Issues of difference and equality in the therapeutic relationship

Health Education Plan

Issues of class, difference and equality in the therapeutic relationship

Class conflicts can complicate the therapeutic relationship. For example, when a counselor urges a client to embark upon a change, such as going back to finish his or graduate degree, the client may respond: "you don't understand. I can't afford it." The therapist may see the client's fixation upon economics as an unconscious 'block' and a way of rationalizing staying in a bad job and life situation -- perhaps even in an emotionally abusive marriage. The client may see the therapist's focus upon change as a reflection of the therapist's greater wealth and social mobility.

Class cannot be ignored: a client with problems with binge eating, for whom it is suggested that he or she eat more healthfully might protest that healthy food costs too much to buy. While the therapist might argue that the physical costs of obesity also translate into economic losses -- a sacrifice of jobs, social opportunities, and the cost of healthcare -- the client may see the ease with which the therapist advocates a change of diet as a product of the therapist's class.

This can put the therapist in a 'bind.' On one hand, the therapist does not want to validate the client's negative thought processes and rationalizations. Part of therapy is becoming more 'open' to new experiences and ideas, under the guidance of the therapist. However, economic realities are a part of life. Additionally, these can become more fraught if payment is an issue for a client who does not have or loses his or her health insurance coverage.

The therapist must give advice with sensitivity to the client's financial situation, without allowing the client's perceptions of his or her class status to dominate the therapeutic discourse in an unquestioning fashion. It must be remembered that the client's self-perceptions of his or her economic situation may not be entirely 'real,' either. A well-to-do person may still see him or herself as lower class, because of his or her upbringing, regardless of income, and see the therapist as part of the educated and privileged elite.

It has been said that all types of therapy, regardless of the type, must be characterized by "constancy of therapist's interest no matter how disturbing the subject; suspension of moral judgment; therapist's empathy, insight, understanding, and acceptance; patient's opportunity to speak the unspeakable now; reliability of therapist in keeping appointments, the duration of the session; the attempt to put patient's welfare first; the safe environment that the therapist's structure provides in which the patient can regress;" and "the therapist allowing him/herself to be used as a transference object without the interference of counter-transference" (Niolon 1999).

Clients should not have to feel as if they must censor class-related issues regarding their concerns about money when debating whether to make a life change, or their feelings about a spouse or relative. However, along with empathy and acceptance, the therapist's duty in many forms of therapy (such as in Cognitive-Behavioral Therapy) is also to challenge negative and self-defeating patterns of thinking. If the client says: "I can't leave this marriage because I can't support myself," the therapist will want to probe deeper to find out why the client believes that it is impossible for her to get a job.