therapists take often is perceived as acceptance to the mental patients. This acceptance forces the mental patients to willingly transfer all the decisive power to the therapists and the dependency of the mental patient on the therapists increases multiple folds. Therefore, this group of mental patients or clients seeking therapy are at the most risk of being exploited by the therapists, and according to the most of the researchers the manifestation of the power imbalance in such cases only increases with the severity of the mental illness that the patient is suffering from (Bennetts, Cross & Bloomer, 2011). 

Factors that define unequal or unjustified manifestation of power

Another very common source of manifestation of power imbalance is caused by the influence of societal determinants on this context. On a more elaborative note, it has already been addressed in the essay that the power imbalance or the difference in power in the therapeutic relationship is often ignored or unnoticed by the therapists themselves, where they are completely oblivious of the controlling and dominating approach in the care technique or therapy design. However, with the addition of the societal factors like race, socio-economic background, gender, sexual orientation and minority status of the mental patient can elevate the power imbalance effectively. In this case, the profound socio-cultural power dynamics and its impact on the therapeutic relationship can pave way effectively for the power difference to be manifested easily and further developed (Lee, 2010). Moreover, when the clinical psychotherapist or practitioner belongs to a strong cultural ideology, the conventional understanding of the above mentioned socio-cultural power dynamics affects the nature of the therapeutic relationship drastically. Most of the authors have suggested that in case of the therapists with a dominant cultural background, the therapists can be already inclined to devalue the cultural ideologies and the beliefs of the client. With the impact of the minor or lower socio-cultural standing of client overshadowing the dynamics of the therapeutic relationship, the manifestation of power difference is by far the most extreme in this case (Shelton & Delgado-Romero, 2011).

Although it has to be mentioned the need for power is crucial for the therapist to have in the therapeutic association with the patient, in order to provide the most effective and safe care to the mental patients. There have been many authors who have agreed to this age-old convention in psychotherapy that therapists should be bestowed with the decision making power, however it also needs to be mentioned that there are considerable criticism as well. With the emphasis of the health care industry on the patient preferences and informed consent, the new age in psychology mandates the therapists to empower their clients. This criticism of the power manifestation is supported by Lee (2010), in their argument they have stated that the power imbalance in the therapeutic relationships is the main cause of client dissatisfaction. The complete decisisve ability on the therapist’s hands often leaves the patients seeking therapy with a sense of helplessness and anxiety, which can be detrimental for the health, and wellbeing of the patient, completely defeating the purpose of the therapy. On the other hand, this idea is also criticised by another school of thought elaborated by Day (2010), the decisive power bestowed on the therapists have also been reported to be facilitating a sense of safety, security and confidence on the expertise of the therapists. Therefore, it can be safely concluded that a consensus regrading the impact of the power manifestation is significant, in order to arrive on a verdict, the impact of the manifestation on both the patients seeking therapy, the therapists and the therapeutic relation is required (Jahoda et al., 2009).

Impact of societal determinants on power dynamics

Considering the impact of the power difference in the therapeutic relationship, first and foremost, it has to be discussed that the therapeutic bond between the client and the therapist is the core element of the clinical psychology. It has to be mentioned here that psychology is nothing above the general idea of help, where the experts of this field help the distressed people cope with the different afflictions of the ever-changing societal dynamics (Kanter, Tsai & Kohlenberg, 2010). According to Ian Parker, the main purpose of the psychology as a clinical genre is being defeated with the complicated and critical treatment practice these days. With the growing power imbalance in the therapeutic relationships between vulnerable mental patients and their therapists, the practice standards have become more of a problem rather than being a solution. It has to be mentioned that patient centred care and autonomy is a fundamental element of safe and effective care practice, regardless of the health care domain that the patient is seeking help from. Hence, the consent of the patients must be given the most priority whenever providing care to the patient, even in the case of therapeutic care (Totton, 2016). 

However in case of the power imbalance in the clinical psychology between the client and therapist complicates the ethics of the therapeutic bond and violates the concept of patient autonomy and patient centred care. According to the Parker (2007), there is a need for a change in the perception of the practice standards in the clinical psychology so that the intended or unintended exploitation of the power imbalance in the therapeutic settings can be addressed. On the other hand, for clients only seeking therapy for better living, there is no transference of power and therefore, there is no power imbalance. This is where the consensus regarding the power imbalance or unethical manifestation of power brews dense, where one school of thought affirms the power imbalance and the other brushes it off as myth (Diener & Monroe, 2011).  

On a concluding note, it can be stated that there is a growing consensus regarding the power difference in the therapy setting of clinical psychology, where one school of thought agrees to the imbalance, the disagreement states the assumption of power imbalance to be a myth. Although, it has been explored in this essay that for the different groups of clients seeking therapy, vulnerable mental patients and clients only seeking therapy for better living, the scenario of power imbalance is completely different. The incidence and harmful impact of the differential power is only imparted for the vulnerable group of mental patients, and the magnitude of the impact cannot be overlooked either. Hence, the understanding of mutual respect and autonomy needs to be reinstated in the therapeutic setting, so that the trust placed by the vulnerable patients on their therapists is not exploited under any circumstances.

Patient-centered care and power dynamics

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