"Manipulation" in Therapy

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Iwillheal

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A few months ago, a few therapy students and I were talking about "manipulation." Therapy is manipulative, like it or not. What do I mean by that? I don't mean it in the pejorative sense, not completely at least. What I mean is that we control the situation in ways that may not be obvious to the patient at the time. We lead them a certain direction, using certain techniques, that may not be apparent. When asked, we may deflect the questions, not allow them to deduce our method. We may--we should--agree about the goal state with the patient, but how we gonna take him there means he has to trust us, do the "homework", engage us, open up to us and let his true self experience us, get shaped by us, get shaped by others in situations outside therapy...all in service of a goal state.

Back to our casual discussion a few months ago, one of my good friends told me of a situation where he changed the temperature of the room for "therapeutic reasons." I said, What do you mean? He said the patient of his had assertiveness problems but also seemed strangely oblivious to his environment, based on his many accounts of people constantly reminding him of such issues. Yet my friend had not noticed this firsthand. What he decided to do was lower the room's temperature before the patient came to see him the next session. When I asked him what if the patient asks you if you did that "on purpose", he said he would say he did that because the room was too hot for himself. He added that this is true, that it WAS too hot for him but he kept it at that temperature for the patient who always seemed to be shivering. Two birds with one hand I suppose.

This brings me to my question. How big are you on being genuine and honest in therapy. Aside from making sure the "manipulation" does not "harm" the patient in a flagrant way, what are the limits of "manipulation"?
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Iwillheal said:
A few months ago, a few therapy students and I were talking about "manipulation." Therapy is manipulative, like it or not. What do I mean by that? I don't mean it in the pejorative sense, not completely at least. What I mean is that we control the situation in ways that may not be obvious to the patient at the time. We lead them a certain direction, using certain techniques, that may not be apparent. When asked, we may deflect the questions, not allow them to deduce our method. We may--we should--agree about the goal state with the patient, but how we gonna take him there means he has to trust us, do the "homework", engage us, open up to us and let his true self experience us, get shaped by us, get shaped by others in situations outside therapy...all in service of a goal state.

Back to our casual discussion a few months ago, one of my good friends told me of a situation where he changed the temperature of the room for "therapeutic reasons." I said, What do you mean? He said the patient of his had assertiveness problems but also seemed strangely oblivious to his environment, based on his many accounts of people constantly reminding him of such issues. Yet my friend had not noticed this firsthand. What he decided to do was lower the room's temperature before the patient came to see him the next session. When I asked him what if the patient asks you if you did that "on purpose", he said he would say he did that because the room was too hot for himself. He added that this is true, that it WAS too hot for him but he kept it at that temperature for the patient who always seemed to be shivering. Two birds with one hand I suppose.

This brings me to my question. How big are you on being genuine and honest in therapy. Aside from making sure the "manipulation" does not "harm" the patient in a flagrant way, what are the limits of "manipulation"?
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I really cant agree with most of your post.

One, the term "manipulative", by definition, IS pejorative, as it indicates attempts to control or guide a situation unfairly, or for ones own advantage. Second, although, I do play a sort of "dumb Colombo" from time to time (especially in the processing parts of PE) in order to plant seeds that will hopefully grow, I hardly view this as manipulation. Similarly, while I suppose the ultimate goal of MI is basically "inception," (lets be honest, we do want the patient to decide to begin the change process) this too i do not feel to be deceptive or manipulative. Third, I certainly never "deflect my methods" or obscure my methods in anyway.
 
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Along with Erg, I don't believe I'm manipulative in therapy. I wouldn't describe myself as client-centered, but I do expect the ideas, direction, and change to come from the clients themselves. I simply provide tools. Clients can use the tools if they're useful and discard them if they're not. I'm also very transparent when I use interventions. If I wasn't transparent, how could I expect the clients to use the intervention themselves after termination? I think the most "manipulative" I get is feigning confusion or intentionally exaggerating something. Even then, I do it with a wink and a nod.
 
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Iwillheal said:
This brings me to my question. How big are you on being genuine and honest in therapy?
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Very!

Iwillheal said:
Aside from making sure the "manipulation" does not "harm" the patient in a flagrant way, what are the limits of "manipulation"?
Click to expand...

It depends. People manipulate themselves every day without realizing it. Many problems are corrected when people learn to let go of manipulating themselves, and do away with their mind before it does away with them. Empathy and a warm relationship is not always enough. I do believe the therapist may at times need to be 'manipulative' in the service of the patient. It should be used only absolutely necessary, and without sadistic reason (so be mindful of your countertransference in session). I am thinking this would especially be true in extreme cases of certain Axis II disorders. I think to do this in such a way that it benefits the client, requires an incredible amount of insight and skill, and cannot be predicated upon sadistic motivation.
 
Iwillheal said:
Back to our casual discussion a few months ago, one of my good friends told me of a situation where he changed the temperature of the room for "therapeutic reasons." I said, What do you mean? He said the patient of his had assertiveness problems but also seemed strangely oblivious to his environment, based on his many accounts of people constantly reminding him of such issues. Yet my friend had not noticed this firsthand. What he decided to do was lower the room's temperature before the patient came to see him the next session. When I asked him what if the patient asks you if you did that "on purpose", he said he would say he did that because the room was too hot for himself. He added that this is true, that it WAS too hot for him but he kept it at that temperature for the patient who always seemed to be shivering. Two birds with one hand I suppose.
Click to expand...

Am I missing something? What was the intended purpose of such an "intervention"? To mess with the client? To see if the client noticed, got pissed off or not? What happens in either case?? I'm so confused.

Seems a little like playing detective--which is a pet peeve of mine among therapists. We're not detectives. And we suck at being voyeurs.
 
This obviously makes me think of MI as well and if I recall there is a section in Miller & Rollnick's book called something like "Is MI manipulative?"

I'm sure they put it better than I could, but I don't think encouraging the client to break out of a confrontation stance regarding a problem behavior is manipulative, nor is highlighting the clients own agency/the fact that they are in the driver's seat. These are all true things. If you use MI to guide a patient along path where they evaluate the problem behavior from all angles and come to value the goal of discarding that behavior I think it's really the opposite of manipulation. Many people go to therapy because their parent/partner can't stand it and they get pressured gently or not so gently to "do something". Isn't that more manipulative?
 
Manipulation involves a hidden agenda on the part of the manipulator. Guiding/Leading/Shaping, on the other hand, involves movement toward a pre-defined and co-constructed goal.
 
In regards to the Miller and Rollnick book, there is a chapter entitled "Ethical Considerations" where they discuss some of the issues touched upon here. I have not read it in some time, but it might be worth a read for those interested in the topic.
 
Killer Diller, I know you said you aren't client-centered, but really it is inherently client-centered to move towards their goal. And really, without buy in about any goal, the person won't do it anyway...

Sure, we have ideas about what the clients should do, but I don't see that as manipulative because we don't have any real power to make someone do something. If some power dynamics were introduced into the therapy (such as court-mandated clients), the therapist would, IMO, have to involve supervision or the treatment/legal teams to ensure that manipulation didn't occur (ex: if you don't do your homework every week i'll tell the P.O. you're being non-compliant and you'll get sent back to prison...). Ethically, that could be handled by setting up the agreements in the informed consent process, anyway.

In regards to the room temperature in a session situation, that sounds more like a covert experiential exercise. I don't see it as manipulative in the sense that, what really would happen if the client said nothing? They'd be cold? oooh. But, they also could have a small, inconsequential but practical example of speaking up about a preference (i.e. "Could you raise the heat?") and have a great example that when speaking, they have new opportunities to be heard. Sounds like a clever/creative intervention to me. Again, I think manipulation involves power dynamics, controlling or forcing behaviors, and something being at stake....
 
ClinPsychEnthus said:
Killer Diller, I know you said you aren't client-centered, but really it is inherently client-centered to move towards their goal. And really, without buy in about any goal, the person won't do it anyway...
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Agreed. I meant that humanistic/client-centered therapy is not my theoretical orientation.
 
Thanks for your replies.

Psychadelic2012, I don't recall the details of the case. It was a complicated case involving some medical issues. And I have to disagree with you somewhat in the sense that we do need to play detective from time to time. It's a collaborative effort with the patient/client, trying to find the reason behind the person's anguish. Surely I won't be relying only on their account and their understanding of what is the cause of their pain. Like a detective (but very much unlike arrogant movie detective), I do need to look for clues everywhere, in their story, in what their partner tells me, in transference, life history, previous doctors' notes, etc. But that's only one part of our job.

Futurepsydoc, thanks for the suggestion.

Nononora, okay, so assume the client and I have agreed on, as you say, a "pre-defined and co-constructed goal." That's the end we will be moving towards. So far so good. But ends do not always justify the means. Assuming that "manipulation" is somewhere between logical persuasion and outright coercion, that it's about artificially limiting someone's choices, framing a situation in a way that encourages certain behavior, etc, what then? Assume that the patient is not perceptive/educated/intelligent enough or that we are not transparent enough. In other words, assume the person could potentially logically poke a hole in the argument I have offered, in the way I have presented the cost/benefit analysis. Or think of what I'm offering as advertisement, or as reasons given by a car salesman. The difference is that the car or the product advertised is what the person had told us he wants...supposedly. But how we get him to buy the product, well, that's a different story.
 
Iwillheal said:
Assuming that "manipulation" is somewhere between logical persuasion and outright coercion, that it's about artificially limiting someone's choices, framing a situation in a way that encourages certain behavior, etc, what then?
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I don't think this is what therapy does, though. In fact, to me it does the opposite. Clients come in having repeated the same patterns of behavior (broadly defined) long enough to feel like that pattern is their only option. These patterns are not working for them in some way, otherwise they wouldn't be in therapy. The therapist's job, as such, is to expand their options for behavior outside of this pattern, not to constrict it in some other way. So, we ask (yes ask, not coerce) our clients to try something new in the service of experiential learning. It's a collaborative effort to choose the something new based on the client's values. It's also their choice, at any given point, whether to go with the new behavior, or whether to go back to the old pattern (which can be, in certain contexts, a good choice). In short, therapy is about giving clients more options, not fewer.

Iwillheal said:
Assume that the patient is not perceptive/educated/intelligent enough or that we are not transparent enough. In other words, assume the person could potentially logically poke a hole in the argument I have offered, in the way I have presented the cost/benefit analysis. Or think of what I'm offering as advertisement, or as reasons given by a car salesman. The difference is that the car or the product advertised is what the person had told us he wants...supposedly. But how we get him to buy the product, well, that's a different story.
Click to expand...

Even though business acumen is often useful for psychologists, and we are under the same economic pressures as everyone else, I would argue that we are not there to pitch our treatments. We should not be making promises we can't keep. Even in sticking to ESTs, I don't know whether my clients will feel better or worse after treatment, and I tell them so. If they walk out the door on the first day, so be it. Maybe they'll walk back in later on, or maybe something they get outside of therapy will work for them.
 
KillerDiller, thanks for your reply, it's quite good. Just to be clear, I was not suggesting that this is what therapy does, that, for instance, it creates artificial restrictions on choices available to us or that it frames issues in logically questionable but emotionally potent manner. I was simply asking IF one would be willing to resort to certain measures that can be labeled manipulative--mainly because of lack of transparency and certain level of deceptiveness to them--to achieve a certain agreed-upon goal or, say, to learn something about the patient where there is no other practical way to find out.
 
I think there are some elements of established treatments that are manipulative, in a sense. For instance, when you use the "door in the face" technique to get someone to do something (such as their "homework"), you're clearly exploiting a known function of their psychology in a way that's not immediately honest; you have a certain goal in mind for what you want them to do, and you ask them to do more than that to make them more likely to do what you want.

That said, I don't see anything wrong with behaviorist techniques, even ones that are manipulative (i.e. hiding true intent at first). People generally aren't going to do things in therapy they don't want to do. We all have a range of behavior we'll agree to, depending on our moods, framing effects, etc. So, for instance, maybe I'd agree to do anywhere from 5 minutes to an hour of mindfulness meditation, depending on my mood and the context. A therapist could do things to get me more likely to agree to the higher end of that range, but they'll never get me to agree to 15 hours of meditation, even if they initially request 60, because it's outside of my "range of comfort."

So yeah, sometimes therapists will behave in a way that's not immediately honest for the sake of encouraging behavior that's more along the side of a person's behavioral repertoire that we're looking for. But it's pretty rare, never egregious, and always in the interest of a person's stated goals. On top of that, the bulk of treatment and interventions involve complete honesty about the intent, direction, and expectations for treatment. In the example you gave, I don't think using any hypothetical manipulative measures would be useful to treatment in the long run; information about a client that they hide from you isn't useful as long as they still want to hide it from you. A warm, honest, and collaborative relationship is going to improve outcomes a lot more than a little extra information.
 
Iwillheal said:
Nononora, okay, so assume the client and I have agreed on, as you say, a "pre-defined and co-constructed goal." That's the end we will be moving towards. So far so good. But ends do not always justify the means. Assuming that "manipulation" is somewhere between logical persuasion and outright coercion, that it's about artificially limiting someone's choices, framing a situation in a way that encourages certain behavior, etc, what then? Assume that the patient is not perceptive/educated/intelligent enough or that we are not transparent enough. In other words, assume the person could potentially logically poke a hole in the argument I have offered, in the way I have presented the cost/benefit analysis. Or think of what I'm offering as advertisement, or as reasons given by a car salesman. The difference is that the car or the product advertised is what the person had told us he wants...supposedly. But how we get him to buy the product, well, that's a different story.
Click to expand...

My reaction to the word "manipulation" is one of ill-intent, which should that come up on the part of the therapist, may suggest that something is being enacted. I do agree that the therapist's role does come with some authority and along with that comes a limitation of choices and framing situations with a twist, and I imagine for most therapists, would not come with a side of malice or ill-intent.

Perhaps it lies partly in what you perceive as your role in therapy? On my part, I am more aligned with contemporary psychoanalysis which stresses co-creation, implying a sense of equality between patient and therapist (whether that is fantasy or reality is a different question). I do know that happens to differ strongly from the more traditional psychoanalytic view that sees the therapist as the expert, which I imagine could be a role where manipulation could be facilitated.

I don't get the sense that an advertisement or a car salesman provides a good analogy to therapy as both are trying to get you to buy something solely for their personal financial gain. But then again, I'm hard pressed to come up with an analogy myself!

Interesting thread by the way. Thanks for bringing it up!
 
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