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.

-- 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.

--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]