The Elephant in the Room
I usually begin my workshops about the uses and misuses of self-disclosure with the comment, "We've been ignoring how much therapist disclosure happens, whether we mean it to occur or not." Then I show a cartoon of an elephant lying on a couch. A psychiatrist sits at the elephant's head, writing on a notepad. The elephant is saying, "I'm right there in the room, and no one even acknowledges me." People in the audience knowingly nod their heads and laugh.
Much of what we reveal is inadvertent. The watches and jewelry we wear or don't wear, how we dress, our hairstyles, how we talk, or how we decorate our offices all tell a story. Then there are unforeseen and undesired encounters outside of therapy, like the time in a grocery store when I was scolding my daughter and looked up to see a client watching me.
In therapy, the current or past events we reference and the themes and topics we pick up on (or don't address) can be telling. In the third session with a divorced couple and their older children who primarily lived with the mother, I found myself focusing on her financial difficulties. I asked questions about how much child support the father gave. It turned out he was paying substantially more than their divorce agreement required, and that wasn't an issue. My inquiries pointed a finger at my own experiences with my parents' divorce. As family therapist Charles Kramer noted, "It is impossible not to reveal ourselves. And when we try to be a blank screen, we reveal that we are concealing, which is a message in deception."
Some disclosures can derail the therapeutic process. Shared information may make clients feel they need to take care of the therapist or that the therapist isn't there for them. A colleague, Ava Lin, worked with a woman, Karen, who'd been sexually abused by her father. After a year of sessions, Karen was still blaming herself for the abuse. She had ongoing difficulties with sexuality and intimacy with her husband, and was still unable to tell him what her father had done. She also didn't feel ready to join a group for survivors of abuse. Ava consulted with her supervisor and made a decision to share with Karen that she, too, had been sexually abused by her father, and this was part of the reason why she'd developed a specialty in helping individuals with sexual problems. Ava then described part of the journey that took her away from her shame and guilt.
At first, Karen seemed surprised, relieved, and a little disquieted to hear these disclosures. She asked Ava about how she'd worked through her self-blame, and conversations ensued that helped Karen let go of some of her feelings and share more with her husband. However, in response to Ava's asking her how it affected her to have this information, Karen said, "It makes me feel protective of you and worried about saying things that will be hard for you to hear, or give you flashbacks. Now I'm watching you to see if you're OK." From then on, Ava worked with Karen to reassure her that she didn't need to "take care of her therapist." She made an extra effort to monitor her own affect whenever she shared anything further in therapy about her abuse experiences and checked in frequently to see whether Karen was feeling concerned about her.
So in the discussion about self-disclosure, we need to move beyond an either/or frame, as in "yes, do it" (often the stance of feminist therapists), or "no, keep tight boundaries" (often the position of traditional psychoanalysts). A both/and frame-which looks at when, where, and how revelations by therapists support the therapeutic process and when they get in the way-establishes a more realistic place from which to analyze and understand the possibilities and dangers inherent in disclosure. Focusing on the timing and process of disclosures can move us out of an "it's good" or "it's bad" position. The ways we disclose, read cues from clients, and ask questions and discuss what's been divulged provide safeguards for our clients and opportunities to advance their therapeutic goals.
The Importance of Emotional Control
I hit the play button on my message machine: "We got bad news; Peter has prostate cancer. Call us as soon as possible. We need a session." Isabella's voice was pitched as high and sharp as a whistle. I'd worked with her and Peter and their two teens off and on for several years, but I hadn't seen them for six months.
I called their house. Isabella answered, "It looks serious. We won't know the details until his surgery. Our lives have been thrown up into the air like pick-up sticks. Who knows where they're going to land?"
My right hand splayed out on my chest over the rhythmic thud of my heart. What would this diagnosis mean for Peter? And for the family?
Isabella went on, "Peter's mom doesn't want us to say the C-word or tell the kids. They're smart; they'll figure it out. What should we do?"
As I listened to her, I wondered if I should tell her that I'd had a bout with cancer when my daughter was a teen, and we, too, struggled through the fear, ambiguity, and deep sense of loss of control she was describing. Would my telling her reassure her or impede or detract from what she was saying? Would it be better to allude to it briefly when we met face-to-face, so I could "read" more easily whether the disclosure was helpful?
I chose not to say anything on the phone, for multiple reasons. I already had a stronger alliance with Isabella than with Peter, so that connection might get tighter if I told her first. I also wanted to have a direct sense of how Peter was doing emotionally and make sure that my own feelings about my cancer experience didn't knock me off balance when I talked to them. When we make disclosures, it's essential that we stay in emotional control of what we reveal and that we keep our attention on our clients.
To see whether sharing my experience would be appropriate and pertinent, I decided to wait until our session the next day. That would give me 24 hours to reestablish my equilibrium. Often, helpful disclosures are about challenging and emotional times in the therapist's life. The process of disclosure is a delicate balance-tapping into feelings that can create affective connection between us and our clients, while ensuring that those emotions don't take over.
I met with Isabella and Peter the following afternoon. A few minutes into the session, he said, "We've decided to tell our daughters tonight and need help. We've never had to do anything like this before."
That provided a natural opening for me to say, "I don't think you know this about me, but I had breast cancer 10 years ago. My daughter was 13, and I, too, struggled with how to talk with her. If you think it would be useful for you to hear a little about that, let me know." As I spoke, I tried to pay careful attention to my tone of voice and body language. When we disclose potent information like this, it's crucial that we don't communicate that we need a particular reaction, such as reassurance or support. We need to be comfortable with a minimal response, a negative response, or no response at all. A small, tentative disclosure like this is usually best. Clients' verbal feedback and nonverbal clues can inform you about whether to say more.
Later, Isabella said, "I'm afraid our daughters are going to have questions that we don't have answers to. How did that go with your daughter?"
I said, "I tried to let her know that there were a lot of unknowns, but we could keep talking, and she was free to ask whatever questions she wanted to. Interestingly, she didn't have a lot of questions; she says now that she just tried to focus on her life, so as not to worry too much or give me things to worry about. But every kid is going to have their own way of coping." This led us into a conversation about the coping styles of their children and what they could do as parents to tap into them.
Later in the session, Peter said, "I want to continue to work. Isabella wants me to use my sick leave and concentrate on my recovery. Work is central for me, and I don't want to be just a 'patient.' What did you do?"
Isabella's gray-blue eyes were locked onto my face. How could I respond in a way that connected with their two different perspectives and concerns? After a moment, I said, "I did continue to teach, but I cut back on nonessential things, like those long committee meetings at the university." I chuckled and they laughed. "And I scaled back my private practice. I needed time for the treatments and getting my strength back after them. You might need more down time than you expect, Peter. But I hear what you're saying about work; continuing to work really helped me focus on things other than the cancer." I then turned the conversation back to them by suggesting that they ask each other questions about their different perspectives on whether Peter should work.
This example reflects several key choice points when deciding to self-disclose. I needed to remain in control of what my disclosures might bring up emotionally. I also needed to consider whether the information would be useful to my clients or get in the way of our conversation. When I did decide to reveal my experience with cancer, it was a brief foray, formed as a question to them, after which I monitored my body language and made sure I behaved neutrally. Later, when Isabella, and then Peter, asked me questions, I responded with a focus on the process, rather than on the solutions I'd reached, and quickly turned the conversation back to their situation.
I realized that revealing something that was so important in my life had connected me with the sessions differently. I felt seen and witnessed by Isabella and Peter, albeit briefly. This is an aspect of therapeutic process we seldom discuss, but one that can help keep us involved and intrigued with our work.