Publication Date: 05/06/2024

Duration: 21 minutes, 46 seconds

KELLIE NEWSOME: To tell or not to tell. Today, mental health professionals who live with psychiatric disorders share the pros and cons of self-disclosure.

CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report.

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

CHRIS AIKEN: Self-disclosure is like the clozapine of psychotherapy. When done poorly it breaks down the boundaries that keep treatment safe. It can make us look biased, or like the treatment is all about us. But when used well, it can breakdown walls of self-stigma, shame, and mistrust. Our own stories can build connection and hope and help patients see us as human. And when the disclosure is about our own mental struggles, the clozapine is even stronger.

I think of a time in my first year of practice when I met with a patient who was floridly psychotic – pacing the room talking to himself. His parents were there two, and we all were working to get him to accept hospitalization. Nothing I said even caught his attention - He seemed totally disconnected – so I took a risk and said, “This is a hospital I trust. I’ve taken my own family there when they’ve needed inpatient care.” He stopped pacing, pulled himself together, and gave me a sharp look. “That’s a little more information than I’d like to know Dr. Aiken,” and went right back into his inner rambling.

KELLIE NEWSOME: This year we put out a call for clinicians with psychiatric disorders to share their stories, and on the issue of self-disclosure our respondents were 50/50 split. Some have laid down the gauntlet, making their diagnosis known to nearly all through social media and the professional community. Others use it sparingly and with a heavy dose of vagueness, and some do not disclose at all. We’ll start with a view from the pro-disclosure side, from a psychotherapist with bipolar II disorder. He spoke first about a kind vague type of disclosure that is usually free of risk – such as sharing how we manage stress or anxiety.

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KELLIE NEWSOME: But he also goes further, disclosing his own diagnoses of bipolar II, and finds it breaks down the tension when patients are resistant to engage in treatment.

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KELLIE NEWSOME: Others chose not to disclose, to avoid distracting from the patient’s care as this clinician with bipolar, ADHD, and PTSD explained

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KELLIE NEWSOME: Let’s pause for a preview of the CME quiz for this episode. Earn CME for this podcast through the link in the show notes, or click on Podcast under the multimedia link on the Carlat Report website.

TRUE or FALSE. Self-disclosure is never recommended when a patient is in crisis.

KELLIE NEWSOME: We spoke with a psychiatrist who has gone public about his own bipolar disorder

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KELLIE NEWSOME: A clinician with OCD leaned toward sharing, but only if it helped engage the patient in treatment.

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KELLIE NEWSOME: Psychotherapists divide self-disclosure into two types: Immediate and non-Immediate. Immediate is when you share your feelings about what’s going on in the immediate moment, such as how you feel about the patient or the therapy. You might say, “I’ve been thinking about the work you’ve done to support your family during this crisis, and admiring your efforts;” or “In the past few sessions I’ve experienced you as more reserved and detached than usual.”

Non-immediate disclosure is when you reveal something outside the session. It could be something factual, like where you went on vacation, or something more personal like how you cope with anxiety or grief. 

Controlled trials have tested both forms of self-disclosure, and they generally improve therapeutic alliance and outcomes. One controlled study tested immediate vs. non-immediate disclosure during eclectic psychotherapy. Both had better outcomes than a control group that was allowed no self-disclosure, and the immediate self-disclosure performed slightly better. I agree. Patients experience us as more genuine when we disclose what’s going on in the moment, and doing so is a powerful way to inspire change. But it has to be done carefully. I think of many patients who fired their therapist because they disclosed too much, making the work seem more like a friendship than a therapy.

CHRIS AIKEN: We’ve emphasized here that self-disclosure has risks, but so does non-disclosure. In the words of psychoanalyst D.B. Ehrenberg, patients can experience nondisclosure “as rude, hostile, uncaring, sadistic, retaliatory, evasive, or tantalizing.”

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CHRIS AIKEN: Many clinicians felt that revealing their own struggles with mental illness is a risky, high level maneuver, and they weren’t comfortable doing it early in their careers. Some recommended seeking supervision before taking these kinds of steps.

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CHRIS AIKEN: Empathy is an art of understanding, not a literal understanding, and one psychiatrist reminded us that attempts to connect with the patient by saying “I’ve been there” can fall flat.

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CHRIS AIKEN: A psychiatrist with bipolar II was very careful about when he shared, aware that his condition has a favorable prognosis that his patients may not share in. He has no comorbidities, psychological strengths, and was raised in a supportive family. He also warned that such disclosures could come across as insincere, especially if done too soon.

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CHRIS AIKEN: He did find disclosure useful to instill hope in extreme situations, like suicidality

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CHRIS AIKEN: Self-disclosure takes many forms. In North Carolina, I’m often asked which college basketball team I’m routing for, which I’ve come to learn is a loaded question. In 2017, politics were a dividing line, and researchers at Cornell Medical Center polled 268 therapists about political self-disclosure in the Trump era. Near all the therapists reported that politics came up in session, and a slight majority – 63% – self-disclosed their political allegiance, either explicitly or implicitly. And here’s the interesting part – which may say something about how our political biases influence what patient’s tell us. If the therapist was a Hillary Clinton supporter, they tended to hear more discussions of politics and expression of negative emotions after the election – after Clinton lost. If the therapist was a Trump supporter, they noticed less discussion of politics and less expressions of negative emotions after their candidate won.

I too recall lots of talk and a lot of distress around the 2017 election. For many, it opened up old wounds from bullying, discrimination, or sexual assault. Others were jubilant, feeling they finally had representation in Trump. But those were different times. 8 years later we are in another election year, and I haven’t heard a whisper about politics from my patients. The issues have become so divisive, it seems most people have doubled down on the old rule: We don’t talk about politics or religion. 

KELLIE NEWSOME: If reducing stigma and instilling hope are your goals, there are ways to do it without disclosing.

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CHRIS AIKEN: I’ll read this quote from a clinician who asked that her voice be disguised:

I want to keep professional boundaries with clients, and I think there is a line you draw about certain things in your life. They may ask where I grew up, and I’m fine with that. In terms of bipolar, the way I connect with them on the bipolar level is that when I’m asking about symptoms I will say “Hey I totally get it there’s no shame here.” I try to take away the stigma and let them know that they are in a safe place and that I’m never going to judge them, but I made a decision long ago not to share my diagnosis with clients.

KELLIE NEWSOME: Only a few people we interviewed were completely open with their colleagues, but we’ll end with one who points out a unique benefit to taking that step.

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CHRIS AIKEN: We started this podcast with a question, to tell or not to tell, and we end without a clear answer. Self-disclosure is complex, and the field is far from unified agreement on it, but let’s at least look at where there is consensus. In 2010 psychologists Jennifer Henretty and Heidi Levitt attempted to distill what we know to some core principles. They felt some disclosure was helpful in therapy – indeed, 90% of therapists do so in practice.

KELLIE NEWSOME: And they listed areas where most therapist should feel comfortable being a little open about:

1. Demographic information, like where you went to school, your theoretical orientation, and professional and marital status

2. Feelings and thoughts about the client or the therapeutic relationship

3. Therapeutic mistakes. 

4. Similarities between the client and therapist

5. Values – there was some debate about this, but they thought it helpful to clarify your values to the client, especially if they differ from those of the client so that you can both be aware and avoid converting the client to your values. 

6. Relevant past struggles that have been successfully resolved

CHRIS AIKEN: But they added a note of caution if that past struggle involved addictions or psychiatric disorders. “Such disclosures may produce results that interfere with treatment, such as clients censoring themselves out of fear they might negatively affect their therapist or a sense of competition between client and therapist.”

Thank you to everyone who shared their story.

KELLIE NEWSOME: Catch up on the latest research updates in the May edition of Carlat Psychiatry News. Click on Webinars on the Carlat Report Website – it’s under the Multimedia tab. The Carlat Report is one of the few CME publications that depends entirely on subscribers. Thank you for helping us stay free of commercial support.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.