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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