Monday, July 09, 2007

Let Me Tell You About Myself

After our last podcast, Shrinks on the Take (now what does that even mean?), we received the following comment/questions.

Can one of you comment on this?OCD can make you feel like a weirdo and so I hid it through most of my treatment b/c it wasn’t to bad, even though I didn’t expect my therapist to judge me for it. When I finally brought it up I was somewhat shocked when my therapist said she too had it, but insisted it was well under control, except in situations she doesn’t encounter much where she’ll sometimes carry out a mental compulsion. She mentioned I should add paxil to my wellbutrin, and I said I thought I heard about a lot of paxil withdrawal problems, and she said “yeah I went thru that”. She rarely talks about herself. Though I was shocked I felt really relieved and un-selfconscious afterward. I guess even though I know you are trained to not judge, I think ocd is a hard thing to understand unless you have it and have actually felt that repetitive irrational doubt and those maddening urges- but since I knew she knew the feeling- I think it helped a ton. Still what do you think of mental health professionals who admit to their patients a shared mental illness, or what medications they were on? Does it also depend on the illness? (-note from Dinah: I shortened the question a bit)

What a great question. I've been thinking about this one for days.
The issue of self-disclosure in psychotherapy has a number of meanings. The uni-directional flow of information is one of the boundaries that differentiates psychotherapy from friendship. Boundaries, as we've noted before, are important for keeping the therapy safe, and more specifically, it's important that the therapy be about the patient and not the other way around. Self-disclosure in psychotherapy gets a particularly hard rap because of psychotherapy's underpinnings in Freudian psychoanalytic theory where the therapist is required to be a "blank slate." In this school of thought, the treatment requires that the patient know little about the therapist, and so to self-disclose isn't just imprudent, it's actually considered to be harmful to the treatment.

And if this isn't a good enough reason for a therapist not to tell a patient about his own psychiatric disorders, perhaps the therapist's desire for privacy is.

Okay, that said, the reality is that no one is a totally blank slate and no one gets complete privacy. Sometimes the only reasonable thing is to tell patients about a medical condition the therapist is coping with. It's hard to hide a pregnancy, and perhaps patients are entitled to know if their therapists are anticipating a prolonged medical leave for any reason. Full details, full disclosure? I suppose that depends on how personal the problem is (Let me tell you about my prostate?) and the therapist's own desire for privacy.

What about in the case where the therapist has a psychiatric disorder, as in the case our reader describes? Our reader makes the point that the therapist does not usually self-disclose, that the therapy is usually about the patient and we might assume that the therapist considered carefully whether to disclose to the patient her own experiences with OCD.

There is nothing inherently wrong, immoral, or illegal about a therapist telling a patient that she suffers from a psychiatric disorder.

If the therapist doesn't mind the loss of privacy and doesn't then use the sessions to talk about her own problems, it's not wrong, but it can be powerful and so there are risks. As in any conversation, whether something said is helpful or harmful is subject to Monday morning quarterbacking and interpretation, and we don't always control how information is taken or used. A patient can have many responses, including the thought that it's troubling to know the therapist has a mental illness or feels burdened by a therapist's problems.

If the patient is distressed by a therapist's self-disclosure, then it was the wrong thing to do.

If the patient is comforted by their shared condition (especially where the therapist can offer hope and a good outcome), and the patient says, as our writer did, "I think it helped a ton," then it was the right thing to do.

And life would be so much easier if we always knew before we opened our mouths what the exact right thing to say is. I'll call when I get there.
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Gerbil said...

I wonder if there's a difference between unprompted self-disclosure and invited self-disclosure. That is: is it generally better for the therapist to wait until the client directly asks about the therapist's own experience? Or could it be an indirect invitation, like "sometimes I feel like I'm the only one in the world with this problem"? (For that matter, is "you know what I mean?" an indirect invitation?)

(oh and Dinah, I think you meant that analysis requires the patient to know little about the therapist... although I guess it could also be said that the patient must at least start out knowing little about the patient!)

Gerbil said...

This also reminds me of that children's book Your Turn, Doctor, wherein a little girl imagines giving her pediatrician a check-up (and shots!).

I can see it now:

therapist: Tell me about your mother.
client: No, it's your turn! Tell me about YOUR mother!

Dinah said...

Thanks, Gerbil, for catching my error.

Gerbil said...

No problem, Dinah--hope it wasn't too obnoxious of me! :)

Anonymous said...

Thanks for answering my Q Dinah, your thoughtfullness shows and is very much appreciated.

Maybe its not neccesary but I want to clairfy, I mispoke slightly with the "rarely talks about herself". It's more like she doesn't take up our sessoin or make it about her, but disclosure doesn't seem to bother her and she'll do so occasionally unsolcited and usually if asked. Just doesn't drone on or do it out of the blue. for example today she was going to give me the YBOCS but forgot the copy at home, and called her kids in front of me and said it was like 2 min away. She's treated me a year and (i think!) knows I'm not dangerous or a stalker tho, so whatever, I could care less she told me.
If I hadn't heard about therapists problems w/self-disclose before, I probably wouldn't have thought anything about this or the other things. Just made me surprised at her un-gaurdedness and wondered if it was odd or discrouaged in other schools of thought. OK I'm talking to much again! Thx again!

Oh, but hilarious about the pregnancy thing, b/c I think she may be. Wouldn't dare ask this early tho! You guys have feelings to, right? :)

Anonymous said...

A good rule of thumb for life in general, with no relevance to psychiatry, is that it's probably a good idea to never ask any woman if she's pregnant.

Therapists differ with what they are comfortable self-disclosing. What really matters is whether the patient gets better.

DrivingMissMolly said...

This is of particular interest to me. I am feeling very close to my therapist. Part of it is that we have been together for several years now and have reached a certain comfort level. I am interested in him as a person because I need him AND my psychiatrist to be "perfect." In other words, I will always be on guard for any indication that they are mean.

In the last session I had with Therapist, we talked a lot about his home, which he is in the process of remodeling. I enjoyed that conversation, but realized later that I needed to steer it back to me. I wonder if he'll do that this afternoon when I see him.

With all except my current psychiatrist, I never or rarely asked a personal question. Now, many times I do. Like I said, I need to know that these people are good, honest, kind and moral, and the only way to find out is in the interstices between "therapeutic" conversation and "just" conversation.

Last psych. appointment, I learned that Psychiatrist has a rescued Great Dane. As a fellow dog person, I was delighted. I also could surmise that he didn't own a cute little sportscar because he'd have to have a huge SUV to carry that beast!

I would NOT want to know if Psychiatrist had any one of my DXs. Since I see myself as fatally flawed. damaged and worthless, if he had the same thing, I would consider him that way as well.

Rach said...

god, all i know about my shrink and my therapist is their favorite foods.

The shrink likes (ok, loves) Chocolate - brownies and cookies. He was very happy to receive triple chocolate chip cookies for a chanukah gift a couple of years back. Oh, and he doesn't drink coffee.

The therapist likes maple syrup and is lactose intolerant.

What else do I need to know?

Anonymous said...

I hear it's fine to give triple chocolate chip cookies to blogger shrinks, too.

Gerbil said...

Oh, Dinah, you have just put evil thoughts in my head.

Anonymous said...

I would NOT want to know if Psychiatrist had any one of my DXs. Since I see myself as fatally flawed. damaged and worthless, if he had the same thing, I would consider him that way as well.

If I thought the only reason I was fatally flawed was a dx, why, that wouldn't be so bad at all.

If that's not the only reason, then is he also flawed for breathing air as you do?

If it is the only reason, it's sad to see you buy in to the stigma. Furthermore, what does it say about your therapist that he's spending so much time on people who are worthless? Does that not make him imperfect or stupid or foolish for pissing away his life instead of doing something useful?

It makes things so complicated to name your dx as a justification for those feelings. Personally, I chalk it up to poor self-image brought on by circumstances and genetics and an unhelpful way of seeing/reacting to things. But I suppose demanding perfection is unhelpful too...oh well.

Anonymous said...

How about this. If one is comfortable with their therapist and feels the therapist seems to know what they are doing, how much lack of improvement should one tolerate before deciding it's time for a change? I know it's impossible to talk about an exact time frame given different diagnoses and personalities and treatment progress, etc etc, but is there any indication?

And if so, what should one do? Bring it up with one's therapist and see what happens, switch therapists, get a second opinion? (I was in a situation where I made no progress after 40 sessions and 3 drugs, had no experience with other therapists, and didn't think the therapy was going anywhere, but my therapist seemed competent. Eventually he recommended a local BPD group even though I only fit one or two of the less relevant criteria for BPD and only during a depressive episode at that, so I wasn't sure if he had given up to and was gently trying to get rid of me...but I'm still with him and never went to the group.)

Rach said...

Dinah, I'm sure I can arrange some triple chocolate cookies for one of your podcast recordings in the fall - it's too hot to bake and ship them right now. Remind me in december!

NeoNurseChic said...

Good post! I haven't read thru the comments because I'm on limited time here, so forgive me if I say the same thing as someone else! I'm commenting from Stone Harbor this time!! Using free internet at a Coldwell Bankere! haha.... (Does this mean I'm a complete internet junky? Maybe I'll save that for exploration in therapy.... j/k!!! Actually what it really means is that I can't go more than 24 hours without checking my bank account....)

So anyway - the last time I had a psychiatry appt, we actually got on the topic of what things I've imagined up in my head about him. I said point blank that I like things to fit into categories. I like people to fit into certain categories, too, and I've never really been "off" about how I perceive someone. I was a lot more nervous when it came to how I perceive him, because it's not like the normal thing where both people are guessing things about the other and information is shared both ways. This is me guessing blindly based on certain observations and comparing them to what I know in similar circumstances.

SO anyway - what I'm getting at is that I often have a lot of anxiety over not really knowing who I'm talking to. What he said, though, I thought was helpful. He said that if he felt that disclosing certain things would benefit me in any way, then he would do it. Otherwise, he wouldn't.

That makes good sense, eh?

And once again I'm left knowing that I have a good psychiatrist.... :)

Alright - I gotta stop checking blogs and go to the beach!!! Actually, I do have to check my work schedule real quick, but otherwise - it's a pretty nice day out, though humid, and I want to put my feet in the sand and return to reading my Harry Potter book. :-P Have a great day!!

Take care,
Carrie :)

Sarebear said...

I bet it's a tough call for therapists. There are more modern schools of thought that have added to the field of psychology, that basically say limited, carefully considered, occasional self-disclosures from the therapist, can increase rapport, help the patient feel understood (if the disclosure relates to the topic at hand, which is kinda the point), etc.

YOU know that, I just thought I'd mention it for others.

Early in therapy, I became bothered by the fact that my psychologist sat . . . open-legged, alot. You know, that casual way men have. I wasn't looking on purpose, but it was distressiong to me, so I mentioned it; he said he'd make sure to change that; he also related that he has a condition where the nerves in one of his feet and ankles go numb/senseless, no sensation, especially when sitting (professional hazard, I guess, lol!). His chair is a recliner, so he puts up the foot rest, puts it up and down a couple times per session (not distracting to me, plus I understand it being due to this medical condition, which I think is why he explained; to lessen the distraction).

I don't feel he disclosed to make me feel bad for mentioning my bothered-ness; I had the sense it was to help me not be distracted by the chair, and I also felt that maybe he felt bad I had been bothered (but that's just my own imagining).

One disclosure that WAS odd, and freaky in a Twilight Zone kinda way but he had no way of knowing, was when he related one experience that was really applicable (and helpful!) to what I had just related to him. The freaky part to me was that he apparently was the school psychologist at the junior high I went to for a couple months at the end of 9th grade when we moved to Utah. I was REALLY in alot of psychological/emotional distress/turmoil at the time, and wished at the time I could have had access to mental help. I wonder, if as a new student, having moved across country, if he saw my file, or me even (I can't remember).

Anyway, so I told him about our connection with that school, the both of us . . . that I had some resentment and anger that he didn't help me then, even though I knew of course that he really couldn't have known. I recognized it was important to mention this irrational anger and hurt, though, at realizing he had been there, and hadn't helped me or anything (again, he couldn't have known, it's just an emotionl, primitive gut reaction to having needed help so badly.)

Anyway, that was wierd, but one of those things you could never know would have a connection like that.

All in all, I can tell that he carefully considers the occasional disclosure, and I appreciate the thought and consideration he puts into that decision, as well as his sharing helpful experience or situation. It also helps me feel less like the therapeutic relationship is a cold, sterile thing, which feeling I had struggles with the first year in therapyl.

Sorry to go on so much, but it's all relevant!

Anonymous said...

I stumbled across this - I'm not sure how, but I found this discussion very interesting as well as the blogging about one's shrink.

I have blogged about helpful/humorous things that have occurred in therapy, but being the paranoid person that I am these posts NEVER address my therapist by an identifiable information, AND they are locked to be visible only to certain people.

I have seen the theory that the therapist/psychiatrist is supposed to be a blank slate to the patient and I have experienced that before in therapy. I found it almost completely non helpful.

I want to know that my mental health professional is a person who has potentially similar thought processes or viewpoints on things.

It could be simply my personal hang ups in that a lot of the reasons I'm in therapy stem from trust issues.

Personally though I know that my shrink is a geek and what taste in movies/tv shows he has, I know a a very little bit about his family life (just the basics such as marital status how many kids and that he has a close knit extended family) and I know his sense of humor.

It's taken a year of sessions to get to the point where I feel I actually trust him, but I feel a fair portion of that has been his willingness to ocassionally self disclose.

Personally if my therapist/psychiatrist had dealt with a mental illness similar to or the same as what I was dealing with, I would find that comforting.

To me that would represent someone who had actually gotten a grip on it and found a way to help other people.

YMMV. :)