Should therapists self-disclose?

[Dr. Richard Grossman]

Hi everybody,

Here's an article about Marsha Linehan, Ph.D., the well-known creator of Dialectic Behavior Therapy (DBT) which is used to treat Borderline Personality Disorder (BPD).  She recently disclosed her own personal struggles with Borderline Personality Disorder in a New York Times article (6/23/2011): "Expert on Mental Illness Reveals Her Own Fight" by Benedict Carey.

http://www.nytimes.com/2011/06/23/health/23lives.html?_r=2&scp=1&sq=Marsha%20Linehan&st=cse

The article raises the issue of self-disclosure by therapists to their patients.  A quote from the article:  

“So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward,” said Marsha M. Linehan, a psychologist at the University of Washington.

And here's a response by a New York psychiatrist, Maureen R. Goldman, M.D., in Clinical Psychiatry News (7/6/2011):  "Editorial: Thoughts on Self-Disclosure for Psychiatrists"

http://www.clinicalpsychiatrynews.com/views/commentaries/blogview40731/editorial-thoughts-on-self-disclosure-for-psychiatrists/36388f6a86.html

This is a topic I have thought a lot about over the years, and one that I have strong feelings about--which I'll share.

But, as usual, I'd like to hear your comments first...

Richard
 

[Hopalong]

Hi Richard,
I didn't see the links so haven't read the articles.

My first gut response is "Yes." For me, simply knowing my therapist is a human being with life issues and feet of clay is comforting.
The old model of rigid boundaries may be important in some cases; for me, it was not helpful.

At times when I was so self-absorbed I couldn't have cared less whether my T was alive or dead or a propped-up rent-an-ear,
so desperate was I to vent...this wouldn't have been so important. I cared only about feeling safe and being heard.

But in later life, I've found it very reassuring to know a few facts that remind me that a therapist is a person too. In one instance,
the T-relationship got boundary-blurred, as much through my lack of boundaries as his own. It wound up dying an appropriate death
with no hard feelings and perhaps relief on both sides. When I gradually learned some things about the hardships of his childhood, I had explanations for things I'd wondered about. I recognize the mistakes he (and I) made, but do not blame him or myself. Compassion and gratitude are how I think back.

Currently, when I was anguishing over my daughter, my now-T let me know that he has a daughter with a severe eating disorder.
It helped me recognized that not only was he being professionally compassionate, but that as a human being, he happened
to truly understand what it's like to have a troubled child in jeopardy. I occasionally ask him how she's doing, and I let him
know I'm not digging for detail. We seem to have a comfortable mutual recognition that boundaries aren't going to dissolve.
But he'll tell me something like--she's in a hospital program. Or, she's home with us now. And, he also mentioned once that
he is Quaker, which for me was also a positive thing to know about him. My trust was stronger and has remained so.

Once, he mentioned a prior marriage. And he often references insights from his work with couples. Those facts too are very
comforting, because I'm divorced. With an earlier T (who turned out to be fundamentalist and had NOT disclosed
to me how much that affected his view of me...even to the point that he pressed me to marry quickly when I'd mentioned
my inner voice was telling me to wait--which turned out to be a disaster for me)...the lack of knowing much (or enough)
about who he was as a human being as well as as a professional and what his values were, both hamstrung the therapeutic
relationship and also wound up causing me considerable personal harm.

If I had a therapist who was bipolar and clearly taking responsibility for being in treatment or on Rx and was behaving effectively
I would be grateful to know this. Maybe not the first session, but the first or second. Again, it would encourage me to see a T
as a human being as well as healer. It would then be my choice to decide whether that issue of theirs was triggering or an obstacle
for me in some way. I would be appreciative of the disclosure. Nothing shame-based about it, just an important factoid, perhaps.

My D and I went to see a counselor who is paralysed and severely disabled and wheelchair-bound. She didn't have to disclose
verbally. But we knew this key thing about her life.

I don't know why a counselor with a condition that required a bite of protein every 30 minutes wouldn't say, I have XX, so you'll see
that I pause to eat something during our session. Or someone with a hearing problem wouldn't say, I need for you to sit
in that chair because I'm deaf in one ear. Or, I have macular degeneration so I need to keep the office quite dark. Or, I am bipolar
and in treatment, it's well controlled, but I prefer to let clients know this in case that would be troubling for you. Etc.


Now, I view a careful and considerate amount of personal disclosure on the part of a therapist as a gift of respect to me.
I do understand that one would have to be very careful with how much to disclose, and when and how. I don't think there's
a blanket rule. But from my own experience, I am both encouraged and humbled by seeing those clay feet. It encourages me to take
fuller responsibility for my own healing, and discourages utter dependence on the therapist for learning about self, other, boundaries, etc.

Very interested in hearing your thoughts on this, and will look forward to the thread.

Thanks for posting this, Richard. (And I hope you and your wife are well...?)

best,
Hops

[Dr. Richard Grossman]

Hi Hops,

Ooops!  Sorry.  I inserted the links...

Richard

[sea storm]

Yes. Of course they should not keep self referring but sharing their experience helps the connection deepen.


Sea storm

[Ales2]

These are all very interesting questions. I think the answer probably lies somewhere in the middle. What to disclose and when? When is it relevant? When would it be helpful and how would it help?  That said, disclosure as part of small talk about getting to know someone maybe not so much.

In my case, my T had written a book where he disclosures his issue with his mother in a small section of one chapter. This was helpful to me, because he said he was co-dependent and had to avoid getting over-enmeshed with needs of patients. Then later in T, he also told me that his own kids were in T, in response to his divorce. As I remember, I think it was relevant to my feeling that good parents turn out good kids who are not in T. He wanted me to feel less of the stigma of T when I was feeling very wounded.

I do think if I knew someone had a similar problem, as in "i know just how you feel", it can help one feel validated, heard and understood at the same time. 

[Meh]

I'm too tired and lazy to read the articles right now. Is there some kind of evidence that shows there is a tangible improvement in the patient's outcome as the result of the therapist's disclosure?

I think if there is evidence that the outcome for the patient is increased positively (not just perception of validation) after therapists disclosure then YES therapists should consider doing this. If there is no real positive outcome improvement for the patients when the therapist self discloses then I think NO it should not be added into the therapeutic model.

I wonder how much the benefits of disclosure are related to the specific therapy goals. Maybe disclosure helps some goals but not others.

[sKePTiKal]

"Officially" and publicly, as in the media? That seems to be the issue here, rather than in the T-client relationship. On the one hand, it could be positive marketing "branding" of the doc as having personal experience (and this implies additional expertise) in the subject problem. But, in T... it's the working methods and personal relationship between the "partners" that's most important. I find the idea that a therapist is an all-knowing, all-powerful Oz who has all the answers and the magic ability to "fix" me... well, it's off-putting. Yet, I think we all start the process with that stereotype in our minds.

It could also work in a negative branding fashion -- as in physician, heal thyself FIRST. Before trying to help others. Many folks would have trust issues with someone who flat out admitted they were human and fallible and had their own issues.

Personally, I don't think a T's personal history is relevant to being able to guide a client through the process of learning a new balance within themselves. You reach out, steady them, help them find their balance... then slowly, give them the room to realize they can move around just fine, without wobbling and falling again. That doesn't require the T to have experienced vertigo, you know?

[BonesMS]

I'm going to respond from the standpoint of being on "both sides of the fence", so to speak, regarding the question:  "Should therapists self-disclose?" 

From my point of view....it depends.  I've dealt with one therapeutic professional who basically wasted my time talking about himself, his culture, his views, his values, his beliefs, and how I SHOULD do "blah-and-so" simply because I'm female!  That gives me reason to suspect he's a Narcissist!  (Didn't understand NPD back then.)  He also attempted to force me to relinquish going to 12-Step Support groups because:  (a) it made him jealous and (b) HE would control my addiction FOR me!  (While he's pressuring me to start taking benzodiazepines again KNOWING FULL WELL MY HISTORY OF ADDICTION TO THEM!)  All of the above factors led me to my decision to terminate him as a therapist as he was clearly NOT hearing me!  (Why pay the expense of seeing a mental health therapist if they continuously REFUSE to LISTEN and HEAR what you have to say in therapy sessions?)

On the other hand....

When I worked, for a short time, in a substance abuse treatment facility, I did not disclose that I am also in recovery.  I felt I was not there to talk about myself or to focus the spotlight on me.  Eventually, my clients figured it out and asked me point-blank:  "Are you in recovery from alcohol and/or drugs?"  I would smile and inquire:  "Why do you ask?"  The response would almost always be:  "Because you recognize my bullsh*t and call me on it!  I can't bullsh*t you like I bullsh*t my friends and family!  You get it!"  Then we will BRIEFLY discuss my history while emphasizing, we are here to talk about YOU and WHY you are in treatment, I am NOT here to talk about ME!  Your time is more valuable than that!. 

Just my two-cents.

Bones

[Guest]

"Should therapists self-disclose?" 

If nothing else, open information about a T prior to therapy might help weed out the real people from the charlatans/Ns/exploitative dickheads/children acting as Gods/plain nutters etc etc.

Yes, some personal life information upfront can't hurt. But therapy can be like trying to fix a problem in a Microsoft program - you have to know the general answer to the question before you start otherwise you don't know what to search for in the 'help' section.

As for disclosing during therapy - that's a different matter.

I didn't read the articles.

[Dr. Richard Grossman]

In my view, the single most important “basis” of therapy (for non-personality disordered people) is that the therapist “gets it”, i.e. understands the patient’s suffering (both at a knowing and feeling level), and conveys this understanding convincingly back to the patient.

Why is this important?  Because it is difficult and not very helpful to form a genuine attachment to a therapist who doesn’t “get it”.  And, in my experience, it is this unique two-way attachment that reduces suffering and ultimately leads to healing.

Is therapist self-disclosure useful in this process?  Self-disclosure of a particular painful common (to both parties) life event/situation can sometimes be exceptionally reassuring to a patient that he or she truly “gets it.”

(As Bones says above, however, sometimes because the therapist “gets it” so well, patients already know…)

More to follow…

Richard

[Dr. Richard Grossman]

Hi everybody,

I want to respond to everyone’s comments, but first I want to post about my own experiences first from the patient side of the room—and then from the therapist’s.

I have written elsewhere on this site about my two experiences as a patient in psychotherapy:

"Dreams, Imagined Dreams--Failed Therapy"   http://voicelessness.com/dreams,_imagined_dreams.html

"Bad Dream"   http://www.voicelessness.com/disc3//index.php?topic=9607.msg153248#msg153248


Both therapists mentioned in these essays were highly recommended, well-trained psychiatrists—the first, well-respected in the field of trauma, and the second, a highly regarded member of the Boston Psychoanalytic Institute and Society.  Sadly, both did more harm than good.  And both, after 2 ½ years and 7 months, respectively, knew me no better from my perspective, than they did the moment I first stepped into their offices.  (Of course, I’m sure they would both disagree with this assessment—and the second did say when I left that I was a “nice guy”--which I suppose is true.)

Why could neither hear me?  My belief is that both ultimately lacked the vulnerability to sit in the room with another person and simply listen.  They had to be smart, wise, have answers, have all their problems worked out—or at least have it appear that way.  They were the experts.  And sitting with their expertise and their knowledge, I felt all alone.  This was not about creating an attachment (patient—therapist, therapist—patient), and discovering the best that life has to offer:  a relationship where one is actually heard, including the suffering and the joy and everything in between.  It was that I had a problem (or multiple problems), and they knew the best way to fix them.

Which brings me to the topic at hand:  self-disclosure.  If just once, either psychiatrist had ever said to me:  “Yes, I’ve experienced that, and I know how painful it is,” I might have been theirs forever.  Or they would have been mine forever, even when therapy was no longer necessary.  But, of course, for this to happen, the therapists would either have had to be different people, or have different training (one that did not value neutrality and the use of patient projection as a therapeutic medium), or both.

If I were to look for a therapist again, following the first session in which they learned about me, I would ask the therapist:

How have you suffered in life?  What helped?  What didn’t?

And if they wouldn’t answer—or answer in a genuine way, I would move on.


Next:   from the therapist’s chair…

Richard

[Guest]

“Yes, I’ve experienced that, and I know how painful it is,”

that would be amazingly good to hear. I'd like to hear that. I'd like to be believed. Oh, when I stop and think about it, I reckon I am believed, the facts tell me I must be, and more than the facts tell me that. But that's all the thinking logical side. I know that I was not believed once. And I can see why. Knowing that, understanding why I wasn't believed - didn't stop it hurting at the time. How ridiculous is that? How unbelievable. Ha, it really hurt; I wonder why. Probably some deep running rut from the prime-evil muds. The logical side knows, but the heart/amygdala doesn't trust logic. It trusts very little. A difficult combination.

ANYWAY That's a great line Richard. It packs some emotional punch. Which is what people need, rather than some detached analyser reading you to fit a 'diagnosis', ready for prescribing.

[Dr. Richard Grossman]

A few decades ago when I was working at Mass. General Hospital, I remember once sitting in on a therapy observation seminar.  A seasoned, well-known therapist conducted psychoanalytic therapy behind a one way mirror, and then after the session, the therapist would discuss the session with the observers/residents.  In this particular session, the patient, a woman in her early 30’s spoke about how painful it was being overweight in our culture.  Sometimes she would stop and look at the therapist—an overweight woman herself, of about 40.

But this was the psychoanalytic era, and the therapist simply nodded.  During the session, the patient never expressed her disappointment at the therapist’s silence.  (Perhaps she did in a later session.  And if she did, the therapist would likely have asked her about her associations to being disappointed in this way.)

After the session in the discussion period, I waited for someone to ask the obvious questions.  What is it like when topics painful to the therapist are raised by patients?  What did it feel like at that moment?  Did you want to answer, but stopped yourself for theoretical reasons?  Aren’t there times when pain is just pain, and it’s best to respond simply and empathically—or as Freud said “a cigar is just a cigar”?

But no one asked these questions or anything like them.  These questions were verboten for two reasons.  They questioned the very nature of psychoanalytic psychotherapy on which this therapist and a generation of therapists had based their careers.  And secondly, the questions were potentially humiliating to the therapist as a human being.  


But the questions should have been asked.   And situations like this radically changed my opinion of the prevailing therapy paradigm.  My view, some 30 years later is this:  an excellent therapist is someone who effectively uses their own suffering, past and present to facilitate an attachment with another person.  Self-disclosure by the therapist can be extremely important in fostering this attachment.  Neutrality (and certainly, I never considered the therapist’s nodding in the situation described above as even approaching “neutral”) is, for the most part, damaging.  There are two words the therapist should have said that would have stayed with this patient for a lifetime (particularly in the context of the group observation):

“I know.”

Richard

[BonesMS]

In my view, the single most important “basis” of therapy (for non-personality disordered people) is that the therapist “gets it”, i.e. understands the patient’s suffering (both at a knowing and feeling level), and conveys this understanding convincingly back to the patient.

Why is this important?  Because it is difficult and not very helpful to form a genuine attachment to a therapist who doesn’t “get it”.  And, in my experience, it is this unique two-way attachment that reduces suffering and ultimately leads to healing.

Is therapist self-disclosure useful in this process?  Self-disclosure of a particular painful common (to both parties) life event/situation can sometimes be exceptionally reassuring to a patient that he or she truly “gets it.”

(As Bones says above, however, sometimes because the therapist “gets it” so well, patients already know…)

More to follow…

Richard

Thanks, Dr. G!

[BonesMS]

A few decades ago when I was working at Mass. General Hospital, I remember once sitting in on a therapy observation seminar.  A seasoned, well-known therapist conducted psychoanalytic therapy behind a one way mirror, and then after the session, the therapist would discuss the session with the observers/residents.  In this particular session, the patient, a woman in her early 30’s spoke about how painful it was being overweight in our culture.  Sometimes she would stop and look at the therapist—an overweight woman herself, of about 40.

But this was the psychoanalytic era, and the therapist simply nodded.  During the session, the patient never expressed her disappointment at the therapist’s silence.  (Perhaps she did in a later session.  And if she did, the therapist would likely have asked her about her associations to being disappointed in this way.)

After the session in the discussion period, I waited for someone to ask the obvious questions.  What is it like when topics painful to the therapist are raised by patients?  What did it feel like at that moment?  Did you want to answer, but stopped yourself for theoretical reasons?  Aren’t there times when pain is just pain, and it’s best to respond simply and empathically—or as Freud said “a cigar is just a cigar”?

But no one asked these questions or anything like them.  These questions were verboten for two reasons.  They questioned the very nature of psychoanalytic psychotherapy on which this therapist and a generation of therapists had based their careers.  And secondly, the questions were potentially humiliating to the therapist as a human being.  


But the questions should have been asked.   And situations like this radically changed my opinion of the prevailing therapy paradigm.  My view, some 30 years later is this:  an excellent therapist is someone who effectively uses their own suffering, past and present to facilitate an attachment with another person.  Self-disclosure by the therapist can be extremely important in fostering this attachment.  Neutrality (and certainly, I never considered the therapist’s nodding in the situation described above as even approaching “neutral”) is, for the most part, damaging.  There are two words the therapist should have said that would have stayed with this patient for a lifetime (particularly in the context of the group observation):

“I know.”

Richard

I agree!

On the other hand, I had the unfortunate experience of a therapist abandoning her patients in group therapy because an issue that came up with us triggered her PTSD.  NOT fun!

Bones