Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
When in doubt, don't
- Joseph More (29 September 2006)
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Uncertainty
- Andrew Montgomery (29 September 2006)
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Doctor-Patient relationship
- Ada Majd (30 September 2006)
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Who benefits ?
- Richard A Rosin (30 September 2006)
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Self-disclosure in psychotherapy (Chakraborti: Personal View)
- Alasdair J Macdonald (1 October 2006)
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Errare humanum est
- Adrian Blaj (1 October 2006)
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Caution and Discretion Necessary
- Jay Ilangaratne (2 October 2006)
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Re: Caution and Discretion Necessary
- Jay Ilangaratne (3 October 2006)
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Self-disclosure : Boon or Bane ?
- Giles MY Tan (3 October 2006)
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'If in doubt, say nowt'
- christopher d douglas (6 October 2006)
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yes many of us had some degree of mental illness such as depression at some time in our lives
- donna maria robinson (10 October 2006)
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Exchanges in Therapy
- Jose Maret (11 October 2006)
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"to disclose, or not to disclose...?"
- Scott Cherry (30 October 2006)
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Joseph More, Retired psychiatrist Retired
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My standard response has been, "sorry, as a professional principle, I do not disclose personal information". Once a therapist answers the first innocent question, another is likely to follow, risking the focus to shifts from the patient to the treater. The premise that you can't understand the patient unless you have suffered similarly, is untenable. You cannot have experienced every ill that any patient may have had. Self disclosure is particularly dangerous in the treatment of patients with psychopathic traits, who may then use such information to manipulate the therapist. Competing interests: None declared |
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Andrew Montgomery, locum Auckland
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Dr Chakraborti has raised a question that does not have any simple answers. I am 50yo and have a personal interest in the issue. I am married with four children, business (non medical) and a predominantly academic interest in medicine below the neck. I can offer some observations which I hope will help those who have interest in mental health and happiness. Firstly – a sense of integration with family and community is good. Secondly – development of trust and sense of communion with others is a continuing experiment and therefore carries with it a risk. Thirdly – it has become clear to me via patient, business, family and political interaction that in the moment it easier to run with the pack – but in the longer term better to run with intuition (which evolves out of experience and observation of the human animal). Finally – those with an interest in science, mental health, religion, philosophy and politics will always be sailing in uncertain waters and are therefore destined to live in an uncertain world. Competing interests: None declared |
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Ada Majd, General Practitioner Tehran-Iran
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Very good question and probably, no certain answer! Doctor-Patient relationship is a very complicated part of clinical practice that seldom gets the attention it deserves. We all face difficult challenges in this issue everyday and sometimes we think about these issues for life. As a psychiatrist, you have even more difficult situation than any other specialist. What would be the best way to keep the bondage of trust with client and avoid transference and counter transference? How much personal information can be shared with the client? Personally, I think at this point the old question of "why you ask this question?" can be appropriate in this specific case. If the question is only a curiosity, that's the time to say as a professional you don't share your personal information, however, I think this answer potentially, breaks the good interaction with the client and induces a sense of rejection in client. I'd simply say, no. Under such a question we can also imagine the concealed fears and anxieties of the patient such as; will a mentally ill patient one day become an acceptable social face? Will he be totally understood by the physician, and probably, how the physician really feels about a mentally ill patient? That's why I believe at this point it's appropriate to ask why the client asks that question, to reach the deepest parts of a hidden anxiety and then professionally, try to handle the situation.
Competing interests: None declared |
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Richard A Rosin, Consultant Psychiatrist VA Puget Sound, Seattle WA98108
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Dr Chakraborti's questions about psychotherapy are completely legitimate and it is a pity that he has had to write them down in the BMJ rather than being able to obtain answers from his training program.It is rather surprising that noone has addressed them at his induction sessions and if not there, then one would have expected them to be dealt with in regular individual supervision. In such supervision amongst other things he might have gleaned that the disclosure of personal details does not necessarily generate trust. Questions such as that asked by his patient shift the focus away from himself and it is not merely a therapist's 'trick' to inquire as to the meaning of such a question as its purpose is to return the patient to his therapeutic task. It is true that discretion needs to be used but that discretion is an educated one - like any clinical skill. Dr Chakraborti is correct when he says that the "boundary between our personal and professional identities is not watertight'. It is in recognition of this that psychoanalytic trainees are required to undergo analysis themselves so that they become aware of their own issues and how these may affect the therapeutic relationship.It probably would also not harm other mental health professionals, not to mention other doctors, to explore their own psyches to some degree. But in lieu of undergoing a more rigorous training in psychotherapy there is one question that can always be asked in these circumstances; How will it really benefit the patient to know these things? And if these vital questions are not being discussed in training, then keep asking them. Competing interests: None declared |
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Alasdair J Macdonald, temporary consultant psychiatrist Dorset PCT, Forston Clinic, Dorchester DT2 9TB
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In my experience self-disclosure in psychotherapy is rarely useful or appropriate. I occasionally use a generalised form of ‘self-disclosure’ to introduce an idea as a possibility to a client. For example, I may say ‘I saw someone recently who found XXX helpful’ as a way of introducing XXX from a non-expert position. ‘I once lived in a farming community’ may assure a farmer that I know something about his troubles, even though I come from the city. If I do have specific advice for a client, I may disclose something about past contact with similar problems. ‘I have worked with a lot of alcoholics in my career’ may reassure a drinker that my advice to reduce his intake is based on professional knowledge rather than moral outrage. Such comments should be kept general and should not be enlarged on; how will it be helpful to the client to know about your life? It is their life that you are paid to talk about. There is more risk of crossing professional boundaries inappropriately if self-disclosure becomes extensive. You also become vulnerable to disqualifications by clients, eg ‘you said you had never been divorced so you don’t know what it is like for me.’ You do not need to have experienced something personally in order to provide therapy for it, but saying that to a client is unlikely to be productive. ‘Tell me more about it’ will be a more useful response. Competing interests: I provide and teach brief therapy |
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Adrian Blaj, SpR General Adult Psychiatry Addenbrookes Hospital, Cambridge, UK
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From what you describe, it seems that your patient was rather in control of the situation, for some time, without you realising it. If indeed you did not ever experience 'any diagnosable mental illness' in your life, I think the patient should have deserved a simple answer, answer which would have put you back in control. Your subsequent panic and the thought: 'will my client engage better if I am able to deliver a positive response', would rather indicate that you were either unsure about some 'skeletons' in your cupboard or, even worse, you were prepared to 'fabricate' something in order to appease and gain 'control' of the patient. I think that a simple clarification of the concept of 'mental illness' and the finding of a common 'denominator' with the patient, would have sufficed re: clarification of your own (and patient's) anxieties - clearly people have a certain agenda when they ask certain questions -:) If you want to gain further knowledge into the subject, you'll find extraordinary insights, not in psychiatric/psychotherapy books, but in the major novels written by the great Russian novelist, Feodor Dostoyevski. Competing interests: None declared |
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Jay Ilangaratne, Founder www.medical-journals.com
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Disclosure of therapist's medical details to a patient is not without pitfalls. However, pitfalls per se should not be a concrete deterrent against,perhaps, some limited disclosure in selected cases. Selecting the correct patient for such disclosure can be a dilemma for the therapist and a considerable challenge to objective thinking,as often such situations arise without notice. Nevertheless, the expereinced and more articulate therapist might tactfully postpone a direct answer to buy some 'thinking time'; surely, exercising caution before discharging discretion cannot be a bad thing or improper.I would prefer a therapist who has had some personal experience of the condition he/she is dealing with, but that is only a personal choice as I believe that would strengthen the patient-therapist relationship and be of mutual benefit.Some may disagree. Competing interests: None declared |
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Jay Ilangaratne, Founder www.medical-journals.com
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I have noticed an error in the second sentence of my response;sorry. It should have been, "However, pitfalls per se should not deter ,perhaps, some limited disclosure in selected cases.". Competing interests: None declared |
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Giles MY Tan, Specialist Registrar in Learning Disability Psychiatry The Hollies, Parklands Hospital, Aldermaston Road, Basingstoke, RG24 9RH
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Dr Chakraborti has raised the important issue of self-disclosure that I'm sure would have confronted most if not all clinicians at some point in their career(1). Significant research has been done in this area(2). Whilst relevant to the practice of medicine in the broader sense, it is particularly relevant to those working in mental health and those involved in the talking therapies. Even within the practice of psychotherapy, depending on the tradition, the use of self-disclosure varies from the psychoanalytic tradition which discourages its use to the humanistic school which is more open to it. Perhaps the question is not whether or not to disclose information to our patients but rather how much to disclose. By choosing which comments we respond to and which we allow to pass, as well as with our tone of voice and body language, we are already revealing alot of ourselves to our patients(3). It is uncanny how much our patients know about us even without us telling them. Self-disclosure can be divided into three types : unavoidable (eg. suntanned after going away on holiday), accidental (eg. facial expression in response to certain revelations) or deliberate(4). It is perhaps this last category of self-disclosure that we struggle with as it is felt to be within some of our control. As Dr Chakraborti has realised, there are no readymade answers and it is a complex issue. The utility of self-disclosure depends alot on its timing and context(5). An inappropriately timed self-disclosure or one given out of context could have hugely damaging consequences. Unhelpful self-revelation could burden the patient unnecessarily. Viewed from an analytic perspective, it results in gratification of the patients' wishes rather than its analysis. On the other hand, a well timed sharing of appropriate personal information in the right context can deepen empathy and strengthen attachment to the therapist, facilitating the work of therapy. Self-disclosure if used appropriately could be a useful psychotherapeutic technique. The motivation of the therapist needs to be carefully examined before any personal information is disclosed. If it is for gratification of the therapist's sexual or narcissistic needs then it may well be viewed as a boundary violation and is damaging to therapy. There are thus dangers as well as potential benefits in disclosing personal information to patients. It requires consummate skill and experience to know when to use it and when best to steer clear of it. Access to regular supervision and greater awareness of our own motivations and needs would help us towards making those decisions. 1. Chakraborti A. Did you ever suffer from any mental illness? BMJ 2006;333:709 2. Psychopathology Committee of the Group for the Advancement of Psychiatry. Reexamination of therapist self-disclosure. Psychiatr Serv 2001 Nov;52(11):1489-93 3. Renik O. The ideal of the anonymous analyst and the problem of self-disclosure. Psychoanalytic Quarterly 1996;65:681-682 4. Pizer B. When the analyst is ill: dimensions of self-disclosure. Psychoanalytic Quarterly 1995;64:466-495 5. Dies RR, Cohen L. Content considerations in group therapist self- disclosure. International Journal of Group Psychotherapy 1976;26(1):71-88 Competing interests: None declared |
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christopher d douglas, Specialist registrar in psychotherapy Horbury Health Centre, 2A Westfield Road, Horbury, Wakefield, West Yorkshire WF4 6LL
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I felt compelled to write in response to Dr Chakraborty’s article, having to deal with similar direct questions on a daily basis myself. I was lucky enough to come across helpful supervisors early in my career, who were clear about the risks and dangers associated with any self-disclosure, giving me the invaluable advice of ‘If in doubt, say nowt’. The crucial point about any self disclosure is that it will impact on the professional boundaries of the doctor-patient relationship. Once this has moved into more of a social relationship, with less acknowledgement of the actual power differential inherent in any such meeting, it may be hard to recover. The often ‘magic’ results that appear to be produced by intentional self-disclosure are likely to be short term gains in rapport for longer term costs to the relationship. Unintentional self-disclosures can however often provide useful pointers to difficult issues that are being avoided. It is important to keep some perspective though as there are differing degrees of disclosure. These might range from the unavoidable stomach rumblings that let my patient know that I’ve not yet had my lunch, to the wedding ring I leave on my finger, and to the trickier question of how to broach a recent unpredictable period of paternity leave. I’d also like to reassure Dr Chakraborty that it was probably helpful for the patient not to have immediately rushed in to allay the anxieties provoked by such a question, however uncomfortable that might have felt. In some sense you will be providing a model of a person that doesn’t rush away from difficult issues and is prepared to wrestle with these difficult thoughts and feelings. Competing interests: None declared |
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donna maria robinson, medical doctor bangkok 10110
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I am surprised at the responses since as we go through life we realise how common depression and stress are at some point and we start to have insight into our behaviours and thoughts and how they can be affected by our mood. I think 30% should answer that yes at some point we have been affected by mental illness such as depression. I have set up Employee Assistance Programmes (workplace mental health/psycholigcal programmes) and seen many patients and certainly when you say how you feel about treating illness and have felt yourself, it builds a rapport. But you need to be sensitive. I think having been so impressed at the effect on individuals trying out counselling and how often they came out on top, I tried counselling and found that when I speak to patients I give them examples of what counsellors do and how medications can help and they are really interested rather than just an abstract let's refer you to counselling. It's not necessary to speak much about oneself to a patient since most people have come to you to be heard and to be helped themselves but your insight itself shows patients how you understand. In a private system where I work patients have selected the doctor and hope that you will meet their expectations. Competing interests: None declared |
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Jose Maret, Senior House Officer, Psychiatry Humber Mental Health Teaching NHS Trust, Trust Headquarters, Willerby Hill, Willerby, HU10 6ED
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Dr Chakraborti brings valid thoughts to discuss in the open. I figured his statement, ‘ the boundary between personal and professional boundaries is not watertight’, as having summarised his angst in the therapy situation. Asking a personal question is very indicative of boundaries not being watertight, and that it’s always an exchange, which happens in an interaction including a therapy situation. It is very difficult at times to define a boundary in the interaction. At times, the structure itself lends a physical boundary, but the exchange or transference, if we call the exchange technically, is difficult to be held in a strict boundary. It is this transference which holds the key to unravelling his past and present life relationship interactions. In a therapy situation it is necessary to understand how a ‘personal question’ came to exist in a ‘therapeutic’ relationship. The requirement to understand the dynamics stems from the need to identify the active defences that take role in the exchange. It is necessary to keep in mind the recreation of past life relationships in any present interaction, including the therapy situation, and active defences of projection, splitting, projective identification, humour and others, keeping it alive. Any question directed towards the therapist, is a resistance to discuss issues related to the client, which is the whole purpose of therapy. If he had been able to deal with the issues himself, he would not have required to be in therapy. It is Resistance to change seen in the process of therapy. If we discuss in Freudian terms, this has to do with oedipal issues. There is a need for the client to know more about the therapist, so that he could undermine his authority and relate to him as a peer. The advantage of having a peer-ship gives the choice to disregard the therapist’s thoughts/ideas with less guilt, rather than when he is constantly aware of the therapist’s authoritative position (parent figure). By entering the personal domain of the therapist the mystery of the therapist as a helpful learned figure is undermined. The purpose to identify with the therapist as a role model to make changes in his life is undone. Most of this exchange does not happen at a conscious level and an interpretation of this kind would sound totally alien to the client. The therapy situation is a ‘tug-of-war’ of an emotional kind. The client who withstands the struggle brings change through the process. Everyone wants change to happen, but change is still a daunting prospect even if it promises a wonderful new life at the end. To conclude, I would like to state,'It is not the question alone, which deems attention, but also the circumstances, which seeded the enquiry'. Competing interests: None declared |
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Scott Cherry, Staff Grade Psychiatrist Assertive Outreach Team, Brighton and Hove
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Generally it is important for the therapeutic relationship not to give direct answers or advice to patients' questions but to explore the reasons for the question further with the patient. In Dr Chakrabati's case the defence mechanisms (identification)used and the transference issues (being made to feel uncomfortable) should be interpreted in supervision. Disclosures can be dangerous in psychotherapy, and dealing with these dilemmas one reason why it might be a good idea for psychiatrists to have their own psychotherapy. Dr Chakrabati raises an important point - that there is a human element to what we do, particularly in psychiatry, and patients can feel more engaged if they 'know' their doctor more personally. The doctor- patient relationship is a professional one, not a personal one, and maintaining the 'disclosure' boundary is more important in psychiatry than in other medical specialties. But there are no right answers, and 'use your discretion' might be good advice. I was intially surprised when, soon after starting my current post in assertive outreach, i observed my consultant disclose some of his family details to a patient. We discussed this in supervision. we work with people who are often extremely socially isolated and difficult to engage, and the care team may be their only meaningful human contact. So it can be helpful, individually and in engagement terms, for patients to feel they 'know' their carers, and if we say "i'm sorry i can't answer that" to every personal question then they might not engage with us at all. So the general advice is 'if in doubt, say nowt', especially in a psychotherapy setting, but there are no set answers to this dilemma. The most important thing is that, as a trainee, you have owned up and explored this dilemma, allowing you to learn, reflect and develop. This approach will help you to become a better doctor, and to feel more comfortable in this situation in future. Competing interests: None declared |
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