Anna: a case of self-disclosure

A woman, Anna, calls to set up an initial appointment. She found you through your website which describes your work with infertility and pregnancy loss clients. When you ask her what is going on, she breaks down and reveals that she has just experienced her second IVF failure: another chemical pregnancy. Without knowing anything else about her, her relationships or history, your genuine response, “I am so sorry to hear that,” reveals much about you and your capacity to empathize, and can set the tone for the therapeutic relationship.

When she comes in for her first session with you, Anna asks if you have any children. A seemingly innocuous question, one that is asked all the time in social situations, undoubtedly is loaded for Anna. Thus how you answer Anna’s question, or if you do, is not to be taken lightly. What does it mean to her if you have children or if you don’t? How is your answer going to make her feel? How much is too much to tell, and is saying nothing too little? What is the potential impact on the therapy?

Anna’s question pushes the conventional boundary of therapist privacy and anonymity [3]. She has delved into territory that may be loaded with profound feelings for you. What if you have had your own series of losses, perhaps similar or completely different from hers? What if your reproductive issues are in the past and have been resolved? On the other hand, what if you are in the midst of trying to have a child yourself? What if you or your partner is pregnant? With new clients, do you address this on the phone? With ongoing patients, do you wait until they notice? How do you answer if having children was easy for you? These are essential questions to consider because not only does Anna have a reproductive story, so do you. The question is: Do you answer her question, and if so, how?

Therapist self-disclosure is a provocative topic: some practitioners believe that revealing personal information will contaminate the therapeutic treatment, while others strongly support it [4]. Although a highly controversial and rarely used clinical strategy (only about 3.5% of all therapeutic interventions) [5], a review of empirical research indicates that more than 90% of therapists have used self-disclosure in their work [6]. This section explores therapist disclosure and addresses if, how, why, and when you answer a question such as Anna’s. Included in this discussion are:

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  A definition of self-disclosure.

  
  
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  The different types of therapist disclosure.

  
  
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  The risks/benefits of therapist disclosure for the client.

  
  
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  Theoretical viewpoints.

  
  
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  The ethics of self-disclosure.

  
  
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  The implications of answering direct, or not-so-direct inquiries (i.e., how did you get into the field of reproductive psychology?).

  
  
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  The timing of disclosures.

  
  
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  The impact of your reproductive story on the client and the therapy: case example.

These issues are important, regardless of theoretical orientation, as the dynamic between the client and the counselor accounts for so much in the therapeutic process. Indeed the strength of the therapeutic relationship has been found to be the best predictor of both positive and negative clinical outcomes [7]. Additionally, when a client asks a direct question, or if personal information about the therapist is inadvertently exposed, the therapist must be prepared. In the moment when a clinician’s private life is revealed, whether intentionally or not, s/he may not have time to ponder all the pros and cons of the most therapeutic response, and may feel a loss of composure and professional control. Thus, thinking about these matters ahead of time can help when clinical decisions need to be made quickly [8–10].

What is self-disclosure?

Broadly speaking, everything a counselor does or does not say is a self-disclosure [11]. Disclosures can be deliberate or accidental, verbal or non-verbal, avoidable or unavoidable. From the way one dresses to one’s office décor, one’s physical attributes, ethnicity, gender and age – these are self-revealing unavoidable, non-verbal disclosures [9,12]. One’s body language – a smile, a look of concern, a change of position – are also non-verbal disclosures revealing instinctual expressions of the therapist’s feelings. If the counselor has a home office or resides in a small community, his/her personal life becomes more transparent as inevitable boundaries may cross. Unexpectedly running into a client in a grocery store with one’s kids in the shopping cart is an unavoidable, unintentional, and perhaps very awkward disclosure. Additionally, with information readily available on the Internet and Facebook, it is common today for clients to search for reviews or other information about the therapist. A click of a mouse can reveal intentional postings (articles, websites), but also may make known information that was posted by others – without the therapist’s knowledge. Anonymity has become virtually impossible with personal information readily available, and may include a home phone number and/or home address, information about family members or other people the therapist knows, reviews, photos, lawsuits, political affiliations and donations [13]. The access to information can feel like a boundary violation with the client potentially knowing more about the counselor at the onset of treatment than the counselor is aware of. Depending on the client’s issues and diagnosis, this kind of information about the therapist can affect the course of treatment.

When therapists think about self-disclosure, they usually refer to deliberate, verbal disclosure of personal information, perhaps prompted by a client’s question, sometimes by the clinical material they are presenting. Seven different types of therapist disclosures have been proposed:

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  Facts: sharing your professional experience and credentials.

  
  
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  Feelings: validating the client’s feelings by comparing your own feelings in a similar situation.

  
  
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  Insight: revealing perceptions of your own life in a comparable situation.

  
  
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  Strategy: advising the client in ways you have handled like circumstances.

  
  
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  Reassurance/support: normalizing the patient’s experience by acknowledging your own experience.

  
  
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  Challenge: divulging information about your own similar life trials.

  
  
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  Immediacy: providing feedback to the client as to how their behavior with others is occurring in the therapy with you [14].

Whether intentional or unwitting, disclosures affect the therapeutic alliance. They may create “a real moment of human sharing of vulnerability and helplessness that has the potential to bring the patient to a new level of feeling and enrich the treatment” [10, p. 15]. On the other hand, a therapist disclosure can have the opposite effect, interfering with transference feelings and/or burdening the patient with concern about the counselor. (See Table 17.1 for the benefits and risks of therapist disclosure.) Decisions about disclosure are influenced by one’s theoretical perspective; the patient’s diagnosis; the strength of the therapeutic alliance; whether it is at the beginning, middle or end of treatment; and, ultimately, by ethical concerns of what is in the best interest of the client. Additionally the therapist’s personal history of loss and trauma plays a factor in these choices.

To disclose or not: theoretical orientation

When Freud first discussed self-disclosure, he suggested that the therapist should be “like a mirror,” reflecting back only what the patient reveals [15, p. 18]. Traditional psychoanalytic therapists were trained to be neutral and not to self-disclose. The theory purports that the key to successful treatment is the working through of transference: the feelings that clients have from earlier significant relationships that are displaced onto the therapist [16]. Self-disclosure is seen as a detriment to therapy because it shifts the focus away from the patient and onto the therapist; by introducing “real” elements of the clinician, the client’s fantasies and transference may be disrupted and contaminated.

Much has changed since Freud’s early work. Some of the more recent psychoanalytic/psychodynamic thinking views therapy as a two-person model, with both patient and therapist contributing to the relationship, and recognizes that strict neutrality is not only impossible, but also may be harmful to the therapeutic experience [17,18]. A therapist who comes across as distant and withholding may in fact do damage to a patient whose self-esteem is already battered and who is feeling depressed and isolated, as many infertility patients feel. In a treatment outcome study at a university counseling center, it was found that an increase in therapist disclosure lowered clients’ symptoms [19]. Thus infrequent and judicial use of self-disclosure may actually facilitate healing: the therapist can serve as a role model, reassure clients that they are not alone, and help normalize their struggle [14].

Other theoretical approaches consider self-disclosure to be an essential component of therapy. Fundamentally different from the psychoanalytic perspective, humanists advocate therapist self-disclosure as a means to foster change. By being authentic and real, counselors help minimize the power differential in the therapeutic relationship, thus aiding their clients’ openness and willingness to share their own struggles. The genuine dialogue between therapist and client is used to address problems that may arise in the therapist–client relationship. Similarly, feminist theories espouse the use of self-disclosure in fostering an egalitarian relationship. Appropriate disclosures are seen as a way to transmit feminist values, and are used to validate and normalize struggles, decrease feelings of shame and promote empowerment of the client. Therapist self-disclosure in the Lesbian Gay Bisexual Transgender (LBGT) community has been used to create a safe space to process feelings of marginality [20]. Cognitive-behavioral therapists (CBT) use self-disclosure to challenge clients’ distortions about themselves or others by providing feedback and modeling more effective behavior [14]. Dialectical behavior therapists (DBT) also judiciously use disclosure to support the emotional experience of the client. As many of the client’s issues are interpersonal in nature, it can be validating, for example, to hear that a therapist also would react in a similar way, given the situation the client described [21].

Disclosure and ethical considerations

Regardless of theoretical orientation, it is important to understand the consequences of disclosing or not. Under what circumstances should a counselor disclose when working with reproductive patients? What types of disclosures are necessary? What is it that the client needs? How will a particular disclosure affect the client and the therapy? Will it be helpful or harmful?

The most salient question to consider is: Is this disclosure in the client’s best interest? The motive for disclosure should be to promote a therapeutic goal and be in the service of the patient [12]. Professional organizations for psychologists, social workers and counselors in the United States as well as in other countries provide guidelines for addressing the issue of therapist disclosure. For example, the American Psychological Association (APA) Ethical Principle A states, “Psychologists strive to benefit those with whom they work and take care to do no harm” [22, p. 3]. Regardless of training, mental health professionals should strive to practice beneficence (do what is helpful for the patient) and nonmaleficence (avoid doing harm) [8,9,23]. Similarly, APA Ethical Standards 3.04 (Avoiding Harm) and 3.08 (Exploitative Relationships) raise the issue of the potential power differential in the therapist–client relationship. If a boundary is broken with a therapist disclosure, is it for the therapist’s need, or is it in service of the client? Clearly, taking advantage of a patient is an ethical breach. A counselor who unburdens him/herself with no clear benefit to the client is in violation of the professional ethical guidelines.

Equally important to consider is therapist non-disclosure. It has been suggested that a refusal to disclose, especially when asked a specific question by a client, is a kind of disclosure in and of itself [8]. In an empirical study with current therapy clients, non-disclosures were twice as likely to be experienced as unhelpful [24]. Non-disclosures can be read as rejections, felt as withholding and increase a sense of alienation and inferiority [13,14]. As many reproductive clients already have low self-esteem from the trauma of infertility treatments and/or pregnancy loss, a counselor who comes across as cold or aloof would not be in the client’s best interest. Non-disclosures have the potential to compromise the therapeutic relationship, but too much disclosure also can be perceived as a burden to the client. Too much information about the counselor’s life circumstances or emotional state can make the client feel as if they are in a role-reversal, having to take care of the counselor. This can feel overwhelming, frightening, unsafe and intimidating – creating a non-therapeutic climate for the client. The questions then arise: If, when, and how much? And should infertility and pregnancy loss clients be treated differently than the general therapeutic population?

Back to Anna’s question: Do you have children?

All of us, clinicians and clients alike, experience illness, death and loss throughout life. As mental health professionals, we are in the unique position of dealing with our own distressing life situations while helping our clients through theirs. The intersection of these events can create feelings of emotional chaos in the patient and a loss of feeling safe and cared for [10]. Likewise, shared experiences with clients can generate uncertainty in therapists, and throw them off their normal professional footing and objectivity [14]. In other words, when the counselor is personally challenged by life events, there may be a disruption in the connection/relationship with clients. Thus, where you are in your own reproductive journey and how that intersects with your client’s will affect the therapy.

As Anna’s new counselor, her question provides you with an array of opportunities and dilemmas. Because you know that Anna may be particularly sensitive to your answer, it is essential to give it some thought and be mindful of what it means to her. Some issues to consider in your response to Anna’s question:

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  Therapeutic Alliance: Research has shown that the effectiveness of therapist disclosure is highly dependent on the strength of the therapeutic alliance [24,25]. This is bi-directional: not only is it important for the patient to trust the counselor, but for therapists to reveal personally sensitive material they, too, must trust the patient deeply [3].

  
  
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  Client Traits: There may be traits in the client that would make disclosure harmful to them. For instance, those with poor boundaries or reality testing, those who might try to take care of the therapist, or clients who are self-absorbed may actually be harmed by a counselor disclosure [9].

  
  
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  Stage of Treatment: Early in treatment, therapist disclosures (your office decor, how you dress, etc.) are inevitable. In the middle phase of treatment, disclosures are likely to be used when therapeutically necessary [23], whereas disclosures at the end of treatment serve a different function. During termination with a client, it can be empowering to demystify the therapeutic process, discuss what was effective in treatment and what was not, and see the counselor as a genuine human being [14,16].

  
  
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  Your Reproductive Story: Are you in the midst of a reproductive crisis yourself or is this something that has been worked through? Disclosure has been found to be much more risky if the therapist’s issues have not been resolved [14].

As this is your first meeting with Anna, and you are just getting to know each other, it may not be possible to explore her fantasies about you at this juncture of the treatment. You may not yet have a sense of her needs, her personality traits, or her history. You may not want to expose private information with concerns of how she will receive it, nor do you want to be dismissive. A question like Anna’s, about whether you have children or not, can elicit a variety of reactions in you depending on your own personal story.

Some possible scenarios for the mental health professional:

Let’s say, for example, that you have recently found out that you are pregnant with your first child. Because the changes of pregnancy are gradual, you can decide, case by case, when it is appropriate to discuss it with your clients. You may decide it is important to let certain clients know as soon as possible, while with other clients, you may decide to wait. Processing clients’ emotional reactions to the pregnancy can be challenging depending on their background, history and the strength of the therapeutic alliance. What are some of the issues that may arise in therapy when the counselor becomes pregnant? Clients may feel abandoned, as the fantasy of the therapist’s care shifts from them to a baby. They may feel angry and jealous, especially if they are trying to conceive as well, but may feel too inhibited to express their negative feelings. Issues of mistrust may surface and patients may leave treatment prematurely. Therapists, on the other hand, may feel more vulnerable because of their pregnancy, and may not want to invite patients’ hostile feelings about them or the pregnancy [10].

In Anna’s case, because you know she is struggling to have a child, you may decide to let her know about your pregnancy when she asks if you have children. To wait may create feelings of tension and anxiety for you; likewise, she may trust you less if she knows you were not forthcoming. Saying something like, “I imagine this will be difficult to hear: I have recently learned that I am pregnant. It has not been an easy journey for me either. I realize this may be hard for you to tolerate, and I would understand if you would like to see another therapist, but perhaps we can work through your feelings about this together.” It may feel like a relief for Anna to be able to process her emotions with you. If she can work through her anger, envy, resentment and grief with you, it is possible that she will cope better with the pregnancies of friends or family members.

A risky and challenging situation is if the fertility counselor and the client are both trying to conceive at the same time. Should the therapist become pregnant, self-disclosure will eventually become a necessity and, as above, a sensitive and honest discussion is called for. If the situation is reversed, that is, if the client should become pregnant, the counselor may feel jealous, angry and competitive. It may be difficult to celebrate the client’s hard-won battle and hard to maintain therapeutic neutrality. If the client is aware that the therapist is “trying” to conceive, she may feel guilty about her own success and may feel the need to take care of the therapist. The client should be reassured that the therapist has her own support and, indeed, it is recommended that the therapist seek consultation.