The literature acknowledges that complete non-self-disclosure is a myth; even the most conservative analysis reveals much about the therapist. The therapist's choice of which of the patient's comments to respond to as well as his or her ability to empathize—as conveyed by interpretation, body language, and tone of voice—tell the patient a great deal about the therapist (
+20). Renik (
+20) argued for "a delicate, judicious balance between asymmetry and mutuality" and proposed that self-disclosure sometimes clarifies a point in the real world and conveys the therapist's respect for the patient as a mature collaborator in the therapeutic endeavor. Referring to the "pretense of anonymity," Renik stated that the issue is not whether the analyst self-discloses, but according to what principles. In fact, writers in the analytic field since Freud have attempted to incorporate elements of self-disclosure into theoretical models of psychoanalytic treatments that involve revealing countertransferance reactions in the interests of the therapy (
+21,
+22).
Pizer (
+13) conceptually divided self- disclosure into three types: inescapable, inadvertent, and deliberate. Inescapable self-disclosures occur when real events in the therapist's life—for example, pregnancy—affect the environment of the therapy. Inadvertent self-disclosures occur in the context of the transference-countertransference dyad and include tone of voice and expressions of empathy.
Pizer offered only vague comments about deliberate self-disclosures, suggesting that they "might contribute [to] or indeed open the intersubjective and intrapsychic spaces between therapist and patient, thereby extending the potential for movement, for growth, for further didactic, and ultimate termination." Andersen and Anderson (
+23) conducted a factor analysis and found that deliberate self-disclosures could be subdivided into three types: disclosure of information related to the personal identity and experiences of the therapist, disclosure of emotional responses, and disclosure of professional experiences and identity.
Other authors, including Greenson, Wexler, and Ferenczi, have maintained that it is important to have a relationship that "feels real" in order for the patient to build a therapeutic alliance with the therapist (
+24). Winnicott (
+25) viewed therapy as a creative process that could not move forward unless the patient felt some attachment to the therapist. Such an attachment was necessary in order for the patient to take healthy risks—to change—later in the treatment. Thus even in more traditional therapeutic modalities, self-disclosures occur regularly and may have therapeutic value.
Gutheil and Gabbard (
+15,
+16) pointed out that boundary issues are often misunderstood and approached with rigidity. Cautioning against such rigidity, they also underscored the dangers of revealing information such as personal problems, dreams, fantasies, and specific details of vacations or family births and deaths. They believed that such self-revelation could burden the patient and that it "reverses the roles of the dyad." Gabbard and Nadelson (
+26) warned that although some self-disclosure may improve therapist-patient rapport, excessive self-disclosure with role reversal may initiate a downward spiral into more serious boundary violations, such as sexual involvement.
Although they did not explicitly state it, these authors suggested that one distinguishing feature of appropriate versus inappropriate self-disclosure is the therapist's motivation. They allowed for the use of self-disclosure when it is in the interest of the patient's treatment.
Changes in society and medicine have changed self-disclosure practices among mental health professionals. First, the public has become more accustomed to self-disclosure in the media—for example, the intimate confessions of celebrities and authority figures. Even psychiatrists and mental health professionals have a greater media presence and may be quoted in the newspapers and on television. Second, a variety of effective treatment modalities that are not constrained by the need for anonymity have arisen, including psychopharmacology and cognitive-behavioral therapy (
+2,
+3,
+5,
+7,
+11,
+33). The self-help movement for substance abuse treatment is based on a premise of shared experience and self-disclosure (
+4). Finally, a variety of community-based interventions—for example, assertive community treatment—place mental health professionals in non-office-based environments that promote nontraditional interactions and exchanges.
Societal changes in attitudes toward clinicians and the clinician-patient relationship have created a variety of pressures to self-disclose. "Patients" have become "consumers," and "clinicians" have become "providers." The consumer-patient, equipped with information, is now empowered to question the clinician-provider and to expect answers. The questions may extend beyond the technical aspects of treatment and into the personal realm. Furthermore, the boundaries between "professional" and "personal" are blurred when consumers believe that they have a right to know whether therapists' personal experiences enable them to be empathic and effective.
Market forces have also altered the traditional power balance, which formerly favored the therapist but now favors the patient. Therapists may feel obliged to answer patients' questions to maintain patient satisfaction. Moreover, technology has enabled patients to obtain information about therapists even if the therapists do not reveal such information directly.
The changing demographic characteristics and diagnoses of patients receiving mental health services constitute another relevant phenomenon. Deinstitutionalization has caused more people who have severe mental illnesses to receive treatment in the community, and outpatient clinicians are treating a broader mix of patients who require more directive interventions (
+34). Overall, more people are receiving mental health care because of broader insurance coverage, improved psychopharmacological and psychosocial treatments, greater numbers of providers in all disciplines, and some reduction in the stigma associated with mental illness. The participation of patients and therapists of different cultures has introduced culture-specific issues about sharing personal information, which demands a more flexible approach to self-disclosure.
Instead of focusing exclusively on the potential harm of deliberate self-disclosure, therapists should consider whether it might be helpful for a particular patient in a particular treatment. This new question assumes that self-disclosure as a psychotherapeutic technique can enhance treatment. In
+Table 1 and in the following sections, the potential benefit of the use of self-disclosure with different types of treatment, in different settings, and with different patient groups is considered.
Several types of treatment provide opportunities for therapeutic self-disclosure. Self-disclosure and mutual support contribute to the effectiveness of peer models, such as 12-step programs and self-help groups. Many of these models have entered the therapeutic mainstream and include clinician-facilitated self-help groups. Such treatments often focus on specific behaviors or life experiences, such as addiction, bereavement, parenting, divorce, trauma, or physical illness. The therapist may disclose past experiences as part of the ethic of sharing. Such disclosure alleviates the patient's shame and embarrassment, provides positive modeling, normalizes the patient's experience, and provides hope. Questions remain as to whether the therapist should self-disclose about current problems or difficulties and about topics outside of the specific focus of the group.
In cognitive-behavioral therapy and social skills training, self-disclosure can be used to model coping strategies and problem-solving techniques. For example, self-disclosure is one of the suggested techniques in dialectical behavioral therapy. Linehan's treatment manual (
+11) describes "self-involving" self-disclosure, in which the therapist reveals his or her immediate personal reactions to the patient, and "personal self-disclosure," in which the therapist gives the patient information about himself or herself that may not necessarily relate to the therapy or the patient. Linehan's manual describes the circumstances and situations in dialectical behavioral therapy under which such self-disclosures are useful. Another example of the utility of self-disclosure involves metaphor, such as when a therapist helps the patient by saying, "It's like when my son was learning to ride a bike. He tried and tried, and suddenly he just got it."
In psychopharmacologic treatments, self-disclosure may increase rapport, enhance the therapeutic alliance, and increase compliance with medications. Answering questions in a straightforward fashion, the psychopharmacologist provides concrete explanations about the patient's illness and medications. Exploration and interpretation are usually confined to issues pertaining to patient's fears about side effects. In the same way that a cardiologist might respond directly to a patient's question about whether the cardiologist personally would take antihypertensives, so might psychopharmacologists answer questions about whether they or a family member have taken a psychotropic medication. The answer would depend on the context and the clinician's own comfort level.
The limited role of self-disclosure in exploratory psychodynamic treatment contrasts with its potential utility in supportive therapies. In supportive therapy—even psychodynamically oriented supportive therapy—self-disclosure can have many of the same therapeutic benefits derived from its use in cognitive-behavioral and psychopharmacologic treatments. In a wide range of reality-based, present-focused treatments, exploration and interpretation of the transference from a neutral standpoint may not be central components of therapeutic efficacy. Miller and Stiver (
+35) challenge therapists to use deliberate self-disclosure as part of the therapeutic armamentarium.
In addition to the type of treatment, treatment setting also introduces opportunities for therapeutic self-disclosure. Setting refers to the actual treatment location and the nature of the community in which treatment occurs. Treatments that take place outside the office, in particular, involve inescapable and inadvertent self-disclosure. During a home visit, the clinician may need to reveal information about food preferences, food allergies, or religious restrictions if the patient offers food. The clinician then needs to integrate these pieces of information into the treatment in a positive and helpful manner. Refusal to self-disclose might seem rude or offensive.
Similar issues arise when treatment is delivered in a small or rural community in which even office-based treatments may be complicated by inescapable or inadvertent disclosure. The patient may be the clinician's grocer or a member of the same church or parent-teacher association. In such cases the patient has probably already learned a great deal about the therapist both directly and indirectly. The clinician can weave such knowledge into the therapeutic experience rather than feigning ignorance, and this approach may require deliberate self-disclosure (
+35).
Finally, it is important to remember that in addition to geography, a community may be defined by certain demographic, ethnic, religious, sexual, or personal characteristics. When patients want to be treated by someone who shares such a characteristic, multiple opportunities for self-disclosure emerge.
+
Patient characteristics
The patient's age, sex, educational level, socioeconomic status, cultural background, and personality merit consideration in decisions about self-disclosure. Children and adolescents and individuals who have mental retardation, dementia, or a diminished capacity for abstract thought tend to ask more personal questions and may benefit from more direct, concrete answers to questions related to self-disclosure. Adolescents may feel demeaned when a therapist does not respond directly to a question. Refusal to answer the question of an elderly patient may be viewed as disrespectful. In addition, patients from more emotionally expressive cultures often expect a more personal form of social interaction.
The clinician should also consider the patient's previous treatment experiences. A patient who encounters a self-revealing therapist after years of more traditional analysis may be confused. On the other hand, a patient who is undertaking long-term exploratory psychotherapy after receiving a supportive or biologically oriented treatment may be angered or daunted by a therapist's more withholding stance. In such situations, a more gradual transition, with repeated orientation to the new "rules," may be needed.
Similarly, persons who have been abused by a therapist by way of boundary violations will need to learn to maintain "normal" boundaries in relationships. This need generally must be addressed in treatment in order to improve patients' interpersonal relationships. In such cases, self-disclosure can be used both for modeling—teaching, through example, the skill of appropriate self-disclosure—and for repair—enabling these patients to experience maintenance of boundaries through helpful self-disclosure in a clinical relationship.
Clinicians should recognize the benefits of self-disclosure as well as its dangers. This is especially true for clinicians who work in self-help or peer formats, cognitive-behavioral therapy, psychopharmacologic management, and supportive therapy. It is also especially relevant for community settings and among subgroups of patients who have high expectations of self-disclosure or concrete thinking. Nevertheless, the choice of whether to self-disclose should be an active decision that is balanced against the risks, and the decision should always be based on the patient's best interests. Skill and sometimes supervision are necessary for making the best choices about self-disclosure.
Consideration of the therapeutic benefits of self-disclosure has been hindered by the association between self-disclosure and flagrant boundary violations. We do not dispute the fact that inappropriate self-disclosure is a component of many harmful boundary violations. However, it is erroneous to conclude that self-disclosure inevitably leads to boundary violations. Such a view has diminished our therapeutic repertoire by limiting the potential benefits of clinician self-disclosure. Psychotherapy research should include the study of self-disclosure as one of the prospective active ingredients of the therapeutic process. In these rapidly changing times, we must be open to addressing the positive aspects of therapist self-disclosure in developing new rules for our new roles.