To Tell or Not to Tell the Disclosure of Events

Clinical Social Work JournalVol. 25, No. 1, Spring 1997

TO TELL OR NOT TO TELL: THE DISCLOSUREOF EVENTS IN THE THERAPIST'S LIFE

TO THE PATIENT

Eda G. Goldstein, DSW

ABSTRACT: Happy or disturbing events may occur in a therapist's life dur-ing the course of treatment that intrude on the therapeutic process whether ornot their true nature is disclosed to the patient. Therapists are not immune fromexperiencing acute, chronic, and even terminal illnesses, divorce, remarriage,adopting a child, mourning the death of a parent or significant other, or majoraccomplishments. In many instances such events affect the treatment process bydisrupting appointments, necessitating sudden absences, restricting a thera-pist's emotional availability and physical stamina, or altering the therapist'smood and affect. In other instances, patients may be aware of such events, atleast unconsciously, because of subtle changes in the therapist. Drawing on selfpsychology and intersubjectivity this paper explores the reasons for therapistself-disclosure of these events based on an assessment of the patient's develop-mental needs and the nature of the transference. It will discuss ways of makingsuch disclosures therapeutic.

KEY WORDS: self-disclosure; therapist illness; special events; treatmentdisruptions.

INTRODUCTION

In addition to the life events that we, as therapists, plan and antici-pate with pleasure and joy, there are those that occur during the courseof our work that are disturbing and over which we are powerless. Theyexpose our human vulnerability, stir our innermost anxieties and feel-ings, and evoke our characteristic defenses and coping mechanisms.Whether or not we disclose the nature of these sometimes traumaticevents to our patients, they almost always are aware of them, at least

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unconsciously. Further, they intrude on the treatment process either bydisrupting appointments and necessitating sudden absences or by theireffect on our emotional availability and physical stamina. Yet the sparseclinical literature on this topic leaves one with the impression that, forthe most part, traumatic events only befall patients.

Therapist self-disclosure in treatment generally is a threateningtopic because sharing personal information can expose the therapist'slack of omnipotence, challenge feelings of invulnerability, and revealone's most personal self. It is noteworthy that there are numerous pa-pers on the impact of a therapist's pregnancy on patients perhaps be-cause women are not able to conceal their condition and must plan for someinterruption of treatment (Chiaramonte, 1986; Fenster, Phillips, & Rap-oport, 1986; Genende, 1988; Lax, 1969; Naperstek, 1974; Rosenthal, 1990).

In a previous paper on self-disclosure in treatment (Goldstein,1994), I considered the questions of whether it is ever therapeutic forthe clinician to respond to patients' requests for personal information orto initiate the sharing of feelings, life experiences, or attitudes at timesin the treatment of selected patients. I argued that the thoughtful andsometimes spontaneous use of self-disclosure can be a form of empathicattunement and responsiveness that is essential for the successful en-gagement and treatment of certain individuals.

As a result of this paper, many therapists shared with me, oftenwith considerable trepidation, some of their struggles with self-dis-closure and its seeming positive and sometimes negative effects on theirpatients. I was struck by their aloneness as they ventured into un-charted territory often feeling that they had to keep the fact of their self-revelations to patients to themselves, not even sharing them with theirsupervisors in some instances. On numerous occasions, a therapist ap-proached me to share his or her quandary about whether to tell apatient that the therapist had breast cancer or AIDS or was divorcing, re-marrying, adopting a child, dealing with the illness or mourning the deathof a parent or significant other. I felt ill-prepared to respond adequately.

As I began to ponder this issue further, I did not immediately thinkabout life's intrusions on my own practice but instead thought aboutpatients whom I had seen after they had left other therapists pre-maturely or were forced to stop their treatment abruptly as a result of atherapist's illness or death. They had to deal with their feelings andfantasies about these traumatic situations alone and were affected quitenegatively as the following example indicates.

Mrs. L., a middle-aged married professional woman, remained in twice weeklytreatment with an older male analyst whom she saw deteriorate markedly be-fore her eyes over the course of a year. She reported trying to broach the subjectof his health with him repeatedly but felt cut off and redirected. She would re-

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hearse what she would do if he collapsed in her presence. She thought of leavinghim but felt that this would be disloyal. One day she arrived at the session tofind that he was not present. Later she found a message on her answering ma-chine from his wife saying that he was unable to resume his practice. She re-ceived no help with a referral and never learned what happened to him but aChristmas card she sent to him was returned to her. It took two years before sheovercame her disillusionment and feelings of abandonment sufficiently to seekhelp from someone else despite problems that were very troubling to her.

The following incident in my own recent past, however, brought theissue of whether to self-disclose in the midst of a traumatic life eventinto clear focus.

I was faced with the disturbing news that a loved one had cancer, necessitatingthe sudden cancellation of my patients and the rearranging of session times overa several week period. I felt quite worried and depressed during this time butdid not want to give information that either would burden patients or lead todiscussion of my personal life or of upsetting issues. Yet I thought it would be tooalarming to refrain from giving any explanation for the sudden and continueddisruptions of the treatment. There was a flu epidemic occurring and I used thisas an excuse, while attempting to explore patients' reactions to my absence,schedule changes, and fatigued appearance.

During the crisis period it was difficult to listen to patients and my ownemotional turmoil affected my feelings and attitudes during session times. Imust confess that I felt resentment at times if a patient did not appreciate whatI was going through. If a patient expressed anger at my forgetting the name of aprevious short-term companion or voiced some other similar grievance, I canremember thinking that he or she ought to be glad I was present at all. I feltimpatient with some of their hypochondriacal or other obsessional worries.When I was able to be empathic with their concerns about an ill parent, partner,friend, or pet, I sometimes became anxiously aware of my own situation. I wasself-conscious about how tired I looked. I wondered if certain patients sensedthat more was going on since they seemed to be talking about cancer and deathmore than usual. To this day I do not know for sure what they really thoughtand felt during this period. Nor do I know whether my handling of this situationwas good or bad or on whose needs my decision about what to do was based.

While this life situation itself resolved as positively as it could havewith a highly favorable prognosis for the cancer victim, it reminded me ofanother more troubling life crisis and its aftermath many years earlier.

The long illness and eventual death of a close companion led to a long mourningperiod during which I continued to practice. I quite consciously kept this infor-mation from my patients at the time. I did not really think about whether thiswas in their best interests. I took for granted the fact that any self-disclosure ofthis kind was contraindicated across the board. I know that I did not feel pre-pared to discuss these events with my patients.

Like many therapists who have sustained losses, my work was therapeuticfor me. Only one patient, a severely borderline woman who was keenly aware ofme, ever pointedly questioned me about my personal life during this time. Inretrospect, however, I think that it is likely that the others must have sensed the

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subtle and sometimes more overt changes in me that they could not name nordid they feel free to question me about. It is possible that I did not pick up ontheir possible questions even though I thought I was being attentive to them atthe time. This latter explanation was supported by an incident that occurred twoyears later from a patient who had terminated treatment and moved to anothercity upon remarrying. In a visit East, she made an appointment to see me inorder to touch base. During the session she asked me if I had some kind of lossduring the end of her treatment. I was not prepared for her question and re-sponded that I was not sure what she really wanted to know. She said she hadoften thought about the last few months of our work together. She felt that I wasvery sad and regretted not discussing this with me. I asked what this meant toher. She explained that she first thought that it had to do with her leaving andwas touched. Later she felt that she was not important enough to warrant sucha reaction and that I had seemed different for some time. She said that she wasafraid to upset me by asking me personal questions but later felt sad and guiltythat she had not summoned the courage to do so. We were able to connect herfeelings in this situation to an earlier experience in her life. She felt that hermother cared more for her sister who died at an early age than for the patientwho was more successful. The patient regretted that she and her mother hadnever had a talk in which she shared her concerns. To her surprise, she releasedconsiderable affect during this exploration.

Afterward, however, the patient asked me if her suspicion about me wasaccurate. I commented that she seemed to feel that she needed to know. Shereplied that she wished I could just respond honestly. I then told her that some-one very close to me had been quite ill and had died but also explained that mysad feelings about her leaving were real. I said that while I felt happy that shewas doing well and embarking on a new phase of her life I also knew I wouldmiss our work together. The patient became tearful and looked visibly relieved.She did not ask me to disclose more of the circumstances surrounding this occur-rence nor did she want to discuss her reactions to my disclosure further. Amonth later I received a letter from the patient in which she thanked me forhaving shared with her. She wrote that something lifted for her that seemed togo beyond our relationship.

In thinking about these situations, I found myself contemplating ahost of questions. If life events intrude on the therapist is not the treat-ment always affected even if the therapist does not share what is hap-pening? Does a therapist's lack of self-disclosure distort the treatment,causing patients to sense things that they cannot name or ask about?Are there times when patients need to know what is occurring in thetherapist's life? Can a therapist help to make disruptions in the treat-ment therapeutic? Does the therapist have a right not to tell even ifpatients need to know? Are there theoretical perspectives or diagnosticindicators that can help to answer these questions?

TRADITIONAL PSYCHODYNAMIC PERSPECTIVES

That psychodynamically oriented therapists traditionally have beenadmonished to be neutral, anonymous, and abstinent has emanatedfrom the view that the uncovering, interpretation, and resolution of un-

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conscious instinctual conflict and the modification and working throughof the associated symptoms, character traits, and defenses are the mainpathways to therapeutic change. Within this framework, the patient'sfantasies and transference reactions must be allowed to develop unham-pered by information about the therapist as a real person. In emphasiz-ing the role of insight, this view minimizes the importance of the experi-ential aspects of the treatment process. It neglects the crucial role of thetherapist's provision of real object or selfobject experiences in facilitatingchange.

Embedded in the traditional model is the belief that the therapist isthe expert observer of the patient's pathology rather than a participantwhose feelings, attitudes, and behavior influence the process. It has en-couraged the mistaken idea that therapists can and should consciouslycontrol, if not eliminate their personality from the treatment process.Thus it is not surprising that psychoanalytically oriented clinicians gen-erally have cautioned against the therapist's disclosure of personal in-formation and that there is a dearth of writing or discussion on how todeal with situations in which some disclosure of personal information isunavoidable or necessary.

While humanistic and some interpersonal theorists have advocatedauthenticity, realness, genuineness, and mutuality in the therapeuticencounter and showed a greater acceptance of the need for therapistself-disclosure generally, their views remained on the fringe of the psy-choanalytic establishment (Bugental, 1965; Fromm-Reichmann, 1959;Jouard, 1971; Rogers, 1951; Searles, 1986; Sullivan, 1953; and Truax &Carkhuff, 1967). Ego psychological interest in the impact of the real aswell as the transference relationship between the therapist and the pa-tient helped to open the door to a different conception of the uses of thetherapist's self in the treatment process (G. & R. Blanck, 1974, 1979;Greenson, 1967; Guntrip, 1975; Winnicott, 1965).

CLINICAL PERSPECTIVES

Some psychoanalytically oriented clinicians have recognized andwritten about the importance of dealing with life events that intrude onthe treatment. For example, in a 1977 article, Weiss writes of the impor-tance of "special events" that occur during the analytic process, the in-terpretation of which can be beneficial in highlighting transference is-sues and the ignoring of which can be detrimental. Weiss, however, givesexamples of such earth-shattering events such as his running into a pa-tient outside of office hours, a patient hearing him talking to anotherpatient, a patient leaving an umbrella in his office, and his answering atelephone call during a session.

In an unusual paper, Dewald (1982), a well-known analyst, dis-

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cusses his experiences during an acute and lingering illness. He ac-knowledges that his initial efforts which he rationalizes as protective ofhis patients were based on his own denial of the seriousness of his condi-tion. He asked his secretary to cancel his sessions and tell patients thathe was ill and would return the following week. Later it was necessaryfor her to tell them that he would be out indefinitely and would callthem upon his return. In deciding how much factual information toshare, he tried to weigh the negative effect of telling too much on thepatient's transference and fantasies against the stress of saving nothingor too little on the patient's adaptive capacities and willingness to con-tinue treatment.

Meanwhile, many of Dewald's patients found out from other sourcesthat he was seriously ill and much misinformation was communicated. Indeciding whom he should see when he returned initially to part-timepractice, he considered who of his patients knew each other. When hereturned and still had visible signs of his illness, he gave the least infor-mation to patients who were in intensive treatment and the most in-formation to those who were in "more superficial" treatment or in thebeginning stages out of concern for minimizing the impact on the trans-ference in the first instance and not discouraging patients from continuingin the second. Later he worried about the effects on the treatment of therole reversal involved when many patients sent him greetings and smallgifts. Dewald further describes how he dealt with his patients' reactions toand fantasies about his illness as well as his own counter-transference. Atthe conclusion of the paper, Dewald concedes, somewhat apologetically,that remaining "abstinent" would have negatively affected the treatment.

Arriving at a different conclusion than Dewald, Abend (1982), an-other prominent analyst, confesses that despite his decision not to do so,he found it impossible not to self-disclose about his illness and did thisin a somewhat arbitrary fashion. Nevertheless he argues that it is betternot to disclose about one's illness to patients even if its lingering effectsare apparent because to do so as he did always reflects the therapist'sconscious or unconscious motives rather than an accurate appraisal ofwhat is in a patient's best interest.

In these rare examples, the authors indicate that they were "flyingby the seat of their pants." While their self-disclosures became grist forthe therapeutic mill and seemed to initiate beneficial discussions inmany instances, the therapists view self-disclosure as therapeuticallynecessary and inevitable but not desirable, potentially constructive butnever optimal.

A compelling and beautifully written article by Alexander, Kolodzie-jski, Sanville, and Shaw (1989) describes how a psychoanalytically ori-ented clinical social worker enlisted the help of several colleagues tohelp her deal with her patients after receiving a cancer diagnosis which

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eventually led to her deterioration and death. Because some patientsnoticed changes in the therapist, the strong likelihood that she wouldneed further treatment, and the possibility that it would be necessaryfor her to prematurely terminate their treatment, she felt a sense ofprofessional responsibility to deal with her illness openly. The authorsshare in some detail how they helped the therapist to reveal the neces-sary details of her worsening condition, to explore its unique meaning toeach of her patients, and to deal with her own ambivalence and highlycharged emotions during this emotionally painful process.

Finally, in a chapter by Morrison (1990), another clinical socialworker courageously describes her own process and the impact on herpatients of her cancer diagnosis, its recurrences, and her ultimately fa-vorable course over a six year period. She discusses the unique re-sponses of each patient including their denial and inattention to theblatant changes in her appearance, the different degree of self-dis-closure based on her assessment of each case, her conscious counter-transference reactions, ethical considerations, and economic issues.

Both of these articles show psychoanalytically trained therapists'efforts to struggle with what they felt to be the necessity of self-dis-closure in a professionally responsible manner but also the very difficultand highly individualized and subjective process.

SELF PSYCHOLOGY AND THE INTERSUBJECTIVE PERSPECTIVE

Both self psychology and the intersubjective perspective recognizethe importance of the experiential as well as interpretive aspects of thetreatment process and provide the underpinnings to a new way of think-ing about the disclosure of events in the therapist's life that intrude onthe treatment. Self psychological treatment focuses on the revival of pa-tients' frustrated early selfobject needs in a new and more empathic con-text. Kohut (1971, 1977) clearly identified three main types of early self-object needs: 1) the need for mirroring that confirms the child's sense ofvigor, greatness, and perfection; 2) the need for an idealization of otherswhose strength and calmness soothe the child; and 3) the need for atwin or alter-ego who provides the child with a sense of humanness,likeness to, and partnership with others. Others have suggested addi-tional selfobject needs, for example, the need for an adversarial selfob-ject (Wolf, 1988). While not all selfobject needs are gratified, rewardingexperiences with at least one type of selfobject give the child a chance todevelop a cohesive self. When traumatic or repetitive empathic failureson the part of early caretakers occur, the self is weakened and does notconsolidate.

The selfobject transferences reflect the revival of these early needs

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and must be allowed to develop. Their emergence provides patients witha second chance to complete their development. Thus the experiential asmuch as the interpretive nature of the treatment is essential to patientgrowth. The therapist's empathic understanding and responsiveness,the repair of disruptions in the transference, and the exploration ofearly caretaker failures in attunement and their effects lead to the de-velopment of a more cohesive self.

While there are differences of opinion within self psychology abouthow much the therapist should depart from empathic listening and in-terpretation actually to provide other types of selfobject responsivenessto patients, I believe that there are situations in which engaging in ex-perience-near-empathy necessitates the therapist actually functioningas a selfobject as I have discussed elsewhere (Goldstein, 1994). Thus, Iregard the selective use of self-disclosure as a form of empathic respon-siveness. For example, certain patients have had repeated early experi-ences in which they were shut out of their parents' lives; vital informa-tion was kept from them; their own feelings and perceptions were nevervalidated; catastrophic events occurred without seeming warning result-ing in deidealization of their parents or traumatic disruption of theirlives; or they were deprived of the mutuality and intimacy involved inclose relationships.

Maintaining an interpretive stance in these situations runs the riskof too closely resembling the original frustration to which these patientswere exposed and also fails to provide the patient with a more responsiveselfobject milieu. Utilizing this framework, the decision about whether itis therapeutically indicated to tell or not to tell a given patient what isgoing on in a therapist's life, the question of how much to share, and thetask of making self-disclosure therapeutic must be examined in the light ofthe patient's selfobject transference and his or her developmental needs.

The intersubjective perspective, which overlaps with but is distinctfrom self psychology, also focuses attention on the therapeutic relation-ship in a new way (Stolorow & Atwood, 1992; Stolorow, Atwood, &Brandchaft, 1994). Within this theory, both therapist and patient shapeall aspects of the therapeutic situation since both participants exist inan intersubjective field in which they mutually and reciprocally influ-ence one another. This framework challenges the traditional view thatthe therapist can be an objective and neutral observer of what occurs inthe therapeutic interaction since a therapist always has an effect on thepatient even if he or she is not fully conscious of the impact. The inter-subjective perspective points out that the therapist, like the patient, isinfluenced by both conscious and unconscious organizing principles, in-cluding those derived from their favorite theories, which affect the treat-ment process and help to shape the patient's behavior in the treatment.

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Like self psychological therapists, the intersubjectivists must striveto understand how their own personalities, belief systems, and needsinfluence what they observe, how they intervene, and the patient's be-havior as well as how the patient affects them. Whatever the therapistdoes or does not do as well as what he or she thinks and feels has animpact on the treatment process. Consequently, a therapist who iscaught in a situation that intrudes on the treatment needs to considernot only the possible effects of self-disclosure on the patient but the im-pact of remaining silent. Further, the therapist's decision not to shareinformation that is uppermost to him or her emotionally can have nega-tive effects on his or her ability to remain empathically connected to thepatient.

While Stolorow (1994) takes the position that the analyst's mainactivity ought to reflect a commitment to investigating the meaning ofhis or her affective responsiveness, or its absence, for the patient, thetherapist should not be constrained by the rule of abstinence. Instead,he or she should use a wide repertoire of interventions to help the un-folding and exploration of the patient's subjective world. Thus intersub-jectivity allows for much more flexibility in the therapist's use of self, solong as their is consistent investigation of its impact on the patient."This greater flexibility frees analysts to explore new modes of interven-tion and to discover hitherto unarticulated dimensions of personal expe-rience" (p. xi). The selective use of therapist self-disclosure seems consis-tent with an intersubjective perspective.

An intersubjective perspective recognizes a broader range of trans-ference reactions, however, than does self psychology, particularly withrespect to those persistent organizing principles of the patient that ap-pear in the form of what Stolorow refers to as the repetitive and conflic-tual aspect of the transference in addition to its selfobject dimension (p.38). This increases the lens that the therapist must utilize in assessingthe patient's subjective world and suggests different interventions. Thedecision whether and how much to self-disclose cannot be based only onwhether the patient shows a selfobject transference or a repetitive andconflictual one. The task of knowing how best to facilitate the treatmentrequires that the therapist, whether by sharing too much or too little, iscolluding with or helping to repair the patient's past traumatic or dys-functional relationships.

While both the self psychologists and intersubjectivists are writingfrom a psychoanalytic framework, in my view it is not useful for thepurposes of a discussion of self-disclosure to differentiate patients whoare in psychoanalysis from those who are in psychotherapy. While therehave been numerous and frequent attempts to distinguish betweenthese two broad types of treatment, it is difficult if not impossible to get

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experts to agree on the appropriate criteria for differentiating them.Further, the important issue is not the nature of the treatment but theneeds of the patient.

CONSIDERATIONS IN DECIDING WHETHER TO SELF-DISCLOSE

While I cannot offer clear guidelines for determining whether or notto self-disclose based on an assessment of the patient's transference anddevelopmental issues, the following are some thoughts that I have aboutthis decision. Not all patients have the same ability to reexpose them-selves to potential disappointment and rejection and to sustain relation-ships in the face of disruptions. If events in the therapist's life intrudeon the treatment in a way that seriously taxes or undermines the pa-tient's feelings of safety and ability to trust the therapist or inadver-tently recreates the traumatic conditions of a patient's childhood, derail-ment of the treatment can result. Threats to the treatment may beparticularly acute in early stages before the patient has developed astable selfobject transference or at points when he or she is dealing withcore issues. That this is true, however, does not necessarily dictatewhether and how much to self-disclose. The therapist needs to askwhether it is better for the development and maintenance of the pa-tient's transference for the therapist to remain unknown or whether de-priving the patient of one's realness or of important information can becountertherapeutic. For example, when an idealizing transference is de-veloping or tenuously present, therapist self-disclosure of events thatcause him or her to be viewed as vulnerable can lead to traumatic de-idealization or to a panic reaction that the therapist, like earlier impor-tant people in the patient's life, will not be sufficiently strong to takecare of the patient or will abandon the patient through illness, self-pre-occupation, or death.

When needs for mirroring are primary and the patient is very self-absorbed to the degree that the therapist does not exist as a real orseparate person, any self-disclosure can be experienced as an unwantedintrusion. In fact, patients with this type of transference often seem tobe among the least likely to consciously notice or ask about the thera-pist's experiences even when it is obvious that something is wrong.

The fact that an attuned patient's sensing that the therapist isgoing through a difficult time and his or her asking the therapist forpersonal information does not, in itself, mean that the therapist shouldself-disclose. Such individuals may have had repeated experiences aschildren, in which they were put in the position of being a confidant andcaretaker to their parents at the expense of their own needs, a rolewhich enhanced their feelings of importance but at the expense of being

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loved for themselves. Self-disclosure can inadvertently recreate disturb-ing past interactions or feed into their worst fears while remaining moreexploratory would be experienced as more therapeutic in the long-run.

When a patient is manifesting an adversarial selfobject transfer-ence or needs to maintain distance to preserve the self from intrusions,self-disclosure of upsetting events in the therapist's life can make thepatient feel too guilty about or further escalate his or her aggressive oroppositional stance or feel too threatening. Likewise, it is problematic toshare personal information when the patient is raging.

Individuals who manifest a twinship transference or who have anintense need to feel connected to the therapist as a real person, often areamong those who seem to elicit or require some self-disclosure fromtheir therapists as the following example illustrates.

Some years ago, it was necessary for me to undergo surgery for what laterturned out to be a benign growth but about which I was quite apprehensive.Since I was able to plan the surgery and recovery time during my August vaca-tion, there was no actual disruption of the treatment. Consequently it was notnecessary for me to share any of this with patients except of course for the bor-derline woman I mentioned earlier. Upon my return in September, a 35-year-old,single woman patient, who viewed me as very much like her and as a profes-sional peer despite our being in different fields, announced that she had learnedfrom an acquaintance who worked at the hospital at which I had been operatedthat I had been there as a patient. While she also was told by her friend that Iwas all right and she could see this for herself she nevertheless was quite agi-tated. She said vehemently that she deserved to know about my health andmade it clear that she was in no mood for my exploring her reactions to andfantasies about this event. The patient became more relaxed when I told her thenature and result of the surgery but indicated that she felt quite hurt and fright-ened by my not having told her myself earlier. More willing to share her reac-tions after I told her what had happened, she said that it upset her that some-thing so important could have happened to me without her knowing about it andit made her feel very unimportant and that I had not considered her.

She also said that she had a much more difficult time with my vacation thanusual, feeling very anxious, and now she knew why. Further exploration led thepatient to recall her childhood relationship with a beloved aunt, the only familymember whom she felt had truly cared about her and with whom she was veryclose and who committed suicide seemingly without warning. She also relatedrepeated incidents when family life was disrupted without apparent warning.Despite her attachment to her aunt, the patient's parents never spoke of herdeath and seemed not to notice her obvious distress. She felt abandoned by heraunt and alone in the midst of her family. She grew up doubting her own view ofreality in close relationships which made her feel quite anxious and fearful. Thepatient sought treatment because she had broken several engagements and onceagain found herself unable to commit to the man whom she was seeing. It tooksome time for the patient to reestablish some feeling of security in our relation-ship although the discussion of this disruption and the patient's earlier experi-ences seemed to help her deal with her earlier loss and its sequelae. After thisincident, she experienced a greater sense of certainty about marrying and set thedate for her wedding. The fact that I had come back from the dead, unlike her


aunt, that we had been able to talk together about what had occurred, and that Iwas sensitive to her feelings was very important to her.

While one could argue that I should have sat with this patient'sagitation and anger and that I was acting-out my countertransference, Ibelieve that not disclosing at this time would have perpetuated the dis-ruption of the transference and led to a therapeutic stalemate. There isno doubt that I was acting out my countertransference as well. I feltguilty about her having found out the way she did and I did wish toallay what I felt to be her unnecessary and countertherapeutic distress.I regretted not having said something to her earlier, not because Ithought she would find out but because I knew that she was extremelysensitive to me and needed to feel that I was a safe, knowable, andpredictable person who would validate her experience and not pull therug out from under her. My own wish to protect her and my other pa-tients as well as myself did not allow me to take her unique needs intoaccount. In repairing the disruption in the treatment I was able to saythis to her and to relate her experience of me to her long history offeeling that no one in her family knew or cared about what she felt.

In this example, one can also question whether my self-disclosing tothe patient initially would have been as therapeutic as the disruption ofthe transference and its repair. I cannot answer this with certainty ex-cept to say that I think that therapeutic responsiveness as well as, if notinstead of the repair of transference disruptions facilitates therapeuticchange. In all honesty, however, I think it was easier for me to discussmy surgery after the fact just as it was more comfortable to discuss theloss of a close friend much later in order to repair the disruption in thetreatment relationship than it would have been to share my health sta-tus or mourning reaction at the times they were occurring.

In addition to patients with twinship transferences, other instancesin which self-disclosure seems indicated are when patients begin toshow an interest in the therapist as a separate person or begin to feelentitled to ask questions. Responding to the patient with "It's importantthat you can ask me that" or relating to the question by helping thepatient understand its link to past experiences can be felt as a trau-matic rebuff.

Further, there are times when the patient's expression of concernand empathy reflects a positive development or permits a mutuality tooccur that is important to the patient as shown in the example belowwhich was told to me recently by a colleague.

Ms. R., a highly expeienced therapist, was forced to put her dog to sleep and wasquite upset in the aftermath. A woman patient, who was somewhat schizoid andisolated and who maintained her emotional distance from the therapist whomshe had been seeing for several years, questioned her about the dog's absence

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and she spontaneously told her about the dog's death. The patient was visiblyupset and showed an empathy for the therapist that was totally uncharacteristicfor her. This seemed to mark a turning point in the treatment after which shebecame more accessible emotionally and appeared more connected. Both thedog's death and the spontaneous and real feelings the therapist showed seemedto enable this patient to respond more freely and feelingly than she had beenable to do previously.

Self-disclosure also can be important when therapists and patientsshare professional affiliations or when patients know colleagues, ac-quaintances, friends, or family members and can learn about the thera-pist in sometimes disruptive ways. The patient's ability to access per-sonal information about the therapist is greater when therapists arevisible in the professional community through teaching, supervision,and organization work, live in small communities, or interact in a sub-group of the larger community. The issue that often confronts such ther-apists is not whether to self-disclose but how much to share and how tomake disclosures therapeutic.

Of course there are likely to be instances in which the therapist haslittle or no time to consider whether or not to self-disclose before takingaction. It is useful to have a general idea about how to handle this typeof situation before it occurs since in the midst of a crisis, it is difficult ifnot impossible to think clearly. A question that often surfaces is whetherit is best to convey information to patients oneself or to ask others to doit. While not always possible, it is more reassuring to patients to hearstressful information from the therapist directly even if the therapistspeaks only briefly to the patient, gives a very general explanation, andpostpones prolonged discussion to a later time. The following exampleillustrates what happened when a sudden disruption of the treatmentoccurred in my own practice.

Just prior to my beginning to write this paper, my 81-year-old father becameseriously ill and was hospitalized on a Friday. Over the course of the weekend Iconsidered what I would do if his condition worsened and necessitated an inter-ruption in my practice. I feared that just canceling sessions suddenly withoutexplanation or saving that I was ill would arouse too much anxiety especially soclose to my planned vacation in August. I decided that I would personally calland tell patients that I had to attend to a family emergency and resume thefollowing week. I thought that calling them rather than asking someone else todo it would reassure them that I was all right and that leaving the reason some-what vague would be less burdensome and allow each to do with the informationwhat they needed to.

By Monday the crisis seemed to pass but my father unexpectedly passedaway the following Thursday. I learned the news late in the evening that I wouldneed to be in Chicago the very next morning. Despite my panic, I recalled andimplemented my plan of the preceding weekend calling those patients whosesessions I knew I would need to cancel. What I did not anticipate was that a few

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of those whom I did not need to cancel and thus did not call knew others whom Idid contact.

Upon my return I learned that one patient had been in another patient'skitchen the night that I called. Even though she understood the situation ratio-nally, the patient whom I had not contacted personally felt less important. Thissame patient was my age and related to me with a combination of mild idealiza-tion and twinship. She had been dealing with the deteriorating health of herown father and her disbelief that he might die. I later learned that when shelearned of my emergency she immediately assumed that one of my parents waseither deathly ill or had died and she became quite panicky. When we resumedour sessions she insisted on knowing what happened. Knowing the truth furtherescalated her anxiety since she realized that if my father could die so could hers.My vacation came quite soon after this episode and this patient uncharac-teristically called several times in the first two weeks for what appeared to beminor reasons. As she felt reassured that I was really all right she becamecalmer and later was able to say that it helped her to know that I had not fallenapart since this made her feel she would be okay too if something happened toher parents. When we resumed treatment in early September the patient re-ported that while she had some sad moments during the month of August shefelt more prepared for her father's death and had spent more time with him inwhich they were able to reminisce about their relationship. Her father died sud-denly two weeks later.

Perhaps one moral of this story is not to have people who know oneanother in treatment. A second lesson is that making mistakes is inevi-table despite our best efforts. Yet a third implication is that even mis-takes can have positive outcomes.

HELPING TO MAKE SELF-DISCLOSURE THERAPEUTIC

Often it is the therapist's willingness to self-disclose and the natureof the experiential process between therapist and patient that is just asimportant, if not more important, as the content of the self-disclosure.Whether or not the therapist self-discloses in a particular situation, theramifications are unique for each patient. While it is important for thetherapist to understand the meaning of the therapist's action as the ac-tual content of the self-disclosure, there are times when exploration isnot possible. Patients sometimes resist or ignore a therapist's efforts toprobe the significance of an interaction that occurs and pushing the pa-tient can be countertherapeutic. For example, there are patients whoare not involved in intense transference reactions and who react to cer-tain disclosures in more socially appropriate ways. Other patients showtransference reactions which lead them not to pay attention to or todeny that which does not immediately fit their concerns or needs.

It is tricky to decide when and how much to explore and interpreteven when the patient is accessible to interventions of this sort. As Dew-aid (1982) noted in his paper, "the therapeutic problem lies in the need

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EDA G. GOLDSTEIN

to explore adequately the full gamut of patients' responses, affects, andassociations to the illness, and to do this in the face of counter-transference temptations either defensively to promote premature clo-sure and evasion of more threatening affects, or to use the experiencefor exhibitionistic, masochistic, narcissistic, or other neurotic satisfac-tions" (p. 361).

COUNTERTRANSFERENCE AND THE THERAPIST'SRIGHTS AND LIMITATIONS

An understandable countertransference problem occurs when thetherapist needs the patient to fulfill archaic or current needs. For exam-ple, in work with particularly self-absorbed patients who see the thera-pist as an extension of themselves, the therapist can resent the patientwho does not see his or her separateness. Likewise, some therapistsseem to need their patients to know what is happening and to showinterest in and empathy for their plight particularly if they feel close tothe patient. This can result in a role reversal in which the patient isexpected to take care of the therapist.

While therapists must strive to keep patients' needs in the fore-ground and refrain from any exploitation of them, sometimes it is appro-priate and therapeutic for a patient to be able to give to a therapist.Thus I do not regard all manifestations of a role reversal to be inher-ently problematic. The difficulty is knowing whether the patient needsto give or the therapist needs to be given to as the following examplehighlights.

A supervisee discussed the aftermath of her elderly father's death some yearsearlier which she had disclosed to all of her patients at the time. She indicatedthat she was quite pleased and moved by the fact that so many had sent hersympathy cards and notes afterward. She seemed to look to her patients as asupport network. While I have no doubt that for some of her patients their ex-pression of concern was positive, I was dismayed by her unquestioning responseand neediness.

A problematic issue for therapists who self-disclose is the ability toexplore patients' disturbing fantasies about the therapist or those closeto him or her at a time when the therapist is stressed. Hearing patient'stalk about one's own worst fears can be very difficult and result in thetherapist cutting off such discussions. Alternatively, avoiding or with-holding self-disclosure can, as I have already indicated, create a situa-tion in which the patient senses things that cannot be discussed and isleft alone with his or her own fears. Some therapists, however, may al-lay their own anxiety by sharing too much information with certain pa-

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tients beyond what is necessary. A countertherapeutic role reversal, anoverstimulating sense of intimacy, or a blurring of boundaries betweentherapist and patient may ensue.

There are other complications that affect the therapist's feelingsabout and willingness to self-disclose that stem from his or her ownfeelings about privacy and how comfortable he or she is in being knownby the patient. Concerns about self-disclosure often are intensified whenthe disturbing events are affecting others in the therapist's life aboutwhom the patient is unaware, such as a spouse, companion, or childrenor when there is a stigma attached to the information as might be thecase in disclosing that one has a live-in partner, or is in a gay or lesbianrelationship, or is going through a divorce. Further, a therapist can becomfortable with one patient knowing more personal information butconcerned about the information going to others who are patients of thetherapist or who know the therapist in another context. Thus, the deci-sion about whether and how much to disclose can rest on what is in thebest interests of the therapist. Sometimes there are negative repercus-sions for the therapist as well as for the treatment when patients andothers learn personal information.

Therapists should feel free not to self-disclose to patients. Thera-pists and those close to them personally do have rights to their privacyand therapists can have limitations about what they can deal with inthe therapeutic process at certain times. The main issue here is whetherthey can non-defensively acknowledge their needs for privacy or theirlimitations and what this means to the patient while showing empathyfor the patient's desire to know more about the therapist and his or herdifficulty tolerating and accepting not knowing.

While therapists have a right to privacy, the exercise of this righthas ethical implications in certain instances, for example, when it in-volves withholding information about the therapists' serious illness oreven impending death. Disclosure can be very difficult for therapist andpatient, creating its own sometimes negative therapeutic consequences,including premature termination. The sense of betrayal, powerlessness,and rejection that result, however, when a therapist withholds crucialinformation that affects the patient outweighs the potentially harmfuleffects of therapist self-disclosure in most instances and constitutes aviolation of professional ethics and responsibility.

There are traumatic situations when it likely is preferable for atherapist not to continue to practice because of the strain that this putson both patient and therapist and in which a referral to another thera-pist is indicated. There is a tendency for therapists, however, both forpersonal and financial reasons, to continue to work no matter whatsometimes well beyond their real capacity to do so and despite the urg-ing of friends and associates. There is no clear solution to this.

EDA G. GOLDSTEIN

SUPERVISORY SUPPORTS

In the article I described earlier by Alexander, Kolodziejski, San-ville, and Shaw (1989), the therapist sought help from several profes-sional colleagues to help her with the treatment of her patients duringher illness. The informal supervisory group that formed served not onlyto aid the therapist in understanding what was occurring in the treat-ment process and in determining how best to intervene but also servedas an important support system to the therapist so that she did not haveto turn to her patients for comfort. While those close to us play impor-tant roles in this regard, they often are not able to help us deal with ourpatients. Of course, supervisors or consultants often have their own bi-ases, blind spots and other countertransference issues so that seekingoutside help is not a panacea. It is an important option, however, indealing with the highly charged situations that I have been describingparticularly at times when our own judgment as therapists is taxed.

REFERENCES

Abend, S.M. (1982). Serious illness in the analyst: Countertransference considerations.Journal of the American Psychoanalytic Association, 30, 365-80.

Alexander, J., Kolodziejski, K., Sanville, J., & Shaw, R. (1989). On final terminations:Consultation with a dying therapist. Clinical Social Work Journal, 17, 307-24.

Blanck, G., & Blanck, R. (1974). Ego psychology: theory and practice. New York: ColumbiaUniversity Press.

Bugental, J.F.T. (1965). The search for authenticity. New York: Holt, Rinehart, & Winston.Chiaramonte, J.A. (1986). Therapist pregnancy and maternity leave: Maintaining and fur-

thering therapeutic gains in the interim. Clinical Social Work Journal, 14, 335-48.Dewald, P.A. (1982). Serious illness in the analyst: Transference, countertransference, and

reality responses. Journal of the American Psychoanalytic Association, 30, 347-64.Fenster, S., Phillips, S., & Rapoport, E. (1986). The pregnant therapist: Intrusion in the

analytic space. Hillsdale, New Jersey: The Analytic Press.Fromm-Reichman, F. (1959). Psychoanalysis and psychotherapy. Chicago: University of

Chicago Press.Genende, J. (1988). A therapist's pregnancy: An opportunity for conflict resolution and

growth in the treatment of homosexual men. Clinical Social Work Journal, 16,66-77.Goldstein, E.G. (1994). Self-disclosure in treatment: What therapists do and don't talk

about. Clinical Social Work Journal, 22, 417-33.Greenson, R. (1967). The technique and practice of psychoanalysis. New York: Interna-

tional Universities Press.Guntrip, H. (1975). My experience of analyses with Fairbairn and Winnicott. International

Review of Psychoanalysis, 2, 145-56.Jouard, S. (1971). Self-disclosure: An experimental analysis of the transparent self. New

York: John Wiley & Sons.Kohut, H. (1971). The analysis of the self. New York: International Universities Press.Kohut, H. (1977). The restoration of the self. New York: International Universities Press.Lax, R. (1969). Some considerations about transference and countertransference mani-

festations provoked by the analyst's pregnancy. International Journal of Psycho-anal-ysis, 50,363-72.

Morrison, A.L. (1990). Doing psychotherapy while living with a life-threatening illness. In

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H. Schwartz & A. Silver (Eds.). Illness in the analyst. New York: International Univer-sities Press.

Naperstek, B. (1976). Treatment guidelines for the pregnant therapist. Psychiatric Opin-ion, 13, 20-25.

Rogers, C. (1951). On becoming a person. Boston: Houghton-Miflin.Rosenthal, E.S. (1990). The therapist's pregnancy: Impact on the treatment process. Clini-

cal Social Work Journal, 18, 213-26.Searles, H.F. (1986). My work with borderline patients. New York: Jason Aronson.Stolorow, R.D., & Atwood, G.E. (1992). Contexts of being: The intersubjective foundations of

psychological life. Hillsdale, New Jersey: The Analytic Press.Stolorow, R.D., Brandchaft, B., & Atwood, G.E. (1994). The intersubjective perspective.

Northvale, New Jersey: Jason Aronson.Sullivan, H.S. (1953). The interpersonal theory of psychiatry. New York: W.W. Norton.Truax, C.B., & Carkhuff, R.R. (1967). Toward effective counseling and psychotherapy. Chi-

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choanalysis. International Journal of Psycho-analysis, 56, 69-77.Winnicott, D.W. (1965). The maturational processes and the facilitating environment. New

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Eda G. Goldstein, DSWNew York UniversityShirley M. Ehrenkrantz School of Social Work1 Washington Square NorthNew York, New York 10003-6654

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To Tell or Not to Tell the Disclosure of Events