Sunday, August 31, 2008

Write on that Slate?


Now here's the next question in my Questions to Ponder Series:

When I asked if it's okay to give a referral for a gay therapist, several readers wrote in saying that it's not reasonable to "out" another therapist. Fair enough. Other readers wrote in implying that the patient's concern should be examined, that it's part of the treatment to use the patient's concerns to help them learn about themselves, Grist For The Mill, so to speak.

I'll take it as a given that a) therapists/people-in-general have the right to their privacy and some things they may feel are personal and they may not want to share with their patients/other-people, and b) therapy should be about the patient and it's an abuse of the patient's time to spend it talking about the therapist's personal life in any detail.

Aside from those facts: How exactly does it damage the patient's treatment if he knows some information about a psychotherapist's personal life? Do we really truly believe that there is a difference in treatment outcomes if a therapist wears a wedding ring or doesn't? If he answers a question about where he went on vacation or if he has children?

24 comments:

sara said...

Yes, I think there is a difference. The blank slate is dead. It's a calling, not a job, and who you are is integral to it.

Rach said...

Years ago I'd have said that I wanted to know about the shrink, his personal life, and now I couldn't care less. Finding out that my therapist had a kid (and that the kid knows how to text message) was more than enough information for me, thank you very much.
maybe this is called "growing up".

Anonymous said...

I think it depends on how well the psychiatrist can maintain his/her boundaries and how good his/her judgment is wrt what he/she decides to self-disclose.

Because I grew up in a family that basically had no boundaries, I do tend to ask personal (hopefully not embarrassing) questions. This has worked really well with my psychiatrist. I know a little about his family, hobbies, and interests we share in common (but not any personal problems he might have), which helps me trust him more. He's always been good about not letting me control the session or evade my own issues, tho, so I don't think it's harmful in this case at all. In fact, I think it's beneficial... I've seen him for 10 years, trust his judgment, and am adherent with medications.

OTOH, my therapist has boundary issues similar to mine, which has resulted in us basically changing roles, with me listening to her talk about her problems/issues for most of the session. Since she seems to be struggling more with her life than I am, I feel guilty interrupting her or steering the conversation back to me. I know way more about her medical, emotional, and family problems than I have a right or reason to, and sometimes endure sessions that stretch beyond two hours (can you say "full bladder"?) I know it's not a healthy or appropriate dynamic. Sigh.

The Silent Voices in my Mind said...

I would be completely uncomfortable working with a 'blank slate' therapist. I want to work with a person. I have issues with feeling like I'm being judged (whether I am or not) and found I spent a great deal of emotional energy worrying if my seemingly perfect therapist thought I was an unsavable mess. I had trouble completely trusting him because he seemed so far above me that he hardly seemed human. As I learned more about him and came to see him as a person who does have flaws (though annoyingly few), I have been able to relax and be okay with being human around him as well.

BUT...

Not every patient works that way. I think, maybe more so that having a strict code of behavior to apply across the board, it would make more sense for a therapist to know the limits of his/her comfort zone then be flexible to move around within them to meet the patient's needs. I wonder if that's too much to expect a therapist to be able to do that?

Dreaming again said...

I could not work with a blank slate therapist. At all. Proof of this is the psychiatrist I've been with for a year and have absolutely no trust in. I've realized part of this is the realization that I've learned nothing about her. Literally nothing other than that she is married because her last name is not the same as that on the diploma hanging on her wall. So this came from observation, rather than sharing. When I asked her about What state she came from (again, diploma) she became offended at having to share information.

I simply don't trust her.

My Therapist that I was with, I fully trusted. While she rarely shared much of her life, I knew that we shared much in common, the least important, but most fun was a love for blue willow china.

The things we had in common, helped to build my trust in her. Had I not known of the things in her life, I guarentee ... I would never have told her the things I needed to in order to open up, because I would not have felt she would have understood ...

Anonymous said...

it's a matter of how much gets written on the slate and why. don't think we have to question patient being curious which is natural and it is fine to share some details IF the patient wants to know and the info does not feel too private to the therapist. not all patients want to know and not all therapists want to tell so given that, how nice if the ones who don't want to know know ended up finding the ones who don't want to tell. given that,
therapists should use common sense and some get surprisingly carried away when they talk about everyones' favorite subject--themselves, or their kids.beware the therapist who, no matter what you tell them, they can do you one better, or the one who minimizes what you are going through or attempts to show they understand by dredging up their own past and saying on i remember when my daughter did that and now she is a corporate lawyer, so don't worry and that ends the conversation.beware the therapist who tells you all about her marital woes and other worries adn tries to keep you in therapy forever because she really needs someone to talk to. these people want blank slates but they want the blank slate to be the patient and they project so much onto the patient that the patient then needs therapy to deal with that therapy. sure its fine to wear the ring. truly unless the patient asks they don't nedd to know if you have kids. it may come up if you have a kid emergency. it would be dumb to pretend that you don't have them. it is not a good idea to spend time talking about them.

Still Dreaming said...

I never wanted to know all that much about my therapists, but some of our best moments came when they shared of themselves. The therapist I did my best work with shared a couple things with me, over time, at appropriate moments, which helped me grow and trust her and myself. Those were deep things though.

As for surface things. I never had a problem with her sharing those. "Sorry, I look uncomfortable, I went white water kayaking yesterday", did not hurt our relationship. Other comments like this only helped make the relationship more real.

Because in a homeless shelter I don't see my clients for therapy, I can be a little flexible about what they know about me. I don't share much of myself, because it's just not relevant or helpful, and of course it depends on the person, but one thing I've found interesting is how apparently my life challenges stereotypes. I mentioned to one of my clients I don't have a TV, and he just can't get over this, he's working hard to fit it into his worldview. Why anyone who had a home wouldn't have a TV. This has been VERY useful in his growth. Interesting...

Tigermom said...

If sharing with a patient, it is very important to ask yourself whether or not the disclosure is to help the patient or to help you feel more comfortable.

Seemingly innocuous responses to personal questions can have far reaching implications about which you might never know.

I only know of two because the patients told me much later that they, both, had kept later information from me because they knew a fact about me and thought that their issue would either offend me or hurt me or that I would not understand.

In addition they assumed that the personal fact about me was going perfectly be it family or other jobs.

Dinah said...

Oy, to therapists who monopolize the sessions with their issues.

Funny, but I'll volunteer to patients something I heard or read or saw on TV that relates to their story, but I never offer to a patient that I have kids (yes wedding ring, no pics in office) unless they specifically ask.

So TigerMom writes:

"I only know of two because the patients told me much later that they, both, had kept later information from me because they knew a fact about me and thought that their issue would either offend me or hurt me or that I would not understand."

My thoughts: so what? What I want to know is did it effect the outcome of treatment? If the patient is so upset they leave therapy, this is not good (yes, it effected the outcome). But if the patient says, I'm not comfortable with you because I want to talk in an office that's purple, do you start painting.

Maybe I'm off base here, maybe you've told the patient something horrifyingly personal that didn't belong in therapy (..."I've served twenty years for murder" could in fact, change things, I think...).

I think we try to accommodate what patients want and who they think we should be, to an extent, and people who are uncomfortable with us are sometimes better served talking to someone they are more comfortable with. But to what extent.

Yeah, I know, you don't want a psychiatrist who has a blog. Or you do want a psychiatrist who has a blog.

Aqua said...

For me it depends on the type of things I know about my Pdoc and how and why they are presented.

I saw a therapist for two years before dr. X who talked a lot about their difficult relationship with their family, especially their mother. Subsequently our therapy really focused on my difficult relationship with a parent (albeit my father)....for two years I feel like that is all I talked about and I got nowhere.

I know a few things about my pdoc...but nothing I know about him has affected my therapy in a negative way. In fact, one of the only personal things he ever told me was that he played the piano.

This re-awakened my love for music (something I had lost to my depression).

I also think because he is a "blank slate" I do project things onto him. In fact, recently he magically "became" my judgemental, ridiculing and rejecting father in a session.

He definitely was NOT like that...my immediate reaction to something he asked made me REACT in the moment the way I would react to my father asking a similar question.

When I left his office and thought about my reaction it was really cathartic and therapeutic for me to recognize this and see that I probably automatically react that way to others in my life who are nothing like my father.

The next session we talked about my reaction and why it happened and how I can work towards changinging that reaction. For me a fairly blank slate intensifies and enhances my therapy.

Anonymous said...

puleez, it is less what you know and more how you found out that is the issue. it is fine to know somehow that the therapist is divorced. it is even ok to have heard it from them but not just because they felt like bringing it up. not okay to have to sit and listen to the gory details of the custody battle and how it is hard to get a date.
it wouldn't be traumatizing to run into the therapist at the market and notice they bought white bread and you are strictly a whole grain person or the other way around but it would be distressing to have the doc spend the session teling me what they were making for dinner.

Gerbil said...

I don't think that a little self-disclosure, appropriately placed, will have a deleterious effect on treatment. In addition, I think the blank slate is, and always has been, a myth.

The therapist doesn't even have to do any overt self-disclosure for the client to gather some personal information about him or her. It's not hard to notice that one's therapist has a venti something-or-other from Starbucks sitting on his/her desk every week; this could mean a lot of things, from caffeine dependence to lots of disposable income to a crush on the barista, but it does tell the client that the therapist really likes Starbucks. More astute clients may be able to figure out where the therapist shops (which also indicates socioeconomic status). The client may never talk about this stuff in session, or even think about it, but it's certainly there, and differences SES can indeed have an effect on the therapeutic relationship.

Similarly, a therapist practicing in Iowa may not be able to help disclosing that she's from Brooklyn--unless she's really good at covering up her accent. She doesn't even have to come out and say where she's from; the information will probably disclose itself in the first few minutes.

And is it necessarily bad if the client knows the therapist is pregnant? My former therapist told me about her pregnancy when she was about five months along, to prepare me for the fact that someone else would be seeing me during her leave. It was a good move--especially as I already knew the therapist who'd be subbing for her and didn't have a great history with her.

When I myself was eight months pregnant, I'd just started a new position, with mobile crisis. I'm not a big person, so my pregnancy was really, really obvious. Most of the people I assessed asked me things like how far along I was, how I was feeling, what I was having, etc., and these questions seemed perfectly appropriate for me to give brief answers. A blank-slate zealot might have said, "What does my apparent pregnancy mean to you?" I suppose that could be grist for some mill or another, but really, when you're visibly pregnant, it's hard not to acknowledge it.

The therapeutic relationship is by definition lop-sided, but that doesn't mean that it has to be one-sided.

Alison Cummins said...

What I have a problem with is a therapist deciding on my behalf what kind of therapy I will get, but not telling me what that is; deciding that I May Not Know things about them or about therapy, but that my not sharing Everything with them is necessarily pathological.

The idea is that this is supposed to be beneficial for me in various ways because it will cause me to regress to an infantile state, which is good for therapy (and therefore good for me). My objection is that my opinion of what is good or important for me counts nowhere in this, which is not empowering and does not promote my ability to advocate effectively for myself outside the office.

I don't usually need to know much about my therapist. But, say, if I were to complain about problems within a lesbian relationship, I would want to be confident that my therapist did not think that lesbian relationships were in themselves a problem. One way to have that confidence would be to know that my therapist was a lesbian.

Straight people don't usually worry about being judged for being straight, so it might not occur to them to be concerned about what their therapist understands about straightness.

There's very little I feel the need to know about my therapist, but there's quite a bit that I know (more or less) about her unavoidably anyway, just by the fact that I meet her face to face in an office in the basement of her home. (Age; sex; race; ethnicity; immigration history; professional status; household income.) I know which hospital she works at in addition to her home practice, because I have a phone number to leave messages at. She's told me some other personal but completely pertinent things such as the health reason she might need to cancel an appointment six weeks in the future, but I haven't asked her any questions because I don't need the answers. I already know more than enough.

The thing is, she doesn't claim all authority on knowledge. She trusts my judgement about what is pertinent to share, she is open about her aims and means and she doesn't undermine me. If I thought I needed to know something, whether about her or the therapy she practices or about the way therapy is made available in the city we live in or by who, I believe she would tell me.

Related: If I call my therapist on something (for instance, making assumptions about my goals without checking in with me), she'll apologise immediately without fuss and then move on to, for instance, discussing my goals. An apology is a personal statement that she has no problem with.

I have seen therapists who will do truly obnoxious things (for instance, ask me if I am comfortable in the room and then ignore my statement that I am not), and then when I call them on it (ignoring my answer to their question) they won't apologise because that would be self-disclosure - they won't even acknowledge having done anything that caused a problem for me, because we aren't there to talk about them or what they do. Instead they want to take a lot of time that I am paying for to explore my feelings about an incident that is only an incident because the therapist is making it one. (How do I feel when someone I am going to for help asks me a question and ignores the answer? Crappy. What do I do about it? I repeat my statement, explain that I meant it, and suggest a way it could be addressed. How do I feel about having my behaviour pathologised by an expert? Crazy.) This is what they believe is "keeping a therapeutic focus on the patient," and what I believe is enforcing power imbalances. Feeling crazier when I walk out of the office than when I walked in is not what I am paying for, though it could be useful to have the therapist explain to me how they achieved that so that I can recognise that sort of manipulative behaviour outside the office and have a label for it. But that would involve engaging with the patient as a client able to make reasonable choices, which is not what this kind of therapy is about.

Anonymous said...

Dinah,

It's interesting that you mentioned no pictures in your office. You couldn't miss the fact that my psychiatrist is a Dad because his office is full of pictures of the girls and their handmade art. Strangely, there's no picture of his wife, tho from conversation I believe he's happily married.

I'm curious whether choosing not to put up pictures has anything to do with protecting your kids' (or his wife's) anonymity? If I were a shrink, I'd be worried I might encounter a stalkerish patient one day who could endanger my family's safety--or at least their privacy. I'd especially worry if I had a job like ClinkShrink's (maybe even go to work incognito myself lol).

And yes, Oy! to my troubled therapist. On the plus side, she makes me feel positively "normal" in comparison. :)

Abby said...

Here's a related question. My therapist is very into non-disclosure, which for the most part I don't really care all that much about. Her training is fairly classically psychoanalytic and her practice is primarily psychodynamic. Sometimes a bit much for me, but she does her best to work with me...and that's mostly enough. I don't know that she'd share something even if I asked, which might frustrate me. Like I said, though, I don't really feel a need to know that much about her, so it hasn't been an issue thus far and I'm not expecting it to become one.

My question is this: I recently became aware through a series of pretty funny (I think!) coincidences outside of therapy and not having anything to do with her, that my (female) therapist very recently became engaged to another woman. It matters to me not at all, but I kind of feel like if I don't say anything about it, I'm hiding it from her. Like any good pathologizing shrink, ;) I'm sure she'd find the "hiding" significant. But...I don't care one way or the other, I just don't want her to feel uncomfortable one way or the other.
So - say something? or not. Psychiatrists, particularly psychodynamic ones, what would you want your patient to do?

Dr. Pink Freud said...

Food for thought. Is the "friend" really conflicted about his/her sexuality, or perhaps, the identified patient is concerned regarding a perceived issue. Second, who asked anybody to out the therapist? Can we say ethics violation if this was the case? Lastly, a "straight", "gay", or "bisexual" therapist could offer help; all in different, and potentially useful ways. Ask clinkshrink if a skilled therapist needs to be a child molester to work with one, or to have been a hostage to act successfully as a hostage negotiator, or work therapeutically with those who have been held hostage. It's presumptuous to make these sort of blanket assumptions.

roses said...

Perhaps a therapist is allowed to be a human who likes to relate sometimes? I have never been to therapy but i would prefer a human sitting in the same room than a stainless steel machine taking notes.

Relationships are difficult - yes - but when i have a bbq, i'd like to know i could invite anyone i want to it. I would really like to relate humanly to another human. We invite our plumbers or carpenters, people who may work on our car if needed, doctors, dentists, optometrists - man! can she ever cook!... why not be in therapy with a relatable human being?

I must have missed something somewhere. Probably another post that is related to this one. Sorry about that. Cheers...

Anonymous said...

Interesting topic. When I sought out a therapist it was very important to me that I know that the therapist did not belong to the religious affiliation I was a part of growing up, because I felt it had been abusive. So, it presented difficulty because while it was really not my place to question their religious background - I needed to know for my own security and sanity.

Doc said...

The blank slate is, in my opinion, impossible, and quite likely counter-therapeutic if tried in many types of therapies. A therapist brings many things with him or her in the office, things which are impossible to hide-- physical characteristics, accent, furniture (or lack thereof) are all elements of disclosure.

More importantly to the dynamic is "neutrality." Part of neutrality is understanding one's own disclosed elements and transference and balancing to a center or neutral point.

As a generally jovial "smart-aleck" type, I found it very difficult to introduce humor into the therapeutic setting. i.e. trying to over neutralize. This cause me to be much more stoic in my early residency years, a habit my patients thankfully broke for me.

That all being said, a good rule of thumb is not to talk about one's self more than the patient. If that's happening, I'd suggest trying a different shrink.

Anonymous said...

I don't think I could open up to a therapist who refused to share anything of themselves. Both of the therapists I've seen have had the attitude that trust is a two-way street. If either of them were like my shrink (excellent doctor, but very closed), I would have kept looking for someone to whom I could relate.

My current therapist has a wonderfully warped sense of humor, which makes for some really interesting discussions. My spouse isn't too sure what to make of him at times, but for me, it's a good fit.....

Aqua said...

I have to say, the only time my pdoc had something personal in his office was one day I walked in and there was a large stuffed bunny rabbit in the corner. His daughter must have left it there.

It was the same day I found out my Mom had terminal pancreatic cancer and had two - three months to live. I never needed a stuffed bunny so badly in my life. I grabbed that thing and clung to it for dear life my whole appointment. I had never been so glad to see a personal momento in his office.

folkswitch said...

This is such an interesting discussion, I wish I had weighed in initially.
As a therapist and a human, I believe in being authentic and that sometimes leads to well thought out disclosures.
As far as the gay issue goes, I am a gay woman and a therapist working in a practice that specializes in working with the GLBT population. I am out in that setting. Clients who are assigned to me because they specifically requested a gay therapist are aware of my sexual orientation and this puts them at ease and gives them confidence that they will be accepted. I also see heterosexual clients in the same setting, with whom the issue has never arisen...if one of those clients asked me about my orientation, I would not refuse to answer. I think most people who seek treatment want to sit across from another human and that people, each in their own way, let you know how much they need to hear in order to make that connection.
Ultimately, in reference to the original gay therapist question, I would refer that young man to a known 'out' therapist. We're out there.

NeoNurseChic said...

I've really enjoyed the conversation that has ensued out of this topic! Sometimes, I really think my psychiatrist tries to be a blank slate. He does have his diplomas hanging in the office, and he usually has a field-related journal or textbook on his desk, but he doesn't have any photos/drawings or anything else like that. He does wear a wedding ring.

He has disclosed things about himself VERY few times, but yet I still feel very comfortable with him. His personality and demeanor are a bit of a disclosure - although sometimes I do wonder if this is really how he is "outside" or if this is just his office persona. He encourages me to ask whatever is on my mind, and it's funny - once in awhile I do ask him something specific. One thing he'll commonly respond with is, "I'm happy to answer that question, but first lets discuss more why you want to know that" or some other phrase. It used to frustrate me as just psychobabble and a way to avoid answering my question. One time he did tell me where he was going on vacation, but the next time I asked him, he really ran around that and went into why I wanted to know and so on. At the end of the appointment, I finally said, "So where did you really go?" And he told me. At that point, I realized that where he went really was not that important to me. Good for him for realizing there is so much more to it than the real answer. Before I got to that point, I had been frustrated and felt like he was trying to make something out of nothing. I felt I was simply being polite, and he was turning it into this whole issue, but later I did realize that the conversation that ensued was valuable!

This most recently happened when we had a discussion over Harry Potter. I have mentioned the impact that the Harry Potter series has had on my life, but I never really brought it up in therapy aside from saying, "This is what I'm reading." So we finally got into a really deep discussion about it several weeks ago. I was about to explain parts of the books and what they meant to me, but then I said that I wanted to know if he had read them. So he countered with the usual, "I'd be happy to answer that question, but first tell me..." something along the lines of how the knowledge that he had or had not read the books would change the discussion. I said that I wouldn't go into near as much description if I knew he had read the books, whereas if he hadn't, I would explain more. I also wouldn't dare give away any major plot points (especially about this!) if I knew he hadn't read them. He said he would be happy to give up knowing the end of the books so that he could have the discussion with me. He never directly answered my question, but said, "To use a phrase from the books, it would 'muggle' it up." (Referring to my talking about the books in therapy, when I feel they are my own precious escape that shouldn't be tainted by real life...) That was my only indication that he had, in fact, read them. This sort of issue has come up before, also - with respect to talking about music. How much detail I go into depends on whether or not I know if he has knowledge of such things. By him not telling me directly, we've actually had some very engaging discussions!

For awhile, he was having me face away from him, which my boyfriend thought was very stupid. When I started working with him at this most recent office, I told him I didn't want to do that anymore. We ended up having a discussion about it, and he said that it takes the element of my reading his facial expressions/body language out of the equation. Therefore I won't get more anxious or more reassured based on seeing him, and perhaps it would allow for more exchange of dialogue, rather than my just relying on what I see and then having it affect my thoughts/what I'm saying. I can appreciate that, and I actually do agree with what he is saying - but I haven't requested to go back to that way of seating! I face him, but a lot of the time I don't look at him directly. It is easier sometimes to just stare at nothing. The eye contact sometimes makes me anxious, especially when talking about very upsetting things - not so much when just discussing less-intense subjects.

So I guess those are just examples. I do think he tries to be some sort of blank slate, yet not to the point where it might actually hinder the therapy. I think he recognizes that there is a place for being a blank slate, but there are times when even a little disclosure about something small and insignificant might actually be appropriate and helpful.

I may know he has read Harry Potter, but I still don't really know anything about his life, but part of that is because I do not feel comfortable asking. I feel it crosses boundaries, and so I tend to hold back on questions about him directly. We've had some discussions - at one point he was away for an un-defined period of time, and I told him I had wondered if his wife had a baby. Thus an entire discussion about how a pregnancy would be hard to hide if he was a woman, but with him being a man, there is basically no way I would know if he and his wife had had a child without him telling me. I never did learn the answer to that question.

I actually have found some things out about him, but have never told him these things I truly do know about him. I was reading the real estate section of the city paper online one day, and saw that he and his wife bought a house at a particular location for a certain amount of money. I actually don't know that it was a great thing for me to know that - because then for awhile I was envious of the fact that they could afford such a perfect, expensive house when I was struggling in my apartment to make ends meet. I've never told him that, just because I feel like it is information I should not have. I'm sure he would probably handle it well, but I wouldn't want to really disturb or upset him by disclosing that I know that information! I would never use it in any way, but it just feels like information I might have once wanted to know (where - generally - he lives - not actual address - what kind of house), but now that I know it, I'd almost rather not!

Will it effect the end outcome of the therapy? Absolutely not! As some have said, there are forms of disclosure that happen even with the most "blank slate" type of therapists. You just cannot avoid certain things. I've seen his car a couple of times as he left the same time I did. I knew he shopped in a certain area because when I asked him for where something was when traveling to his old office, he told me of a certain shopping center that was nearer his home rather than the office - but still on the way home for me from the office. He wears a wedding ring - so I knew he was married - that was probably one of the very first pieces of information I did learn about him. These things do weigh on my mind at times, in that I do give them some thought. To him, that would make them significant. So, at times these things may impact the therapy. But do they impact the overall outcome? Probably not. They may have some positive impact in my knowledge that he is a "real" person, but other than that, I do not feel that the little knowledge I have will cause any negative outcome in the end!

OK enough rambling now! I've been following this post, and wanted to comment, but I had so many thoughts on it that I needed time to think about my response! I ended up rambling and thought-spewing just the same! haha

Take care,
Carrie :)

Rach said...

Carrie, it's interesting you mention all of those things. I often find myself asking my shrink "do you know what I'm talking about?" because it saves me having to go into a long-winded explanation about whatever I'm going to discuss... Generally he does know, especially because he's dealt with a lot of people from the same community (I live in a big city but he treats a particular population).

The shrink's kid went to the same school as me, and while it made for some awkwardness, it was really good because he had encountered a lot of the same teachers, and also had a really REALLY amazing understanding of the system, etc, as well as the stressors related to it.

I agree with not wanting to work with a blank slated psychiatrist - the more I work with my shrink, the more I enjoy working with someone who has a slick and sly sense of humour similar to myself... which you definitely don't get with a blank slate.