Saturday, April 25, 2009

Self Disclosure and Being Genuine


In the comment section to the post below on Sally Satel and Stigma, mysadalterego writes:

I am rotating through psychiatry now (family practice traning) and really enjoying it, yet I feel terribly inauthentic treating bipolar patients ("I know what you mean, it is hard to give up the highs...") while being so secretive myself.

My first thought was, well, if in a given situation it seems like it would feel more genuine to the doctor and might be helpful to the patient, then why not? It got me thinking about the reasons a physician might self-disclose a personal diagnosis to a patient, or not.

Pros:
-- It really is destigmatizing when successful people 'come out' and let people know they've been treated for an illness. On a person-by-person basis, this is not any individual's obligation, but I believe it does help when public figures discuss their mental disorders and treatment with the press.
--In illnesses where the prognosis is in question, it offers hope. So yes, I think it's helpful to a patient if a doctor says, "I had the exact same type of cancer and I got treated and I'm doing great." and I think it may well be helpful if a doctor says, "I have bipolar disorder and I've been able to manage it and I'm able to function well."
--The patient may feel better able to be helped by someone who has had similar struggles.
Do note that having the same illness does not always make for the best mix: the clinician may think "I didn't think/feel/behave that way when I was sick, so you shouldn't" and the clinician's views of treatment may be narrowed if some treatments were helpful or harmful to him.
--In substance abuse treatment, clinicians are often people who've had problems and often they are quite open about their own struggles.

Cons:
--There is no right to confidentiality on the part of the physician, so the doctor must be willing to forgo his privacy if he reveals personal things to a patient.
--There is the risk that the doctor's issues/stories will become a prominent focus of the treatment if the patient uses this as a door to ask questions and compare and contrast symptoms/treatment responses. This can detract from the patient's treatment, and the physician may have trouble setting boundaries with regard to his own privacy (but may be not?)
--The patient's response is not predictable. The patient may feel comforted by the like diagnosis, or the patient may feel angry: "How come your illness is under control and you get to be a doctor while I keep going in and out of the hospital!"
--Revealing personal information to patients can be considered a boundary violation. In and of itself, a single revelation like this is simply a single revelation. But if the doctor is ever in legal/disciplinary proceedings over a boundary violation (for example, if a patient alleges sexual improprieties), the fact that he revealed highly personal information may well be used as further evidence of poor boundaries.
--It's important to keep in mind that the goal is to help the patient as much as possible. Being completely 'genuine' isn't necessary and isn't always desirable.

Any thoughts? Are there mental health professionals out there who've told patients their own psychiatric diagnoses? And what's it like from the patient's point of view?

[Edit 7/18/2011: See also Self-Disclosure: To Patients Versus to the World]

15 comments:

talesofacrazypsychmajor said...

Interesting post. I'd have assumed it would be a 100% never tell in any situation type of answer. I'm interested in seeing what comments popup here.
Personally I don't think I'd want to know that information about a therapist and if I become therapist I wouldn't want to reveal my history of mental health problems to a patient.

Anonymous said...

I'm a physician assistant in internal medicine and have selectively told patients outright, of my history of depression.

Medicated said...

I have a significant history of both mental and physical illness, and coincidentally, I wrote a post on this very subject just a couple weeks ago http://www.mindonmedicine.com/?p=1143 . I am very glad to see it addressed here with much more authority than I possess as a student. I'm still negotiating with myself just how open I ought to be when I start my clinical rotations in June, so it's good to have the input. :)

Ruth Z Deming said...

just discovered your fascinating blog when i googled the drug mirapex for a deeply depressed friend of mine.

i call myself 'the bipolar therapist' as i HAD bipolar disorder one from ages 38 to 58. been med-free for 5 years w/nary a sign. my clients love to hear this and have hope that someday they may be among the lucky ones whose illness abates later in life.

our sessions totally focus on the client. they rarelyy ask me personal questions about my own illness. i have terrific insights into how to deal w/many issues - such as time on your hands due to unemployment (make up a daily schedule) and also i've created a stop-suicide plan since i've had intense suicidal ideation myself.

as you mentioned, when successful people disclose it helps destigmatize mental illness. and as healers, we can be superb b/c of our inside view.

Anonymous said...

I like that my psychiatrist is steady, even, predictable. If he told me he'd been depressed or suicidal or had a psych hospitalization in the past it would not bother me at all. If he were wildly moody and I never knew what I'd encounter in his office, then it would bother me. If he were actively showing depression in session with me it would probably cause me to turn the tables and try to find out what's wrong with him, so it's a good thing he stays even, and I can concentrate on my problems. I had a psychiatrist who did not tell me he was mentally ill, but he seemed like he had a major problem in dealing with people so I left him after a short time. Since psychiatrists do need to interact with their patients they need people skills and enough feeling and empathy to understand their client's issues. When I was taking Abilify and Zyprexa I had no feelings whatsoever. I did not feel happy or sad. Nothing. I was a robot, and blank emotionally. I would not want to go to a psychiatrist who was on meds such as those that take away the ability to feel any emotion. Considering how much cognitive damage is done by electroshock therapy, I also would not want a psychiatrist who had had electroshock therapy either, though I think those who administer it ought to volunteer for a full round of treatments before they begin using it to treat patients.

Karla said...

As with almost everything, I think this too depends on the situation and the particular interaction between clinician and patient. When the clinician discloses personal information about herself, the therapeutic relationship can change and she may inadvertently lead the patient to believe that there is more than a strictly professional relationship. Obviously, this doesn't happen always and with every patient, and it can sometimes even be used as a focus of therapy. However, I think it is important for the clinician to consider carefully, before disclosing personal info, whether it is the right time, situation, person and reason to do so.

Anonymous said...

I had postnatal depression and the first clinical psych I saw disclosed in our first or second session that she'd had twins and suffered from it, subsequently going back to university to become a psychologist.

I HATED learning this. "She had twins? Well I've only got 1, what've I got to be depressed about?" "Is this hour about me or her?" "Did she go and study psychology to work out her own issues instead of help other people?"

None of which I'm sure she intended by disclosing it, but that was the effect, and the relationship didn't develop.

However, the therapist I ended up seeing with a happy outcome did disclose, in very guarded and general terms, that she'd had problems with depression - but she did this about a year into our relationship. This was a helpful disclosure, and made very much in terms of "I'm telling you this because I think it's helpful to you to know it" - not for any other reason.

I think clinicians should approach with great caution. We do want them to be our infallible parents and only when we're grown up can we handle knowing that they have human frailties.

Esther said...

As a patient I would not want to know what psychiatric disorders my shrink has/had. I see this issue mainly from the side that it limits the doctor's perspective. I have asthma and every time I have to find a new doctor (or meet a nurse) who says he or she has asthma I notice that they take me less seriously than the doctors/nurses who do not have asthma (or don't mention it). Granted, I am not a whiny patient or anything. However, I have had one nurse tell me that she had asthma and it was "all in [my] head." Not to say they weren't nice, I just found that doctors and nurses with the same diagnosis as me -- who wanted to talk about their diagnosis -- had limited perspective on the illness.

I can accept that my shrink has probably been through difficult stuff, but I don't really want it to be compared to my problems. It just doesn't help me.

Sarebear said...

Interesting.

My psychologist self-discloses on a very limited basis, when it seems like it will be helpful, situationally in therapy, depending on what is being discussed, the subject, what our current conversation is, etcetera . . .

Over the years it's added up to knowing he does yoga, has several children, one a boy in his teens who tends to be a bit needy in calling him sometimes (that last I know as, well, it has interrupted the sessions on very RARE occasion, but when their cat died, that happened). They had a cat. It died. I gave my condolences when that happened, because one's therapist IS a person even though one isn't there to socialize, I'm not going to ignore such a thing and not give condolences when learning such a thing - the fact of the loss was in his apology for the interruptions of the session that day, although I considered it understandable.

I suspect he was a bit mortified, but an emotional adolescent losing a beloved pet, well, I've been there.

And other things, but life happens - the oddest coincidences, that could never have been predicted, can occur from self-disclosure on the therapist's part . . .

I learned from a story he related, to help me, it was pertinent to the issue at hand, that he had been very early in his career, the school counselor at the junior high right around the time I moved to Utah as a teenager - I was VERY emotionally tied up in knots and desperately needing somewhere to turn but I didn't even know that such things as school counselors existed.

As soon as I knew this fact, however, I immediately became angry inside that he hadn't helped me back then.

See? Such a coincidence could never have been predicted! We worked through it, of course, and his original story WAS helpful!

It's funny, that coincidence. I may have seen him around for that month and a half and never known it; he may have seen a file on me and I'd never know (my grades had dropped precipitously in the two months before we moved - the school knew exactly why, and the teachers all gave me a break - the grades should have been much worse, at the end . . . . I was seriously bad off).

Anyway. THAT school system in New York must not have had a counselor, because the signs all indicated obviously I needed one, lol.

Gah, I go on and on. Perhaps to distract myself from recent stuff. The psych stuff doesn't seem as bad, relatively, anymore, now that the future of surgeries and body part replacements seems so much more real and imminent than it ever did, before, because of my arthritis diagnosis.

Damn genes. I'd like a new set, please . . .

tracy said...

i would love to know anything my Psychiatrist would feel comfortable telling me about himself. i have been seeing him for therapy for about 5 months and feel like i know very little about him. And i know how weird this sounds, however, he must want it this way, as his office is very plain...just various diplomas, no photographs or pictures of any type, nothing personal...unless you count his clock and water bottle...heh.
Somehow, this really bothers me, i guess because the last therapist i saw (a Psychiatric Resident), was very open about himself and the Psychiatrist before-we moved, so i had to "leave him"-had photos of his family all over, personal items, etc. i am fortunate, though in that this Psychiatrist is a good therapist.

Ladyk73 said...

Hm....I have disclosed to a client once. I was not in individual therapy with him. I was running a MICA group occasionally as a student. It was after I knew him for many months and the topic was in regards to therapists never understanding symptoms, or don't know what is like....It sounds defensive as I write it right now, but it really seemed to help at the time.

I find it REALLY hard to come out to other students and professionals. Many mental health professionals can have stigmatizing views on certain diagnoses. I have borderline personality traits when I am severely depressed. I have issues with short term memory (working memory) from the illness and/or the drugs. Personality disorders are hugely stigmatized in the mental health field. I think most clinicians are completely accepting of depression and anxiety in other professionals, but someone who has been involuntarily hospitalized because of a suicide attempt?

By the way, I've told my clinical supervisors of my diagnosis. Just because it is the right thing to do.

Anyways, I am split. In two weeks I will have my MSW. No matter my talent, I do not want to be a therapist. It is to much of a conflict. I would rather be an intensive case manager or nonclinical person all together.

I don't know. Some people say.."oh...but it is different...you are in remission." hmmm I am on a boat load of drugs...

I wish I knew what to say or do. But the stigma is THERE!

Also, one cannot be an employee and a client at the same time. It would be very diffult to work at a clinic or hospital where you have been a patient!!!!! Just imagine that for a moment.

My psychiatrist is an attending at the hospital that I am doing my internship. The hospital is affiliated with the school, and I go to the school counceling center. Oh yeah...the school counceling center that four of my classmates are doing their internships at.... Imagine how strange it is to see your doctor in the elevator at work. I a sure it would have been a nightmare if I had to be the discharge planner for one of his patients...ick.

Anonymous said...

I actually know a lot about my therapist, but that has come over time, and through a lot of guidance and processing.

For me, the self-disclosure is necessary - and it really isn't about particularly deep subjects - is more about, in a way, day to day living.

I say this, because I am very good with theoretical and physical models, but I work within a misinformed belief system, so, learning every day things of normal function, helps.

For example, who would write a sentence like above? =)

But, seriously, my peer base is lacking. a brief example is being the only person in my family to receive a parking ticket, does not mean I am incompetent, uncaring, or neglectful. I can prove this because someone I respect and see as capable has received them too. Same with not eating 3 meals and 2 snacks a day, or having a sleepless night, whatever.

Anyway... today i have an idea that a lot of my feelings are normal - because my therapist has them too. I just have a harder time processing and regulating.

mysadalterego said...

Wow thanks for the attention!

The main thing that bothers me is the idea of being out with patients means being out with colleagues.

And not every patient, but sometimes it seems like it is begging to be said. Mostly when people are talking about stigma or how it is the end of their life, or that no one understands.

In my experience, patients don't keep asking for more details (maybe this is different outside psychiatry where there is a much closer connection) - they really don't want to know much. I've never been uncomfortable by being asked a personal question, and never felt under pressure to disclose much of anything personal. But how can you be human with another human while denying things that make you human? if that makes any sense.

R.A.D Momma said...

After reading the comments, I can see both sides of this issue.

The common thread was 'disclosure with careful thought on how/what/when it would effect the patient'.

I've had the same pdoc for going on 9 years. She has seen me go threw some really rough times. She has carefully, shared little tidbits about herself.

During the last 9 years, I've had 5 different therapist ALL from the same office. Each have left the clinic for one reason or another (only one retired and another was because of a maternity leave of the current therapist). Some have disclosed more than others.

I 'really' need someone to connect to. Someone that can relate to the significant loss and trauma that "I as a MOM" have went threw. Someone that UNDERSTOOD what Reactive Attachment Disorder (severe) can do to not ony a child and their family members - but as a mother to a child who had to say 'enough, we can no longer do this..we must disrupt this adoption...' I need a therapist who can say 'yes, I have/did adopt. yes, i did disrupt, yes.....this loss is like none other." ect ect.

I've thought about going to school and getting my degree so that I could in turn help other MOMS like myself. Be able to say "YES..I UNDERSTAND" and offer love and support.

It can go both ways - good and bad.

Syna said...

I am a clinician in the therapy business. I've read your post and the comments and my feelings about self disclosure tend to be more on the cautious side.

I don't disclose personal-personal history to my clients. I may tell them the previous place or town I worked but I don't tell them about my previous relationship traumas.

The difference is like concentric circles - the outer layers of information about yourself that you can share with acquaintances or colleagues and that *may* be appropriate to share with your client to foster rapport, to the inner most parts of who we are that we may only share with our spouse/significant other/family - or no one.

As for mental health history of the therapist, I don't think that its helpful to share that at all. I think it raises more questions and potential problems than it ameliorates. Boundary issues, over identification, trust, professionalism all potentially come under scrutiny, and you can't tell how someone will react. And you can't take it back once its been said. So in my mind, better to not say it at all.

The other issue re mental health status of therapists, pdocs, etc is definitely about their professionalism and expertise. I don't wish to offend those who are clinicians with mental illnesses who are diligent with looking after themselves/ in recovery, but I would feel uncomfortable if my therapist told me they had a personality disorder or other ongoing serious mental illness.

The questions it brings up for me is - how can i trust and rely on this person to help me when they are so *potentially* ill themselves? How will I know if they are becoming unwell, which leads on to its not the patients responsibility to monitor the mental health of their therapist. I believe that sharing your history of mental illness with your client puts them in this situation, whether the client is consciously aware of it or not.