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DSC8883 - SECTION 9: ANALYSIS OF THE SCENARIOS

 

In an earlier section, trainees were asked to evaluate the scenarios in light of some general questions related to self-disclosure. At this time, we will revisit the scenarios in order to examine them in more detail.

After each scenario, there will be several questions. Please take some time to write your answers to these questions, so you can compare your answers with the analysis that follows. If you have not already printed the scenarios, you may do so now.



CASE I

Susan Brown is a medical social worker in a large suburban hospital. Her client, Mrs. Morgan, is a middle-aged woman whose husband is dying of cancer. Behind the closed door of Susan’s office, Mrs. Morgan tearfully tells Susan of her struggle to remain hopeful for her husband and family in the face of Mr. Morgan’s obviously deteriorating condition. Mrs. Morgan is ready to realistically face the inevitable loss of her husband but feels the family is not ready and would be shocked and angry at her suggestion that they prepare for his death. During this emotional dialogue, the office door opens and Susan’s social work supervisor, Mrs. Rushing, enters without knocking. The supervisor recognizes Mrs. Morgan and sees her tear stained face and pained expression. Being familiar with the client’s circumstances, the supervisor acknowledges that the client is discussing her husband.

Mrs. Rushing then begins to talk of her own reaction to her father’s death, stating that she could still feel the emotional pain ten years after the fact. She talks on for several minutes becoming very emotional and tearful and finally leaving. Susan then turns to the client who makes no comment about the interruption and resumes where she left off. Later Mrs. Rushing tells Susan that this kind of self-disclosure is helpful to get the client’s mind off the problem and to let them know that others have experienced the same thing.

Questions:

If you were Susan, what would your reaction be?

Why is Mrs. Rushing’s particular self-disclosure inappropriate?

How do you think the client reacted to Mrs. Rushing?


Analysis

Susan most likely experienced the disruption as depriving the client of attention to her feelings and detracting from the client’s needs. She was annoyed at her supervisor’s lack of boundaries in entering an office with a closed door without even knocking.

Furthermore, she was upset that the client’s rather critical discussion was interrupted. Finally, while Susan knows that self-disclosure is a useful intervention, presented in this way, it was not helpful.

Mrs. Rushing’s particular self-disclosure was inappropriate for three important reasons. First, it was not in the client’s best interest and only loosely related to what the client was discussing. Second, the timing, content, and intensity were inappropriate.

Third, Mrs. Rushing is not the therapist in this case. She had not established the therapeutic relationship that would have provided a meaningful context for her intervention. She had not taken the time to gather a detailed assessment of all the facts that would allow her to know whether this kind of self-disclosure would be helpful.

We can only speculate as to why Mrs. Rushing may have chosen this ill-advised approach to the client. She may have been uncomfortable with her inappropriate entry into the situation and also uncomfortable with the degree of emotion being expressed by the client.

Clearly, however, Susan will need to conduct an evaluation of the effects upon her client from this intrusion upon the therapeutic relationship.

Since the client was able to continue her discussion as soon as Mrs. Rushing left, there is some indication that there may not have been too much damage to the therapeutic environment that Susan is attempting to create.
Susan did her part to protect the integrity of the therapeutic relationship by not engaging with Mrs. Rushing and, at Mrs. Rushing’s departure, immediately re-focusing on her client. This helped to underscore and reinforce Mrs. Morgan’s sense of being Susan’s priority.

However, Susan should carefully observe the client for signs of any damage to Mrs. Morgan’s state of being or the therapeutic relationship. This observation should look for both verbal and non-verbal cues.

If any problems are noted in this area, Susan should conduct a debriefing to repair any damage and then continue to evaluate the effects of the self-disclosure on the therapeutic relationship she has with Mrs. Morgan.



CASE II

Jill Brooks is a social worker in a middle school. She began a group counseling program that meets during students’ lunch time in her office. Topics include a broad range of issues important to the 12 and 13 year olds with whom she works. Initially these groups became popular with the students because it was a way to get out of the supervised lunch room and have lunch with your friends in a less structured atmosphere. At first the groups attracted only girls and some of the “less than cool” boys. However, at one point six of the male "jocks" in the school approached Jill about forming a group. Although Jill knew their motivation was to get out of the lunch room, she began meeting with the boys on a weekly basis. After some difficulty focusing during the initial group sessions, and once they had confidence that group discussions were confidential, the boys "bought-in" to the activity of discussing the problems of school life with each other. For Jill this was a triumph because it demonstrated that social work programs were for everyone, not just the discipline and academic problem children in the school.

One day, the boys really let their hair down with each other and began to talk about times when other kids had teased them about some physical characteristic and how bad this made them feel. Each boy shared the anguish of being called "shorty", or "geek", or "four-eyes", or about having been teased because their pants were too long or too short, or their shirt wasn't "cool". During one moment of silence, one of the boys asked Jill if she had ever had this experience. Jill thought for a moment about how personally invested she was in this group, and how the group had enhanced her professional status in the school. So, in a matter-of-time tone she replied, “When I was 13 my best friend used to call me "F. F." which was short for "Fat, flat". Before anyone could react, the bell rang and it was time to go to class.

As Jill reflected on the group process that had just occurred an uneasy feeling came over her, but she could not identify its source. Throughout the afternoon, as students would periodically change classes, Jill would see members of the boys’ group. She immediately noticed that as they passed by her they exchanged looks and laughter. By the next day, the laughter was louder. By the third day, they were waving at Jill and blatantly shouting, “Hi ‘F. F’!"

Questions:

Was Jill’s self-disclosure inappropriate in terms of timing? intensity? content?

Aside from the content, was Jill’s disclosure in the interest of the group and related to the discussion?

If Jill had been able to elicit feedback from the group, might the outcome have been different?

What might Jill do to follow-up on this situation?


Analysis

On one aspect of timing, Jill’s disclosure was right on target. A member of the group asked for the disclosure, indicating he was ready and wanted to hear. The intensity of her statement - spoken in a “matter-of-fact” way - was also quite correct.

The content of the particular self-disclosure, however, was ill-chosen. The group consisted of 13-year-old boys, all of whom are at an age where there are a number of awkward issues related to sex and sexuality. Jill called attention to her breasts, a sexually explicit part of the body, and created anxiety and perhaps excessive excitement in the boys.

She also raised this issue very late in the group session, where there would not be adequate time to debrief should the self-disclosure go awry. As a result, the boys were left to handle their own reactions until the next group meeting.

This kind of practical consideration must be factored into decisions about self-disclosure, since there is always the possibility that self-disclosures may not work as planned.

If the content had been more appropriate - perhaps a disclosure about some other aspect of physical appearance - it would clearly have been in the interest of the group and related to the discussion. It could have helped the boys see that adults survive adolescence, and that they will, too.

Since less provocative material would not have created a need to debrief, it would also have solved the problems with timing that have been noted.

If Jill had had enough time at the end of the session to evaluate the reaction to her self-disclosure, she probably would have recognized that the boys were anxious.

This would have alerted her to the need to debrief and to see what other interventions were needed to prevent harm from being done.
She might then have diffused the situation by emphasizing that her feelings in response to being called a “name” were the same as theirs. She might have also had time to process the provocative content of the material. Furthermore, some discussion of confidentiality might have been timely.

Given that the disclosure had already been made, Jill should assess the effects of her self-disclosure on the group at the next group meeting. She should evaluate whether they are still anxious, and whether the disclosure allowed them to cross an inappropriate boundary where Jill is concerned.

Jill can integrate the issues raised into the content of the session before, while addressing the reactions at a feeling level. Also, without blaming, Jill might ask how this circumstance relates to the group’s understanding about confidentiality.

If the group has a well-established relationship with Jill, it is likely that the self-disclosure can be adequately debriefed without undue harm to the group process. Jill may want to proceed cautiously in the future, however, so that her professional authority as a group leader is not damaged by further errors of this sort.



CASE III

Roger White is a licensed therapist who is establishing a private practice. He recently received a referral from a colleague. The client, Mrs. Hopkins, arrives for her first appointment with Roger. She is a 40 year old homemaker, married for 20 years to the same man. Her children are 17 and 15 years old. She describes her symptoms that include weeping for no apparent reason, anxiety, sleep disturbance, and irrational fears while driving, riding in elevators, or flying. These symptoms began three months ago and have persisted. Mrs. Hopkins recently underwent a physical exam and was found to be in good health. After relating her symptoms Mrs. Hopkins states, “I suppose I sound silly and maybe all this is just in my head. I don’t know why I feel this way when I’ve never experienced anything like this before. It is awful to spend every day like this. Do you think you can help me?” Roger responds emphatically, “Of course. My wife recently went through the same thing. It was as awful as you describe. We just didn’t know what to do for her and it affected the whole family. We thought she’d never be herself again."

Roger continues, "My wife spent hours just lying in bed. She neglected all the household chores so we ordered pizza and my daughter did the laundry. We came close to divorce and the kids spent as much time away from home as they could. I can tell you the family almost came apart at the seams. My wife finally pulled herself together and began to function. I can tell you I was greatly relieved. So you see I believe I can help you.” For the remainder of the session Roger offers information about his professional background, insurance reimbursement, and policy on missed appointments while Mrs. Hopkins sits quietly. He offers to schedule a follow-up appointment and Mrs. Hopkins states that she isn’t certain of her schedule and will have to call him.

Questions:

Was Roger’s disclosure for the benefit of the client?

Was Roger’s disclosure appropriate in content and intensity?

How else might Roger have responded to the client’s question, “Do you think you can help me?”

What does Mrs. Hopkins behavior throughout the remainder of the session indicate?


Analysis

Roger’s disclosure would be perceived as more in his interest than in the client’s. The impression Roger gives is that he still has strong feelings about his wife’s illness and used this opportunity to vent some of those feelings, rather than to create an environment of safety and comfort for his client.

In taking care of his own emotional needs, Roger does not evaluate the self-disclosure with regard to timing, intensity, or content. The self-disclosure occurred long before rapport and trust were established. The content was too personal a revelation for so early in the relationship, and the intensity of it gives the impression that Roger had little sympathy and much irritation with his wife’s problem.

Roger should have been more attuned to the client's issues, specifically her need for relief from her pain, and inserted an intervention to provide reassurance that what she was experiencing was not permanent. Whereas an intervention to normalize her experience and reactions to these life stresses would have been helpful, Roger's self-disclosure was not an effective way to provide this normalization.

Mrs. Hopkins's behavior indicates a withdrawal from the therapeutic process. She is experiencing a loss of confidence in Roger and increased feelings of hopelessness about her condition. Her reluctance to set another appointment would indicate a low probability that she will return.
Here we have a client who just wishes to get out of the first session without further assault, and then discontinue therapy with Roger. It is unlikely that even a very skilled debriefing process could rescue the therapeutic relationship following this kind of self-disclosure.

Were Roger able to recover enough to recognize the potential harm he had done, his best course of action would be to acknowledge the breakdown of the therapeutic relationship. He should then offer to help the client find a different therapist, and try to restore the client to some degree of hopefulness about her situation.

This scenario helps to highlight the importance of maintaining conscious control over any decision to bring self-disclosure into the therapy process. There is a much smaller margin of error for mistakes early in the therapeutic relationship before trust and rapport have been established.

If a self-disclosure is going to be a useful and relevant intervention in treatment, there will usually be many potential times to insert it into the relationship - not just one. Because of the potential risks involved, it is far better to err on the side of caution and use self-disclosure later rather than earlier.



CASE IV

Jim Smith is a licensed clinical social worker and a certified addiction counselor at a county mental health facility. For the past three months he has conducted twice-weekly psycho-educational groups for adults with alcohol and drug abuse problems. The clients are between the ages of 18 to 45. About one-third of them are voluntary, one-third were recommended to attend by DFACS, and the remaining third were ordered to attend by the courts. Jim has worked hard to make the group successful. He reviewed the current literature on substance abuse and group treatment, the skills needed for group leadership, and group process. He attended group sessions held by colleagues in other agencies. He recalled previous experiences leading groups and identified what was successful and what was not. In the three months since he took over the group, attendance has increased from an average of eight to the maximum number of fifteen. He knows that he has the group’s trust and confidence and that he is perceived as capable and competent. Group members have indicated that they feel he understands their struggle.

Group sessions always begin with a check-in where each group member states their name, drug of choice, and pertinent information about their struggle. On one particular night as check-in ends, a member says to Jim, “We know what our drugs of choice are, but what is yours?” Jim has never had an addiction to alcohol or to any illegal substance. He has, however, struggled to deal with overeating and smoking since he was a teen-ager. He believes that dealing with his own addictions have allowed him to understand the experience of his clients. He also knows there is substantial literature indicating that substance abusers relate well to group leaders who are recovering addicts. He is concerned that he will lose the respect of the group if he tells them the truth.

Questions:

What other factors can Jim take into consideration in deciding how to answer?

How should Jim respond to this question?

If this question had been asked in one of the early sessions, would Jim assess different factors?

What would have been the proper way for Jim to respond to this type of question if it were posed early in the group's formation?


Analysis

In looking at all the factors in deciding how to answer the question posed to him, Jim can consider group process and the particular stage this group currently is in. At three months, the group has coalesced, is well into the working stage, and trust and rapport have been established.

The question is most likely due to members feeling comfortable with Jim and seeing him as a separate person in whom they are interested.

Secondly, Jim can look at indicators of his success: increased group attendance, group feedback that they feel he understands their struggle. Thirdly, Jim might weigh the consequences if he is caught in a lie versus the possible consequences if he tells the truth.

Finally, Jim might recall his profession’s Code of Ethics and passages that have application to this kind of situation. He will want to consider if he will damage the integrity of the profession by misrepresenting the truth. This could be an ethical violation on his part.

With his careful and planned approach to undertaking this group, it is surprising that Jim did not anticipate this question coming up at some point in time, and had not already conceived some plan for how he was going to address it in a way that supports the purposes of the group treatment.

Jim should answer by saying that cigarettes and food are his drugs of choice and, while neither is illegal, the difficulty of quitting smoking and decreasing food intake has been his struggle.
The dynamics behind addictions to legal substances (including alcohol) and illegal substances are the same. Also, Jim can briefly relate some of the lengths he has gone to in order to smoke and hide his overeating. He might also point-out that the group has indicated that he understands their struggle and this is no less true whether his drugs of choice are legal or illegal.

Then Jim can ask for feedback on how members of the group feel about this and direct the thrust of the communication back to the purposes of the group.

If this question had been asked in one of the early sessions, Jim would have undertaken an assessment for different factors. The group would be in the formation or transition stage, with trust and rapport not completely established.

Under those conditions, an involuntary group member might be asking the question as a challenge to Jim’s authority, or an expression of anger.
At this point in group formation, however, role modeling by the leader is very important. Jim needs to be open, genuine, and unthreatened by the question.

If this had occurred earlier in the group, and Jim had reason to believe that the question was a challenge to his authority or an expression of anger he might also have asked, “Are you wondering if you’ll get anything out of being in this group?"

By asking this he would have invited the group to examine what meaning his answers might have for them. This could be used as an opportunity to examine issues of trust and competence, as well as any resistance that would be generated by Jim not having exactly the same experiences at the members of the group.

Given the importance of timing issues to self-disclosure in groups, it is usually wise for the clinician to prepare ahead of time how he/she is going to respond to this sort of question during different stages of treatment.

This preparation process allows the clinician to move smoothly in whatever direction is required at the time: towards appropriate self-disclosure if the group is ready for it, or to a redirection of the focus back towards the group members if the group is not.



CASE V

Linda Stone, a social worker in her late 20’s, was working with a 50-year-old client, Mrs. Bell, who was trying to cope with profound depression due to the sudden and untimely death of her husband. During the first two sessions, Linda sat quietly while Mrs. Bell talked about her husband, his death, and the emotional pain she was experiencing. She cried throughout these sessions. At the end of each session Linda would indicate that time was up and she would see Mrs. Bell the next week. At the third session Mrs. Bell became angry and stated that the therapist was too young to understand. Linda responded by asking, “Do you think no one really understands what you’re going through? The client than began to talk about how alone she felt. Later, in that same session, Mrs. Bell again made reference to Linda’s apparent youth and not understanding what she was going through since Linda was too young to have experienced deep loss.

Linda responded by saying, “Why do you think that although I am younger than you, I have not experienced great loss? My father died when I was only 12 years old. While that’s not exactly the same as losing a husband, I do relate to the depth of your feelings. I know what it is like to feel intense pain and wonder if you will always feel like this.”

Questions:

Was Linda’s disclosure well timed?

Could any of Linda’s professional behaviors have contributed to Mrs. Bell’s anger?


Analysis

It is doubtful that during the first two sessions - when Mrs. Bell was the most distraught - that she would have appreciated Linda’s disclosure. It is very likely that had Linda made the disclosure, Mrs. Bell would have discounted it.

It is possible, however, that by this third session, Linda may have established enough of a professional relationship that the self-disclosure may not constitute a problem. The larger question, of course, is whether there are other problems in Linda's approach that made this self-disclosure necessary.

Despite the fact that anger is a part of the grief process, it is very possible that Linda could have done some things better to lessen Mrs. Bell’s feeling that Linda did not understand her pain. Linda could have had shown more empathy by her body language, or expressed understanding by empathetic paraphrasing and feedback at the close of each session.

Given the narcissistic hurt and pain that is often in evidence when someone has experienced a loss of this sort, Mrs. Bell is very likely expressing aspects of her own feelings through her accusation, not concerns about whether Linda really is able to empathize. It should not necessarily be construed as a personal reflection of Linda’s inexperience.

Linda seems to understand this by her first remark. However, as the second remark is phrased in this scenario, there appears to be a somewhat accusatory tone in Linda’s response, when she says, “Why do you think … I have not experienced great loss?”

It probably would have been preferable for Linda to soften the entrance into the self-disclosure by saying, “I can understand why you might think that I don’t have experience in the type of loss that you feel, given my age and life experiences…" This protects Mrs. Bell from feelings of guilt at being confronted about her accusations towards Linda.

Linda can then get back into the real issue, which is the grieving process Mrs. Bell is going through, and the very real pain she is in.

Should Linda respond in the way that occurs in this scenario as presented, there would likely be some fallout. Mrs. Bell would likely feel that the focus was being shifted onto Linda’s unhappiness about Mrs. Bell’s complaints about her youth. This would require some debriefing, and then work to shift the focus back to Mrs. Bell.

This scenario is very effective at pointing out the high degree of emotional control that is required to utilize self-disclosure in a positive manner. Because self-disclosure is necessarily designed to bring forward personal material of the clinician, it runs the risk of loosening the boundary between the personal and the professional agenda of the clinician.

Without careful monitoring and self-control, the clinician may find him/herself using self-disclosure in ways that promote his/her own interests over the primary agenda of attending to the needs of the client.

For this reason, it is probably wise to keep in mind a quote from another respondent in the previously cited Borenzweig (2) study:

“…Self-disclosure [is] like spice in cooking—
A little goes a long way—
And it should embrace, not overwhelm."

This concludes our course material. Prior to moving to our test section, we will present our bibliography.

 

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