". . . he knows if you've been bad or good, so be good for goodness sakes . . ."
Disclosure: Many, many years ago, I played Santa Claus for my daughter, and she did not know who I was. Ho! Ho! Ho!
More recently, a patient I had not seen for over a year, came back after a letter was sent to him about closing his file. He had been treated for Attention Deficit Disorder in the past, and wanted to know if I would again take over prescribing that medication from his primary care physician. That seemed reasonable enough, but, I wondered, why now?
As I was reviewing these medications on the computer, he asked how I had been doing, commenting that I looked thinner. Knowing I wasn't, but now noticing that he in fact was thinner, I responded, "Thanks for your interest, but you look thinner, too."
Then his usual jovial expression disappeared and he got tearful, saying that indeed he had lost 20 pounds in the last six months. He explained that his wife had gotten depressed, and that in turn made him more nervous and depressed. Now I seemed to know why he returned. It was not for me to take over the same medications, but to reluctantly convey his depression.
The key to overcoming his shame seemed to be that I did not just answer his seemingly innocuous social question for self-disclosure. Once again, it reminded me of the complicated aspects of self-disclosure by a clinician. Nowadays, that seems to be more of an expectations of patients, perhaps reflecting the shifting social norms of self-disclosure that the public has seen on such popular shows as Oprah and on all the internet chat rooms and blogs.
Certainly, in personal relationships, self-disclosure is necessary for establishing and maintaining a good long-term relationship.
The Santa Claus story offers some clues as to how self-disclosure can help or harm. Hardly any young child recognizes who Santa may really be under the suit. Santa is sort of a transference figure, an authority who may know a lot about you or, if not, get you to tell him whether you've been good or bad. The implication is that you'll be rewarded for being good.
Now, if Santa would take off his suit, the transference magic would disappear, the child might feel deceived, and harm done. At best, this is the case with young children. With older children or adults, it is the meaning of Santa Claus that usually will continue, and Santa's self-disclosure would not be so harmful. Now, my daughter, a mother of her own with two children, knows who the Santa was who awakened her in the middle of the night. For children who were taught that they shouldn't believe in a Santa Claus and for those adults who are atheist or have non-Christian religious beliefs, it will not matter much whether Santa self-discloses or not.
With clinicians and patients, this can be much more complicated than Santa with children. Clinicians will come from many different training settings other than the North Pole, and any goals of treatment can be quite more varied than just being good or bad (as important as that may still be). Here are some of the variations that should be considered.
Santa's sleds and reindeer tend to look all the same, but there are many ways to decorate one's office. Do you have pictures of family, interests, or other revealing information? Whereas Freud recommended being a "blank screen" to patients, even his office belied his words, displaying many artifacts of antiquity that he loved.
A general rule of thumb, whether in decorations or communications, is that as much as practically possible should be done primarily for the benefits of patients, not to address our own needs, desires, or anxieties. Another slant on this, as attributed to Hippocrates, is to do as little harm as possible.
Tradition and research indicates some distinct variations in how and when self-disclosure can help or harm (see Dr. Sabin's blog from Dec. 1). Some of this research may seem surprising or counterintuitive. In a study of medical settings, it seemed like self-disclosure by physicians occurred in 15% of appointments. Now, with primary care physicians in particular, patients were less satisfied when self-disclosure occurred and felt less warmth, comfort, and reassurance in those appointments.
On the other hand, surgery patients reported positive reactions to such disclosure. How to interpret this? Perhaps the self-disclosure by surgeons made up for their more usual formal behavior and brief visits. For primary care physicians, perhaps the disclosure felt unnecessary or more to serve the physician's needs. This seemed confirmed in another study of patient records, where the reviewers felt that most self-disclosures were non sequitors and 85 percent not useful to the patient.
In psychiatry, in particular, even minor self-disclosure sometimes precedes and stimulates more serious boundary violations with patients. With self-disclosure, there is also always the potential risk of being accused of being inappropriate or unethical, even if you were not. Working in a group with administrative assistants on-site seems the reduce the occurance of major risks.
Such caution doesn't seem to be common in AODA treatment settings. For AODA counseling, having a personal history of problems in this area is common, if not expected. Patients often want advice and seem to respect clinicians who have learned how to overcome self-destructive usage.
For those counselors and case managers who do a lot of supportive psychotherapy, including advice giving, certain kinds of self-disclosure may help. These would be along the lines of practical guidance of how to do things, which the mental illness prevented from learning or now doing.
On the other side of the coin, self-disclosure is usually discouraged, or even prohibited, in a jail or prison setting. The reasons may be obvious: misuse of that information by the inmate, tracking you—or loved ones—down when released, and other security risks. Nevertheless, it still seems quite possible to establish a respectful and compassionate therapeutic alliance.
From my time as an administrator, self-disclosure is an important consideration with staff and employees. How much to share for cementing a sense of teamwork versus emphasizing the special power and image of a leader is an ongoing consideration. In general, what is shared should be with all. Whether to ever socialize with employees outside of work is fraught with possible unintended consequences.
In contrast to Santa Claus, other aspects of our upcoming winter holidays can be a bigger challenge to self-disclosure. Patients often assume—or want to find out—whether you celebrate Christmas, Hanukah, Kwanza, or any other holiday they know. No matter your religious or ethnic background, how much do you share as a clinician? Do you base your response on the holiday you celebrate, or base it on the patients? That is, do you say "Happy Holidays", "Merry Christmas", or something else? To close this blog, Happy New Year to you!
