by Edmund Howe, MD, JD
Dr. Howe is Professor, Department of Psychiatry, Director, Programs in Medical Ethics, and Senior Scientist, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Innov Clin Neurosci. 2011;8(12):14–17
Funding: There was no funding for the development and writing of this article.
Financial Disclosures: The author has no conflicts of interest relevant to the content of this article.
Key Words: Ethics, psychiatrists, self disclosure, patient trust, transference, Marsha Linehan, hope, shame, normalization, harm, intrusive, minority groups, gay patients, gay psychiatrists, being “real,” psychiatrists’ feelings, psychiatrists who are ill, psychiatrists and pregnancy, psychiatrists and divorce, the internet
Abstract: The extent to which psychiatrists disclose personal information about their feelings, their pasts, and themselves to their patients has always been an important ethical and clinical question. In the past, psychiatrists tended to believe they should not self disclose personal information to their patients, mainly to help patients by exploring their transference. More recent work has suggested that self disclosing by the psychiatrist may benefit some patients and cause harm to other patients. This article presents the author’s present understanding of some of the core pros and cons of self disclosing by the psychiatrist, as well as some specific contexts in which self disclosure is indicated or should be avoided.
Introduction
One of the most challenging ethical questions psychiatrists may ask themselves on an ongoing basis is whether they should disclose to their patients personal information about themselves.[1] This question can be ethically challenging because self disclosures by psychiatrists may help some patients and may harm others, and psychiatrists cannot know with certainty which will occur. Thus, psychiatrists must base the decision to disclose or not to disclose on each patient’s most likely individual treatment needs.
Some patients may feel greater trust in a psychiatrist who shares personal information, and as a result, may be more likely to disclose inner feelings that otherwise they might not share.2 On the other hand, if a psychiatrist shares too much information, some patients may lose trust. They may see the psychiatrist as getting too involved with them.[2]
Psychiatrists may self disclose to their patients more frequently than they would like to admit to other clinicians. One study of psychotherapists showed that 90 percent admitted to self disclosing to their patients,1 and yet, many may keep this practice to themselves. One group referred to the practice of self disclosure as something about which they “don’t ask and don’t tell.”[3]
This “don’t ask and don’t tell” viewpoint may be because in the not-so-distant past many psychiatrists believed they should never disclose personal information to their patients. This belief was based largely on psychoanalytic theory. In other words, psychiatrists believed that if they disclosed personal information to their patients, this might interfere with their being able to first elicit and then effectively address a patient’s transference responses. Thus, if addressing transference was an important component of the therapy, many psychiatrists believed they could help patients most by not self-disclosing.[3]
Disclosure of personal information by a clinician has been fueled or re-fueled most recently by Marsha Linehan, the founder of dialectical behavior therapy (DBT). DBT is the first treatment shown to be effective for patients with borderline personality disorder (BPD), and Linehan disclosed she had this disorder.[4] Decades ago, Linehan revealed that she was hospitalized for BPD, and at one time, was placed in a seclusion room where she would bang her head into the walls. She also habitually burned her wrists with cigarettes and slashed her arms, legs, and midsection with “any sharp object she could get her hands on.” Thorazine and electroconvulsive therapy (ECT) did not work as effective treatment for her illness.
Linehan’s self disclosure follows most notably Kay Redfield Jamison’s disclosure of having bipolar disorder.[5] Like Linehan, Jamison was an internationally recognized expert on the very disorder that she, herself, had.
World experts like Linehan and Jamison disclosing that they have serious psychiatric illness differs in many respects from a psychiatrist disclosing personal information to his or her individual patients in the privacy of the office. The self disclosures made by Linehan and Jamison bring to the forefront the question for all psychiatrists: “When, if ever, should a psychiatrist disclose personal information to his or her patients?”
Pros and Cons of Self Disclosure
Psychiatrists and other therapists often find that disclosing some personal information about themselves to their patients can help their patients have better results. The kind of self disclosures they may make widely differ. These disclosures range from sharing experiences they had in the past to here-and-now feelings. There are many reasons why self disclosure may optimize treatment success in some patients.
Pros. Instilling hope. When a psychiatrist discloses that he or she has dealt with a similar problem as the patient, this may increase the patient’s hope that, like the psychiatrist, he or she can overcome the problem successfully.[3] Surely, this is an outcome that the disclosures Linehan and Jamison have had.
Reducing shame. By disclosing that he or she has dealt with a similar problem as the patient, the psychiatrist may help the patient overcome feelings of shame surrounding the problem.[1] Shame can have a profoundly negative impact on the patient, and knowing the psychiatrist has experienced a similar problem may help reduce the feeling of shame in the patient.
Reducing feelings of isolation. Even if a patient does not express feelings of shame, knowing that the psychiatrist experienced a similar situation may help “normalize” the patient’s behaviors,1 which in turn may help the patient feel less isolated and alone.
Real-life examples in which self disclosures have brought about these gains are especially compelling. One therapist disclosed to her patient, for example, that she had fond memories of time spent at the beach. The patient, in response to this, recalled good times as well, which enabled her to then see her parents “as ill instead of evil,” and “to forgive her parents before they died.”[2]
Cons. The psychiatrist is perceived as impaired. A downside to self disclosure by the psychiatrist is that a patient may think the psychiatrist is too impaired to help him or her. A patient may also construe the information shared by the psychiatrist as negative, which may, in and of itself, eliminate the psychiatrist’s capacity to be effective with the patient. For example, a therapist once revealed to a patient that the only person who had ever acted as badly toward him as the patient was his daughter. The patient then cried. She described the effect of hearing this from the therapist as “throwing her against a wall.” She also continued to have “lingering memories” of this disclosure thereafter.[2]
The psychiatrist is perceived as not wanting to listen to the patient. Even when a psychiatrist’s self disclosure does not have negative effects as severe as in the previous example, a disclosure may still be harmful because it interrupts the patient from talking about his or her own problems.[1] The patient may wait impatiently for the psychiatrist to stop talking about him or herself, and may experience this interruption as intrusive and annoying.
Different Kinds of Self Disclosure
Often, the key consideration underlying the question of whether a psychiatrist should or should not disclose personal information to patients is the kind of self disclosure that would be made. In some contexts, the likely gains versus harms of a psychiatrist self disclosing certain types of information are much more substantial than in others.
An example is when the patient and psychiatrist are in the same minority group but this fact is not known by the patient.1 It may help the patient greatly to know that his or her psychiatrist is in the same group. A good example of this is when the patient and the psychiatrist are both gay.[1]
This same principle extends to many other contexts as well. For example, after getting divorced, a patient may reveal to his psychiatrist that he does not feel able to date another woman seriously. He may tell the psychiatrist that he distrusts his judgment too much. His psychiatrist may then find it beneficial to disclose to the patient that he too has gone through divorce and has since met and married another wonderful woman with whom he now had a family. This may help the patient to feel more confident in his ability to decide whom to date seriously because the psychiatrist has revealed himself to be “fallible” like the patient. On the flip side though, this patient might conclude that since the psychiatrist is fallible and has been divorced himself, the psychiatrist will not be able to help him.
It is likely that psychiatrists disclose personal information more with some patients than with others.[2] A psychiatrist, for example, may be more likely to disclose personal information with patients who are more emotionally stable and who are more capable of recognizing and respecting patient/psychiatrist boundaries. Patients who do not recognize boundaries as well as others may be more likely to misinterpret the psychiatrist’s self disclosures and may misconstrue these disclosures as intimacy when this is not the psychiatrist’s intention. Ethically, however, this presumption may be a mistake. That is, less-stable patients may need that indication from their psychiatrists that shows the psychiatrist is “real.”[2] Furthermore, by not self disclosing at all with this type of patient, the psychiatrist may be discriminating against the patient by helping those patients who are less ill get better, but leaving those who are very ill no better than they were before. Therefore, in cases such as this, the psychiatrist may choose to offer limited self disclosures to this worse-off group of patients more often.
Optimal rules-of-thumb are as follows: 1) If a psychiatrist believes that a self disclosure most likely will further the patient’s good, it probably will; and 2) A psychiatrist should self disclose only information about which he or she feels comfortable.[2] On the contrary, if the psychiatrist fears at all that he or she could be sharing in part for his or her own benefit, or to “vent,” he or she should probably not; and, likewise, if the psychiatrist feels at all nervous about self disclosing, he or she should not self disclose.
There is one instance where I believe it is in the patient’s best interest for the psychiatrist to self disclose. This is when a patient asks if the psychiatrist is well. This question will most likely reflect the patient’s genuine concern. If the psychiatrist were to respond by not answering this question and turning this inquiry into one involving the patient, the psychiatrist may lose this patient’s trust in one fell swoop, because the patient may feel, rightly so, hurt and misunderstood.
Some psychiatrists respond to questions about themselves almost routinely by saying in response that the patient’s asking must reflect some underlying need that should be explored. They may say, somewhat reflexively, “I wonder why you are asking?” or “I will answer you, but only after we discuss why you are asking.”
One therapist’s question warrants reflection. She asks, “Can we expect ourselves to maintain a professional stance when we are in great physical or emotional pain?”[9]
This example, turning a patient’s genuine concern into an inquiry about the patient illustrates the likely truth of this claim about psychiatrists not disclosing: the single, most detrimental effect of nondisclosure may be its negative effect on the patient/psychiatrist alliance.[1]
Psychiatrists are likely to be safest in self disclosing when they share personal, positive feelings. This includes, for instance, their feelings of sadness when the patient-psychiatrist relationship must end.[2] For example, a psychiatrist has just had a baby and decides to give up her psychiatric practice to stay at home with her child. One of her patients gets so upset when she tells him they must end their therapy that he’s unwilling to accept a referral to see another psychiatrist. The psychiatrist may then tell him how much she regrets not being able to continue to see him and how difficult for her this choice has been. The patient, in response, feels better and accepts her referral to another psychiatrist. Again, important to consider, it is possible that this patient may construe her disclosure to mean that she has feelings of intimacy for him, when this is not the case. The psychiatrist should consider each patient carefully before disclosing personal feelings.
Psychiatrists may more safely express positive personal feelings, such as exuberance. For example, I once had a patient who felt ashamed to attend a college reunion because after college she stayed at home and raised her children rather than pursuing a professional career. Many of her classmates had gone on to have successful careers. I knew of some exceptional strengths that her adult children had, such as others seeking them out for their empathy, that she had told me during our sessions.
I said, “Well, I believe there is nothing more important than raising children, and what you have told me about others seeking them out to share with them tells me what you, as a parent, with your gift have done,” I effused.
She seemed to feel better then and actually did go on to attend her reunion.
Less safely, psychiatrists may risk self disclosing how they felt and coped in stressful situations, even, and perhaps especially, if they did not fare “optimally well.” They might say, for example, “When I was in this same situation, I too felt scared,” or (taking more risk), “I understand your anxiety because I too have a difficult time when I have to give a talk.”[2]
Another example, going back to the psychiatrist who shares that he went through divorce, would be to make an acknowledgment of the difficulties in overcoming a problem: “I too am divorced and have had to think hard about my contributions to the failure of my marriage.”[2]
Conclusion
The concept of self disclosure by the psychiatrist is an important one. In fact, self disclosures made by psychiatrists to their patients may be some of the few remarks that patients will always remember about their therapy sessions.1 Psychiatrists considering self disclosure may justifiably choose to draw the line at different places. Before making the decision to disclose personal information to a patient, the psychiatrist most importantly should assess whether this self disclosure will benefit the patient (and not the psychiatrist) and assess his or her comfort level with disclosing personal information to the patient.
References
1. Henretty JR, Levitt HM. The role of therapist self-disclosure in psychotherapy: a qualitative review. Clin Psychol Rev. 2010;30:63–77.
2. Knox S, Hill C. Therapist self-disclosure: research-based suggestions for practitioners. J Clin Psychol. 2003;59:529–539.
3. Psychopathology Committee of the Group for the Advancement of Psychiatry. Reexamination of therapist self-disclosure. Psychiatr Serv. 2001;52:1489-1493.
4. Carey B. Expert on mental Illness reveals her own fight. The New York Times: Health. June 23, 2011. http://www.nytimes.com/2011/06/23/health/23lives.html?pagewanted=all , 1-6. Accessed October 11, 2011.
5. Jamison KR. Night Falls Fast. New York: Vintage Books; 1999.
6. Gutheil TB, Gabbard GO. The concept of boundaries in clinical practice. Am J Psychiatry. 1993;150:188–196.
7. Gutheil TG, Gabbard GO. Misuses and misunderstanding of boundary theory in clinical and regulatory settings. Am J Psychiatry. 1998;155: 409-14.
8. Gabbard GO, Nadelson C. Professional boundaries in the physician-patient relationship. JAMA. 1995;273:1445–1449.
9. Simon JC. Criteria for therapist self-disclosure. Am J Psychother. 1988;42:404–415.
10. Geller J. Self-disclosure in psychoanalytic-existential therapy. J Clin Psychol. 2003;59:541–554.
