Malin Fors on Power in Psychotherapy

This is the latest in a series of interviews with APA Books authors. For this interview, Susan Herman, developmental editor and consultant for APA Books, spoke with Malin Fors, a Swedish psychotherapist living and working in Hammerfest, Norway. Fors is the author of A Grammar of Power in Psychotherapy: Exploring the Dynamics of Privilege, for which she won the Johanna A. Tabin Book Proposal Prize from Division 39 for first-time authors.

In the book, Fors exposes patterns (a “grammar”) to explain how social power issues may influence the therapy partnership­—including dimensions of race, gender, class, sexuality, age, and ability.

Note: The opinions expressed in this interview are those of the author and should not be taken to represent the official views or policies of the American Psychological Association. This interview has been edited for conciseness and clarity.

Malin Fors is an assistant professor at University of Tromsø, the Arctic University of Norway, where she teaches medical students about diversity, privilege awareness, and critical perspectives on cultural competency and a guest lecturer in clinical psychology at Gothenburg University Sweden. 

What assumptions about psychotherapy or how it works do you take on in this book?

I’ve thought for a long time that people who try to address power issues in psychotherapy tend to do it from the position of teaching majority persons how to work with one or another kind of minority.

For the book I wrote from four different kinds of dyads: where both therapist and patient are majority, or both being minority, or the patient being in the privileged position compared to the therapist, [or vice versa]. I tried to expand the idea that power and privilege belong only to the therapist. That’s the first thing.

Editor’s note: the figure below illustrates the four types of therapist-patient pairings relative to privilege and non-privilege.

The second thing is, I’ve found that the literature is often just dealing with one kind of human rights issue at a time. It’s for example about ethnicity, or skin color, or religion, or class issues, or feminism or sexual orientation. Even if people try to make their discussion intersectional, they often don’t. They address one social position at a time, and I wanted to share contributions from all these movements and put it in these four dyads. And I wanted to be very clinically oriented, to boil down theory and research to the clinical room. So that was my idea.

When we talk about power and how it enters the therapy relationship, where does the power come from?

There are different kinds of power systems. One kind of power is that the patient always has the power of being a consumer, at least if you’re working in private practice. If you’re working in public healthcare, it’s not so simple to fire your therapist.

But therapy is not like every other kind of consumer relationship. It’s also an emotional attachment, an emotional dependency. And that has been written about a lot—this responsibility that comes about from having other people depend on you. I try to widen it and write about how external power issues, such as social status, affect this power balance.

For example, sometimes we talk about self-disclosure like that’s a choice but if you’re black, that’s not a choice. Everybody can see that. If you’re a lesbian, at least if one has the privilege of passing, it is a choice to tell people or not. So, self-disclosure is one issue. Power also comes into interpreting resistance; into internalized oppression, and internalized privilege (in both patient and therapist) and in invisible norms. And also, how you talk about society and politics, if you use that in your interpretations or not.

I’ve heard privilege described as having more choices available to you than someone else has. Is that a good definition? And how does privilege affect the therapy relationship?

Being the one with privilege means you have the privilege of not seeing that you are the norm. A lot of men, for example, don’t consider themselves as a group. But minorities are already a group. If you are Chinese [in Scandinavia or the USA] you can’t say, “no, I’m not Chinese, I’m just a person.” But people do say, “No, I don’t consider myself as male, I’m just a person.”

So I think privilege is about having the fortune of being blind to norms. To never have collisions with norms. That’s why it’s so hard to see. It’s quite invisible if you are the one who’s never the strange one, who never feels “different.”

I don’t think one can be completely aware of one’s privilege, but one can be humble about it. One will always have blind spots, but I think awareness makes one more sensible to the other person’s vulnerable sides. It might make one less defensive.

For example, with homophobia, it’s very hard to explore homoerotic transference if the therapist has internalized homophobia. And it doesn’t matter if the therapist is gay or heterosexual. You can say whatever they want with your mouth, but inside of yourself, if you fear having homosexual feelings for another person, you can never acknowledge that you have that possibility. If that happens it’s very hard to acknowledge homoerotic countertransference and it might be hard to bring up during supervision. That’s dangerous because it takes an important topic out of the room. Things that are not understood or talked about with yourself or in supervision, that is more likely to be played out in some way during therapy.

If a white therapist cannot acknowledge there is a racist structure, or that they gained from it by being white, then it’s very hard to feel safe as a black patient. How can you feel safe with someone who is not acknowledging the truth, or the reality?

There is also able-bodied privilege. Think about the messages and pep talks about how, if you really want to, you can be in a good mood and overcome your cancer. It’s so discriminating to people who are suffering.

Help us understand the title of the book. If grammar is the hidden rules behind language, is privilege the hidden rules behind power?

What I’m talking about as grammar is a kind of pattern that is played out. The power interaction. How things are negotiated in the therapy relationship, and how these negotiations affect common therapeutic interventions and tools and choices.

For example, if you work with somebody who has more social status than yourself, and they suddenly find themselves dependent on someone with lower status—usually something will happen.

I often have male clients who are struggling with depending on me as a young woman. Some of them handle it by giving me advice: “I could paint your walls for you.” They give all kinds of “male” suggestions about how they could be helpful.

Or, they start to flirt. That’s a way to try to make it into a more ordinary male-female relationship where they can assert some kind of control.

Or, they treat me as their private chihuahua—like, “you’re so small, but you’re so devoted, and you really listen to me!” That’s not the same kind of respect they would give a male therapist. So then how do you talk about this fear of dependency? With some patients you can talk about it, and with some patients you can’t. You can just be aware of the pattern, and that makes you freer in your choices.

Some people will start to think that you are more powerful than you are. They’ll say, “My therapist is a woman and she’s the best in the world.” They’ll idealize you because they cannot connect with a weak person. They wouldn’t be dependent on someone like you in real life.

If a patient handles the loss of his privilege in a narcissistic way, he might say “well I really expected an experienced person, I expected an older male.” As a therapist you can then say, “Well, maybe you should go to an older male therapist” because you don’t have the energy to stay devalued. But at least you will be aware that this is devaluation that comes from society and not from your bad work.

You cannot say, “Well, I’m not helping sexist patients.” That’s not ethical. Still, that doesn’t mean that you always need to agree with your patient, if he is treating you as his pet. I mean, a dog bites you—you still need limits.

Dorothy Holmes has written a lot about how her blackness comes into therapy. She has therapy with white clients who are not overtly racist, but after a while in therapy they kind of explore their own racism, they also have a negative transference symbolized on her blackness. She’s had patients say that they didn’t trust her because she was black. You really need a high level of trust to be able to say that to your therapist: “I’m afraid I’m a racist person.” She writes about that so warmly and brilliantly. I’ve been inspired by a lot of her writing.

So, what do you do in those situations—when the dog bites, so to speak?

There’s no “neat” answer to “what to do?” Sometimes you’re also part of an enactment. I bring this up in the book, when the white clients of a Black colleague at our Norwegian clinic claimed to have trouble understanding her accent. The clients were re-assigned to me.  As I explain in the book:

my own accent was never a problem…Even though my own Norwegian grammar was terrible compared with [my Kenyan colleague’s], I was never rejected because of language issues. Even though it was hard to prove in every case that it was not a matter of personal chemistry or alliance, I found myself having the creeping suspicion not only that I was treating all the racist patients, but worse, that I was part of a racist enactment at our clinic.

It’s very hard. How can we keep empathy for people that we don’t agree with?

It can be helpful to discover or acknowledge the dark sides in ourselves. [M. Fakhry] Davids writes about internalized racism, saying that everyone internalizes societal structures. So during stress or when we feel pressure, everybody has the possibility of enacting racism. I think that’s so true, we all have these possibilities. One is in a really vulnerable situation when one comes into therapy. And to have empathy with patients who aren’t aware of their privilege, we have to remind ourselves that we are not just the “good ones” all the time either.

A lot of people will hopefully recognize themselves in an example I share in the book, where I’m acting out my privilege by going to a psychiatric inpatient unit and I explain to the taxi driver (who hasn’t asked any questions) that I’m not a patient, I’m a therapist there. By saying this I asserted my own privilege as a healthy person. I didn’t want to be seen as sick or crazy. It’s quite painful to discover this dominant side of oneself. We often want to think about ourselves as the good ones.

It’s not easy to stay in that empathy for the badness, though. It’s easy to come into the position that we should moralize about the patient or tell them what is right or wrong. Sometimes I do that, like with younger patients. When they talk bad about Muslims, for example, I can say “well, I think it’s racist to say stuff like that.” And then I just change topics. But I don’t do that with everyone. I think it’s more important when we work with teenagers or really young people. We are also role models. They sometimes test us out, like are we a real person; is everything OK to say?

But there’s no one answer. That’s why I wrote the book, because I’ve sometimes been fed up with the omnipotent position when people trying to explain The Solution, like if you have this answer then that will happen.

I’m trying to write about this complexity. I don’t intend to solve the problem, I intend to ask more questions so people could, from the questions, hopefully find more questions. Or more choices.

Many of the clinical examples in the book come from your own psychoanalytic therapy practice. Does the book offer helpful information for therapists working in different orientations, such as CBT?

I have a psychodynamic background, but in the book I’m talking about the alliance and other things that happen in therapeutic relationships—in counseling, and all kinds of treatment relationships.

I tried to include references to other paradigms besides psychodynamic paradigms, so people could recognize their own favorite theories in the book. Laura Brown is a feminist hero that I cite throughout the book—she is from the CBT movement.

People who have read the book say that this book is a good fit for graduate students or early professionals, that it can be used for diversity training and psychotherapy courses. That makes me happy because I wanted it to be accessible, to write it in everyday language.

References:

Davids, M. F. (2003). The internal racist. Bulletin of the British Psychoanalytical Society, 39, 1-15.

Holmes, D. E. (1992). Race and transference in psychoanalysis and psychotherapy. The International Journal of Psychoanalysis, 73, 1-11.

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