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Friday, June 18, 2010

How Psychotherapists' Self-Disclosure Affects the Therapeutic Relationship with Clients

The topic of psychotherapists' self-disclosure is still a controversial and much-talked about subject in therapeutic circles. I believe that most psychotherapists try to strike a balance between rigid adherence to no self-disclosure vs. too much self-disclosure. The primary goal should always be that self-disclosure is in the interest of the work with the client and not based on the needs of the therapist.

How Psychotherapists' Self Disclosure Affects the Therapeutic Relationships with Clients
The Problems with Too Much Self-Disclosure:
The problems with too much self-disclosure are many. First and foremost is that too much personal self-disclosure can lead to boundary violations between psychotherapists and their clients, the most egregious being sexual violations. Studies have shown that, when there were sexual boundary violations between psychotherapists and clients, it most often occurred along a slippery slope when psychotherapists began by divulging too much personal information to clients, creating a sense of intimacy in the therapeutic relationship that was inappropriate. In these cases, regardless of the type of therapy or the client involved, the therapist is always responsible for boundary violations.

Another problem with too much self-disclosure on the part of the psychotherapist is that the treatment should be focused on the client, not on the therapist. So many clients come to therapy because they were emotionally neglected in their families of origin or they just were not "seen" in their families, so that the psychotherapist should not, however unwittingly, replicate this experience in therapy.

Psychotherapists who find themselves either disclosing a lot about themselves indiscriminately to their clients, or who are tempted to self-disclose a lot, should seek professional supervision to deal with this issue and/or seek their own personal therapy because something is a miss and needs to be rectified before clients are hurt by this.

Several years ago, I remember talking to a client who had just left a prior therapy because her therapist tended to focus the therapy on herself rather than the client. The client was struggling with a breakup and the therapist divulged that she had also just gone through a breakup in her relationship.

The client felt that the therapist completely hijacked their sessions with the personal details of the therapist's breakup. This particular client had a history of feeling "not seen" by her mother, who always tried to "one up" the client with whatever problem that client had as a child. If the client was feeling bad about something, her mother made it a point to tell her that she was feeling worse. The client had a very emotionally depriving experience when she was growing up, and the prior therapist, who seemed caring in other ways, had, without realizing it, created the same experience in therapy.

As I often do, with the client's permission, I called the prior therapist and we discussed this aspect, as well as other aspects, of the prior therapy. Unfortunately, this therapist was not very well trained, and prior to our conversation, she had no idea how her self-disclosure had affected the client. Worse still, there seemed to be no therapeutic reason for her self-disclosure, how ever misguided that might have been. There seemed to be no forethought about it at all. Although she seemed to be a very caring person, she just had very poor boundaries in her psychotherapy sessions. It was not my job to criticize or correct her. I only wanted to understand, from her perspective, what happened, since I was dealing with the aftermath of this boundary violation in the current therapy with this client.

Psychotherapists Must Self Disclose Based on What is Best for the Client
Another problem with too much self-disclosure is that it affects the client's transference in the therapeutic relationship. On the most basic level, transference can be understood as the feelings (often projected, but sometimes quite accurate) that the client has towards the therapist. Many times, the client transfers his or her own feelings for a mother or father onto the therapist. If a therapist is psychoanalytically or psychodynamically trained, he or she will use the transference to work through the client's issues. Working through the transference usually provides an emotionally safe place for clients to work through issues in therapy that they could not work through with their families of origin. Obviously, the more that a client knows about his or her therapist, the less room there is for transference, so it deprives the therapist and the client of an important aspect of the therapeutic environment for healing and growth.

How much self-disclosure is too much? Reasonable people can disagree. Like most things, it depends on the particular client-therapist relationship. It's usually obvious to most therapists when self-disclosure, or a client's demands for self-disclosure, are starting to go down the seductive slippery slope to possible boundary violations in the treatment, and this needs to be dealt with and avoided for the safety and effectiveness of the treatment.

But what about inadvertent self-disclosure? By this, I mean self-disclosure that might occur unintentionally.

For instance, I remember a psychiatrist, who was a psychoanalyst, telling me years ago that one of his clients felt deeply crushed when he saw the psychiatrist driving a Chevy rather than a Mercedes Benz or some other luxury car. The client just happened to be walking along the same street where the psychiatrist was driving, so this was not a planned event and no one could accuse this psychiatrist of perpetrating a boundary violation. Yet, the client was extremely upset because, in his transference towards the psychiatrist, he needed to see his psychiatrist in a particular way, and seeing him driving in a Chevy didn't fit with the picture that he needed to have of him. According to the psychiatrist, this incident was the subject of numerous psychotherapy sessions with this client, who felt that his image of his psychiatrist was shattered.

In this case, the transference, which was positive before this incident, quickly became negative. The client was disillusioned and disappointed because he needed to see his psychiatrist as being "powerful," and "powerful" to this client meant that the psychiatrist should drive a luxury car. This incident was all "grist for the mill" in therapy and, ultimately, the client and the therapist were able to explore the multiple layers of meaning that it had for the client and how it related to deeper psychological issues relating to his father. The client longed for his father to be "powerful" when he was growing up but, unfortunately, he often saw his father disempowered. So, ultimately, what started as a source of pain and disappointment for this client turned into a rich and fruitful topic to be mined by the psychiatrist, who happened to be an extraordinarily talented and caring psychoanalyst.

In my own experience, I have run into clients outside the therapy room several times over the years. While this is often a common occurrence in small towns, you wouldn't think it would happen too often in NYC, but it does. My experience has been that, for some clients, running into their therapist in a restaurant or in the neighborhood, is not a big deal. For other clients, it's a deeply exposing experience. They prefer to think of their therapists as remaining in the therapy room until their next session. Some clients will express curiosity about these incidents and others don't want to know anything and they are uncomfortable even discussing how it made them feel to see their therapist outside of the therapy room. Once again, this is all rich material to explore in treatment and it often has deeper meaning.

After my psychoanalytic training, I obtained training in the substance abuse field. Initially, I was surprised and somewhat concerned about how much substance abuse counselors disclose to their clients. Many, although not all, substance abuse counselors are recovering addicts themselves and often disclose their experience to clients who come for treatment. Most of the time, I think this is done in service to the clients so they know that their counselors understand, on a personal level, what they're going through. It's a sort of "joining" with the client. I understand now that it often helps to dispel the shame that many clients feel about their addiction. It also raises the question, which is too large a topic for this article, of whether a therapist or counselor must have the same experience as the client in order to be effective.

I would say that self-disclosure under these circumstances has many factors to be considered. In many cases, it can enhance the work, but I've also seen cases where it was detrimental because the therapist or counselor can make certain assumptions about the client, which might not be true. So much will depend on the training and expertise of the particular professional involved. However, I believe that, like any form of self-disclosure, this should be done with much caution and forethought for the particular client involved, and it should always be in the primary interest of the client and not the counselor.

The Benefits of Carefully-Attuned Self-Disclosure in Psychotherapy:

The Benefits of Carefully-Attuned Self-Disclosure in Psychotherapy
Compared to prior times, when psychotherapists were encouraged to be "blank slates" to their clients, which was unrealistic and often emotionally depriving to clients, most psychotherapists today recognize that some self-disclosure, when done in a therapeutically appropriate way, can be beneficial, at times, to clients. Also, even when a therapist does not make overt self-disclosures, clients who are astute often intuitively pick up on aspects of the therapist's personality or the therapist's state (e.g., the therapist looking tired), so that, in my opinion, therapists are never complete "blank slates."

Once again, I believe that therapists need to be exquisitely and carefully attuned to the particular client and the particular client-therapist relationship and what effect self-disclosure will have on the treatment.

Self-disclosure should always be done when it will be in service to the client's treatment and not to satisfy the needs of the therapist. Making that distinction is not always easy. Many therapist, especially those who are in full-time private practice, feel isolated at times in their work and, if they are not careful, they can self-disclose as a way of satisfying their own emotional needs rather than serving the client. This is also why it's so important for therapists to have rigorous professional training, including clinical supervision, and also have rich personal and collegial relationships.

So, when would self-disclosure be beneficial to clients and under what circumstances?

Often, psychotherapists will self-disclose judiciously when it's what the client needs at that time. For instance, some gay and lesbian clients want a therapist that they know is an "out" gay or lesbian therapist from the outset. For psychotherapists who are open to self-disclosing their sexual orientation, they will often be open to clients who only want a gay or lesbian therapist.

However, although this is often a positive use of self-disclosure, it cannot be assumed that this self-disclosure won't also create problems in the therapy with regard to some client's transference issues. Just like any other topic, a client can project his or her own feelings of inadequacy or internalized homophobia onto a therapist who self discloses that he or she is gay. And what might start out as the client's positive transference to the therapist could turn into a negative transference quickly. But, once again, if a therapist is psychoanalytically or psychodynamically trained, both the positive and the negative transference are useful in furthering the treatment.

Psychotherapists Must Use Good Judgment When Self Disclosing
Other beneficial self-disclosures might be much smaller and less personal. For instance, in the case of a client who came to therapy because she had difficulty asserting herself, she had a particular problem one day asserting herself with her insurance company. She was getting the runaround and she was being bounced from one representative to another. The result was that her hospital claim, which should have been paid by the insurance company, was not being paid and the client was getting bills from the hospital. At that point, I told her how I was faced with a similar issue for a professional insurance claim (not a personal claim), and how I was able to handle it with the insurance company.

When deciding how to respond to this client, who was feeling particularly helpless in this situation, I could have just provided her with information about what to do. But I thought it would be much more helpful to provide this information in the context of my own frustration with a professional claim that was not being paid and how I was able to overcome this problem by asserting myself with the insurance representative and asking for a supervisor.

It's important to note that I knew this client very well, and I knew the timing of this self-disclosure was right. We had been working together for a while, and I knew that this would be helpful to her for her particular problem and also helpful to our work together. As I assumed, she felt relieved that she was not alone in having problems with insurance companies and that I had struggled with the same issue and overcame it. I "joined" her with where she was at that particular time, and she didn't feel alone with her problem any more. She felt empowered and she was able to use this information to assert herself to get the bill paid.

However, if this was a client that I didn't know well, I probably would not have self disclosed in the same way because I couldn't be sure if this would serve the client or not. For instance, where there is a negative transference, this self disclosure might exacerbate the negative transference. Or, where clients don't want to know anything at all about the therapist, whether it is personal or professional, because they find it too impinging on them, I wouldn't have made this disclosure.

Self-Disclosure that Cannot Be Avoided:
Even the psychotherapist who is most conservative with regard to self-disclosure often finds him or herself in situations with clients where self-disclosure is unavoidable. In these cases, self-disclosure must be handled as carefully as possible. For instance, when a therapist becomes sick, he or she must often cancel clients' sessions. Recently, I lost my voice to laryngitis, and I had to cancel my sessions for several days until I recovered my voice. Fortunately, this did not cause problems for any of my current clients.

However, in the past, with certain clients who felt very emotionally vulnerable and who needed to feel that I was always "strong" or clients who had a lot of loss (deaths in the family) even if I had a simple cold, this created a lot of anxiety for them. I understood this in the context of their history and knew that it would be very meaningful and emotionally threatening to them. This is completely understandable, and yet, many times, it cannot be avoided. However, if it is handled with sensitivity and empathy, even these emotionally threatening situations for vulnerable clients can lead to the realization that people can become sick and survive, and not all illnesses result in loss.

The key is often how this is handled by the therapist or whoever the therapist appoints to handle these types of situations when he or she cannot handle it him or herself. Recently, a friend was telling me that he might need a psychotherapy referral from me because his therapist was ill, and he was not sure if the therapist was returning to his private practice. He told me that the therapist did not look at all well during their last session and when he called to make his next appointment, the therapist's wife told my friend that the therapist was very ill, and she asked my friend "not to call again."

Needless to say, this was very disturbing to my friend, who had been attending treatment with this therapist for over a year due to several close deaths in his family. He felt he had a strong bond with this therapist, and hearing the news that his therapist was seriously ill was very upsetting to him because he cares for his therapist but also because it triggered all of his feelings of loss and sadness. But being told "not to call again" by the therapist's wife was even more upsetting. It triggered the very issues that he came to therapy to work through, and it also made him feel completely shut out and emotionally abandoned.

Self Disclosure that Cannot Be Avoided
While it's true that spouses of therapists might not be trained on how to deal with this type of disclosure, it's the therapist's responsibility to leave instructions with a designated person, usually another therapist, on how to contact and work with clients in the event that the therapist cannot do it him or herself.

Another form of self-disclosure that often cannot be avoided is when a therapist will not be in the office due to a vacation. Most clients are able to handle this type of self-disclosure (i.e., the fact that the therapist will be on vacation, but not necessarily all of the details). However, some clients have a lot of difficulty with this, especially if the therapist is going to be away for an extended period of time. They might fear that the therapist might not come back or something will happen to the therapist while he or she is away and they will be abandoned. They might also be afraid that they won't be able to handle whatever might come up while the therapist is away. With clients who are vulnerable in this way, usually due to their own personal histories, I'll ask another therapist to be on-call in case a client needs to talk to a therapist while I'm away. In this way, clients who feel emotionally fragile during those times, often feel taken care of and know that there is someone that they can see, even if they never actually call on these therapists.

A colleague, who works with many clients who struggle emotionally as well as financially, told me that, even though she travels quite a lot on vacation outside of the country, she doesn't tell clients that she is going on vacation because she thinks it will make them feel badly that they cannot afford to go on vacation too. Instead, when she goes away, she always tells clients that she is going to a conference.

We had a lengthy discussion about this because it was an interesting topic with regard to psychotherapists' self-disclosure. On the one hand, I wouldn't want to second guess this colleague because she's the one who is actually "in the room" with these clients and has experience with them, whereas I'm hearing about this second hand. I also know that she happens to be a particularly empathic therapist and she thinks carefully about what she says and does beforehand so as not to harm clients.

On the other hand, I found it hard to believe that none of her clients could tolerate hearing that she was going on vacation and that, for some of them, it might be a good way to show that self care is important for their therapist as well as for themselves. Clients who tend to be focused on others and neglect themselves often benefit from hearing that their therapist is taking care of herself, and this type of self-disclosure can help them to reflect on their own self care or lack of self care.

Another example of an unavoidable type of self-disclosure is when a therapist is pregnant. For many clients, this is not an issue. They might react in a number of ways, including being happy for the therapist. However, for some clients, finding out that their therapist is pregnant is cause for much unhappiness.

About 10 years ago, a colleague told me that some of her clients were very unhappy about her increasingly obvious pregnancy. Apparently, there were women in her private practice who were trying, unsuccessfuly, to get pregnant and the sight of my colleague's growing belly was a source of sadness and envy for them. Other clients, both men and women, felt uncomfortable with the obvious sign that their therapist was a sexual being. Whatever the particular issue, all of this was discussed and explored in therapy by my colleague with her clients, and, in most cases, it was useful in working through their own personal issues as well as their transferential issues with my colleague.

With the advent of the Internet and all of the personal information that one can find on almost anyone online, clients can often find information about their therapists, including information that is readily available becasue it's public (e.g, political contributions) or information that is obtained by paying a service online.

What might it mean to a client to find out that his or her therapist made a political donation to a particular candidate? Maybe this won't fit in with his or her perception of the therapist. Will it be disappointng or affirming? What might it mean to the client to find out that the therapist owns property or is married (or not married)?

What does it mean when a client reads a therapist's professional blog? Will he or she inadvertently find out certain things that were not known before. Hopefully, the therapist is very careful with whatever he or she writes online. But even though many therapists are keeping professional blogs these days, for some clients, it's uncomfortable to read it, while for other clients it's a way to continue to feel connected to the therapist between sessions.

Obviously, this is a big topic and I haven't covered all of the issues involved with psychotherapists' self-disclosure to clients.

The most important aspect of this topic that I want to emphasize to clients and therapists alike is that, even though the idea of the psychotherapist as a "blank slate" has mostly gone by the wayside in recent years, self-disclosure should always be done carefully and always in the service of the client.

Clients need to feel that their therapist is caring and has a positive regard for them. This includes the therapist protecting the therapeutic boundary with empathy and respect for the client to avoid boundary crossings.

I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing.

I work with both individuals and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up an appointment, you can call me at (212) 726-1006.

Also, see my article:  Boundary Violations and Sexual Exploitation in Psychotherapy

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