Clinical Social Work Journal Vol. 25, No.

1, Spring 1997

TO TELL OR NOT TO TELL: THE DISCLOSURE OF 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 during the course of treatment that intrude on the therapeutic process whether or not their true nature is disclosed to the patient. Therapists are not immune from experiencing acute, chronic, and even terminal illnesses, divorce, remarriage, adopting a child, mourning the death of a parent or significant other, or major accomplishments. In many instances such events affect the treatment process by disrupting appointments, necessitating sudden absences, restricting a therapist's emotional availability and physical stamina, or altering the therapist's mood and affect. In other instances, patients may be aware of such events, at least unconsciously, because of subtle changes in the therapist. Drawing on self psychology and intersubjectivity this paper explores the reasons for therapist self-disclosure of these events based on an assessment of the patient's developmental needs and the nature of the transference. It will discuss ways of making such disclosures therapeutic. KEY WORDS: self-disclosure; therapist illness; special events; treatment disruptions.

INTRODUCTION In addition to the life events that we, as therapists, plan and anticipate with pleasure and joy, there are those that occur during the course of our work that are disturbing and over which we are powerless. They expose our human vulnerability, stir our innermost anxieties and feelings, and evoke our characteristic defenses and coping mechanisms. Whether or not we disclose the nature of these sometimes traumatic events 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 by disrupting appointments and necessitating sudden absences or by their effect on our emotional availability and physical stamina. Yet the sparse clinical literature on this topic leaves one with the impression that, for the most part, traumatic events only befall patients. Therapist self-disclosure in treatment generally is a threatening topic because sharing personal information can expose the therapist's lack of omnipotence, challenge feelings of invulnerability, and reveal one's most personal self. It is noteworthy that there are numerous papers on the impact of a therapist's pregnancy on patients perhaps because women are not able to conceal their condition and must plan for some interruption of treatment (Chiaramonte, 1986; Fenster, Phillips, & Rapoport, 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 for the clinician to respond to patients' requests for personal information or to initiate the sharing of feelings, life experiences, or attitudes at times in the treatment of selected patients. I argued that the thoughtful and sometimes spontaneous use of self-disclosure can be a form of empathic attunement and responsiveness that is essential for the successful engagement and treatment of certain individuals. As a result of this paper, many therapists shared with me, often with considerable trepidation, some of their struggles with self-disclosure and its seeming positive and sometimes negative effects on their patients. I was struck by their aloneness as they ventured into uncharted territory often feeling that they had to keep the fact of their selfrevelations to patients to themselves, not even sharing them with their supervisors in some instances. On numerous occasions, a therapist approached me to share his or her quandary about whether to tell a patient that the therapist had breast cancer or AIDS or was divorcing, remarrying, adopting a child, dealing with the illness or mourning the death of a parent or significant other. I felt ill-prepared to respond adequately. As I began to ponder this issue further, I did not immediately think about life's intrusions on my own practice but instead thought about patients whom I had seen after they had left other therapists prematurely or were forced to stop their treatment abruptly as a result of a therapist's illness or death. They had to deal with their feelings and fantasies about these traumatic situations alone and were affected quite negatively as the following example indicates.
Mrs. L., a middle-aged married professional woman, remained in twice weekly treatment with an older male analyst whom she saw deteriorate markedly before her eyes over the course of a year. She reported trying to broach the subject of 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 leaving him but felt that this would be disloyal. One day she arrived at the session to find that he was not present. Later she found a message on her answering machine from his wife saying that he was unable to resume his practice. She received no help with a referral and never learned what happened to him but a Christmas card she sent to him was returned to her. It took two years before she overcame her disillusionment and feelings of abandonment sufficiently to seek help from someone else despite problems that were very troubling to her.

The following incident in my own recent past, however, brought the issue of whether to self-disclose in the midst of a traumatic life event into clear focus.
I was faced with the disturbing news that a loved one had cancer, necessitating the sudden cancellation of my patients and the rearranging of session times over a several week period. I felt quite worried and depressed during this time but did not want to give information that either would burden patients or lead to discussion of my personal life or of upsetting issues. Yet I thought it would be too alarming to refrain from giving any explanation for the sudden and continued disruptions of the treatment. There was a flu epidemic occurring and I used this as 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 own emotional turmoil affected my feelings and attitudes during session times. I must confess that I felt resentment at times if a patient did not appreciate what I was going through. If a patient expressed anger at my forgetting the name of a previous short-term companion or voiced some other similar grievance, I can remember thinking that he or she ought to be glad I was present at all. I felt impatient 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 was self-conscious about how tired I looked. I wondered if certain patients sensed that more was going on since they seemed to be talking about cancer and death more than usual. To this day I do not know for sure what they really thought and felt during this period. Nor do I know whether my handling of this situation was 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 have with a highly favorable prognosis for the cancer victim, it reminded me of another more troubling life crisis and its aftermath many years earlier.
The long illness and eventual death of a close companion led to a long mourning period during which I continued to practice. I quite consciously kept this information from my patients at the time. I did not really think about whether this was in their best interests. I took for granted the fact that any self-disclosure of this kind was contraindicated across the board. I know that I did not feel prepared to discuss these events with my patients. Like many therapists who have sustained losses, my work was therapeutic for me. Only one patient, a severely borderline woman who was keenly aware of me, ever pointedly questioned me about my personal life during this time. In retrospect, 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 nor did they feel free to question me about. It is possible that I did not pick up on their possible questions even though I thought I was being attentive to them at the time. This latter explanation was supported by an incident that occurred two years later from a patient who had terminated treatment and moved to another city upon remarrying. In a visit East, she made an appointment to see me in order to touch base. During the session she asked me if I had some kind of loss during the end of her treatment. I was not prepared for her question and responded that I was not sure what she really wanted to know. She said she had often thought about the last few months of our work together. She felt that I was very sad and regretted not discussing this with me. I asked what this meant to her. She explained that she first thought that it had to do with her leaving and was touched. Later she felt that she was not important enough to warrant such a reaction and that I had seemed different for some time. She said that she was afraid to upset me by asking me personal questions but later felt sad and guilty that she had not summoned the courage to do so. We were able to connect her feelings in this situation to an earlier experience in her life. She felt that her mother cared more for her sister who died at an early age than for the patient who was more successful. The patient regretted that she and her mother had never had a talk in which she shared her concerns. To her surprise, she released considerable affect during this exploration. Afterward, however, the patient asked me if her suspicion about me was accurate. I commented that she seemed to feel that she needed to know. She replied that she wished I could just respond honestly. I then told her that someone very close to me had been quite ill and had died but also explained that my sad feelings about her leaving were real. I said that while I felt happy that she was doing well and embarking on a new phase of her life I also knew I would miss our work together. The patient became tearful and looked visibly relieved. She did not ask me to disclose more of the circumstances surrounding this occurrence nor did she want to discuss her reactions to my disclosure further. A month later I received a letter from the patient in which she thanked me for having shared with her. She wrote that something lifted for her that seemed to go beyond our relationship. In thinking about these situations, I found myself contemplating a host of questions. If life events intrude on the therapist is not the treatment always affected even if the therapist does not share what is happening? 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 the therapist's life? Can a therapist help to make disruptions in the treatment therapeutic? Does the therapist have a right not to tell even if patients need to know? Are there theoretical perspectives or diagnostic indicators that can help to answer these questions? TRADITIONAL PSYCHODYNAMIC PERSPECTIVES That psychodynamically oriented therapists traditionally have been admonished to be neutral, anonymous, and abstinent has emanated from the view that the uncovering, interpretation, and resolution of un-

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conscious instinctual conflict and the modification and working through of the associated symptoms, character traits, and defenses are the main pathways to therapeutic change. Within this framework, the patient's fantasies and transference reactions must be allowed to develop unhampered by information about the therapist as a real person. In emphasizing the role of insight, this view minimizes the importance of the experiential aspects of the treatment process. It neglects the crucial role of the therapist's provision of real object or selfobject experiences in facilitating change. Embedded in the traditional model is the belief that the therapist is the expert observer of the patient's pathology rather than a participant whose feelings, attitudes, and behavior influence the process. It has encouraged the mistaken idea that therapists can and should consciously control, if not eliminate their personality from the treatment process. Thus it is not surprising that psychoanalytically oriented clinicians generally have cautioned against the therapist's disclosure of personal information and that there is a dearth of writing or discussion on how to deal with situations in which some disclosure of personal information is unavoidable or necessary. While humanistic and some interpersonal theorists have advocated authenticity, realness, genuineness, and mutuality in the therapeutic encounter and showed a greater acceptance of the need for therapist self-disclosure generally, their views remained on the fringe of the psychoanalytic 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 as well as the transference relationship between the therapist and the patient helped to open the door to a different conception of the uses of the therapist'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 and written about the importance of dealing with life events that intrude on the treatment. For example, in a 1977 article, Weiss writes of the importance of "special events" that occur during the analytic process, the interpretation of which can be beneficial in highlighting transference issues and the ignoring of which can be detrimental. Weiss, however, gives examples of such earth-shattering events such as his running into a patient outside of office hours, a patient hearing him talking to another patient, a patient leaving an umbrella in his office, and his answering a telephone 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 acknowledges that his initial efforts which he rationalizes as protective of his patients were based on his own denial of the seriousness of his condition. He asked his secretary to cancel his sessions and tell patients that he was ill and would return the following week. Later it was necessary for her to tell them that he would be out indefinitely and would call them upon his return. In deciding how much factual information to share, he tried to weigh the negative effect of telling too much on the patient's transference and fantasies against the stress of saving nothing or too little on the patient's adaptive capacities and willingness to continue treatment. Meanwhile, many of Dewald's patients found out from other sources that he was seriously ill and much misinformation was communicated. In deciding whom he should see when he returned initially to part-time practice, he considered who of his patients knew each other. When he returned and still had visible signs of his illness, he gave the least information to patients who were in intensive treatment and the most information to those who were in "more superficial" treatment or in the beginning stages out of concern for minimizing the impact on the transference in the first instance and not discouraging patients from continuing in the second. Later he worried about the effects on the treatment of the role reversal involved when many patients sent him greetings and small gifts. Dewald further describes how he dealt with his patients' reactions to and fantasies about his illness as well as his own counter-transference. At the 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), another prominent analyst, confesses that despite his decision not to do so, he found it impossible not to self-disclose about his illness and did this in a somewhat arbitrary fashion. Nevertheless he argues that it is better not to disclose about one's illness to patients even if its lingering effects are apparent because to do so as he did always reflects the therapist's conscious or unconscious motives rather than an accurate appraisal of what is in a patient's best interest. In these rare examples, the authors indicate that they were "flying by the seat of their pants." While their self-disclosures became grist for the therapeutic mill and seemed to initiate beneficial discussions in many instances, the therapists view self-disclosure as therapeutically necessary and inevitable but not desirable, potentially constructive but never optimal. A compelling and beautifully written article by Alexander, Kolodziejski, Sanville, and Shaw (1989) describes how a psychoanalytically oriented clinical social worker enlisted the help of several colleagues to help her deal with her patients after receiving a cancer diagnosis which

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eventually led to her deterioration and death. Because some patients noticed changes in the therapist, the strong likelihood that she would need further treatment, and the possibility that it would be necessary for her to prematurely terminate their treatment, she felt a sense of professional responsibility to deal with her illness openly. The authors share in some detail how they helped the therapist to reveal the necessary details of her worsening condition, to explore its unique meaning to each of her patients, and to deal with her own ambivalence and highly charged emotions during this emotionally painful process. Finally, in a chapter by Morrison (1990), another clinical social worker courageously describes her own process and the impact on her patients of her cancer diagnosis, its recurrences, and her ultimately favorable course over a six year period. She discusses the unique responses of each patient including their denial and inattention to the blatant changes in her appearance, the different degree of self-disclosure based on her assessment of each case, her conscious countertransference 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-disclosure in a professionally responsible manner but also the very difficult and highly individualized and subjective process. SELF PSYCHOLOGY AND THE INTERSUBJECTIVE PERSPECTIVE Both self psychology and the intersubjective perspective recognize the importance of the experiential as well as interpretive aspects of the treatment process and provide the underpinnings to a new way of thinking about the disclosure of events in the therapist's life that intrude on the treatment. Self psychological treatment focuses on the revival of patients' frustrated early selfobject needs in a new and more empathic context. Kohut (1971, 1977) clearly identified three main types of early selfobject needs: 1) the need for mirroring that confirms the child's sense of vigor, greatness, and perfection; 2) the need for an idealization of others whose strength and calmness soothe the child; and 3) the need for a twin or alter-ego who provides the child with a sense of humanness, likeness to, and partnership with others. Others have suggested additional selfobject needs, for example, the need for an adversarial selfobject (Wolf, 1988). While not all selfobject needs are gratified, rewarding experiences with at least one type of selfobject give the child a chance to develop a cohesive self. When traumatic or repetitive empathic failures on the part of early caretakers occur, the self is weakened and does not consolidate. The selfobject transferences reflect the revival of these early needs

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and must be allowed to develop. Their emergence provides patients with a second chance to complete their development. Thus the experiential as much as the interpretive nature of the treatment is essential to patient growth. The therapist's empathic understanding and responsiveness, the repair of disruptions in the transference, and the exploration of early caretaker failures in attunement and their effects lead to the development of a more cohesive self. While there are differences of opinion within self psychology about how much the therapist should depart from empathic listening and interpretation actually to provide other types of selfobject responsiveness to patients, I believe that there are situations in which engaging in experience-near-empathy necessitates the therapist actually functioning as a selfobject as I have discussed elsewhere (Goldstein, 1994). Thus, I regard the selective use of self-disclosure as a form of empathic responsiveness. For example, certain patients have had repeated early experiences in which they were shut out of their parents' lives; vital information was kept from them; their own feelings and perceptions were never validated; catastrophic events occurred without seeming warning resulting in deidealization of their parents or traumatic disruption of their lives; or they were deprived of the mutuality and intimacy involved in close relationships. Maintaining an interpretive stance in these situations runs the risk of too closely resembling the original frustration to which these patients were exposed and also fails to provide the patient with a more responsive selfobject milieu. Utilizing this framework, the decision about whether it is therapeutically indicated to tell or not to tell a given patient what is going on in a therapist's life, the question of how much to share, and the task of making self-disclosure therapeutic must be examined in the light of the patient's selfobject transference and his or her developmental needs. The intersubjective perspective, which overlaps with but is distinct from self psychology, also focuses attention on the therapeutic relationship in a new way (Stolorow & Atwood, 1992; Stolorow, Atwood, & Brandchaft, 1994). Within this theory, both therapist and patient shape all aspects of the therapeutic situation since both participants exist in an intersubjective field in which they mutually and reciprocally influence one another. This framework challenges the traditional view that the therapist can be an objective and neutral observer of what occurs in the therapeutic interaction since a therapist always has an effect on the patient even if he or she is not fully conscious of the impact. The intersubjective perspective points out that the therapist, like the patient, is influenced by both conscious and unconscious organizing principles, including those derived from their favorite theories, which affect the treatment process and help to shape the patient's behavior in the treatment.

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Like self psychological therapists, the intersubjectivists must strive to understand how their own personalities, belief systems, and needs influence what they observe, how they intervene, and the patient's behavior as well as how the patient affects them. Whatever the therapist does or does not do as well as what he or she thinks and feels has an impact on the treatment process. Consequently, a therapist who is caught in a situation that intrudes on the treatment needs to consider not only the possible effects of self-disclosure on the patient but the impact of remaining silent. Further, the therapist's decision not to share information that is uppermost to him or her emotionally can have negative effects on his or her ability to remain empathically connected to the patient. While Stolorow (1994) takes the position that the analyst's main activity ought to reflect a commitment to investigating the meaning of his or her affective responsiveness, or its absence, for the patient, the therapist should not be constrained by the rule of abstinence. Instead, he or she should use a wide repertoire of interventions to help the unfolding and exploration of the patient's subjective world. Thus intersubjectivity allows for much more flexibility in the therapist's use of self, so long as their is consistent investigation of its impact on the patient. "This greater flexibility frees analysts to explore new modes of intervention and to discover hitherto unarticulated dimensions of personal experience" (p. xi). The selective use of therapist self-disclosure seems consistent with an intersubjective perspective. An intersubjective perspective recognizes a broader range of transference reactions, however, than does self psychology, particularly with respect to those persistent organizing principles of the patient that appear in the form of what Stolorow refers to as the repetitive and conflictual aspect of the transference in addition to its selfobject dimension (p. 38). This increases the lens that the therapist must utilize in assessing the patient's subjective world and suggests different interventions. The decision whether and how much to self-disclose cannot be based only on whether the patient shows a selfobject transference or a repetitive and conflictual one. The task of knowing how best to facilitate the treatment requires that the therapist, whether by sharing too much or too little, is colluding with or helping to repair the patient's past traumatic or dysfunctional relationships. While both the self psychologists and intersubjectivists are writing from a psychoanalytic framework, in my view it is not useful for the purposes of a discussion of self-disclosure to differentiate patients who are in psychoanalysis from those who are in psychotherapy. While there have been numerous and frequent attempts to distinguish between these 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 the needs of the patient. CONSIDERATIONS IN DECIDING WHETHER TO SELF-DISCLOSE While I cannot offer clear guidelines for determining whether or not to self-disclose based on an assessment of the patient's transference and developmental issues, the following are some thoughts that I have about this decision. Not all patients have the same ability to reexpose themselves to potential disappointment and rejection and to sustain relationships in the face of disruptions. If events in the therapist's life intrude on the treatment in a way that seriously taxes or undermines the patient's feelings of safety and ability to trust the therapist or inadvertently recreates the traumatic conditions of a patient's childhood, derailment of the treatment can result. Threats to the treatment may be particularly acute in early stages before the patient has developed a stable selfobject transference or at points when he or she is dealing with core issues. That this is true, however, does not necessarily dictate whether and how much to self-disclose. The therapist needs to ask whether it is better for the development and maintenance of the patient's transference for the therapist to remain unknown or whether depriving the patient of one's realness or of important information can be countertherapeutic. For example, when an idealizing transference is developing or tenuously present, therapist self-disclosure of events that cause him or her to be viewed as vulnerable can lead to traumatic deidealization or to a panic reaction that the therapist, like earlier important people in the patient's life, will not be sufficiently strong to take care of the patient or will abandon the patient through illness, self-preoccupation, or death. When needs for mirroring are primary and the patient is very selfabsorbed to the degree that the therapist does not exist as a real or separate person, any self-disclosure can be experienced as an unwanted intrusion. In fact, patients with this type of transference often seem to be among the least likely to consciously notice or ask about the therapist's experiences even when it is obvious that something is wrong. The fact that an attuned patient's sensing that the therapist is going through a difficult time and his or her asking the therapist for personal information does not, in itself, mean that the therapist should self-disclose. Such individuals may have had repeated experiences as children, in which they were put in the position of being a confidant and caretaker to their parents at the expense of their own needs, a role which enhanced their feelings of importance but at the expense of being

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loved for themselves. Self-disclosure can inadvertently recreate disturbing past interactions or feed into their worst fears while remaining more exploratory would be experienced as more therapeutic in the long-run. When a patient is manifesting an adversarial selfobject transference or needs to maintain distance to preserve the self from intrusions, self-disclosure of upsetting events in the therapist's life can make the patient feel too guilty about or further escalate his or her aggressive or oppositional stance or feel too threatening. Likewise, it is problematic to share personal information when the patient is raging. Individuals who manifest a twinship transference or who have an intense need to feel connected to the therapist as a real person, often are among those who seem to elicit or require some self-disclosure from their therapists as the following example illustrates. Some years ago, it was necessary for me to undergo surgery for what later turned 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 vacation, there was no actual disruption of the treatment. Consequently it was not necessary for me to share any of this with patients except of course for the borderline 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 professional peer despite our being in different fields, announced that she had learned from an acquaintance who worked at the hospital at which I had been operated that I had been there as a patient. While she also was told by her friend that I was all right and she could see this for herself she nevertheless was quite agitated. She said vehemently that she deserved to know about my health and made it clear that she was in no mood for my exploring her reactions to and fantasies about this event. The patient became more relaxed when I told her the nature and result of the surgery but indicated that she felt quite hurt and frightened by my not having told her myself earlier. More willing to share her reactions after I told her what had happened, she said that it upset her that something so important could have happened to me without her knowing about it and it 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 than usual, feeling very anxious, and now she knew why. Further exploration led the patient to recall her childhood relationship with a beloved aunt, the only family member whom she felt had truly cared about her and with whom she was very close and who committed suicide seemingly without warning. She also related repeated incidents when family life was disrupted without apparent warning. Despite her attachment to her aunt, the patient's parents never spoke of her death and seemed not to notice her obvious distress. She felt abandoned by her aunt and alone in the midst of her family. She grew up doubting her own view of reality in close relationships which made her feel quite anxious and fearful. The patient sought treatment because she had broken several engagements and once again found herself unable to commit to the man whom she was seeing. It took some time for the patient to reestablish some feeling of security in our relationship although the discussion of this disruption and the patient's earlier experiences seemed to help her deal with her earlier loss and its sequelae. After this incident, she experienced a greater sense of certainty about marrying and set the date for her wedding. The fact that I had come back from the dead, unlike her

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

While one could argue that I should have sat with this patient's agitation and anger and that I was acting-out my countertransference, I believe that not disclosing at this time would have perpetuated the disruption of the transference and led to a therapeutic stalemate. There is no doubt that I was acting out my countertransference as well. I felt guilty about her having found out the way she did and I did wish to allay what I felt to be her unnecessary and countertherapeutic distress. I regretted not having said something to her earlier, not because I thought she would find out but because I knew that she was extremely sensitive to me and needed to feel that I was a safe, knowable, and predictable person who would validate her experience and not pull the rug out from under her. My own wish to protect her and my other patients as well as myself did not allow me to take her unique needs into account. In repairing the disruption in the treatment I was able to say this to her and to relate her experience of me to her long history of feeling that no one in her family knew or cared about what she felt. In this example, one can also question whether my self-disclosing to the patient initially would have been as therapeutic as the disruption of the transference and its repair. I cannot answer this with certainty except to say that I think that therapeutic responsiveness as well as, if not instead of the repair of transference disruptions facilitates therapeutic change. In all honesty, however, I think it was easier for me to discuss my surgery after the fact just as it was more comfortable to discuss the loss of a close friend much later in order to repair the disruption in the treatment relationship than it would have been to share my health status or mourning reaction at the times they were occurring. In addition to patients with twinship transferences, other instances in which self-disclosure seems indicated are when patients begin to show an interest in the therapist as a separate person or begin to feel entitled to ask questions. Responding to the patient with "It's important that you can ask me that" or relating to the question by helping the patient understand its link to past experiences can be felt as a traumatic rebuff. Further, there are times when the patient's expression of concern and empathy reflects a positive development or permits a mutuality to occur that is important to the patient as shown in the example below which was told to me recently by a colleague.
Ms. R., a highly expeienced therapist, was forced to put her dog to sleep and was quite upset in the aftermath. A woman patient, who was somewhat schizoid and isolated and who maintained her emotional distance from the therapist whom she 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 visibly upset and showed an empathy for the therapist that was totally uncharacteristic for her. This seemed to mark a turning point in the treatment after which she became more accessible emotionally and appeared more connected. Both the dog's death and the spontaneous and real feelings the therapist showed seemed to enable this patient to respond more freely and feelingly than she had been able to do previously.

Self-disclosure also can be important when therapists and patients share professional affiliations or when patients know colleagues, acquaintances, friends, or family members and can learn about the therapist in sometimes disruptive ways. The patient's ability to access personal information about the therapist is greater when therapists are visible in the professional community through teaching, supervision, and organization work, live in small communities, or interact in a subgroup of the larger community. The issue that often confronts such therapists is not whether to self-disclose but how much to share and how to make disclosures therapeutic. Of course there are likely to be instances in which the therapist has little or no time to consider whether or not to self-disclose before taking action. It is useful to have a general idea about how to handle this type of situation before it occurs since in the midst of a crisis, it is difficult if not impossible to think clearly. A question that often surfaces is whether it is best to convey information to patients oneself or to ask others to do it. While not always possible, it is more reassuring to patients to hear stressful information from the therapist directly even if the therapist speaks only briefly to the patient, gives a very general explanation, and postpones prolonged discussion to a later time. The following example illustrates what happened when a sudden disruption of the treatment occurred in my own practice.
Just prior to my beginning to write this paper, my 81-year-old father became seriously ill and was hospitalized on a Friday. Over the course of the weekend I considered what I would do if his condition worsened and necessitated an interruption in my practice. I feared that just canceling sessions suddenly without explanation or saving that I was ill would arouse too much anxiety especially so close to my planned vacation in August. I decided that I would personally call and tell patients that I had to attend to a family emergency and resume the following week. I thought that calling them rather than asking someone else to do it would reassure them that I was all right and that leaving the reason somewhat vague would be less burdensome and allow each to do with the information what they needed to. By Monday the crisis seemed to pass but my father unexpectedly passed away the following Thursday. I learned the news late in the evening that I would need to be in Chicago the very next morning. Despite my panic, I recalled and implemented my plan of the preceding weekend calling those patients whose sessions 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 I did contact. Upon my return I learned that one patient had been in another patient's kitchen the night that I called. Even though she understood the situation rationally, the patient whom I had not contacted personally felt less important. This same patient was my age and related to me with a combination of mild idealization and twinship. She had been dealing with the deteriorating health of her own father and her disbelief that he might die. I later learned that when she learned of my emergency she immediately assumed that one of my parents was either deathly ill or had died and she became quite panicky. When we resumed our sessions she insisted on knowing what happened. Knowing the truth further escalated 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 uncharacteristically called several times in the first two weeks for what appeared to be minor reasons. As she felt reassured that I was really all right she became calmer and later was able to say that it helped her to know that I had not fallen apart since this made her feel she would be okay too if something happened to her parents. When we resumed treatment in early September the patient reported that while she had some sad moments during the month of August she felt more prepared for her father's death and had spent more time with him in which they were able to reminisce about their relationship. Her father died suddenly two weeks later.

Perhaps one moral of this story is not to have people who know one another in treatment. A second lesson is that making mistakes is inevitable despite our best efforts. Yet a third implication is that even mistakes can have positive outcomes. HELPING TO MAKE SELF-DISCLOSURE THERAPEUTIC Often it is the therapist's willingness to self-disclose and the nature of the experiential process between therapist and patient that is just as important, if not more important, as the content of the self-disclosure. Whether or not the therapist self-discloses in a particular situation, the ramifications are unique for each patient. While it is important for the therapist to understand the meaning of the therapist's action as the actual content of the self-disclosure, there are times when exploration is not possible. Patients sometimes resist or ignore a therapist's efforts to probe the significance of an interaction that occurs and pushing the patient can be countertherapeutic. For example, there are patients who are not involved in intense transference reactions and who react to certain disclosures in more socially appropriate ways. Other patients show transference reactions which lead them not to pay attention to or to deny that which does not immediately fit their concerns or needs. It is tricky to decide when and how much to explore and interpret even when the patient is accessible to interventions of this sort. As Dewaid (1982) noted in his paper, "the therapeutic problem lies in the need

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to explore adequately the full gamut of patients' responses, affects, and associations to the illness, and to do this in the face of countertransference temptations either defensively to promote premature closure and evasion of more threatening affects, or to use the experience for exhibitionistic, masochistic, narcissistic, or other neurotic satisfactions" (p. 361). COUNTERTRANSFERENCE AND THE THERAPIST'S RIGHTS AND LIMITATIONS An understandable countertransference problem occurs when the therapist needs the patient to fulfill archaic or current needs. For example, in work with particularly self-absorbed patients who see the therapist as an extension of themselves, the therapist can resent the patient who does not see his or her separateness. Likewise, some therapists seem to need their patients to know what is happening and to show interest in and empathy for their plight particularly if they feel close to the patient. This can result in a role reversal in which the patient is expected to take care of the therapist. While therapists must strive to keep patients' needs in the foreground and refrain from any exploitation of them, sometimes it is appropriate 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 inherently problematic. The difficulty is knowing whether the patient needs to give or the therapist needs to be given to as the following example highlights.
A supervisee discussed the aftermath of her elderly father's death some years earlier which she had disclosed to all of her patients at the time. She indicated that she was quite pleased and moved by the fact that so many had sent her sympathy cards and notes afterward. She seemed to look to her patients as a support network. While I have no doubt that for some of her patients their expression of concern was positive, I was dismayed by her unquestioning response and neediness.

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

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tients beyond what is necessary. A countertherapeutic role reversal, an overstimulating sense of intimacy, or a blurring of boundaries between therapist and patient may ensue. There are other complications that affect the therapist's feelings about and willingness to self-disclose that stem from his or her own feelings about privacy and how comfortable he or she is in being known by the patient. Concerns about self-disclosure often are intensified when the disturbing events are affecting others in the therapist's life about whom the patient is unaware, such as a spouse, companion, or children or when there is a stigma attached to the information as might be the case in disclosing that one has a live-in partner, or is in a gay or lesbian relationship, or is going through a divorce. Further, a therapist can be comfortable with one patient knowing more personal information but concerned about the information going to others who are patients of the therapist or who know the therapist in another context. Thus, the decision about whether and how much to disclose can rest on what is in the best interests of the therapist. Sometimes there are negative repercussions for the therapist as well as for the treatment when patients and others learn personal information. Therapists should feel free not to self-disclose to patients. Therapists and those close to them personally do have rights to their privacy and therapists can have limitations about what they can deal with in the therapeutic process at certain times. The main issue here is whether they can non-defensively acknowledge their needs for privacy or their limitations and what this means to the patient while showing empathy for the patient's desire to know more about the therapist and his or her difficulty tolerating and accepting not knowing. While therapists have a right to privacy, the exercise of this right has ethical implications in certain instances, for example, when it involves withholding information about the therapists' serious illness or even impending death. Disclosure can be very difficult for therapist and patient, creating its own sometimes negative therapeutic consequences, including premature termination. The sense of betrayal, powerlessness, and rejection that result, however, when a therapist withholds crucial information that affects the patient outweighs the potentially harmful effects of therapist self-disclosure in most instances and constitutes a violation of professional ethics and responsibility. There are traumatic situations when it likely is preferable for a therapist not to continue to practice because of the strain that this puts on both patient and therapist and in which a referral to another therapist is indicated. There is a tendency for therapists, however, both for personal and financial reasons, to continue to work no matter what sometimes well beyond their real capacity to do so and despite the urging of friends and associates. There is no clear solution to this.

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SUPERVISORY SUPPORTS In the article I described earlier by Alexander, Kolodziejski, Sanville, and Shaw (1989), the therapist sought help from several professional colleagues to help her with the treatment of her patients during her illness. The informal supervisory group that formed served not only to aid the therapist in understanding what was occurring in the treatment process and in determining how best to intervene but also served as an important support system to the therapist so that she did not have to turn to her patients for comfort. While those close to us play important roles in this regard, they often are not able to help us deal with our patients. Of course, supervisors or consultants often have their own biases, blind spots and other countertransference issues so that seeking outside help is not a panacea. It is an important option, however, in dealing with the highly charged situations that I have been describing particularly 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: Columbia University 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 furthering 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: International 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 manifestations provoked by the analyst's pregnancy. International Journal of Psycho-analysis, 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 Universities Press. Naperstek, B. (1976). Treatment guidelines for the pregnant therapist. Psychiatric Opinion, 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. Clinical 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. Chicago: Aldine. Weiss, S.S. (1977). The effect on the transference of 'special events' occurring during psychoanalysis. International Journal of Psycho-analysis, 56, 69-77. Winnicott, D.W. (1965). The maturational processes and the facilitating environment. New York: International Universities Press. Wolf, E. (1988). Treating the self. New York: The Guilford Press.

Eda G. Goldstein, DSW New York University Shirley M. Ehrenkrantz School of Social Work 1 Washington Square North New York, New York 10003-6654