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Self disclosure by health professionals

Blogging about my mum's illness and my reactions to it led me to think again about self disclosure by health professionals.  Our job is to be helpful for our clients - it's what we're about.  Self disclosure by health professionals is a mixed bag.  It can sometimes be helpful and sometimes damaging.  Different schools of therapy and different styles of doctor have strong opinions about what's right and wrong in this area.  Strong opinions without research back-up tend to generate more heat than light.  As has been so delightfully stated "The plural of anecdote is not data".  This post is not at all intended to be exhaustive about research on health professional self disclosure.  It is intended to shine a light on some interesting facts and to raise some questions.

For example, a study a few years ago found that a health professional sharing with clients their own personal experience of struggling with and making healthy changes in their lifestyle was viewed as more believable and more motivating than the same health professional giving identical lifestyle advice without including any personal details (Frank, Breyan et al. 2000).  It seems likely that the value of sharing some of our personal experiences may at times also apply to health professionals working to help people cope better with stress, manage their emotions more adaptively, have more fulfilling relationships, and live more healthily and happily. 

As the US "Group for the Advancement of Psychiatry" put it in their report (Psychopathology Committee, 2001) "In mental health practice, a commonly held view is that therapist self-disclosure should be discouraged and its dangers closely monitored. Changes in medicine, mental health care, and society demand reexamination of these beliefs. In some clinical situations, considerable benefit may stem from therapist self-disclosure. Although the dangers of boundary violations are genuine, self-disclosure may be underused or misused because it lacks a framework ... The role of self-disclosure in mental health care should be reexamined."  

There's some data (Barrett and Berman 2001) showing that increased self disclosure by counsellors results in their clients reporting lower levels of symptom distress and liking the therapist more.  As the study authors concluded "Such findings suggest that self-disclosure by the therapist may improve both the quality of the therapeutic relationship and the outcome of treatment."  One important function of therapist self disclosure is in "normalising" emotions and behaviours (Leudar, Antaki et al. 2006).  So often people keep silent over their experiences and this can lead them to feel that they are unusual, weak, bad or inadequate.  It can be very important to share with a client that what they are experiencing is a widely reported part of the experience of being human.  Clients who feel too ashamed to share openly with their therapists tend to do worse (Hook and Andrews 2005), and it's been known for many years that self disclosure by one partner in a dyad tends to elicit greater self disclosure in the other partner (Jourard 1971).

A paper on therapist self disclosure in cognitive-behavioural therapy (Goldfried, Burckell et al. 2003) commented on " ... the use of therapist self-disclosure to provide feedback on the interpersonal impact made by the client, enhance positive expectations and motivation, strengthen the therapeutic bond, normalize the client's reaction, reduce the client's fears, and model an effective way of functioning."  The paper went on to conclude "Therapists need to observe appropriate boundaries when self-disclosing, and in particular, should consider their own motivations for self-disclosing. Although more research is needed on the effects of self-disclosure, cognitive-behavior therapists have found that self-disclosure can be a powerful intervention."  The same issue of the Journal of Clinical Psychology that contains the Goldfried et al paper also includes nine other papers on self disclosure, at least half of which also address the issue of therapist disclosure.

Good therapist self disclosure serves the needs of the client, not the therapist.  Clients typically want their therapists to be "confidence-inspiring and calm" (Littauer, Sexton et al. 2005).  There's plenty of tiger country in therapist self disclosure - for example, with sexual attraction (Fisher 2004), with major traumas in the therapist's own life (Philip 1993), and with disclosing aspects of the therapist's past (Fox, Strum et al. 1984).  There is also much that can be usefully explored by self disclosing thoughts and feelings about the actual interaction between therapist and client (e.g. Yalom, 2002) - an area that some schools of psychotherapy focus on greatly and others largely ignore.  As nearly always, the most useful position is probably a balanced middle road.

Barry Farber's recent book "Self-disclosure in psychotherapy" (Farber, 2006) explores this whole area in much more depth.  John Norcross, a well respected academic, reviewed the book saying "Farber brilliantly addresses self-disclosure from therapist, patient, multicultural, and even supervisory perspectives. He embraces the complexity of self-disclosure while simultaneously augmenting our effective use of it. Bravo!"  Important territory ... and well worth reflecting on.       

Barrett, M. S. and J. S. Berman (2001). "Is psychotherapy more effective when therapists disclose information about themselves?" Journal of Consulting and Clinical Psychology 69(4): 597-603.  [PubMed]
Farber, B. (2006).  "Self disclosure in psychotherapy."  Guilford Press.  [AbeBooks]   [Amazon UK
Fisher, C. D. (2004). "Ethical issues in therapy: therapist self-disclosure of sexual feelings." Ethics Behav 14(2): 105-21.  [PubMed]
Fox, S. G., C. A. Strum, et al. (1984). "Perceptions of therapist disclosure of previous experience as a client." J Clin Psychol 40(2): 496-8.  [PubMed]
Frank, E., J. Breyan, et al. (2000). "Physician Disclosure of Healthy Personal Behaviors Improves Credibility and Ability to Motivate." Arch Fam Med 9(3): 287-290. [Abstract/Free Full Text]
Goldfried, M. R., L. A. Burckell, et al. (2003). "Therapist self-disclosure in cognitive-behavior therapy." J Clin Psychol 59(5): 555-68.  [Abstract/Full Text]
Hook, A. and B. Andrews (2005). "The relationship of non-disclosure in therapy to shame and depression." Br J Clin Psychol 44(Pt 3): 425-38.  [PubMed]
Jourard, S. M. (1971). "Self-Disclosure: An Experimental Analysis of the Transparent Self." New York, NY, John Wiley & Sons Inc. [AbeBooks]    [Amazon UK
Leudar, I., C. Antaki, et al. (2006). "When psychotherapists disclose personal information about themselves to clients." Commun Med 3(1): 27-41.  [PubMed]
Littauer, H., H. Sexton, et al. (2005). "Qualities clients wish for in their therapists." Scand J Caring Sci 19(1): 28-31.  [PubMed]
Philip, C. E. (1993). "Dilemmas of disclosure to patients and colleagues when a therapist faces life-threatening illness." Health Soc Work 18(1): 13-9.  [PubMed]
Psychopathology Committee of the Group for the Advancement of Psychiatry (2001) "Reexamination of therapist self-disclosure." Psychiatr Serv 52(11): 1489-93.  [Abstract/Free Full Text
Yalom, I. (2002) "The gift of therapy: reflections on being a therapist."  London: Piatkus.  [AbeBooks]   [Amazon UK


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