Ethical Boundaries in Balancing the Power Dynamic in the Therapeutic Relationship

Helping difficult clients involves much more than adopting a particular set of attitudes or establishing an effective alliance; it requires intervening, sometimes quite forcefully, to stop a client’s self-defeating patterns and to help channel energies in more constructive directions. The particular nature of these action strategies, whether variations of providing structure, using cognitive interventions, setting limits, or employing paradoxical techniques, is probably less important than the practitioner’s willingness to equip himself with a variety of therapeutic options he can draw on as the situation requires.

This section is not meant to be a comprehensive compilation of all the action-oriented interventions that are at the therapist’s disposal as much as a sampling of the most common possibilities. So often with difficult clients we are unable to apply “standard” strategies that have proved effective before; we are usually required to modify and adapt interventions to the unique requirements of a case.

Ethics - Balancing Your Power with Cognitive Interventions
At the heart of most forms of resistance is some underlying thought disorder in which the client distorts reality and applies erroneous, illogical, irrational, or self-contradictory reasoning processes. This conception of client difficulty falls within the province of cognitive therapists but most practitioners also find it helpful to hone in on what clients are thinking and processing that leads them to interpret and respond to the world the way they do.

Absolutist thinking
Once clients, even very difficult clients, are helped to realize that their absolutist thinking is a gross distortion of reality, that the “shoulds,” “musts,” and other dogmatic demands that are part of their vocabulary are actually setting them up for failure, the stage is set for considering alternative ways to look at their situation.

Although greater patience and repetition is needed to reach clients with severe disturbances and thought disorders, they can often be led to understand that the following statements apply to them. As you read through the following list, ask yourself how you might accomplish a balance in the power dynamic with one of your resistant clients when approaching them with these ideas:
• You are the one creating the obstacles to getting what you want; it is not being done to you by others.
• Just because you are not progressing as fast as you would like does not mean you will not eventually reach your goals.
• Pain and discomfort accompany any growth; there is no sense in complaining about it because that will not make it go away.
• Setbacks are an inevitable part of life and simply signal that you need time to gather your momentum.
• Just because you are struggling in these few areas of your life does not make you a complete loser and failure.
• You have the capacity to stop making things difficult for yourself and others when you decide to think differently about your situation and your life.

Ethics - Cognitive methods
In spite of claims by Ellis and others who argue that cognitive methods are successful in countering the resistant behavior of borderline personalities and even psychotic individuals, I would suggest that these methods are probably even more helpful when we use them with ourselves. One of the hallmarks of the cognitive therapist is supposed to be that he practices what he preaches. As almost any therapeutic impasse involves some contribution by the clinician, it is often necessary for us to challenge our own belief system to understand what is occurring. There are thus parallel processes operating simultaneously: on the one hand we are identifying those counterproductive beliefs that the client is using to sabotage progress; on the other we are confronting ourselves to let go our own irrational demands. These usually take the form of unrealistic expectations we hold for our own behavior or for that of the client, standards of perfection that can never be met.
Donna Aguilera

Psychodynamic Perspective on Therapeutic Boundaires:
Creative Clinical Possibilities

- Bridges, N. A. (1999). Psychodynamic perspective on therapeutic boundaries: Creative clinical possibilities. J Psychother Pract Res., 8(4). p. 292-300.

Peer-Reviewed Journal Article References:
Kenny, M. (2021). A psychiatrist’s experience of mindfulness-based cognitive therapy. The Humanistic Psychologist, 49(1), 162–178.

Macdonald, J., & Muran, C. J. (2020). The reactive therapist: The
problem of interpersonal reactivity in psychological therapy and the potential for a mindfulness-based program focused on “mindfulness-in-relationship” skills for therapists. Journal of Psychotherapy Integration. Advance online publication.

Roberge, E. M., Weinstein, H. R., & Bryan, C. J. (2019). Predicting response to cognitive processing therapy: Does trauma history matter? Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Segal, Z. V., Anderson, A. K., Gulamani, T., Dinh Williams, L.-A., Desormeau, P., Ferguson, A., Walsh, K., & Farb, N. A. S. (2019). Practice of therapy acquired regulatory skills and depressive relapse/recurrence prophylaxis following cognitive therapy or mindfulness based cognitive therapy. Journal of Consulting and Clinical Psychology, 87(2), 161–170.

Ethics CEU QUESTION 23
What is an example of a forceful cognitive intervention to use with a client’s self-defeating patterns, if used correctly will not violate the balance of power? To select and enter your answer go to Ethics CE Test.