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Contemporary Psychoanalysis
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/uucp20
Power Dynamics in the Clinical Situation: A
Confluence of Perspectives
Malin Fors
To cite this article: Malin Fors (2021) Power Dynamics in the Clinical Situation: A
Confluence of Perspectives, Contemporary Psychoanalysis, 57:2, 242-269, DOI:
10.1080/00107530.2021.1935191
To link to this article: https://doi.org/10.1080/00107530.2021.1935191
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MALIN FORS, MSc
POWER DYNAMICS IN THE CLINICAL SITUATION:
AC
ONFLUENCE OF PERSPECTIVES
Abstract. Power issues in psychotherapy are often addressed from the perspec-
tive of intersectional and societal power, enacted or embodied in the therapy
relationship. Following the thinking of Young-Bruehl, who argued for
acknowledging the heterogeneity of oppression, this article posits a heterogen-
eity of power themes in psychotherapy. Four areas of power are highlighted:
Professional power, transferential power, socio-political power, and bureau-
cratic power. All these kinds of power are explored through the case of
“Sonja,” with the overall aim of illuminating power issues in psychotherapy
and illustrating how they may operate simultaneously and synergistically.
Keywords: power, transference, bureaucracy, obesity, odontophopia,
psychotherapy
In contemporary psychoanalytic writing, there is increasing emphasis
on appreciating unconscious power dynamics. Many of these have
been conceptualized by earlier philosophers and political theorists.
The application of their ideas to psychotherapy, however, is relatively
new and insufficiently theorized. I propose to examine four types of
power as they affect the clinical situation, through the case of a patient
whose experiences suggest that power themes are complex, fluid, vari-
ous, and heterogeneous. Often, we talk about power issues in psycho-
therapy only from the perspective of intersectional and societal power
Address correspondence to Malin Fors, MSc. Email: malin.fors@uit.no
This is an Open Access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/
by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in
any medium, provided the original work is properly cited, and is not altered,
transformed, or built upon in any way.
242
Contemporary Psychoanalysis, 2021, Vol. 57, No. 2: 242–269.
#The Author.
ISSN: 0010-7530 print / 2330-9091 online
DOI: 10.1080/00107530.2021.1935191
issues enacted or embodied in the therapy relationship. In contrast,
here, I want to use the case of “Sonja” to explore a larger range of
power issues that affect psychotherapy.
Most theoretical writing on power (for an overview see Haugaard,
2002) addresses political or sociological power rather than interper-
sonal power or the power endemic in treatment relationships. For
example, Marx (1867/1887) wrote about the violence and power of
capitalism; Bourdieu (1984) addressed power in what he called
‘habitus,’ the underlying structure of social life, including the power
inherent in embodied cultural capital such as the higher classes’ formu-
lation of privilege as “taste”; Machiavelli (1532/1985) wrote about
power in governance—specifically about how a sovereign ruler can
maintain power. Weber (1920/1997) addressed questions of the legit-
imacy of power, arguing that bureaucratic power is preferable to that
of a charismatic leader. Power was also an interest of the liberal phil-
osopher J. S. Mill (1859), who worried about the “tyranny of the
majority.” Such preoccupations are ancient: Plato’s concern with issues
of power led to his suggestion that a good society should be ruled by
philosophers (Malnes & Midgaard, 1994). If one interprets the term
broadly, virtually every social or political theorist has written about
power in one sense or another.
Scholars addressing human right issues (e.g., Crenshaw, 1989;
hooks, 1990,2000; Lugones, 2010) have focused on systems of discrim-
ination and on exposing how power works subtly, implicitly, or
overtly in norms—favoring, for example, White, male, heterosexual,
Western, industrialized people—and is reflected in colonization behav-
ior toward non-Western societies, rural areas (Fors, 2018b), animals
(e.g., Donaldson & Kymlicka, 2011), and nature. Contributors to this
literature include, among others, feminist scholars investigating
power in language (e.g., Kristeva, 2004; J. Gentile & Macrone, 2016),
postmodern feminist writers (e.g., K. Gentile, 2013,2017), intersec-
tional scholars (e.g., Crenshaw, 1989; hooks, 1990,2000), queer theo-
rists (e.g., Butler, 1990), and writers addressing critical whiteness (e.g.,
Yancy, 2015) or critiquing norms on ableism (e.g., McRuer, 2006;
Vaahtera, 2012). Power is also addressed by postcolonial contributors
(e.g., Fanon, 1952/2008; Greedharry, 2008; Spivak, 1987). A seminal
twentieth-century influence on theories of power is Foucault’s
POWER DYNAMICS IN THE CLINICAL SITUATION 243
poststructuralist
1
understanding (e.g., 1981) that power is located in
action rather than position; Foucault described power as fluid, rela-
tional, and always in interaction with counter-power. He also
addressed the link between knowledge and power.
This summary of perspectives on defining and investigating power is
far from complete and is not intended to be so. But it does call attention
to the myriad ways in which the topic has been approached. Political sci-
entists and philosophers have addressed power by trying to define what
it is, to specify when it is legitimate, to discern how it operates, and to
infer whether it is located or fluid, ranging from a focus on international
conflict to the exploration of more subtle issues of agenda-setting,
norms, and influence. All these angles of vision can be relevant to the
operation of power dynamics that affect psychotherapy. Thus, there are
multiple way to think about power issues in therapy relationships.
Power in Psychotherapy
In psychotherapy, there are several issues operating simultaneously that
may be understood via different perspectives on power. Certain clinical
situations involve overt control; that is, power that is manifest and
acknowledged. For example, the therapist has the obligation to assign a
diagnosis even if a patient objects to the label. Even when therapists try
to make diagnostic decisions in collaboration with patients (Fors &
McWilliams, 2016; Worell & Remer, 2003), in a disagreement, the clini-
cian’s view typically prevails over that of the patient. If the patient dis-
agrees, one cannot refrain from diagnosing as psychotic a person who is
evidently suffering a schizophrenic break or from diagnosing with a per-
sonality disorder a patient who evidences a borderline psychology. In
extreme situations, therapists also have duties to contribute to involun-
tary hospitalization, to report patients to child protection services, or to
attest that the patient should not have a driving license or a gun.
Power issues in clinical treatment seldom, however, involve overt
domination (A decides for B against B’s wishes). Instead, psychother-
apy is replete with nuances of power that appear in such areas as rela-
tional asymmetry, emotional dependency, and norms of normalcy.
1
Foucault had some objections to being called poststructuralist or postmodernist, but he
is often labeled as such. I do not intend this characterization to be disrespectful.
244 MALIN FORS, MSc
These power operations are sometimes exquisitely subtle and often
unconscious to one or both parties to therapy.
Four Perspectives On Power in Psychotherapy
I submit that in the field of psychotherapy, power issues are most evident
in the following four areas:
1) PROFESSIONAL POWER
The first perspective involves the asymmetry inherent in a professional
relationship. The clinician has extensive information about the patient; the
patient lacks similar data about the clinician. The therapist is paid to see
the patient, keeps a medical record, and in most cases has more extensive
psychological knowledge. This kind of power asymmetry involves overt,
observable factors. Power themes arising from the explicit power opera-
tions named above would include: reporting to child services, involuntary
hospitalization, assigning a diagnosis, and so on. So would more subtle,
often mutual understandings of the clinician’s greater authority by virtue
of their training. In the relational psychoanalytic literature, Aron (1996)
acknowledged this reality of discrepant power in psychotherapy by refer-
ring to the mutual but asymmetrical relationship.
2) TRANSFERENTIAL POWER
A second way, and a common one, of conceptualizing power in psycho-
therapy concerns the implications of the transference and other uncon-
scious parts of the therapeutic relationship. Greenacre (1954) posited
that because of the emotional dependency in the patient role and the
phenomenon of transference, the therapeutic relationship is tilted:
Now in the artificial situation of the analytic relationship, there develops
early a firm basic transference, derived from the mother-child relationship
but expressed in the confidence in the knowledge and integrity of the
analyst and the helpfulness of the method; but in addition the
nonparticipation of the analyst in a personal way in the relationship
creates a “tilted” emotional relationship, a kind of psychic suction in which
many of the past attitudes, specific experiences and fantasies of the patient
are re-enacted in fragments or sometimes in surprisingly well-organized
dramas with the analyst as the main figure of significance to the patient.
POWER DYNAMICS IN THE CLINICAL SITUATION 245
This revival of past experiences with their full emotional accompaniment
focused upon the analyst, is not only more possible but can be more easily
seen, understood, and interpreted if the psychic field is not already
cluttered with personal bits from the analyst’s life (1954, p. 674).
In appreciation of the patient’s vulnerability in a situation of unequal psy-
chological power, Freud (1915) warned against acting out erotic counter-
transferences. He also cautioned analysts not to take on the role of
prophet or savior on the basis of this artificially constructed position of
emotional power (Freud, 1923).
Writers from the relational movement (e.g., Aron, 1990,1991; Mitchell,
1984) have critiqued the assumptions underlying the Freudian construc-
tion of the problem of power imbalance in transference dynamics, ques-
tioning the classical emphasis on the developmental tilt (Mitchell, 1984).
They contend that classical psychoanalytic ideas on transference, concep-
tualizing the patient as having regressed to a childhood state, are patron-
izing and problematic. For example, overemphasizing regression to
dependency (Winnicott, 1955,1963,1965) might infantilize the patient.
Commenting on the relational movement, Slochower writes:
We relationalists may be theoretically diverse, but we share an implicit
and relatively distinct professional ideal. It first coalesced around the
value of asymmetrical mutuality and uncertainty. Emphasizing the
therapeutic potential inherent in mutually unpacking and working
through what’s enacted, we moved away from authoritarian models and
toward asymmetrical egalitarianism (Aron, 1991). We reacted against the
authoritarianism implicit in visions of interpretive accuracy; some also
rejected the developmental tilt (Mitchell, 1984) embedded in ideas of
parental (analytic) repair. Moderating our power and omniscience, we
affirmed our patients’ capacity to see us, to function as an adult in the
analytic context. We rejected sharply tilted clinical models lodged in
beliefs about the power of both interpretation and confrontation.
Relational writers emphasized the mutative potential inherent in
enactment. Unformulated experience, dissociation, and shifting self
states shaped analytic process for both patient and analyst. Unpacking
these dynamics required mutual exploration because we were
implicated along with our patients (2017, p. 283).
Relational theorists thus continue to appreciate unconscious aspects
of the patient-therapist relationship, but they have emphasized more
246 MALIN FORS, MSc
mutual, interactive processes. According to Slochower, therapists in the
interpersonal tradition were the first to move the paradigm of transfer-
ence beyond the notion of the regressive patient: “They formulated a
model in which the patient is an adult and the analyst a participant
observer (Sullivan, 1954)” (2017, p. 283). To sum up: The relational
perspective appreciates transference phenomena but construes power
as issuing from unconscious shared dynamics and the emotional inter-
dependency of patient and therapist.
3) SOCIO-POLITICAL POWER
The third perspective on power in psychotherapy includes extensive
and heterogenous phenomena. In this domain are various issues of
external social power as they enter the therapeutic space. It includes,
for example, attention to how gender, social class, and overall social
norms affect the therapeutic relationship. Such questions have been
addressed by contributors from the paradigms of cultural competency/
cultural sensitivity (e.g., Kirmayer, 2012; Tummala-Narra, 2015,2016);
feminism (e.g., Brown, 2004; Herman, 1992; Worell & Remer, 2003);
anti-racism (e.g., Holmes, 1992,1999; Leary, 1995,1997,2000,2002);
neuro-diversity (e.g., Emanuel, 2016), and overall social justice (e.g.,
Fors, 2019a; Layton, 2020; Layton et al., 2006). I have previously sug-
gested the term relative privilege to explore these issues (Fors, 2018a).
Others have critiqued concepts such as neutrality, normality, and the
politics of diagnosis (e.g., Drescher 2002,2015a,2015b; Drescher &
Fors, 2018). Some have even critiqued the normativity of psychother-
apy in a way that I read as more pessimistic, suggesting that any kind
of psychotherapy assumes norms and operates according to agendas
of power (e.g., Firestone, 1970; Kitzinger & Perkins, 1993). This area
encompasses politically related, internalized processes that affect psy-
chotherapy, including internalized oppression and internalized privil-
ege (Davids, 2003,2011; Fanon, 1952/2008; Fors, 2018a,2018c;
LaMothe, 2014; Layton 2002,2006a,2006b; Weinberg, 1972). Writing
on this topic addresses both conscious and unconscious themes related
to how our social surround affects clinical functioning (e.g., Fors,
2018a,2018b,2018c,2019b).
POWER DYNAMICS IN THE CLINICAL SITUATION 247
4) BUREAUCRATIC POWER
The fourth common perspective on power in psychotherapy involves
bureaucratic aspects of access to care. Subordinated groups are often
at a relative disadvantage in obtaining treatment or social benefits. A
number of writers have addressed the effects of class, gender, and sex-
ual orientation disparities in access to health care (e.g., Johannisson,
2001; Prilleltensky & Nelson, 2002; Smirthwaite, 2010; Smirthwaite
et al., 2014; van Doorslaer et al., 2006). The question of whether to
remove the diagnosis of “gender dysphoria” or “gender incongruence”
from the ICD system belongs in this area; there is a tension between
the aim of reducing stigma by eliminating such diagnoses and the aim
of ensuring needed services (in many countries, abolishing these diag-
nostic labels would make it difficult for transgender people to get
access to necessary health interventions) (Drescher, 2015b; Reed et al.,
2016; WHO, 2018). This problem has so far been addressed by keep-
ing the diagnosis in ICD-11, but moving it from the section on mental
disorders to a new chapter on sexual health (WHO, 2018).
Heterogeneity of Power
I submit that all these perspectives illuminate power issues in psycho-
therapy and that they may operate simultaneously and synergistically.
In parallel with the thinking of Young-Bruehl (1996), who argued for
acknowledging the heterogeneity of oppression, I am arguing for the
heterogeneity of power themes. Here follows my illustrative account
of “Sonja” (a pseudonym), with whom I worked not via “classical” psy-
choanalysis but according to psychoanalytic ideas in the context of the
Norwegian public health care system. In many ways, I ended up doing
more social psychiatry than psychotherapy.
Sonja was a traumatized patient with severe avoidant dynamics and
an overall psychotic level of functioning. She was under continuing
pressure from the health care system to undergo surgical treatment for
weight reduction. Her struggle with this directive, along with her
efforts to claim her legitimate right to disability support, exposed
numerous power issues, including feminist concerns about women’s
bodies as targets of social control, observations about the insensitive
power of bureaucracy (Clegg et al., 2016), and the equation of coerced
work with slavery (Marx, 1867/1887). Ultimately, Sonja was able to use
248 MALIN FORS, MSc
her avoidant tendencies on her own behalf, in the service of counter-
power. I suggest that her case can be understood from all four per-
spectives on power. Sonja has approved the publication of her story.
2
Sonja’s Experience of a Bureaucratic Persecutor
Some time ago, as I was assessing the week’s referrals at our small
psychiatric outpatient unit, one patient stood out as desperate and
slightly odd. The referring physician, Dr Edvardsen, wrote: “I don’t
know why I am sending this referral, but I do not know what else to
do. Sonja and I both know that she has too much anxiety to show up
at your clinic—but she has severe auditory hallucinations and seems
depressed, so I am worried. I have known her for some time, but she
has not told me previously that she hears voices. Please give me some
advice here.”
I called this general practitioner, who said she was worried about
psychosis. I advised her to hospitalize the patient and gave her the
option of our sending a psychiatrist for a home visit, since she was
certain Sonja would not show up for an ordinary outpatient consult-
ation. Dr Edvardsen called back a few minutes later, after having
talked by phone with Sonja about these options. She said they had
agreed to come to our clinic together, and accordingly, we scheduled
an appointment a few weeks later with a psychiatrist, a professional
with a reputation for the skillful handling of avoidant patients. Sonja
canceled the session. Her doctor called in on her behalf, explaining
that she was seeing a psychologist at a center for pain treatment and
did not want too much going on at the same time. The case was
treated as closed for the present.
Odontophobia
A few weeks later, the same patient was referred to my private prac-
tice. I recognized Sonja’s name immediately. I work several hours a
week for the local dental team, who regularly send me odontophobic
patients for assessment and possible psychological treatment. Sonja did
not arrive for the first scheduled session. When I called her, she said
2
This issue of publication was also discussed with Regional Ethics Board which, after
protocol assessment, waived the need for extensive board review (2019/275/REK nord,
18.02.2019). After telephone consultation, the data protection officer for Finnmark
Hospital Trust found no extensive data protection impact assessment necessary.
POWER DYNAMICS IN THE CLINICAL SITUATION 249
that she had been outside my clinic at the time of our appointment,
but that I was not there (something I suspect was not true). Knowing
her story from my other role, I was understanding and empathic of
her anxiety about coming in. We rescheduled, and she showed up. It
turned out she had already had major dental treatment under anesthe-
sia, and when I saw her, she conveyed her sense of deep relief that
her mouth was finally pain-free after many years of dental suffering.
Still, it seemed important to start encouraging her to reduce her anx-
iety about seeing a dentist regularly, managing dental follow-ups, and
(most important) starting to brush her teeth—something she did not
do because efforts to do so caused her to choke or feel nauseated.
We met a few times in my office before it was possible to schedule
a meeting with the dental nurse who does CBT exposure therapy. In
Sonja’s case, the problem was clearly not odontophobia in its narrower
sense, but dissociation, post-traumatic symptoms, and fear of losing
control. I advised the dental nurse to work on relational issues, trust,
and the therapeutic alliance rather than narrowly addressing the
habituation curve of anxiety. This nurse is seen by her colleagues as
unusually skilled and warmhearted, and under her step-by-step care,
dental treatment became increasingly tolerable for Sonja. They started
with tooth-brushing, with removing tartar. Sonja gradually became
more and more relaxed and proud of being able to handle dental
issues. She even dared to take her children to the dentist—something
she saw as a new area of competence. According to her, the turning
point came when the nurse, sensitive to Sonja’s fear of white hospital
garb, dressed instead in blue medical clothing—a gesture of flexibility
that Sonja interpreted as thoughtful and caring.
Family History and Trauma
Sonja was from a successful family. Because she struggled at school
and, because of her learning problems, found most work demanding;
she always felt like the “black sheep.” She had a history of being
severely bullied by classmates and had tried to protect her parents
from knowing about this. Their ignorance of her pain, however, left
her extremely alone with it. Her account was that they were occupied
with surface and status and did not know anything authentic about
her inner world. Growing up, she felt closer to her grandparents: They
were the rocks in her life, and she was reportedly their favorite.
250 MALIN FORS, MSc
Sonja experienced at least one instance of sexual abuse by a friend
of the family. She has no explicit memories of the episode, but she
vividly recalls waking up surrounded by blood and sperm. She has
said that I am the first person to whom she has ever told this story.
Since her childhood, she has heard several voices in her head, talking
down to her and commenting critically on everything she does. Sonja
also reports that she experiences serious memory losses several times
during an ordinary week; she seems to dissociate frequently. Despite
the severity of such post-traumatic symptoms, I could not find any-
thing overtly psychotic in her presentation; her reality testing
was normal.
Sonja’s personality style was clearly avoidant. She was shy, yet when
others got to know her, she was bubbly and likable, even delightful.
Still, Sonja was anxious around people and in social settings to a
degree that seemed agoraphobic. In addition to her dental phobia, she
had a psychologist phobia; she viewed coming to see me as crossing
an important psychological threshold. I think I earned her trust by not
only my patience and empathy but also by talking to her about her
finances and disability pension.
Work and Family Life
At the time I met Sonja, she was working part-time in a sheltered
employment
3
situation where the work seemed meaningless and she
felt patronized. She cried on the bus trip to the facility and could
barely cope with her daily schedule of two hours of work. At times,
waiting for the bus to take her to work, she would panic and return
home instead of getting on the bus.
Contrastingly, Sonja seemed highly competent in her family role:
She was happily married and loved taking care of her two children.
She put a lot of effort and energy into making the family work. In fact,
it was the only part of her life that seemed successful. She coped
adequately with all kinds of parents’ meetings and children’s activities,
even though such participation exhausted her. Sonja engaged herself
to participate, she said, because she was afraid of becoming crazier if
she did not. In settings where she was “the mum” she felt less shy and
3
“Sheltered employment” in Scandinavia is government-subsidized work for people who
would struggle in the ordinary workforce, such as those who are cognitively or
psychiatrically disabled.
POWER DYNAMICS IN THE CLINICAL SITUATION 251
inhabited, a more competent self-state. I learned that her previous
breakdown, when her regular physician had become so worried, came
after NAV (the Norwegian Labor and Welfare Administration) tried to
force her to work a few more hours a week. Sonja had no capacity for
such flexibility, as she was already not attending to her sheltered work
as much as required. This demand from the NAV induced a sense of
severe stress, an increase in her auditory hallucinations, and a period
of suicidality. Her husband was becoming overwhelmed with the situ-
ation as well and their marriage fell into crisis. Sonja told me she had
lived with the voices for years without telling anyone, but her mental
state at this point felt dire enough to impel her to tell Dr Edvardsen
about these hallucinations.
Fibromyalgia and Recommended Obesity Surgery
Another narrative slowly emerged. Sonja was diagnosed with fibro-
myalgia, a diffuse soft-tissue pain disorder that is generally thought to
be only minimally treatable and probably incurable. She told me she
had suffered with massive pain in her joints and muscles since she
was about eight years old. NAV had no documentation of her psychi-
atric condition, only the diffuse pain problems for which doctors had
found no medical explanation. She therefore saw a pain psychologist
for a few sessions before the psychologist concluded she needed psy-
chiatric treatment and terminated her. Sonja also told me that as a con-
dition of getting sufficient money from NAV to be able to pay her rent,
she felt forced to undergo surgery for obesity (gastric bypass). To me,
this sounded like either a delusional belief or a grave misunderstand-
ing. I was reluctant to believe that the Government would force some-
one into obesity surgery.
In Norway, everyone has governmental insurance that covers illness,
but this benefit requires recipients to meet certain criteria. To receive
long-term financial support based on chronic illness, in the absence of
a disability pension, one needs to have a treatment plan. Because
Sonja got no psychiatric assessment, and because the somatic situation
was a bit foggy, officials at the NAV office could not provide financial
support to her without a defined plan. From Sonja’s perspective, this
reality turned a well-intended program into a bureaucratic persecutor.
To fill out the forms correctly, government officials needed to put
something in the space for “treatment plan.” They clearly wanted
252 MALIN FORS, MSc
to help. Because Sonja was overweight, it was suggested that losing
weight might be helpful for her body and might decrease her pain. I
am not sure whether the suggestion came only from the NAV person-
nel or whether, at some point, it was also Sonja’s idea. She clearly had
a weight problem, and the state of her body contributed to her severe
difficulties with self-esteem. Her general practitioner referred her for
gastric bypass, and—despite her telling the obesity doctor about her
poor self-confidence and history of trauma (not the whole truth as I
understood it)—Sonja was put on the list for the obesity surgery.
I reacted with shock. How could a person with such severe psychi-
atric illness, with a disturbed sense of time, different self-states, voices in
her head, poor self-confidence, anxiety, depression, and avoidance be
seen as a good candidate for that type of surgery? If she struggled with
basic self-care, such as teeth-brushing, how could she be expected to
commit to a lifelong diet in the aftermath of bypass surgery? How could
she be seen as competent to give her consent to such surgery?
Kafkaesque Bureaucracy
In the context of my own concerns, I found myself viewing the
approval of such a procedure as professionally unethical. I started to
secretly hate the obesity expert, Dr Dale. Sonja, however, talked about
him as a wonderful doctor who was very empathic and nice. Out of
respect for her experience, I tried to curb my anger and fought hard to
keep my neutrality intact. Later, I learned that Dr Dale was the first pro-
fessional who had looked into the status of her teeth and asked her
about mouth pain. He had concluded that she could not be recom-
mended for bypass surgery because of her poor dental health. Because
food needs to be chewed with particular care after this type of surgery,
he was unwilling to authorize it until she had dental treatment. As the
person who referred her to the dental phobia team, the first source of
practical help and pain relief, he had earned Sonja’s gratitude and trust.
However, it turned out that Sonja was no longer interested in gastric
bypass. Trusting that I would help her navigate through her financial
rights, she canceled the recently scheduled surgery. For some time,
she said, she believed those who would carry out the surgery were
predatory. It turned out she had “missed” several follow-ups and was
nearly kicked off the waiting list, but her general practitioner—with
characteristic compassion—called in several times to help the surgical
POWER DYNAMICS IN THE CLINICAL SITUATION 253
team appreciate her “shyness.” She was kept on the list as medical per-
sonnel made exceptions to keep her scheduled for the surgery, despite
her refusal to commit to follow-up phone calls in which she would
report her weight. Her doctor told her they had made recurrent excep-
tions to “help her out.” Her explanation to me for letting this con-
tinue—which indeed it did for some time—was that she expected to
feel too anxious to call after the operation. At that point, she said, she
did want the surgery. When she then changed her mind, she did not
feel free to back out because of her commitment to NAV’s treatment
plan. My suspicion is that she was ambivalent throughout, and that her
avoidance worked in a self-protective way.
Yet, I remained skeptical about her report that NAV was pressuring
her into obesity surgery. She said she got the question every time she
met with them: When was she going to have the surgery? I thought it
had to be a misunderstanding. It was not evident that bypass surgery
would help her with the pain in her joints, but—according to Sonja—
NAV officials painted a rosy picture of post-operative life: “When you
are less heavy—maybe your body will feel less stiff and painful.”
Although certainly overweight, Sonja was not so heavy that losing
weight would significantly relieve her joints. I suspected that her ver-
sion of what she was hearing was an exaggeration. Maybe she was not
skillful in navigating bureaucratic systems. Perhaps she was slightly
paranoid. Maybe she was not cognitively competent to understand
what was going on. Perhaps it was something with her.
When I attended a meeting with NAV to explain her psychiatric con-
dition and argue against the surgery and instead for permanent disabil-
ity money, the NAV representative—to my surprise—confirmed that
gastric bypass was in Sonja’s treatment plan. The NAV representative
saw herself as being responsible for motivating Sonja toward the sur-
gery, and then following up to see that she maintained compliance
with that treatment plan. I felt guilty for not having believed Sonja.
Subtly, I had been looking for the source of the problem in her—won-
dering if she was misreading what she had been told.
Obesity Conference
After Sonja and I discussed her situation and we spoke with Dr
Edvardsen, Sonja was referred back to the psychiatric clinic and began
to address the paperwork necessary to apply for permanent disability
254 MALIN FORS, MSc
support. Just after this development, I received an invitation. Doctors
Edvardsen and Dale asked me to join them at a medical obesity con-
ference at which they were speaking. Their thought was that all three
of us should present the same case from our respective perspectives—
a kind of 3-D look at the situation. Their position was that Sonja
should never have been approved for surgery, and they wanted other
doctors to learn from the case. After all, this story had a happy ending:
Sonja had managed to cancel surgery.
When I asked Sonja for consent to talk about her experience at this
conference, she was very proud. “I lied so much to my dear doctor. I
did not tell her how ill I was, so she did not know how to help me. It
took so many years for me to tell her about my voices. If anyone can
learn from my experience, I am delighted.” Meeting the obesity expert,
Dr Dale, I realized again that Sonja had been more accurate than I
was. I had projected badness on to him, seeing him as a surgeon in
love with using his knife to “correct” women’s bodies. He turned out
not to be a surgeon at all, but an experienced senior physician who
had worked for many years supervising a wide range of general practi-
tioners. He was doing all the assessments on his own, with no help
from psychologists or psychiatrists (another doctor would have done
the surgery). He seemed thoughtful and wise. Going through the case,
I saw his compassion for Sonja and appreciated the persistence of his
effort to help her cope with the program for calling in and reporting
her weight. He had an overall view on health and talked vividly about
her pain conditions and her oral health. The presentation from Dr.
Edvardsen included her sense of paralysis in not being able to
help Sonja.
My presentation focused on Sonja’s trauma, dissociation, and
the issue of what self-state she could count on to commit to the post-
surgery eating regimen. The question I raised, as to how someone
who could not even reliably brush her teeth could manage the post-
operative regimen, was a new perspective for the medical audience.
They had no idea how psychiatrically sick she was. We were all dis-
tressed to learn about the subtle pressure from NAV, and we were all
made aware of our own accountability (in other cases, not just this
one) in not offering NAV officials enough help to do realistic treatment
plans—leaving them to create their own. A neurologist in the audience
suddenly suggested that there might be a certain rare genetic disorder
POWER DYNAMICS IN THE CLINICAL SITUATION 255
behind Sonja’s pain. She was tested and found negative for this condi-
tion, but the incident nonetheless evidences a level of professional
cooperation not previously available to her.
When Sonja came to the psychiatric outpatient unit again, she
was assigned to me for continuity. She began to meet with both me
and a psychiatrist. When asked for consent to publish her story
anonymously, she said again that she was proud and happy to con-
tribute. If only one doctor could learn something, it would be
rewarding. I suggested that she read the account and approve it.
She refused, saying she did not want to read it. “You can write
whatever you want, but I do not want to read it. I am truly very
happy to contribute, but I do not want to read it.” My anxiety about
this response impelled me to ponder this dilemma with the head of
the research board for my hospital trust, who asked, “Is it your
need for her to read it, or hers?”
Reminding myself of her learning problems, which would make
reading in English especially difficult, I saw that the need was mine. I
wanted to be able to say (and write) that she had read the case report.
That would have made me look ethically above reproach. But, hon-
estly, it was my interest, not hers. She trusted my anonymization. I
asked her to think about her consent for several weeks and checked
in with her weekly, letting her know she could retract her consent at
any time. But she insisted, and, eventually, I accepted her decision. I
hoped this might actually turn out to be an empowering decision: A
mental health professional had heard what she was saying and vali-
dated her experience. The NAV’s approval of her permanent disability
pension arrived around this time. Paradoxically, she now declared
with some delight, she was not merely happy—she said she felt 44
pounds lighter. Carrying her own weight was not a problem, but carry-
ing the weight of powerlessness was very burdensome.
Power Themes
The power dynamics affecting Sonja’s treatment are multiple and various.
They include professional power, bureaucratic power, transferential
power, and the power of social norms about ideal body sizes for women,
attitudes toward women’s pain and somatic condition, class issues, and
access to disability benefits.
256 MALIN FORS, MSc
Bureaucracy and Powerlessness
What has been most striking to me about this confluence of various
sources of power is that everyone in this story seemed to feel power-
less. The source of power was projected by all of us somewhere else.
In addition, many of the players in this story felt an absence of power,
based on a lack of information or knowledge. Dr Edvardsen described
feeling powerless in trying to help Sonja because, for a long time, she
had no information about the severity of her psychological problems.
When she did have that information, Sonja was too afraid to cooperate
and come to the psychiatric clinic. The NAV official felt powerless in
response to the requirement for a treatment plan, and consequently
followed bureaucratic rules that were clearly not in Sonja’s
best interest.
Sonja herself felt powerless. She felt persecuted by NAV, the voices,
and the sheltered work expectations. She truly saw no way out
Relevant to this last consideration, Clegg et al. (2016) contrast
Weber’s relatively positive view of bureaucracy with Kafka’s, noting
that “The Kafkaesque organization … … reduces the sense of agency
of outsiders; it creates a perception of disempowerment via careless-
ness, leading to inaction” (Clegg et al., 2016, p. 166). Specifically, they
note that,
While Weber suggests the inevitability of the technical superiority of
bureaucratic forms and describes the attendant ‘iron cage’ that it
produces, Kafka spoke from within this cage, telling dark and enigmatic
stories of the ironic futility of bureaucratic life. While Weber told us
about bureaucracy’s rationality, Kafka led us through its dark labyrinth.
While Weber wrote about the impersonality of bureaucracy, Kafka
vividly evoked the lived experience of its supplicants being constantly
confounded by its machinations (2016, p. 157).
In Sonja’s experience, both conceptualizations apply. Sonja felt per-
secuted by a well-intended bureaucratic treatment plan, produced by a
good-hearted NAV officer who wanted to solve the problem with the
empty box on the formal sheet. On one hand, this decision turned
into a Kafaesque monster, whose direction Sonja felt powerless to
reverse. On the other, the same bureaucratic system finally rescued
her by approving her permanent disability pension.
POWER DYNAMICS IN THE CLINICAL SITUATION 257
Weber was not unaware of the pitfalls caused by human behaviour in a
bureaucratic setting; rather, he proposed an ideal type model that
condensed the features of actually occurring bureaucracies into an
artificially accentuated model. Objective analysts could use such a model
as a forensic tool for actual investigations. For Weber, being a
bureaucrat is a vocation, one that demands an exemplary professional
ethic. Weber’s focus is concentrated on the mechanics and working of
bureaucracy from the insider point of view of the ideal typical
bureaucrat; Kafka looks at the bureaucratic subject from the experience
of the outsider, from the perspective of the subject; his interest is in the
phenomenology of power rather than issues of governance. Where
Weber sees a character-forming ethic Kafka sees only doorkeepers
(Clegg et al., 2016, p. 160).
Dr. Dale suggests another kind of powerlessness, making the com-
ment that he felt uncomfortable about doing assessments on his own
and that he had little support from others in doing them. I felt a sense
of status inferiority and helpless anger toward the obesity expert, who
I assumed (wrongly, as it turned out) would not have listened to my
arguments if I had called him. Dr Edvardsen’s feeling of powerlessness
in not getting Sonja to make her scheduled follow-up appointments
led to her calling the obesity clinic to ask for an exception for Sonja,
to plead that she not be seen as a drop-out. That powerless “begging”
role had the unexpected consequence of contributing to Sonja’s sense
that she was being persecuted by a kind of unstoppable bureaucratic
invasion (e.g., Clegg et al., 2016).
Paradoxically, Sonja’s avoidant tendencies ultimately were helpful to
her because they effectively postponed the surgery long enough for
her to gather enough courage to retract her consent to the procedure.
This dynamic, which can be viewed in Freudian terms as resistance,
may be seen from a different perspective as exemplifying the concept
of counter-power explicated by Foucault (e.g., 1981). According to his
understanding of such processes, the bureaucratic system is under-
mined by both internal and external power sources; thus, the question
of who has the power is unclear and complicated, supporting his
notion that power is not situated in a specific role but revealed
in action.
In a seminal 1960 paper on organizational dynamics, Menzies
described unconscious “social defenses” in a hospital setting, among
258 MALIN FORS, MSc
the nursing staff and students. These processes led to numerous less-
than-satisfactory clinical outcomes despite the conscious efforts of the
nurses to do their jobs as well as possible. Their struggles against cer-
tain anxieties inherent in their roles created shared defense mecha-
nisms: “The socially structured defense mechanisms then tend to
become an aspect of external reality with which old and new members
of the institution must come to terms” (p. 101). Menzies goes on to
suggest that common social defenses include denial of the significance
of the individual, detachment and denial of feelings, ritual task per-
formance, and collective social redistribution of responsibility and irre-
sponsibility—all examples, in the terminology of Clegg et al. (2016), of
an impersonal (or anti-personal), badly functioning bureaucracy.
In line with Menzies’s (1960) empirical findings, we might conclude
that all of us attending the obesity conference, where we suddenly
became aware of our own responsibility to help NAV do reasonable
treatment plans, were recovering from a collective denial of our own
power to intervene and exert influence. Menzies writes: “People in cer-
tain roles tend to be described as responsibl
e by themselves and to
some extent by others, and in other roles people are described as
irresponsibl
e.” (p. 105). Specifically, she observed that “Each nurse
tends to split off aspects of herself from her conscious personality and
project them onto other nurses. Her irresponsible impulses, which she
fears she cannot control, are attributed to the juniors” (p. 105). Her
observation illuminates my own inclination to cast Dr. Dale as irre-
sponsible and to see myself as contrastingly responsible and well-
intentioned.
I myself also felt powerless in the context of professional regulatory
power and potential consequences to psychologists of failures to oper-
ate within accepted norms. I wanted Sonja to read the case report not
only because of my own need to see myself as of the highest ethical
character but also because of my anxiety about possible legal conse-
quences if I did not insist that she read it.
Money
In Sonja’s pursuit of the right to a disability pension, it seemed
empowering for her to describe herself in the terms of a diagnostic
system that provides access to governmental benefits. From a
Scandinavian perspective, I felt for a long time that she was being
POWER DYNAMICS IN THE CLINICAL SITUATION 259
discriminated against, that simply to get her rights to money, she was
being treated symbolically as a kind of slave (Marx, 1867/1887), forced
to dance to NAV’s tune. But while I was writing about this construc-
tion, a contradictory thought arose; namely, that having governmental
health insurance at all is a privilege. In that sense, living in Norway
might be construed by itself as a privilege.
Regulation of Women Bodies
An obvious power theme in Sonja’s case involves the regulation of
women’s bodies. Would the idea of an obesity surgery, no matter how
well-intended, be suggested to a man? Would a male patient have
been examined earlier than Sonja was for the condition the neurologist
suggested? Is the delay in considering such a diagnosis accidental, or
is it embedded in a social system in which the pain of women is taken
less seriously than that of men? There are numerous issues of relative
power in the areas of women’s access to health care, including a social
norm to the effect that women can simply be expected to suffer more
than men (Johannisson, 1994; Smirthwaite, 2010).
The normative loading in the question of weight surgery recalls
Vaahtera’s (2012) concept of national compulsory able-bodiedness. In
an investigation into how attitudes about swimming affect politics in
Finland, Vaahtera ponders, with dry humor, how not being able to
swim is very stigmatizing there. The country has a thousand lakes, and
its Government insists that every citizen be able to swim at least 200
meters to be “civically skilled” (kansalaistaito). She considers this a
form of ableism instantiated in nationalism: The aim is to stop people
from drowning; yet most people who drown in Finland can indeed
swim, but are drunk (Lunetta et al., 2004).
A critique of the regulation of women’s bodies has been formulated
by many feminists (e.g., K. Gentile, 2013,2017), and the stigma suf-
fered by overweight people has increasingly been seen as an issue of
social justice (e.g., Nutter et al., 2016). Harjunen (2017) addresses
issues of class and gender in fatness and reflects upon the norm of
seeing the overweight body as unproductive and socially unaccept-
able. van Amsterdam (2013), similarly investigated the intersection of
body size, gender, race, class, and age.
260 MALIN FORS, MSc
The Privilege of Thinness: Unconscious Dynamics
All the health professionals trying to help Sonja were relatively thin.
Our body sizes were never discussed with her, and my privilege as a
thinner person was not named in our sessions. In retrospect, I feel a
bit like a male therapist who tries to indicate his support of feminist
concerns without mentioning his own gender (e.g., Fors, 2018a).
Offman (2020) notes that there is significant shame in talking about
body size in therapy. I believe I felt shame in relation to Sonja; I won-
dered if I was convincing enough while trying to support her when
she told me she wanted to cancel the surgery. I may have been hesi-
tant to investigate bad experiences related to being overweight. There
may be elements of reaction-formation and avoidance (i.e., ignoring
my own privilege in thinness) in my taking the feminist position that
size does not matter. We have yet to explore such issues. Because the
treatment so far has involved mainly practical matters, Sonja and I
have not ventured into this psychological territory.
Empowerment in Integration—Power in Professionals
Where is Sonja’s empowerment situated and when did it arise? A crit-
ical moment is easy to identify: the point at which she got approval
for the disability pension. But this is probably not the essence of the
psychological process of empowerment. For someone like Sonja,
whose experience involved chronic fragmentation and dissociation,
being able to integrate the sense of her physical body (notably pain in
her mouth and muscles) with her mental representation of that body
seems to have been ultimately empowering. As has been described in
the clinical literature about our most seriously disturbed patients, there
doubtless were complex enactments churning in the clinical surround
in which she found herself. This parallel process phenomenon
(Ekstein & Wallerstein, 1972) began with a split in the field: Several
different health professionals felt powerless and had to accomplish
their own integration step by step rather than swirling in a pool of
psychological splitting (Klein, 1946).
Paradoxically, it was the obesity doctor who helped Sonja to get
help for odontophobia, the first treatment she was able to make use
of, and by which she felt concretely helped. Her experience also sug-
gests another issue related to status and symbolic power (Bourdieu,
1984). Although a dental nurse is lower in the professional hierarchy
POWER DYNAMICS IN THE CLINICAL SITUATION 261
than a doctor, it was the nurse who managed to help Sonja, first by
sending her for dental treatment under anesthesia and then by gently
pursuing the traumatic origins of her odontophobia. Sonja’s road to
empowerment started with this experience of a person whose power
was not as far removed from her own as the doctors’ power was.
There may have been a deep personal unconscious significance for
Sonja in finally gaining a healthy set of teeth. Once relieved of mouth
pain, perhaps she was ready to “bite back,” fighting for her rights, and
also “biting” into the work of psychotherapy.
Consent
In terms of consent two questions arose: I wondered if I should trust
Sonja’s consent or consider it as avoidance similar to her early avoid-
ance of treatment? This question parallels the issue that Slochower
(2017) has construed as between contemporary relational and more
traditional ego-psychology-oriented psychoanalysts. Is Sonja a grown-
up who can make her own decisions? Or is she more vulnerable psy-
chologically, unable to determine what is in her own best interest? Is it
empowering or irresponsible to publish this paper? And are those
polarities the proper way to frame the question? Is Sonja so emotion-
ally dependent on me that she is unable to know her true feeling?
Theoretically, it is possible to see the question from both perspectives.
To me, Sonja’s delighted reaction to the conference presentation
weighted her consent more toward the realm of adult empowerment.
(Of course, I would not have published her story here if I had not
drawn that conclusion.) The fact that I pondered the question with the
head of the research board and consulted the Regional Ethics board
for protocol assessment, (2019/275/REK nord, 18.02.2019) made the
decision easier. But it is an irony, and perhaps an enactment or a par-
allel process intrinsic to the type of case I am presenting, that I am
referring to a bureaucratic system to justify my decision.
Concluding Thoughts
Issues of power in psychotherapy can be illuminated via multiple
lenses and models. I have found it fruitful to try to hold different per-
spectives in mind simultaneously. I have suggested that there are at
least four dimensions of power relevant to psychotherapy: profes-
sional, transferential, socio-political, and bureaucratic. Most of them
262 MALIN FORS, MSc
are unconscious or partly so. All these areas intertwine. Power themes
are constantly shifting, interacting, and influencing clinical work in
multiple directions.
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268 MALIN FORS, MSc
Malin Fors, MSc, is a Swedish psychologist and psychoanalyst living in the
world’s northernmost town, Hammerfest, Norway. She has worked for a
decade for Finnmark Hospital Trust and also has a busy private practice. She is
an assistant professor at the UiT The Arctic University of Norway, and a guest
lecturer at Gothenburg University in Sweden. She is the 2016 recipient of the
Division 39 Johanna Tabin Award for her book, A Grammar of Power in
Psychotherapy, released by APA Press in 2018 and recently published in
Swedish. Malin was featured in a demonstration DVD in the APA
Psychotherapy Video Series, released in October 2018. In the spring of 2020,
she was the Erikson Scholar at Austen Riggs Center, MA.
POWER DYNAMICS IN THE CLINICAL SITUATION 269
