Monday, July 11, 2011

Self-Disclosure: To Patients Versus To the World

Dr. Maureen Goldman talks about self-disclosure for psychiatrists and brings the topic up in the context of Marsha Linehan's recent announcement that she was treated for a psychiatric disorder as a teenager.

In Clinical Psychiatry News, Dr. Goldman notes:
Psychiatric care and psychotherapy are different from the Alcoholics Anonymous fellowship, where the mutual sharing of personal experience is an integral part of helping people maintain sobriety. I believe that there is middle ground between disclosing personal information and presenting myself as a blank slate. In my practice, I show myself to be a real person. I make mistakes and admit them. I joke about my poor bookkeeping skills and inferior technological skills. I look things up during sessions if necessary, and I tell patients when I need to do research or consult with a colleague. I treat them as real people, too, not just as patients. 

I do not, however, share my own story. Mostly, I think that I can help people feel heard, understood, and known, and create a therapeutic plan without personal disclosure. I communicate that "I get it" without being clear that "I really get it." 

I cannot speculate about the motivation behind Dr. Linehan’s decision to allow her mental health history to be chronicled in the New York Times. The story was a very public disclosure, and in that way quite different from a disclosure made in the context of a one-on-one, doctor-patient therapeutic relationship. 

We've talked in detail about self-disclosure before, and specifically about whether psychiatrists should tell their patients if they've suffered from a psychiatric disorder.  See our post on Self Disclosure and Being Genuine.

I thought it was interesting that Dr. Goldman used this particular example to discuss why psychiatrists should not self-disclose.  Mostly, I thought it was interesting because I disagree-- otherwise this would not have made it to a Shrink Rap post.

In the course of a patient's treatment, the decision to disclose information is a personal one and it needs to be made in the context of what is best for the patient.  With the exception of inevitable life events on the part of the psychiatrist (I'm sorry, I won't be here next week because I'll be delivering twins and I may be out for a while taking care of them....) the patient's interest is always what matters.  I agree that if the doctor is not sure how the patient will receive information, it is safest not to disclose personal information.

The dynamic that goes on is a complicated and unpredictable one.  The patient may feel burdened by any adversity in the doctor's life.   They may feel disappointed that their doctor is flawed.  They may feel special, in a good way or bad, that their psychiatrist let them in on secrets.  Or they may simply feel that it's nice to share a world with someone who has been in a similar circumstance.  The issue remains one to be handled between the individual psychiatrist and the individual patient and what is in their best interest.

The dynamic that goes on between the psychiatrist and the world is a different story.  It's not about what's best for the patient, it's about the doctor and their right to freedom of speech and self expression.  The problem with saying that Dr. Linehan should not have made such an announcement is that it's too much burden to place on psychiatrists to say they must live their lives in ways that won't upset their patients.  Is it okay to be seen in public entering a synagogue, church, or mosque?  To have a political bumper sticker or sign on one's house (I would contend that it's problematic to have political material in the office)?  To wear a Yankees hat?  To have tattoos? To post ducks on a blog?  To participate in an undignified hobby?  To be gay?  Certainly, patients have feelings about all these things and may have negative feelings which interfere with their treatment.  But psychiatrists are people and they have the right to inhabit the world in a way that is comfortable, just as patients have the right to find another psychiatrist.

Personally, I thought Dr. Linehan's statement took courage and I thought it was a wonderful proclamation of hope for those who struggle with chaotic feelings and behaviors as teenagers.  They don't all drop off the face of the map---some recoup to live full and productive lives and contribute a great deal to society.  I didn't see a problem with this announcement and I applaud her for coming forward.