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.
Scenario analysis is helpful in terms of integrating the knowledge from the material in the course with the actual clinical work of clinicians who are working with clients. In the end, theories of practice are not the same as applications in practice. General rules and guidelines for how to approach the subject of self-disclosure will be met with exceptions and differences determined by the complex circumstances of the real world.
From an ethical standpoint, boundary violations are the most frequently encountered instances in which clinicians get themselves into trouble. This is why clinicians must be very clear about where the boundaries are located when it comes to the topic of self-disclosure.
It is also recommended that the trainee remember some of the important items that determine whether or not the intervention addresses concerns related to the content, intensity and timing of the self-disclosure. These items are summarized below and in a format that will help the trainee make a more informed decision:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? ___Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? ___Yes ___No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? ___Yes ___No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? ___Yes ___No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? ___Yes ___No ___Not clear
Is the client ready for the intervention? ___Yes ___No ___Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? ___Yes ___No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? ___Yes ___No ___Not clear
It is also important to remember some of the reasons why self-disclosure may be indicated. These are summarized below:
You should consider the use of self-disclosure:
When a client expresses the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Present ___Not present ___Not clear
When the client engages in all or nothing thinking. ___Present ___Not present ___Not clear
When the client believes he/she is the only one to have experienced something. ___Present ___Not present ___Not clear
When the client has been struggling to achieve a particular goal and seems to be losing confidence. ___Present ___Not present
Please take some time to look over the scenarios again with greater care for the clinical questions involved, maintaining clarity in particular about boundaries between the clinician and the client, and reviewing the key questions noted above. See if your interpretation and analysis is the same as our interpretation and analysis. If there are differences, can you make a case - clinically and ethically - for how you see the case differently.
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.
Review of Key Questions:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? _X__Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? ___Yes _X_No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? ___Yes _X_No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? ___Yes _X_No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? ___Yes _X_No ___Not clear
Is the client ready for the intervention? ___Yes _X_No ___Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? ___Yes _X_No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? _X_Yes ___No ___Not clear
Has the client:
Expressed the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Yes _X_No ___Not clear
Engaged in all or nothing thinking. ___Yes _X_No ___Not clear
Believed he/she is the only one to have experienced something. ___Yes _X_No ___Not clear
Been struggling to achieve a particular goal and seems to be losing confidence. ___Yes _X_No ___Not clear
Overall Verdict: Inappropriate use of self-disclosure on several fronts. Attempts will need to be made to repair harm from the use of the intervention.
Scenario 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.
Review of Key Questions:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? _X__Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? _X_Yes ___No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? ___Yes _X_No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? ___Yes _X_No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? ___Yes _X_No ___Not clear
Is the client ready for the intervention? ___Yes _X_No ___Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? _X_Yes ___No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? _X_Yes ___No ___Not clear
Has the client:
Expressed the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Yes _X_No ___Not clear
Engaged in all or nothing thinking. ___Yes _X_No ___Not clear
Believed he/she is the only one to have experienced something. ___Yes _X_No ___Not clear
Been struggling to achieve a particular goal and seems to be losing confidence. ___Yes _X_No ___Not clear
Overall Verdict: Inappropriate use of self-disclosure on several fronts. Attempts will need to be made to repair harm from the use of the intervention.
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.
Review of Key Questions:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? _X__Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? _X_Yes ___No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? ___Yes _X_No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? ___Yes _X_No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? ___Yes _X_No ___Not clear
Is the client ready for the intervention? ___Yes _X_No ___Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? _X_Yes ___No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? _X_Yes ___No ___Not clear
Has the client:
Expressed the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Yes _X_No ___Not clear
Engaged in all or nothing thinking. ___Yes _X_No ___Not clear
Believed he/she is the only one to have experienced something. ___Yes _X_No ___Not clear
Been struggling to achieve a particular goal and seems to be losing confidence. ___Yes _X_No ___Not clear
Overall Verdict: Inappropriate use of self-disclosure on several fronts. Attempts will need to be made to repair harm from the use of the intervention.
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?
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.
Review of Key Questions:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? _X__Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? _X_Yes ___No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? _X_Yes ___No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? _X_Yes ___No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? ___Yes _X_No ___Not clear
Is the client ready for the intervention? ___Yes _X_No ___Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? _X_Yes ___No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? ___Yes _X_No ___Not clear
Has the client:
Expressed the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Yes _X_No ___Not clear
Engaged in all or nothing thinking. ___Yes _X_No ___Not clear
Believed he/she is the only one to have experienced something. ___Yes _X_No ___Not clear
Been struggling to achieve a particular goal and seems to be losing confidence. ___Yes _X_No ___Not clear
Overall Verdict: Appropriate use of self-disclosure on several fronts. The clients have asked a direct question that would typically need to be addressed in a professional manner.
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."
Review of Key Questions:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? _X__Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? _X_Yes ___No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? ___Yes _X_No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? ___Yes _X_No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? ___Yes _X_No ___Not clear
Is the client ready for the intervention? ___Yes _X_No ___Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? ___Yes _X_No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? _X_Yes ___No ___Not clear
Has the client:
Expressed the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Yes _X_No ___Not clear
Engaged in all or nothing thinking. ___Yes _X_No ___Not clear
Believed he/she is the only one to have experienced something. ___Yes _X_No ___Not clear
Been struggling to achieve a particular goal and seems to be losing confidence. ___Yes _X_No ___Not clear
Overall Verdict: Inappropriate use of self-disclosure on several fronts. The relationship has not been allowed enough time to develop to allow this intervention, and the intervention has not been utilized in a manner in which the client's needs are front and center. Attempts will need to be made to repair harm from the use of the intervention.
CASE VI
Gerald Taylor is a licensed clinical social worker in private practice. For the past year and a half, he has been addressing an illness to his 10-year-old daughter that has created significant disruptions to his schedule and has caused him on more than one occasion to be pre-occupied with the well-being of his loved one. He has been very selective about addressing this issue with his clients, as he does not wish to place clients in the position of providing support to him during the periodic medical flare-ups. He has been noting with clients when a "family emergency" is responsible for needing to cancel appointments at the last minute. However, a number of his clients have pressed him for more specific information about why he needs to reschedule his appointments so frequently, a couple of them even asking if he is okay when he comes into a session with a particular heaviness about him.
One of his clients is a nurse at one of the local children's hospitals. Although it has never been addressed in the sessions, Gerald is aware that she may have had access to medical information about his daughter during her stay at that hospital on one occasion. He is concerned because the presenting issues for this client have to do with a history of co-dependence and over-responsible caretaking behaviors on the part of this client. Gerald is concerned that his client is withholding her acknowledgement of the medical issues of his daughter in an attempt to be protective of Gerald within the relationship. Worried about this component of their relationship, Gerald elects to provide some additional information about the nature of his family emergencies, while noting that his client may work at a position where she has some awareness of this part of his personal life. He then goes on to ask the client if she knew of his daughter' condition, and if it would be helpful to discuss the implications for the therapeutic relationship.
Questions:
Is the disclosure in the interest of the clients?
Is it germane to what the client is currently expressing?
Are the content, timing, and intensity of the disclosure appropriate?
Analysis
Given the nature of the client's identified problems, including her tendency to be over-responsible and end up in a caretaking position, it is likely appropriate for Gerald to enter into some discussion with the client about his daughter's medical concerns. The client is possibly going to be put into a more difficult position if she is left to decide whether or not to address this issue with Gerald. This may cause her to assume a caretaking role in that relationship where she is responsible for keeping secrets in order to protect the well-being of the clinician. This is not an appropriate responsibility for her to undertake within that relationship.
For this reason, some degree of disclosure may be germane to the interest of the client and the issues she is addressing in treatment. There may be a normalizing aspect to bringing the reality of the clinician's experience into the conversation - depending upon how well the discussion is handled and the manner in which limits and boundaries are set for the discussion. The discussion must clarify for this client that the client will not be tasked with providing emotional support for Gerald; the discussion is to help reduce any burden on the client around carrying this knowledge.
It will be important for Gerald to select a time for this discussion where it will not interfere with higher priority items that the client is addressing. It will also be important to present it in a way that clarifies the purpose of the discussion - to protect the client from assuming a caretaking role - and in a way that de-intensifies the severity of what Gerald is going through.
The danger in addressing this issue for Gerald might lie a reversal of the therapeutic role, whereby Gerald finds himself receiving support from the client inappropriately. It is Gerald's task to secure for himself sufficient support from his how resources to avoid such a temptation. However, Gerald must also be cautious about refusing to acknowledge any concern or well wishes that may come from the client, as this may be experienced as a rejection.
Review of Key Questions:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? _X__Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? ___Yes _X_No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? ___Yes _X_No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? _X_Yes ___No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? _X_Yes ___No ___Not clear
Is the client ready for the intervention? ___Yes ___No _X_Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? _X_Yes ___No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? ___Yes _X_No ___Not clear
Has the client:
Expressed the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Yes _X_No ___Not clear
Engaged in all or nothing thinking. ___Yes _X_No ___Not clear
Believed he/she is the only one to have experienced something. ___Yes _X_No ___Not clear
Been struggling to achieve a particular goal and seems to be losing confidence. ___Yes _X_No ___Not clear
Overall Verdict: Appropriate use of self-disclosure for this circumstance. The intervention is designed to be protective of the client and responsive to a reality in which there is the potential for role confusion.
CASE VII
Patricia Flynt is a licensed social worker currently working as a supervisor at a small, publicly funded mental health center in a suburban location. Many of the treatment sessions are conducted by newer clinicians who are not yet licensed at the independent level, with Patricia serving as the clinician of record. As part of her training approach, she will occasionally sit in on a session to be able to see more clearly where her supervisees are in terms of their skill development. This set-up is explained very clearly to the clients when they first come in for treatment and is reinforced each time that Patricia attends one of the sessions.
One of her less successful supervisees, Jim, has been struggling with several of his substance abuse clients lately, and Patricia has decided to work a little more closely with him and sit in on sessions more frequently to get a better picture of where his work is falling short and what additional education, guidance and support might help his performance improve. James became a social worker later in his life after he overcame a long-standing problem with alcohol abuse, and he has been sober for over 5 years.
The first session of the day for Jim is a 32 year-old female who is trying to overcome an addiction to methamphetamines. Jim is providing ongoing relapse prevention work for her, with a detailed relapse prevention plan, but the client has been unable to maintain sobriety for more than a week or two at a time. She has been presenting as increasingly discouraged and has been making vague suggestions that she is ready to give up and wishes that she didn't have to deal with this anymore, which has led to increased worry about suicide on the part of Jim. In the course of the session, Patricia can see the level of anxiety rise in Jim, and she can see Jim move away from using the structure of the relapse prevention plan and the techniques of Motivational Interviewing as primary approaches.
Patricia is aware that Jim has shared with all of his patients his own experience and his own journey through recovery. She is also concerned that Jim's worries about his client may also be connected to potential threats to his own recovery posed by his difficulties in making progress with his clients of late. She decides to suggest to Jim that he spend a little time talking with his client about some of the dark places that he found himself during his own recovery and some of the things that he found helpful as he worked his way gradually towards a point of sobriety, including some of the Motivational Interviewing approaches that were used by his clinicians to develop and strengthen his own motivation for staying with the program.
As Jim begins to go into some of the details of his own journey of recovery, and some of the things that he found helpful, Patricia sees him start to relax a little bit and bring his therapeutic skills back into the treatment with his client. While there is not an immediate improvement in the client's state of mind with regards to her own recovery, Patricia believes that Jim may be better prepared to stay on track with using the correct techniques within his work.
Questions:
Is the disclosure in the interest of the client?
Is it germane to what the client is currently expressing?
Are the content, timing, and intensity of the disclosure appropriate?
Analysis
This case presents some important complications about the effective use of self-disclosure. Because self-disclosure requires a substantial amount of expert knowledge to use effectively, it is not usually recommended that relatively inexperienced clinicians employ self-disclosure on a routine basis. However, please note that in this scenario, the use of self-disclosure, including the content and timing of the disclosure, is being directed by someone who presumably has considerably more experience in how to use this technique effectively. Patricia will also be available to provide additional guidance and support to both Jim and his client should the intervention not have its intended effect.
Furthermore, there is somewhat different set of expectations for self-disclosure within communities where substance use disorders are being addressed. Clinicians who have a successful history of recovery from substance use problems may possess a more intimate knowledge of the recovery process and its complications than clinicians who do not have that personal experience. While there exists a need to be very clear on the boundaries between the role as a clinician and the role as a fellow member of the recovery community, this kind of personal experience can lend a higher degree of authenticity to the information that is shared to support the journey towards recovery of the client.
The one area for concern in this scenario lies with the potential that Jim may be experience concerns about his own sobriety in the presence of a client who is clearly struggling. If this exists as a potential trigger for Jim, then additional support for him and his recovery might be indicated. Then it would need to be clarified whether the act of going back into his darker days and his journey towards sobriety would represent a negative choice for Jim - with implications for his capacity to help his client - or a circumstance where his experience of successful recovery would support his work as a clinician and provide a positive model for his client. In the opinion of Patricia, it is likely that she believed that the intervention would be positive for both parties, and a legitimate case could be made that she might be right.
It is important to note that in the absence of the expert knowledge and guidance of Patricia in her role as supervisor, this may not be an intervention that would be recommended. Newer clinicians may not always have a sufficient degree of understanding about the risks and dangers of using self-disclosure.
However, it is also important to note that clinicians of all levels of experience may not have developed the capacity for emotional control at a sufficiently high level to avoid allowing the self-disclosure in this case to become about the clinician's experience and needs, instead of serving as a tool for moving forward the goals and purposes of treatment - on behalf of the needs of the client.
Review of Key Questions:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? _X__Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? _X_Yes ___No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? ___Yes _X_No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? _X_Yes ___No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? _X_Yes ___No ___Not clear
Is the client ready for the intervention? _X_Yes ___No ___Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? _X_Yes ___No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? ___Yes _X_No ___Not clear
Has the client:
Expressed the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Yes _X_No ___Not clear
Engaged in all or nothing thinking. _X_Yes ___No ___Not clear
Believed he/she is the only one to have experienced something. ___Yes _X_No ___Not clear
Been struggling to achieve a particular goal and seems to be losing confidence. _X_Yes ___No ___Not clear
Overall Verdict: Appropriate use of self-disclosure for this circumstance. The client is struggling to achieve a particular goal and is losing confidence. The clinician's experience represents an alternative narrative that may provide hope and optimism.
CASE VIII
Marsha Vega is a licensed professional counselor who works in a small, publicly funded agency in a small town and specializes in child and family concerns. She has a son who struggles with Tourette's Disorder, and who has been having difficulties at school with verbal outbursts in class. While Marsha has provided extensive consultation to the school about her son, and helped the school personnel to understand and respond to the disorder in optimally effective ways, her son has had a difficult time making and keeping friends, as the children in this school view him as "weird".
One of Marsha's tasks in her agency is to run a group to expand the knowledge and skills related to parenting. While the group provides a good deal of emotional support to all the parents and may, at times, engage in some actions that resemble group therapy, the larger focus of the group is on developing parenting skills. Marsha is quite skilled at bringing the focus of the group back to the primary focus and preventing the group from becoming in-depth therapy. That said, there have been occasions where the flow of the meeting required that some therapeutic work be done with group members who needed that additional level of support. As a follow-up to those instances, the parents were offered the option of family therapy.
Because she lives and works in the same small town, many of the people in the group have children who attend the same school as her son. Accordingly, whenever any new parent comes into the group, she provides some information about her son and his condition, using that time to provide some education about Tourette's and other disorders affecting children, and the impact on the kind of parenting skills that are required to address those kinds of problems successfully.
During one of these introductory speeches, one of the newest group members blurts out something about Marsha being the mother of that "weirdo" who curses her daughter out at school. Marsha uses this as an opportunity to discuss in more detail the signs and symptoms of Tourette's disorder, the neurological basis of the disorder, and some of the challenges of working with special needs in children, including the social challenges and the parenting issues related to protecting the self-esteem of children who suffer from these kinds of special needs.
While Marsha works very hard to maintain her emotional composure while providing this information, one of the members of the group asks her in a very supportive way if she is doing okay. Marsha provides reassurance in this regard, but realizes that she is beginning to tear up in spite of her best efforts. One of the group members offers her a tissue and Marsha thanks her then tries to move forward to refocus on the concerns of the group.
Is the disclosure in the interest of the clients?
Is it germane to what the group is going to be addressing?
Are the content, timing, and intensity of the disclosure appropriate?
Analysis
As we have noted, the expectations for self-disclosure can be somewhat different within group settings. The group leader still retains responsibility for assuring that the self-disclosure serves the needs of the clients, not the personal needs of the clinician. However, there can be a higher expectation within groups for the group leader to be willing to share some of their own experiences, if they are germane to the work of the group.
In this scenario, there are two additional complications. First, the orientation of the group is more directed towards psychoeducation and the development of parenting skills, rather than a focus on therapy. While there may be occasions when the therapeutic skills of the clinician may be necessary to move the group forward, Marsha makes every effort to establish a boundary between education and therapy in line with the goals and mission of the group. This may allow a little more latitude in terms of self-disclosure.
The second complication is the fact that this group is being provided in a smaller community, where it is more likely that dual roles will be encountered and where information about Marsha's child and his challenges will be shared knowledge prior to its introduction into the group setting. If Marsha were to attempt to hide information about her child, rather than presenting it openly and honestly, it may give the impression that the subject is one that Marsha wants to avoid. Members of the group would then be free to interpret that avoidance based upon their own thoughts and prejudices. They may think that Marsha is ashamed of her child's problems, or unable to deal with complications in an open and honest manner. This might make it more likely that group members will be more cautious and less honest in raising concerns about their own children.
We have noted in this training that it is usually best for self-disclosure to occur later in the course of treatment, when a relationship has already been established and there has been time to assess the needs and readiness of the client in terms of the choice to self-disclose. While this is generally speaking a good guideline, there are occasions where the purposes in play suggest an exception. This scenario may show where such an exception may be found.
Like any other technique employed in clinical work, the decision of whether and when to use a technique requires careful consideration of all of the prevailing circumstances. There needs to be careful analysis of the advantages and disadvantages of bringing the technique into the clinical work with the very real people with whom the technique is being applied and within the very real context that will determine the effects of the technique.
In a setting in which there is much less likelihood that any of the participants in the group might have knowledge of Marsha's son, it might be more appropriate for her to wait for the right moment to bring her own experience into the clinical work. But under the current circumstances, the self-disclosure early in the clinical work is based upon the practical realities of the setting in question.
Review of Key Questions:
Is the self-disclosure oriented towards subjects that are in the client's interest and directly related to matters the client is discussing? _X__Yes ___No ___Not clear
Is the self-disclosure oriented towards past versus present events? ___Yes _X_No ___Not clear
Does the self-disclosure represent what the client would consider professional behavior? ___Yes _X_No ___Not clear
Will the self-disclosure create a positive impression of the clinician, as opposed to a negative impression? _X_Yes ___No ___Not clear
Does the self-disclosure address concerns about transference and/or countertransference? ___Yes ___No _X_Not clear
Is the client ready for the intervention? ___Yes ___No _X_Not clear
Has there been enough time for the formation of a therapeutic relationship with good trust and rapport? ___Yes _X_No
Will the intervention move the attention away from the client and his/her concerns in ways that are detrimental to the progress of the treatment? ___Yes ___No _X_Not clear
Has the client:
Expressed the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true. ___Yes _X_No ___Not clear
Engaged in all or nothing thinking. ___Yes _X_No ___Not clear
Believed he/she is the only one to have experienced something. ___Yes ___No _X_Not clear
Been struggling to achieve a particular goal and seems to be losing confidence. ___Yes _X_No ___Not clear
Overall Verdict: Mixed. There are components that may make this an appropriate use of self-disclosure for this circumstance. However, there is limited knowledge about the new member to the group that may require careful scrutiny with regard to that new member's reaction to the intervention.
This concludes our course material. Prior to moving to our test section, we will present our bibliography.