Continuous Consent as a Sacred Practice in Psychotherapy

Intro

We only have the power the client gives us, and we only know what that power is if we ask and/or ask permission. This is fundamental to making psychotherapy a collaborative and peaceful endeavor, and yet it’s annoyingly easy to forget. After all… didn’t they hand over all the power when they walked in? They’re in my space, asking for my help, so why not run with it? And yet-- taking power is always a violation of the client’s dignity, and so the practice of negotiating power (AKA consent) must be continuous throughout sessions and the course of therapy.

How to, First Principle: Make as Few Assumptions as Possible

“Tout autre est tout autre.” (Derrida) “Every Other is completely other.” I cannot assume I understand someone else, even when I think I understand every word they just said. If a client says they have anxiety, I’ll admit to them that it might sound silly, but that I don’t actually know what they specifically mean when they say “anxiety.” I might say: “I could understand a few things by what you just said,” and then wait for them to clarify, or I might offer them some of my possible interpretations for their approval, adjustment, or rejection. The short version: Never say “I hear you” or “I get it.” The better practice is to attempt to understand, express my tentative understanding, and if/once I’m right, the client will say “You get it.” All of this is twice as important when I think I might be “relating” to the client.

Similarly, I can’t assume that my interpretations or interventions are desired or correct.

“Can I offer an interpretation/intervention?” “There are a few ways to approach this-- here’s what I’m thinking so far, and you tell me what sounds good/promising/attractive.”

Most broadly, I can’t assume I know what my role is in the room. The good helper is in the eye of the beholder.

How to, Second Principle: Be as Transparent as Possible

All consent is informed consent. That means the therapist should provide transparency about their orientation, their process, their interventions, and even their silence. The client must be able to say “yes” or “no” or “kinda but what about this instead,” and all of that requires transparency. I like to call it “Playing therapist with an open hand.”

If I’m leaning heavily on a particular psychological theory, I name-check it, offer psychoeducation, and encourage them to look it up independently. If I’m starting to feel strongly about using a certain intervention, I’ll share my plan, how it works, why I think it will work, and then solicit questions, suggestions, and rejections before we might move forward.

I do not keep the client wondering what I’m thinking. Silence might be what the client needs sometimes, but silence is the most ambiguous, and so it should be given context. “Ok if I stay silent? I want to leave room for you to just think and feel and see what comes up.” “I’m pausing because there’s a lot of ways to approach this, so I’m considering some options so I can share them with you.”

I do not “pull moves” on the client, without giving them prior notice, so they know it’s a move. If I want to be provocative-- “I’m gonna use strong language, not because I mean it, but in hopes that you’ll push back and we’ll discover something.” “I’m gonna ask you a question that sounds rhetorical but it’s a genuine question.”

And all of this is less important than…

How to, Third Principle: Always Share Power

Every first session, the same speech: “We must both be experts in the room. I’m at my job; I went to school for this, so I must be some kind of expert. But you will always be the topic of discussion; it’s your time; I work for you. I will never know you as well as you know you. That means that you will always know first when I’m anywhere from 1 to 100% wrong, and it’s my job to respond graciously and collaboratively to your feedback.”

Process conversations are the ultimate practice in power-sharing. “Where would you like to start today?” “Now that you feel I understand your topic-- what’s your agenda on this topic?” “Where would you like to take this?” “I’m doing a lot of (questioning/ interpreting/ suggesting) today-- how’s that for you?” “Looking back, how do you feel about our conversation today?”

If I see one or more exploratory or interventionary paths to go down, I can only offer them as options. The greatest power I have is to generate and offer a menu to the client, and encourage them to add/edit/delete. If the client seems to be opening a (conversational) door, I don’t step through it. I observe it to them, and ask if they want to head in that direction. If the client is agreeing too easily, I invite challenges.

Ending

There’s so much more to say about this-- additional best practices, as well as discussing important ethical limitations to power-sharing (see: imminent danger)-- but I wanted to keep it short, at least as a start. This is (clearly) a sacred topic for me, so… let’s keep talking about it, yeah?