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Balancing the Power Dynamic in the Therapeutic Relationship

Section 5
Ethics and The Manipulation Boundary: When is it Healthy and When is it Pathological?

Question 5 | Test | Table of Contents

By Karen Lindhurst

Karen Lindhurst, the author of this article, has experience in community mental health to include a substance abuse residential treatment facility. The following are my thoughts on the pros and cons in using manipulation in a therapy session.

Manipulation is a “loaded word.” It can elicit very negative emotions. However, I propose that therapists attempt to re-frame the word as they enter into practice. A common definition might be “the act of changing others by unfair means to serve one’s own purpose." This first definition might be what we are most familiar with in our society. However, I would propose the following definition, “the act of improving one’s life situation through the skillful management of another person or system without consent from the affected party.”

I see manipulation daily in the mental health field. The clients I serve are actively trying to improve their current life situation. Many of them are masters at managing other people or systems. In practice, I often find myself as one of the people whom they attempt to manage. The following paragraphs contain highlights of a few experiences I’ve observed in my years of practice.

Marital issues.
Several years ago, I was working with a couple struggling with marital issues. The husband shared that he was not happy with his wife because she expected too much of him. He stated that he wanted to have some time to go fishing, to play pool or to just have an evening to himself once in awhile. He described her as “manipulating” every hour of his life. The wife in turn shared that she believes the marriage is falling apart because her husband is not happy being at home with her. She admitted she plans activities for the two of them and is not happy if her husband wants to spend time away from her. He responded with assurance that the marriage was solid but that he needed more space. He said he felt “smothered.” Further discussion revealed that the woman had been previously married and the first marriage had ended in divorce. She became tearful as she expressed fear that the same would occur with her current marriage. Several sessions went by with the couple. It was fairly clear the woman was trying to control her husband’s free time or behavior to decrease her own anxiety about the marriage. She was able to identify that her sense of security was better when her husband was physically with her. Was it her motive to control her husband or preserve the marriage?

Thankfully, the couple was able to address the behaviors of concern and create new behaviors focused on fulfilling both partners’ needs. Their relationship improved as did the woman’s sense of security in the marriage. It was important through the therapeutic process to identify the process of manipulation but not to label it as a negative behavior. It was simply a survival skill used by the woman. Redirecting the behavior was a key to a positive treatment plan.

Another example presented itself in my work with a family consisting of three children living with their grandparents. The family had received outpatient services off and on for a couple years for the two older children. Therapy focused on behavior management and parenting strategies. The family received disability insurance for the two children. A third child in the home had begun having behavioral issues at school which prompted the contact with myself. The grandmother entered my office and presented me with disability paperwork to complete for the youngest child.

Historically, the grandmother had struggled to maintain a job for various reasons. She would work for several weeks and would leave the job with little notice to her employers. She appeared to be a capable worker or employee. However, the grandmother had never maintained steady employment. The grandfather was retired but had suffered from health related issues for several years. He tried to do odd jobs around the community but his abilities were limited due to his health. The children had resided with their grandparents for more than three years. For various reasons, there was limited support from the biological parents.

During the session, the grandmother shared that none of the children were doing well. She wanted the older children back in therapy. She talked briefly about the third child who was reportedly being disruptive at school. This had prompted her visit to my office. Grandmother spoke of her latest job experience. She said she had been working nights and couldn’t get the kids to school on time because she didn’t get off until thirty minutes before they were to be at school. She said she couldn’t keep the job because the school was upset about tardiness and attendance. She spoke of her concern about paying the bills and buying medication for her husband. With increased emotion she again referred to the children’s behavior.

I asked some questions about the school and the behaviors of concern. I touched briefly on some stress relief strategies for the grandmother, agreed to look through the paperwork, and rescheduled to meet with the grandmother and youngest child. She seemed somewhat relieved.

My Ethical dilemma.
As I reviewed my session with the woman, I identified several areas of concern. I was aware that I that I might have an ethical dilemma to address regarding the disability paperwork, but I didn’t believe this issue needed immediate attention. My biggest concern was the amount of stress expressed by the grandmother. She was struggling to maintain at many levels. She was physically tired, emotionally drained, and was trying figure out how to generate enough money to pay bills and maintain her husband. The woman was desperately trying to improve her life situation by changing other’s behaviors and by trying to access services. To be specific, the grandmother was trying to change her grandchildren’s behavior, was trying to get me to help her change their behavior, was seeking my service to help her secure disability assistance, and was trying to manipulate a financial system with little success.

The woman’s behavior could be identified as manipulative. I would suggest that she was trying to skillfully manage others for personal gain. However, the personal gain was at a level of self-survival. She was trying to preserve her family in the only way she thought possible. Is this a negative skill?

I can remember a conversation in my clinical practice course during graduate school very clearly. This particular conversation evolved as one of the students referred to a client as “manipulative.” The instructor emphatically asked, “What do you mean by that comment?” It appeared as though the entire class was taken back by the instructor’s question and her pointedness. The student attempted to answer but was unclear as to what the instructor was asking.

Our instructor went on to ask several questions. The two that remain most clearly in my mind include, “Why do we use the word manipulation to describe perceived negative behaviors of a person?” and “Why is it ethical for therapists to use manipulation in their practice?” She then gave us an assignment. The assignment seemed simple. We were to think about how we used manipulation in our own lives and to write a two-page summary.

The responses presented in the next class period included a vast variety of experiences. One student tried to get a good grade by spending time after class talking with the instructor. Another male student talked about going on a date. He washed his car for the first time in two months, got a much needed haircut, and spent extra on cologne. He did all these things to try to impress a woman he really didn’t know. Other examples included interviewing for jobs, trying to talk a police officer out of a ticket, and parents trying to gain good behavior from children through rewards and promises. One student spoke of the process of writing a check with the knowledge that you would not have money in your account until tomorrow (or later) to cover the amount of the check. Another student even talked about applying for a loan and not giving complete and accurate information to the bank officer. There were many other examples but the instructor made her point. We are all guilty of manipulation as we live our daily lives. Finally, she concluded the lesson with the next question. “Is manipulation a bad thing?”

One last example involves an intervention at a residential treatment facility. Our staff at the facility had been struggling to maintain the group of teens in the program. Behaviors of concern included defiance, refusal to maintain their rooms, poor school performance and general negative attitudes. The staff had a meeting to try to address the problems. A reward of some kind became the proposed solution. The staff selected a pizza party for the reward if all the residents maintained a certain point level through the week. The residents were made aware of the incentive. Some were excited about the opportunity and others showed no enthusiasm. Staff went ahead with the intervention plan to see if behaviors would improve. The outcomes were not perfect but were positive. The group of teenagers who had been so disruptive one week, showed improved response to the staff and all activities the following week. Several positive leaders even began to emerge. Although not all residents met the goal of maintaining the point level, the entire group’s behavior improved. We did go ahead and offer some pizza but not a full blown party. The kids responded to the staffs’ reward intervention which was actually an act of manipulation. Was this planned reward intervention an example of negative manipulation or positive manipulation of the teens behavior? I believe the staff actually utilized some positive manipulation skills.

We hear references to manipulation very frequently. “She’s manipulating the system.” “ He manipulates the kids every weekend.” “Her behavior is so manipulative.” All these comments can be heard in the clinical setting as well as in our daily conversations. The references often have a negative overtone to them. They hint that the person doing the manipulation is breaking some unwritten rule of behavior. They also bring about the idea that the person involved in the manipulative behavior is harming another person in some way. I believe this is in part due to the lack of permission or awareness of the affected party or system. Manipulation does not allow for one to seek permission to initiate change.

I would challenge the negative references to manipulation. I see the skill as a strength that can be utilized to help persons improve their life situation. The key in treatment is trying to redirect the identified manipulative behavior into something that will benefit the client without harming others. If at all possible, making the client aware of the behavior will create even more avenues for future success and effective transference of the skill. If a client can “skillfully manage” their own behavior, master the skill of managing others without harm, and use these skills in a positive manner, the opportunity for self-growth and self-survival is unlimited. Manipulation is only a negative behavior if we choose to define it as such. It can be the strength or treatment tool necessary to successfully empower clients to change their life situation. Manipulation is a word loaded with treatment opportunities.

Personal Reflection Exercise #2
The preceding section contained information on the manipulation boundary. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

Peer-Reviewed Journal Article References:
Allen, L. R., & Dodd, C. G. (2018). Psychologists’ responsibility to society: Public policy and the ethics of political action. Journal of Theoretical and Philosophical Psychology, 38(1), 42–53.

Conlin, W. E., & Boness, C. L. (2019). Ethical considerations for addressing distorted beliefs in psychotherapy. Psychotherapy, 56(4), 449–458.

Conrad, M. (2019). Moving upstream in the post-Hoffman era: When ethical responsibilities conflict with the law. Professional Psychology: Research and Practice, 50(6), 407–418.

Kim, S., & Rutherford, A. (2015). From seduction to sexism: Feminists challenge the ethics of therapist–client sexual relations in 1970s america. History of Psychology, 18(3), 283–296.

Pizer, B. (2017). “Why can’t we be lovers?” When the price of love is loss of love: Boundary violations in a clinical context. Psychoanalytic Psychology, 34(2), 163–168. 

Summers, F. (2017). Sexual relationships between patient and therapist: Boundary violation or collapse of the therapeutic space? Psychoanalytic Psychology, 34(2), 175–181.

What are two definitions of manipulation? To select and enter your answer go to Test.

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