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Thursday, April 26, 2007

On Self-Disclosure and Family Therapy

The question is on the table, eloquently served by readers

Why AREN'T you anonymous, TherapyDoc? I quote:
"Even your highest functioning clients could so easily become internally disorganized around learning so much about you, your views, your family, your experiences, etc."

"I am a budding therapist (psychology student) and wondered about your thoughts regarding the amount of self-disclosure you are making available to your patients via this blog. I know from my own therapy that 1) I am endlessly curious about my therapist's personal life and obsess about it sometimes while 2) it is much better for me therapeutically NOT to know too much. I think I would feel uncomfortable as a patient having access to so much of my therapist's personhood via a blog, and I imagine that as a therapist I would be worried about being so transparent to patients. Any thoughts? Do you ever worry about affecting your patients adversely because of your blogging?
Many thanks,
a loyal reader in PA"
Have I Any Thoughts? Well, now that you've asked.

But for a second opinion I showed these quotes to F.D. and asked him what he thought. He smiled, shook his head and said, "Anybody reading your blog knows nothing about you. Virtually nothing. Who knows your thoughts when you pray?"

Uh, well. . .

What he means is that we're all very complicated people and it takes a therapist many, many visits to really understand someone, so a couple of posts on a blog don't really tell you very much.

But as cute as he is, and even though I respect what he says, he's wrong. You know plenty. And I have a very different answer, anyway.

It's all about orientation. I'm a family therapist and a behaviorist.

It's about time you learned what that really means. And oh, I have so much to say, so get yourself a cup of tea and come back when you're ready.

In family therapy it really is all about the patient's family, no matter who presents as an "identified patient." From the very first encounter on the telephone it is the family and the way the family is coping with problems that is the focus of treatment. Although as therapists we recognize that we have a place in a patient/family system, the therapy is NOT about the patient-therapist relationship.

It's not about me. Family therapists like me very, very, very rarely talk about themselves in therapy unless a particular anecdote demonstrates a point and will clearly "work." But again, that's going to be rare and with a great deal of discretion and it's not necessary. There's so much better material to present, the reservoir of material the patient and the patient's family already have.

Oh, there's so much to say.

Family therapists not only treat, but we diagnose differently.

In couples therapy, for example, there really are 3 patients, the partners make 2, the relationship between them, 3. In family therapy you add a couple of kids or another member of the extended family or community, and you may have many, many dyads and triangles and individuals that might need tweaking! You need to know your algebra to do a decent assessment!

A doc who graduates with an MD, PhD, PsyD , MSW, etc., who hasn't really been through family therapy training certification is NOT a marital or family therapist. Individual therapists have the right to say they treat families and couples, but I'm sorry, they don't KNOW family therapy. In their heads it's still more likely to be about the patient/doctor relationship and how the doctor can get the patient (the most dysfunctional member of the family) to behave differently. Please, challenge me. Say it's not so.

But we really do use the family as the change agent.

Thus our take on the centrality of the patient/doctor relationship is very different. It is the patient's relationships with OTHER people that are important prognosticators for change.

Even when I'm seeing an individual, no matter what the content of the discussion, very early into it, unless it's a long initial patient soliloquy, a narrative of the story which I total hope for and encourage, I'll ask a variant of:
So what did So and So say about that? or
How does So and So feel about that?
What do you want out of your relationship with So and So? or
How do you want to fix that with So and So? or

If you could go back in time, how would you look at that relationship and what it meant to you, to So and So, to your future, to how you look at life, people, relationships, etc, now?
There are many variants of those questions.

The So and So's are multivariate, too. There are many people who both affect and are affected by every patient we see. Examining the psychological motives of these significant others and their relationships, we tease out patterns and feed-back loops.

This is where we discuss the therapist, too, how the therapist plays into the patient's ecology. The patient's transference does enter into the therapy and is discussed as such. But it's not the focus of therapy. The other relationships are paramount and more interesting. Most of the time, that is.

Family therapists see shifting the patient's relationships as ideally ameliorative. But many of us have a good deal of other training and know many other behavioral techniques, most with an individual's behavior as a target for change. We'll use family to reinforce a new behavioral sequence or interactional change that's been established as a treatment objective.
Still with me?

Even in individual work a behavioral family therapist will work to capitalize on the power of the family or others in the individual's eco-system. Strategies for change can and should be "designer" strategies, unique to a particular individual, couple or family. Determining what will work is a joint enterprise. I, for one, can't possibly know what will work for an individual or family without patient/family feedback.

I would guess, and it IS a guess, that behaviorists who put patients in charge of choosing designer therapeutic interventions are working to empower them. I do. There is little or no "resistance" in this process, usually, in my practice, probably because we're working together and the patient is in charge and feels in charge.

Another way of looking at it is that family therapists like myself who trained at the Family Institute of Chicago/Center for Family Studies (now a part of Northwestern University in Evanston) use a problem solving therapy which is very different, I think, from a psycho-dynamic or psychoanalytic therapy in which interpretation and transference play a much larger role.

Not to put down psycho-analysis, for I would hope that the training has changed by now, but in the 1980's I heard the following story from a colleague- again, I'm sure this would never happen now, in our hyper-therapy-Oprah-conscious-media-driven world:
A man, an alcoholic, tells his new therapist about his previous therapy. He saw an analyst (omniscient) for many years and talked about relationships with women. The new therapist asked why the analyst never got around to treating his alcoholism, or had he tried? The patient said, and I quote, "The doctor never asked about my drinking. We never discussed it."
What did they talk about? I don't know. But in family therapy that would never happen.

Being a family therapist does NOT mean that a patient's individual psychology is irrelevant, obviously, not in individual "family" treatment, not in couples therapy, not even in family treatment. Of course we talk about the past and how it has affected everyone in the family.
Transgenerational family dysfunction is one of the mysteries we want to unravel. One's family of origin can hold the key to understanding today's thinking and behavior. This is why we use genograms (family trees) to help us understand where individual responses, patterns and feedback loops come from.

Nor does family therapy obviate the need to discuss diagnosis or medication of family members who have an Axis I or II disorders. Family therapists probably don’t label people as often as other therapy docs, but many of us, depending upon our training still hold by a medical model of treatment. Medical diagnosis matters.

Okay. But for those patients who might obsess about me, like B? What about that?

I've handled it by telling all of my patients that I have a blog and that I share some of myself on the blog. I tell them that indeed, if they think that's too weird for them or if it makes them at all uncomfortable they have three options:

(1) they don't have to read the blog, it's not required, I explain all of the concepts that might relate to them in therapy anyway, first hand
(2)they can discuss anything that they do read on the blog with me and we can discuss how it relates to them
(3) We can always arrange for a referral to a therapist who is more of the omniscient variety.

I also tell patients that what they read on Everyone Needs Therapy (ENTx) is either about me or is fusion of case material or stuff I've seen on television or in the movies. Or I made it up entirely. I always change possible identifiers like age, race, gender, and context.

Perhaps it's the nature of family therapy, but people who see me really do want their problems solved and rarely ask about my life. They'll mention my bicycle. They'll ask where I go on vacation. Most questions about me are off limits and they respect that boundary. Most of the time I answer a question about me with a question about themselves. It's the Jewish way of learning.

I'm much more interested in you than I am in talking about me.
Me, I know.

The mission of this blog is international psycho-education. I feel, however, that the hypnotic quality of personal writing delivers powerfully, teaches by keeping the average attention span longer than might a list of things to do in a particular situation with a particular disorder or problem. We’ve all seen those lists. How-to’s, lists of symptoms-- those you can find anywhere. You can Google them or go to a bookstore. Research? You can access university libraries and journals on the Internet, too.

There's more. One of the reasons I blog is a religious conviction that if a person knows something, something important that should be common knowledge, then there is have an obligation to teach it. In therapy, during a psycho-educational discussion, patients have said to me, This should be taught to every school child.

I whole-heartedly agree. So I tell you on this blog. Teach your children.

As a social worker, my mission, the mission of my profession, is to educate and serve mankind, to reach out to individuals, families, organizations, and communities. It is only in the latter years of the 20th and now in the 21st century that we have begun to talk about reaching international communities. What I am doing here on this blog might be considered international social work.

Do I believe that the Internet is changing the way that we communicate professionally for the better?
Yes, I do.

Do I believe that the professions are changing and will continue to change for the better due to the ease, speed, utility, and price of disseminating knowledge on the Internet?
Yes, I do.

Do I believe that the face of psychotherapy and family therapy will change in ways we can’t even imagine due to the Internet?
Yes I do.

And we will have to adapt.

If we are going to prevent things like the Virginia Tech massacre in the future, professionals have their work cut out for themselves. No, we don’t have to tell the world what we prefer for dinner, or that we even go out for dinner. We don’t have to disclose some of the conversations we’ve had with our mothers, fathers, sisters or significant others; we don’t even have admit that we HAVE living relatives. But I don’t think it hurts anyone. I really don’t. It's more important that people read, that many people read.

The system does seem to work. We are talking. People are learning a lot with the price of a click. G-d knows I don't know everything (and I try to keep learning every single day.) But I feel good about doing this.

Now, all of that said, Couldn't I still have worked this blog anonymously? What was the point of putting my John Hancock on it?

As much as I want to give it all away for free, like I've said many times before, I don't want kids cutting and pasting and putting what I write in their papers. And I don't want other writers to take my way of saying things. I feel these are my words and if someone wants to steal them, not cite me properly, then I want them to feel guilty.

Guilt is the greatest motivator, you should know.

Aye, but you ask, why is it that my identity no longer is posted on the blog? What happened?

Family and friends, to be honest, have been on me about safety issues. The Internet is a dangerous place, they say. You're vulnerable. We worry.

And they're right, of course. I have a responsibility to protect myself from stalkers and sociopaths. I can't be naive about them.

If you've been reading my personal posts you know there's a lot about me that's very PollyAnn-ish, that gives the benefit of the doubt, expects the best from everyone, that closes her eyes to real life and negative aspersions, "evil" motives. It is the Jedi in me that says,

Fear leads to Anger. Anger leads to Hate. Hate leads to Suffering (Star Wars, Phantom Menace). So I've tried very hard NOT to be afraid as an identifiable blogger on the Internet.

But I have told you about my home invader dreams, right?

Who needs this?

Copyright, you bet, 2007, Therapydoc

17 comments:

socialworker/frustrated mom said...

A good point brought up, very interesting and sooooo long lol.

bjurstrom said...

Dear Doc,
you may get this blog twice--as I somehow made a mess of remembering how to blog.....if so please delete this version ....Anyway ---Courage is a good thing--we need examples of courage. Your blogs are informative (read Very informative),thoughtful (makes one think), and COURAGEOUS (you could be wrong-you could offend). It takes courage to teach and teach you do---things can get fixed, there is hope---knowledge is passed on----Anonymous is not OK it does not teach the value of the person. I listen and read because you are not anonymous. I see blogging as becoming more civilized--I think we are in a kind of "Wild West" period. Stay courageous like any self-respecting pioneer. Deb

TherapyDoc said...

Thanks, SWFM.

Deb, the Wild West is a great metaphor. And YOU'RE not alone.

In the Chronicle for Higher Education , Colleen Mondor writes:
The . . .blogosphere is a messy place with many formats, thoughts, and opinions, but that is what democracy is all about. Sometimes, folks, you just have to live with the delightful chaos that freedom of expression brings forth.

J said...

Thanks for putting yourself out there for the likes of us.

I'm not sure if blogging with a name and a few vague personal details is any inherently more dangerous than anything else (maybe greater #s, disinhibited aggrsn), but you're braver than I.

Anyway, is there any class of disorders or situation you address without intensive family involvement? For example, what do you do if they or a family member is schizoid (though if I recall they don't seek therapy much) or if the patient is estranged from most of their family?

J said...

Oh...and since you mentioned it, at what point does obsessing exceed normal? I obsess on occasion to the point where I start wondering what my problem is. You know, squirrels and My Little Ponies. But, maybe that's normal. I've no clue, but I guess I'm full of questions today--I'll pipe down now.

TherapyDoc said...

J, since the diagnosis is only one piece of information, it can't dictate who i see when. I make that call as i go along, based on what my objectives are. People don't HAVE to bring in significant others, although I've found therapy is much easier if from the first visit we have an understanding that it will probably help to bring people in when nec.

About obsessing, if it's not classifiable (see the OCD post) well, that's just how we're wired. It's our personal test to attend to what will ultimately be a growth experience (like reading or concentrating on a task), or perhaps do something for our mental health (exercise or self-relaxation) instead of obsess- go over a situation, thinking about a person, over and over again. It ain't easy choosing.

the mind candy tends to win. now back to work

Chana said...

I know who you are, and that's all that matters. (ggg)

TherapyDoc said...

Chana, thanks

PsychoToddler said...

Since you blog primarily about therapy related issues, from a position of professional authority, it's appropriate (and more effective) for you not to be anonymous.

For me, it's a little different. I have maybe 3 patients who know about my blog (which is really not anonymous).

While I have no problem with my readers knowing that I'm a doctor, I would feel a little uncomfortable with the bulk of my patient's knowing about my blog. Or that once a year I dress up like a caveman.

TherapyDoc said...

Pycho, I'll have you know that this blog is really down on poking fun at people who live in caves. One of our favorite ancestors tried it for awhile, of course, he was hiding from a king suffering from an affective disorder.

Thanks for writing.

Jonathan said...

TherapyDoc: Thank you for your thoughtful observations (as usual) on this issue. I have added a link to your post on my disclaimer page.

On another note, thanks for the brief Imagine plug on the absurdly long commentary to my Trifkovic post. You made me smile just when I really needed one.

TherapyDoc said...

Jonathan, you're welcome. For those of you who care to see his post (it's worth it) he's a dreamer so of course what other comment could there be than a reference to John Lennon's Imagine?

Anonymous said...

i can understand...there used to be a girl who would blog about various things and she was sent death threats and pictures and she had to stop blogging...it was in the news. :(
but personally i love your blog i find it very learnable even if the the links can be a pain in the butt
i love you keep on writing

therapydoc said...

Anon, I intend to keep on writing, thanks. Thanks for the support.

cardiogirl said...

This is such an interesting perspective. I thought I was unique in that my main issues are with my family of origin (FOO), not my husband or children.

While some of that has overflowed into my adult life, mainly the issues are with the FOO.

I always joke with my therapist and tell her, Why do all roads lead back to my childhood? Just once I'd like to find out something is because of the color purple and not my father.

Such is life.

therapydoc said...

It's a year later. I wrote all that?

Chana said...

That, and a lot more since then. :) Thank you!