Intended for healthcare professionals

Reviews Personal view

“Did you ever suffer from any mental illness?”

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7570.709 (Published 28 September 2006) Cite this as: BMJ 2006;333:709
  1. Arnob Chakraborti, senior house officer (ac97dmc{at}yahoo.co.uk)
  1. psychiatry, South Staffordshire NHS Trust

    At one of my psychotherapy sessions the first thing my client asked me, after the usual greetings and smiles, was, “Did you ever suffer from any mental illness?” I had been engaged in therapy with this particular client for a few weeks. We had a good rapport, and in terms of the therapy I felt we were making better than average progress. But nothing in the previous sessions had prepared me for this question. I had never had the opportunity to discuss the nature and degree of self disclosure that would be appropriate to a particular context. I had always and only understood self disclosure as a personal matter: no rules, no guidelines, only discretion. I have not had any diagnosable mental illness; but now, faced with this opening question and put on the spot, I felt a salvo of thoughts shooting through my mind. How should I answer this question? I was apprehensive of losing our rapport, the engagement in therapy, and progress in future sessions. Will my client engage better if I am able to deliver a positive response? Is this type and degree of identification necessary? In my mind I thus intellectualised the situation, and, while struggling to maintain my confident and unruffled appearance, I reverted to using that old therapist's trick of asking the Socratic question: “I wonder why you ask me that?” “Just like that,” came the answer, accompanied by an uncertain smile. I am certain my client was now wondering whether this had been an appropriate question. Sensing this discomfort, I waffled on, albeit defensively, about stress and individual vulnerability, hoping that my status as the trusted therapist, the all knowing and good doctor, was undamaged despite my not having been “empathic” enough.

    Will my client engage better if I am able to deliver a positive response

    Looking back, I wonder about this ethical quagmire of self disclosure. What constitutes empathy? How much of it does the therapist need? How is it measured, and how does it need to be expressed for a good interaction—a therapeutic relationship? What degree of self disclosure is appropriate? When does it become violation of a boundary? What constitutes excessive? What is professional and what personal?

    It is not that I have not witnessed senior psychiatrists and therapists, my consultants and trainers, breathing magic into a session by disclosing some personal detail about their life experience or friends, families, or partners. However, having had a mental illness is a more deeply personal issue, and some of my colleagues would agree that sharing such experience with a patient helps the therapist to relate better to the patient, to be more trusted. Even a simple disclosure such as, “You seem to have flu—I was off sick two weeks back with it, and it's so annoying,” generates a personal touch that may leave the patient leaving your consulting chamber more satisfied. Once I saw one of my colleagues suddenly bring to life a therapy session after disclosing the ordeal suffered when a family member was given the diagnosis of an ominously advanced carcinoma. I have also seen the effect of a consoling hand on a shoulder or an empathic, assuring hand on an anxious and tremulous one.

    But I continue to wonder at this. Is it necessary? If so, with whom and when, and how much? Speaking hypothetically, how important is it for achieving therapeutic benefit to disclose that my wife has diabetes or my daughter has epilepsy? Natural curiosity gets the better of you when you are trusting important details about yourself to a stranger. And if, say, I used Prozac, should I make everyone I prescribe it to, and who may a bit uncertain about taking it, aware that it worked and that the side effects didn't last long? And if it didn't work for me, should I stop prescribing it? For three years now I have attended induction sessions at the beginning of every six months of my basic psychiatric training, and never have the answers to such questions or even the questions themselves figured there. I had discussed the issue with my trainers, the summary of whose answers is, “Use your discretion.”

    But is my judgment free from error? And do all doctors have a similar degree of discretion? So many factors would need to be taken into account. I would imagine that the age and sex of my patient matters, how he or she presents and behaves in consultation, his or her past experiences, vague resemblances, attire, presenting complaint, and degree of distress. Whether somebody was accompanying the patient might also be a factor, as well as non-verbal communication and the patient's understanding of his or her needs. Self disclosure and tactile assurance may be seen as minor matters, but the boundary between our personal and professional identities is not watertight. I wonder how important it is to get this aspect of the therapeutic relationship right; it is so easy to get it wrong.

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