Ethics in Psychotherapy and Counseling. Kenneth S. Pope

Chapter 5 TRUST, POWER, CARING, AND HEALING

      Psychotherapy is a remarkable venture. It harnesses three forces—trust, power, and caring—to help people heal. In our work, we face the ethical challenge of understanding, respecting, and handling carefully all three.

      TRUST

      When we apply to states and provinces for professional status via licensure and certification, we accept the responsibility that comes with that status. Society expects us to be trustworthy, to avoid abusing the trust that people place in us. Society depends on us to fulfill that trust for the good of our clients as well as society. Ethical dilemmas can arise from the clash between the client’s interests and society’s interests, or between the client’s interests and the therapist’s interests. In return for assuming a role in which the safety, well-being, and ultimate good of clients is to be held as a sacred trust, we are entitled to the roles, privileges, and power that governments and society entrust to professionals.

      This concept of trust is key to understanding the context in which clients enter into a working relationship with us. Clients expect or desperately hope that they can trust us. Many fear we might betray their trust. Some agonize over trust issues. Others find barriers to trust almost insurmountable. And others, like Black, Indigenous People of Color (BIPOC) clients come to therapy knowing that the profession we represent has violated their trust many times throughout history. Still others come to therapy unaware of how their problems trusting others have made it hard for them to love, work, and enjoy life.

Trust is at the core of therapy and clinicians put it to good use. In therapy we expect clients to walk into the consulting room of an absolute stranger and say things that they would say to no one else. We therapists may ask questions that would get us slapped, punched, or sued if we asked them outside of therapy. What patients tell us in confidence carries potential to be therapeutic or harmful depending how we use that information and/or, whether we violate the client’s trust by breaking the sacredness of confidentiality. This potential to help or hurt has led virtually all states and provinces to recognize some form of professional confidentiality and therapist–patient privilege. Laws prevent therapists, with some specific exceptions, from talking to others about what clients share with them during therapy.

      Therapy, like surgery, relies on trust. Surgery patients allow themselves to be physically opened up in the hope that their condition will improve. They trust or may reluctantly trust surgeons not to take advantage of their vulnerability to harm or exploit them. Therapy patients undergo a process of psychological opening up in the hope that their condition will improve. They trust us or want to trust us not to harm or exploit them. Freud (1952) noticed this similarity. He wrote that the newly developed “talking therapy” was “comparable to a surgical operation” (p. 467) and emphasized that “the transference especially … is a dangerous instrument … If a knife will not cut, neither will it serve a surgeon” (p. 471). Recognizing and respecting the potential harm that could result from psychotherapy was, according to Freud (1963), essential:

      It is grossly to undervalue both the origins and the practical significance of the psychoneuroses to suppose that these disorders are to be removed by pottering about with a few harmless remedies … Psychoanalysis … is not afraid to handle the most dangerous forces in the mind and set them to work for the benefit of the patient.

      As patients, only if we trust the therapist and their intentions are we likely to speak truthfully about—or even disclose at all—events and topics that make us feel fear, shame, guilt, anxiety, or all the other forms of discomfort and apprehension. Research by Farber et al. (2019) found that trust played a “role for clients concealing depression symptoms; 42% of respondents saw it as a way to foster honesty. Increasing trust was also important to clients concealing mistreatment in relationships and even for those lying about self-harm” (p. 3203–3204).

      Our ethical responsibility includes respecting our clients’ trust that we will do nothing that places them at risk for harm. When we betray the client’s trust, they may lose hope in the system and profession we represent and not just in us as individual providers. When we betray our clients’ trust, we can sometimes cause deep, pervasive, lasting damage. The poet Adrienne Rich wrote a vivid description of the effects of shattered trust:

When we discover that someone we trusted can be trusted no longer, it forces us to reexamine the universe, to question the whole instinct and concept of trust. For awhile, we are thrust back onto some bleak, jutting ledge, in a dark pierced by sheets of fire, swept by sheets of rain, in a world before kinship, or naming, or tenderness exist; we are brought close to formlessness (1979, p. 192).

      Research by psychology professor Jennifer Freyd and her colleagues (e.g., Freyd, 1998; Freyd et al., 2005; Gobin & Freyd, 2014; Platt & Freyd, 2015; Smith, 2017) has explored and described how betrayal trauma can result when our trust is violated. Freyd emphasized:

      Psychologically, betrayal is toxic to the mind and body. We know this from decades of research on betrayal trauma. People who are betrayed are likely to suffer mentally and physically. This is true whether the betrayer is a trusted person—like a psychotherapist or supervisor—or a trusted institution—like a clinic, hospital, or university. In the case of institutional betrayal, the harm can be particularly acute and even associated with increased thoughts of suicide (personal communication, August 7, 2020).

      We all face the challenge of understanding what inspires and validates trust and what misreading, misunderstanding, or mishandling trust can mean