Monday, July 11, 2011

Self-Disclosure: To Patients Versus To the World

Dr. Maureen Goldman talks about self-disclosure for psychiatrists and brings the topic up in the context of Marsha Linehan's recent announcement that she was treated for a psychiatric disorder as a teenager.

In Clinical Psychiatry News, Dr. Goldman notes:
Psychiatric care and psychotherapy are different from the Alcoholics Anonymous fellowship, where the mutual sharing of personal experience is an integral part of helping people maintain sobriety. I believe that there is middle ground between disclosing personal information and presenting myself as a blank slate. In my practice, I show myself to be a real person. I make mistakes and admit them. I joke about my poor bookkeeping skills and inferior technological skills. I look things up during sessions if necessary, and I tell patients when I need to do research or consult with a colleague. I treat them as real people, too, not just as patients. 

I do not, however, share my own story. Mostly, I think that I can help people feel heard, understood, and known, and create a therapeutic plan without personal disclosure. I communicate that "I get it" without being clear that "I really get it." 

I cannot speculate about the motivation behind Dr. Linehan’s decision to allow her mental health history to be chronicled in the New York Times. The story was a very public disclosure, and in that way quite different from a disclosure made in the context of a one-on-one, doctor-patient therapeutic relationship. 

We've talked in detail about self-disclosure before, and specifically about whether psychiatrists should tell their patients if they've suffered from a psychiatric disorder.  See our post on Self Disclosure and Being Genuine.

I thought it was interesting that Dr. Goldman used this particular example to discuss why psychiatrists should not self-disclose.  Mostly, I thought it was interesting because I disagree-- otherwise this would not have made it to a Shrink Rap post.

In the course of a patient's treatment, the decision to disclose information is a personal one and it needs to be made in the context of what is best for the patient.  With the exception of inevitable life events on the part of the psychiatrist (I'm sorry, I won't be here next week because I'll be delivering twins and I may be out for a while taking care of them....) the patient's interest is always what matters.  I agree that if the doctor is not sure how the patient will receive information, it is safest not to disclose personal information.

The dynamic that goes on is a complicated and unpredictable one.  The patient may feel burdened by any adversity in the doctor's life.   They may feel disappointed that their doctor is flawed.  They may feel special, in a good way or bad, that their psychiatrist let them in on secrets.  Or they may simply feel that it's nice to share a world with someone who has been in a similar circumstance.  The issue remains one to be handled between the individual psychiatrist and the individual patient and what is in their best interest.

The dynamic that goes on between the psychiatrist and the world is a different story.  It's not about what's best for the patient, it's about the doctor and their right to freedom of speech and self expression.  The problem with saying that Dr. Linehan should not have made such an announcement is that it's too much burden to place on psychiatrists to say they must live their lives in ways that won't upset their patients.  Is it okay to be seen in public entering a synagogue, church, or mosque?  To have a political bumper sticker or sign on one's house (I would contend that it's problematic to have political material in the office)?  To wear a Yankees hat?  To have tattoos? To post ducks on a blog?  To participate in an undignified hobby?  To be gay?  Certainly, patients have feelings about all these things and may have negative feelings which interfere with their treatment.  But psychiatrists are people and they have the right to inhabit the world in a way that is comfortable, just as patients have the right to find another psychiatrist.

Personally, I thought Dr. Linehan's statement took courage and I thought it was a wonderful proclamation of hope for those who struggle with chaotic feelings and behaviors as teenagers.  They don't all drop off the face of the map---some recoup to live full and productive lives and contribute a great deal to society.  I didn't see a problem with this announcement and I applaud her for coming forward.


Anonymous said...

Agree about M. Linehan. If she were an oncologist who had overcome cancer, she would not need to hide that. Also agree that a public disclosure is far different than telling one or some patients as in a just between you and me sort of thing.

rob lindeman said...

B'sha-ah Tovah, Dinah! Nothing but nachas and simchas!

Meg O said...

I think your title is well chosen. There is a big difference between self disclosure to the patient vs to the world. Self disclosure to the world, of the sort Dr. Linehan has done, affects not only her patients, but also the world they live in--by reducing the stigma associated with mental illness and informing other patients, professionals, and the world at large that even people with very troubled histories can go on to lead happy and productive lives.

It is also worth noting that Dr. Lineman has important roles and responsibilities aside from her role as therapist, since she is an academic leader, charged with a mission to create and disseminate knowledge.

It seems to me that her decision to share her story with the world is appropriate, courageous, and responsible.

Sharing her story privately with a patient in therapy, however, raises completely different issues. It burdens the patient with a confidence that he may not feel able to share, discuss, and process with others.

Alexis said...

I also don't see the problem. This was a public, general disclosure, very different from an "I understand your pain" disclosure in therapy. As a patient, I would see a general disclosure (unless it were accompanied by some sort of terrible, confessional memoir) as a positive-to-neutral background fact. While I am not always aware of my providers' backgrounds in much detail, I sometimes do know about things that make them who they are--that they have children, that they are from a particular religious background. These things inform their world view as well.

I also feel that in general, the disclosure is a positive thing because of the stigma associated with mental illness. At this point in her career, it's not going to define her. She made her name and her reputation already. It may make some people adjust their perception of her, but her career stands on its own. For better and for worse, I think such a disclosure from a younger clinician would have much more of an effect on their career. I'm not sure exactly what effects her critics expect this revelation to have.

On the other hand, I would find a one to one disclosure in therapy to be uncomfortable and intrusive. It's meant to be some kind of personal connection, and I always find it awkward at best when providers (not just in mental health--I've actually gotten it worst in OB/GYN) try to bring personal experience or anecdote into treatment. At worst, it will lead me to discontinue treatment with that provider.

Anonymous said...

Rob, I presume you are making reference to Dinah's recent delivery of twins.

The Alienist said...

I think that Dr. Linehan's revelation is likely to give great comfort to her patients and many like her. I also think that Dr. Jamison's openness about her bipolar illness was very helpful. They have given my patients hope that their illness will not define them and need not limit their abilities.

rob lindeman said...

I thought she said was GOING TO deliver twins. If so, Dinah, sorry about the B'Sha-ah Tovah, and i'll change it to a Mazal Tov. If not, the B'sha-ah Tovah stands.

Dinah said...

The twins were a "for example." But it would perk things up a bit around here.

Anonymous said...

Dr. Linehan is at the end of her career, so it may be somewhat different. She's unlikely to take on many new patients. She can be a model of public success.

I think that a lot of people knew some of it already. People who have been to her trainings told me that she had said that she was comfortable with the term borderline, that people wouldn't want to treat patients with BPD even if they changed the name etc., and she said this while revealing a wrist which had clearly been injured.

Sunny CA said...

Part 1
I agree with you in applauding Marsha Linehan's announcement. As a patient, I mostly considered that her public statement helped reduce stigma against mental illness. If many well-know people on the verge of retirement from all professions would announce publicly that they suffered mental health issues at some point in their life it would help mental illness lose its stigma.

I have struggled with the question of psychiatrist self-disclosure recently, because as our relationship has continued, my psychiatrist has increased his self-disclosure, but not in a useful way. Initially there was an example contained in his stories which sometimes were about himself and sometimes about other patients or his friends. Now he tells me unrelated things that sometimes interrupt the flow of my self-disclosure and at times I feel he takes over talking to the point that the session is no longer "my" time. He does not disclose personal problems, though I know about his cognitively disabled adult child, his deceased wife who died of cancer, and his mentally ill sister. I know about his mother and the poor parenting he got from his father. I have noticed, though, that mostly he likes to talk about his political viewpoints and his personal acquisitions. I am a lot less politically involved and interested than he is, so rarely am I interested in a detailed analysis of current events. He feels that he brings a "world view" in that patients who are unemployed or not employed as they wish to be employed are not alone due to the situation of the world economy. While this is true, I don't wish to hear more details of it than I already know. I am more interested in discussing how I am personally coping in my little corner of the world. Before the last session I was reading my Kindle in the waiting room which he asked to look at as I entered his office. I showed it to him and he proceeded to criticize the Kindle for lacking the features of his iPad which he let me know is the better product. I know the features and cost of each and don't need to discuss it during my session, nor do I plan to buy an iPad which I gave consideration to, but opted not to buy. The session before that he told me that he traded in his 2008 Porche Cayman S for a 2011 Porche Cayman S. At the time I listened in bewilderment as it did not fit naturally into my session, but several hours later it made me angry that he would flaunt his possessions in this way. I drive a 1996 that I could have much more easily afforded to replace had I not been paying his fees. However, then I got upset at myself that hearing he bought a new sports car would make me angry, as normally I am not heavily emotionally invested in my personal possessions and feel generally satisfied with my house, car, and choice of possessions and generally I do not find myself envious of others' possessions. Then I considered that I shouldn't be emotionally wrestling with this at all when I have other issues that are "more" important to work on.

Sunny CA said...

Part 2

I don't know quite what to do about the excess of information. I thought about quitting seeing my psychiatrist, but we now have a long history, and I think he's extremely empathetic, insightful, and supportive. Do I just ask him to stop disclosing? As mentioned in Dinah's post, I did feel special, at first, when my psychiatrist shared with me. He has told me he does not do this with other patients. I know too much though! I know the last movie he saw and the last book he read and what book he is reading now. I know his favorite restaurants, his favorite wine, what he likes to do in his spare time. I even know personal problems that his closest friend (another psychiatrist) is having, though not the name of that shrink. I know the brand and type of TV he has, what kind and brand of high-fidelity audio he owns and what he watches and what he listens to. I have seen his art collection which he photographed and put on his iPad, including room photos of the family room, living room and dining room. I know what baseball team he roots for and that he watches the TV while listening to the audio on the radio. It is TOO much considering I am paying for the sessions. Also, I still, after all this time have a difficult time disclosing deep emotional issues, and the biggest drawback to him talking too much is that I don't express what I ought to be expressing during the session because it takes me time to get it out and I can't have the flow interrupted and hope to express myself. How does a patient change the nature of the therapeutic relationship? I don't feel like starting over with somebody else.
I hate criticizing him. I do think he is very gifted and brilliant. He has a terrific memory and can accurately bring up things I said a long time ago. I want the situation to change, though, and don't know how to handle it.

Sarebear said...
This comment has been removed by the author.
J said...

I don't know, it certainly was courageous, but I nonetheless found it impossible to take such a public disclosure without a small grain of salt. I would bet Dr. Linehan's disclosure benefited her university and/or practice and/or DBT-as-a-whole practically or financially. I honestly don't see much reason for a disclosure of that variety in The TIMES.

That said, I agree with other commentators that there is a huge difference between disclosing to the world and to an individual patient, one on one. I would also bring up that disclosure itself is on a scale - Dinah's "for example" was meant as humorous, but I once saw a psychiatrist for therapy who came from an extremely rigid psychoanaltyic background...and did not "disclose" that she was pregnant until her 9th month. (It had been noticeable for a while....)

I don't think that I need to know if my psychiatrist has suffered from the same illness as me. In fact, I could see how that would create potential for messy -- more then anyone, a patient knows that remission from mental illness is not exactly dependable. Other times, my psychiatrist (not the pregant one!) has "disclosed" minor, neutral things and I find that those small things that are completely irrevelant helps me still see her as human.

So - it's a scale.

jesse said...

Sunny: you could bring your concerns up to your psychiatrist, just as openly as you brought them up here. One issue would be what led you to be hesitant to bring them up earlier. Well worth exploring with him.

I thought that Dr. Goldman's piece was very thoughtful, although saying the revealing self-information "is wrong" put it too strongly and absolutely I think. But if one needs a position to stand on, from which one might modify it as carefully considered, her position is correct. We all agree that one should do what is best for the patient, but are there guides as to how to discern that?

In general, self revelation is more about the doctor than the patient, and risks interfering with treatment. There is a difference between offering information and corroborating it, but still it is risky, and frequently occurs when the doctor has become uncomfortable with what he might feel to be a superior position. In other words, "don't envy me, I have suffered just as you have, I too have had depression."

Another factor is that self revelation may prevent the patient from talking about his fantases and feelings, because the doctor has essentially short-circuited that process. This can be helpful in many forms of therapy, not just in analytic or psychodynamic ones.

We do not need to be anonymous to our patients. Patients have many ways to find out where we live, went to school, and, yes, what model Porsche we drive, but that information should be left for them to discover ("I saw you at the ballgame, Dr. X... was that your wife, or your daughter...") rather than for us to impose upon them.

Sunny CA said...

Thanks, Jesse. I will do that.

Anonymous said...

I think the key to the issue (as with so many issues) is "everything in moderation." Professionals I have seen in the past have been very careful about what they disclose to me, but what they disclose has always been very helpful.

That aside, I also have a habit of deliberately trying to find out more about psychologists and psychiatrists I have seen. I read their diplomas - where did they come from? What was their undergraduate major? About how old are they? I read the titles of the books on their shelves and look for a wedding ring. When I speak about things like religion or politics, I watch their expressions (despite her efforts to keep a neutral expression, I figured out the political leanings of my first psychologist). I have never directly asked them questions knowing that most therapists limit their disclosure, but I have certainly been very observant. I do it more out of curiosity than anything else - I like to have an idea of where people come from, even when they're my therapist. I do the same thing in the offices of my professors.

Steven Reidbord MD said...

I recall one of my fellow residents being concerned about marching in the annual Gay Pride parade here in San Francisco. What if a patient saw? I'll never forget how the renowned Dr. Robert Wallerstein, who was teaching our psychotherapy seminar, replied. "You've got to live your life." I've tried to take that to heart over the past 20+ years, and with very rare exceptions do not let my profession impede my private life.

On the other hand, I disclose very little in the therapy office. It's not that patients can't find out — we're easy to google. It has more to do with whose session it is (the patient's) and whether my disclosure would advance the work, versus merely gratify me. I don't often find a good reason to talk about myself on my patient's dime.

As a blogger, I am conscious of walking a line between public disclosure that my past/curent/future patients can read, and offering personal insights that can only come from experience. Perhaps anonymous bloggers have it easier this way.

Dial Doctors said...

I remember discussing this very subject in college. I was told repeatedly that our job as therapists isn't to share our story because the session is for the patient. In fact, it was suggested that a weak/ineffective/bad therapist would do this. We were encouraged to use our personal experiences and mask them as another patients. I've struggled with this for years because I've been diagnosed with a mental illness. I've finally found something that can help others but I'm not reprimanded if I share it.

Personally, I don't talk about myself because I fear my colleagues. I'm currently being supervised by both teachers and fellow students. Wouldn't want to get in trouble.