Author’s Note: Some of the material included in this article was adapted from the following presentations: 2016 dissertation defense, 2016 University of Maryland Bartlett Dissertation Award, 2014 Society for Psychotherapy Research Annual Meeting, and 2013 thesis defense.
Clinical Impact Statement: This manuscript provides information for mental health clinicians, mental health trainees, and those who educate them to assist therapy practitioners to consider and improve their use of therapist self-disclosure. Specific recommendations based on recent research are provided to enable clinicians to disclose more effectively.
My Confusion About and Interest in Therapist Self-Disclosure (TSD)
As I begin to establish my private practice, I have been reflecting on the evolution of my thoughts about and use of therapist self-disclosure (TSD), which I am using here to mean "therapist statements that reveal something personal about the therapist" (Hill & Knox, 2002, p. 256), and which does not include immediacy, or "here-and-now" discussions about the therapeutic relationship. In my first psychology course, we read several articles that caused me to become intrigued by TSD. In a study of the effects of therapist response modes in psychotherapy, Hill et al. (1988) stated that although they occurred only 1% of the time in their sample of therapy sessions, TSDs received the highest client helpfulness ratings and led to the highest client experiencing levels of all therapist responses. In a qualitative investigation, clients described the positive effects of TSDs from therapy (Knox, Hess, Petersen, & Hill, 1997). Finally, Barrett and Berman (2001) experimentally manipulated TSD levels and found that the condition with higher (but still moderate) levels of TSD resulted in lower levels of symptom distress and increased liking of the therapist. These authors concluded that TSD might improve the quality of the therapeutic relationship and the outcome of treatment.
Given the role TSD plays in establishing intimacy in most interpersonal relationships, and the fact that the literature pointed to such positive effects, it was fascinating to me that TSD is such an infrequent occurrence in therapy (accounting for about 3.5% of interventions; Knox & Hill, 2003). Furthermore, as a beginning trainee, I was flummoxed when my Basic Practicum instructor strongly discouraged us from using it. I understood the need to focus on the client, but I couldn't quite make sense of being encouraged to be authentic and real as a therapist, but not self-revealing. What harm could it possibly do to share a little something with a client? These seeming contradictions led me to study, among other TSD-related subjects, what factors influence therapists' use of TSD, how TSD is used in therapy, what characterizes a therapeutic TSD, what differentiates successful from unsuccessful TSD, and what recommendations experienced clinicians have for trainees and early career practitioners.
Disclosure in "Real Life" Versus in Therapy
The lack of TSD is one of the key factors that most distinguishes psychotherapy from other relationships. Self-disclosure research findings in social psychology suggest that sharing feelings and thoughts with others is an important skill for developing and maintaining close relationships (Altman & Taylor, 1973; Berscheid & Walster, 1978; Cohen, Sherrod, & Clark, 1986), and that failure to disclose suggests attempts to avoid intimacy (Mikulincer & Nachshon, 1991).
In typical interpersonal relationships, self-disclosure seems to facilitate development of intimacy, mutual understanding, validation, and caring (Berg & Derlega, 1987; Chelune, 1979; Laurenceau, Barrett, & Pietromonaco, 1998; Reis & Shaver, 1988). The most common responses to self-disclosure in social psychology research are liking for the discloser and disclosure reciprocity (Berg, 1987; Berg & Derlega, 1987), which is the tendency to disclose something about oneself at a similar level of intimacy to something someone else shared with you. In contrast, a therapeutic relationship is extremely intimate, but also professional, and lacking in the reciprocity that so often characterizes self-disclosure in relationships outside of therapy.
Historical Debate and Contemporary Literature
On one side of the historical debate about using self-disclosure in therapy, traditional psychoanalysts argued that TSD shifts the focus away from the client, hinders the therapist's ability to act as a mirror or "blank screen" onto which the client projects emotional reactions, and undermines the therapist's credibility, thereby damaging trust (Curtis, 1982; Freud, 1958; Greenson, 1967). On the other side, humanists maintained that TSD has a positive impact on treatment because it facilitates client exploration, encourages honesty as a foundation for building a stronger therapeutic relationship, and lays the groundwork for cultivating client trust (Bugental, 1965; Derlega, Hendrick, Winstead, & Berg, 1991; Jourard, 1971; Kaiser, 1965; Strassberg, Roback, D'Antonio, & Gabel, 1977).
Contemporary literature indicates that therapists and theorists of various orientations are converging on the beliefs that: a) TSD can have a variety of beneficial effects if used intentionally and judiciously, and b) avoiding disclosure in all circumstances may have harmful effects for both the client and the therapy (Eagle, 2011; Farber, 2006; Henretty, Currier, Berman, & Levitt, 2014; Henretty & Levitt, 2010; Hill & Knox, 2002; McWilliams, 2004). Indeed, current thinking is that the appropriateness and effectiveness of TSD depend heavily on therapist skill (Hanson, 2005) and situational and contextual factors (e.g., the moment-to-moment interaction of a specific dyad within the context of specific presenting issues and a unique therapeutic relationship, TSD type and timing, information shared, and client's expectations and preferences; Henretty & Levitt, 2010).
Factors That Influence Therapists' Use of TSD: Training and Personal Therapy
In a recent investigation of 13 experienced therapists' perceptions and use of TSD (Pinto-Coelho et al., in press), participants had typically been encouraged during training to be open to using TSD and also instructed not to self-disclose (all participants had seen more than one supervisor). Participants reported having supervisors, co-therapists, and other colleagues who discussed and modeled appropriate use of TSD; they also reported receiving feedback that you "didn't reveal yourself at all" and having a supervisor "horrified" by TSD.
Consistent with Hanson's (2005) finding that clients preferred disclosure to nondisclosure, therapists in the Pinto-Coelho et al. (in press) study reported the beneficial effects of disclosure in their own therapy. For example, one participant described having put the therapist on a pedestal and stated that "every time the therapist would disclose that helped humanize" him. Participants also reported negative feelings related to nondisclosure by their therapists (e.g., feeling "deprived a lot" or feeling their therapists were "cold" or "withholding"), which supports the growing literature suggesting that avoiding disclosure entirely may be ill-advised.
How TSD Is Used in Therapy
Given the recommendation in the literature that therapists should be prepared to disclose something, some of the time, I set out to study: "What do therapists actually do?" To answer this question, my colleagues and I investigated TSD occurence in 16 therapy cases from a psychodynamic training clinic (Pinto-Coelho, Hill, & Kivlighan, 2016). A total of 360 sessions were reviewed looking for TSD events. Approximately one disclosure occurred every other session, yielding 185 TSDs in 115 sessions. Doctoral student therapists initiated three-quarters of disclosures, and the focus of the session almost always returned to the client afterward. Disclosures fell into four primary categories, with disclosures of facts occurring most frequently (facts-59%, feelings-23%, insight-15%, and strategy-3%).
Consistent with recommendations in the literature, these therapists disclosed with low to moderate levels of intimacy. Certain TSD types (feelings and insight) and characteristics (challenging, and both reassuring and challenging) were rated by judges as significantly higher in intimacy than others (factual TSDs that were neither challenging nor reassuring), and higher-intimacy disclosures were associated with stronger client ratings of the real relationship and the working alliance. Feelings TSDs were positively related to strong client-rated real relationship and insight TSDs were positively related to strong client-rated working alliance; factual TSDs were more likely to occur in the context of a weak relationship.
Judges' rating of TSD intimacy and quality were positively associated. Feelings and insight TSDs were significantly higher in quality than factual TSDs. Similarly, challenging, reassuring, or both challenging and reassuring TSDs were significantly higher in quality than disclosures that were neither reassuring nor challenging. Although these findings were correlational, not causal, and the therapists were all trainees, these results suggest that further study of different types of TSDs and their outcomes and correlates is warranted.
Characteristics of Therapeutic TSDs
Pinto-Coelho et al. (2016) indicated that therapists may wish to use their urges to self-disclose as a gauge for what is happening in the relationship. For example, if a therapist feels pulled to disclose facts, this may be an indication that the relationship needs strengthening. Similarly, the association of factual disclosures with weaker client ratings of the therapeutic relationship suggests that therapists should think twice before using factual TSDs once a strong therapeutic relationship has been established.
In interviewing clients, Audet and Everall (2010) also discoverd a link between TSD and the working alliance, indicating that TSD affects clients' willingness to disclose and consider therapeutically relevant information. Clients' confidence in therapists and in the working relationship was related to clients' sense of therapists' attunement to clients' issues, as reflected by therapists' TSDs, and TSD content relevance affected clients' levels of engagement. These authors highlighted that TSD of inappropriate or clinically irrelevant material could harm the working alliance.
Hanson (2005) interviewed clients about their perceptions of disclosure and nondisclosure. Participants in this study indicated that therapist nondisclosures were likely to be unhelpful and to damage the therapeutic alliance, whereas TSD was likely to be helpful, contributing to the real relationship by providing clients with a sense of increased egalitarianism, warmth, and trust. Clients perceived TSDs that were brief, well-timed, directly relevant to their own material, and designed to highlight similarities between the dyad members to be skillful. Unhelpful disclosures were described as lacking in technical neutrality, oversharing, and poorly timed.
What Differentiates Successful From Unsuccessful TSD?
Pinto-Coelho et al. (in press) compared actual instances of successful and unsuccessful TSD and found that helpful disclosures were directly relevant to clients' issues. These were not simply instances of therapists sharing a little about themselves to build rapport with clients, but were personal experiences that were meaningful and intended to help clients overcome negative emotions and feel hope about their circumstances. For example, one therapist disclosed an experience from his own childhood, conveying that it was possible to get past the effects of having a difficult father.
Successful and unsuccessful disclosures were remarkably similar in terms of antecedents, intentions, and content, with the exception that in some cases therapists identified no intention for unsuccessful TSD. In successful as compared with unsuccessful TSDs, clients were more often experiencing negative emotions and therapists were less often experiencing personal or professional concerns (countertransference) before the TSD. Also importantly, in successful TSDs, content was accurate and relevant, whereas in unsuccessful TSDs, therapists often misjudged similarities or learned following TSD that they were not attuned to clients' experiences.
Perhaps most importantly, the consequences of successful versus unsuccessful TSD differed remarkably. Clients reacted positively to the former, with one client stating it was the most helpful thing that had ever been said to the client. Successful TSDs alleviated clients' negative feelings, deepened the work, improved the therapeutic relationship, and even led to client changes outside of therapy. In contrast, unsuccessful TSDs resulted in negative client reactions and therapist regrets and self-doubt. Two therapists thought the poorly delivered TSD led to premature termination. Thus, it seems clear that an ill-considered TSD can, indeed, cause harm. That said, when delivered effectively, TSD can be an extremely powerful therapeutic tool, and its outcomes are more likely to be beneficial than harmful (Hill, Knox, & Pinto-Coelho, in press).
Experienced Psychologists' Recommendations for TSD Use
Experienced therapists recommend that practitioners consider the following guidelines when trying to decide whether or not to use TSD (Pinto-Coelho et al., in press):
- Be thoughtful and strategic, and have a clear intention.
- Proceed with caution when feeling an urge to disclose or when the client requests TSD.
- Disclose in the context of long-term therapy or a strong relationship.
- Ensure that the focus is on the client rather than on the therapist's needs.
- Establish and abide by clear guidelines for how to approach TSD with clients and monitor yourself for any temptation to deviate from your standard procedure.Do not disclose with clients who cannot tolerate knowing about the therapist (e.g., because of presenting issues, difficulty with boundaries, or personal preference).
- Disclose when not disclosing violates the basic social contract (e.g., if you're wearing a cast or if there's unusual noise that disrupts the treatment that should be explained).
- Do not disclose material that is too personal, emotional, or unresolved.
- Get training, supervision, and consultation about using TSD.
- Evaluate the effects of TSD by observing the client's reaction, and adjust accordingly (e.g., be aware that some clients have difficulty tolerating knowing too much about their therapists, while other clients may crave TSD as a way of blurring professional boundaries or feel TSD is outside the realm of appropriate behavior in therapy).
TSD should be viewed as a complex and multifaceted intervention for practice, research, and training purposes. TSD is not one therapeutic intervention, but many, and should be treated as such. Different types serve different functions and have different effects on clients. Even within a given type, quality levels, intimacy levels, and outcomes may vary from one TSD to the next. Accordingly, it follows that each type of TSD should be taught and researched separately, with attention paid by type to differing intentions, characteristics, and impacts. All TSDs are not created equal.
My main takeaway from years of studying TSD is that it is difficult to disclose in a way that is therapeutic and meaningful for clients. My Basic Practicum instructor knew what she was talking about! Even experienced therapists who have been in practice for 30 years sometimes have a hard time choosing the right moment and accurately assessing clients' readiness, openness to, and likely responses to TSD. The more I study TSD, the less inclined I am to use it in my own clinical work. Based on the research, I expect that trend will shift with time. Until then, I am content to resist my urges to disclose, to respond to clients' requests for TSD with caution, and to use other methods, such as empathic attunement, immediacy (as distinct from the self-revelatory TSD being discussed in this article), and reassurance and support to be real and genuine with clients.
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