". . . 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.