Robert L. Morasky, Ph.D. Field Services Psychologist Division of Developmental Disabilities, State of Washington
Power struggles are common to relationships (Fisher & Sharp, 2004). The relationship between staff and a person with a dual diagnosis is as prone to power struggles as any other and, perhaps, even more so (Young, 1999). Training to avoid power struggles should be an integral part of a staff person's preparation (Beck, 1994; Zimmerman et al, 1992). It is crucial to an understanding of therapeutic alliance and recovery. A model of power struggles can be used to facilitate staff training.
Figure 1 shows a three factor model of power struggles that is drawn from various sources. The three factors of this model are Type of Struggle, the Escalation Spiral, and Sense of Self.
Types of Power Struggles
Neath and Schriner (1998) identified two types of power that are central to power struggles: power-over and personal power. Power-over struggles are characterized by the participants attempting to dominate each over. In short, each participant is trying to have power-over the other. As an example, when a client is trying to take soda pop from a store without paying, and the staff person is trying to have the client leave the soda pop or pay for it, they are in a power-over struggle.
Personal power is akin to empowerment. Personal power allows an individual to act in order to achieve desired ends. One such end is to be able to evaluate oneself positively. A personal power struggle is characterized by each participant attempting to gain personal power by winning, being right, being faster, or any other end that empowers the person. For instance an argument between client and staff over the time when the bus comes is a personal power struggle. One person gains personal power by being right, the other loses personal power by being wrong.
Note that power-over struggles involve an exercise of power. The outcome of a power-over struggle is the establishment or confirmation of a hierarchical relationship. Position on a hierarchy is what is gained or lost in a power-over struggle. On the other hand, personal power struggles involve empowerment or disempowerment.
Figure 2 shows a typical escalation spiral associated with a power struggle. The intensity of the struggle increases as it spirals upward from the Discussion/Problem Solving stage to Assault. Escalation in any specific power struggle may not follow this spiral exactly. A person may jump from yelling and screaming to threats or assault. In general, however, this escalation spiral serves to illustrate what happens as the intensity of a power struggle increases.
As a power struggle increases, the nature of the interaction changes from agitation to intimidation to violence. That is, behaviors such as raising one's voice, yelling, swearing, and being obscene exemplify agitation. Once behaviors such as insults, name-calling, and verbal threats occur, the intent is to intimidate. Of course, physical threats and assault are violence. The distinction between agitation, intimidation, and violence is important because a personal power struggle becomes a power-over struggle somewhere in the intimidation phase. A participant in a personal power struggle can be empowered or disempowered even while agitated. However, the purpose of intimidation and violence is to establish power-over. Once a personal power struggle escalates to the intimidation phase, then it is likely to become a power-over struggle.
To avoid escalation staff need to keep the struggle at the discussion/problem-solving stage (Fisher & Sharp, 2004). Training in redirection, clarification, cognitive restructuring (Meichenbaum, 1976; Dodge, 1993; Mahoney, 1993), and reality therapy (Glasser, 1965) are just a few of the techniques that can be used to avoid escalation. Staff need to be skilled in these techniques. However, the third factor, sense of self, introduces an element that may be as important as staff competence.
Sense of Self
Sense of self is made up of the "selfs" such as self esteem (Meloy, 2000). Taken together, self-image, self-concept, self-esteem, self-confidence, and self-worth give each of us a sense of who we are. Sense of self is related to empowerment; hence the connection to personal power struggles (Neath and Schriner, 1998) (Young, 1999). If personal power struggles are about "win or lose", "right or wrong", "good or bad", "same or different", "fast or slow", "successful or unsuccessful", these are the same outcomes that impact our sense of self (Hillman, 1995). In short if power is one of our basic needs (Glasser, 1976), if empowerment is embedded in our sense of self, and if personal power struggles are about empowerment, then we might very well engage in personal power struggles to preserve or enhance our sense of self.
We can assume that everyone has a sense of self. Furthermore, we can assume that everyone will at some time struggle to preserve or enhance that sense of self. We should not find it surprising that people with disabilities in general are thought to be less empowered (Young, 1999). It follows that their sense of self, from which personal power is derived, would also be lessened. Being right, fast, good, successful, same, and winning in our society can be difficult without the interference of cognitive deficits, hallucinations, delusions, depression or any of the other many symptoms of mental disorders. It becomes a tremendous challenge when a person has a developmental disability and a mental disorder. For that reason staff training needs to include the skills to avoid power struggles.
Training, while necessary, may not be sufficient preparation for staff to avoid power struggles. Both persons in a personal power struggle have a sense of self to preserve or enhance. The question that we need to ask is, "What role does the caregiver's sense of self play in avoiding power struggles?"
Data From a Best and Worst Caregiver Exercise
While conducting training workshops for caregivers, a simple exercise was used to get participants thinking about the role of caregivers in interpersonal conflict with persons with a dual diagnosis. With a few simple procedural adjustments the exercise became a means for evaluating the three factor model of power struggles.
108 staff who provide care for persons with mental health and/or developmental disability diagnoses completed a "Best and Worst Caregiver" survey prior to any instruction on power struggles or the three factor model. The survey was presented on one, two sided, page. On one side participants were instructed to answer 15 questions "as you think the BEST caregiver you have ever known would answer them." The same statement appeared on the reverse side with WORST substituted for BEST. The surveys were randomly distributed with BEST or WORST side up. Participants were told they could respond to either side first. They were reminded not to answer the questions for themselves, but, rather, for the BEST or WORST caregiver they have known. The fifteen questions on the survey are presented in Table 1. Items 1, 2, 3, 6 relate to stages in the Escalation Spiral. Items 4 and 5 relate to personal power and power-over struggles, respectively. Items 7 through 15 relate to the outcomes of personal power struggles that impact sense of self, i.e., items 7 and 9 are about being right or wrong, item 8 is about being fast or slow, items 10 and 13 are about winning or losing, item 12 is succeeding or failing, item 14 is good or bad, and item 15 is a general statement associated with self-esteem. Participants were also asked to indicate how many years they had been paid caregivers.
Figure 3 shows the median values for items 1 through 6. Figure 4 shows the median values for items 7 through 15. The robust differences between the participants' perceptions of "Best" and "Worst" caregivers stands out in these two charts. "Best" caregiver scores were greater than a median value of 1 on only two items, 5 and 12, and, then, for those two items the median score was only 2. "Worst" caregiver scores were less than a median value of 4 on only item 3.
The perceptions of the 108 participants in this exercise were that the "Worst" caregivers that they have known: (a) get into more power struggles, (b) escalate the struggles higher, and (c) have greater need than the "Best" caregivers to enhance personal power by winning, being right, fast, good, and successful.
The differences based on years of experience were noted. Staff with less than five years of experience: (a) believed that the "Best" caregivers were seldom, if ever, yelled at; (b) believed that the "Best" caregivers needed to "&ldots;succeed in order to feel good about myself," and (c) believed that the "Best" caregivers would agree that their worth was determined by how good they were. Caregivers with more experience generally disagreed with those statements.
In summary, power struggles can be characterized by a three factor model which includes Type of Power Struggle, Escalation Spiral, and Sense of Self. Staff who provide services for persons with dual diagnoses need to have skills to keep potential power struggles at the Discussion/Problem-solving stage. However, staff, like clients, have a sense of self that is the source of personal power. A sample of data from active service providers suggests that the worst caregivers are those that need to be right, be fastest, win, etc. in order to enhance their own sense of self. As a result they get into more power struggles and escalate them higher than caregivers who are regarded as the "Best." The implication for training and managing staff is that staff sense of self has to be considered. Service provider organizations would be wise to focus on the sense of self of staff as well as clients in order to protect and enhance it. When sense of self is secure, staff can practice a cardinal rule of caregivers: Vulnerable people should never be put in a situation where they lose personal power to a caregiver.
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