By Michael Babcock
For many of us working in the helping profession, who also live with some form of mental illness have learned to �pass� (i.e., to blend in and not share information of our personal struggles) with our fellow co-workers and supervisors. However, learning to pass can incur personal costs such as shame from hiding one�s psychiatric disability and lack of close relationships with co-workers because of limited self-disclosure. Yet, disclosing one�s psychiatric disability is not without risks. Job advancement might be limited after disclosing one�s mental illness (Mancuso, 1993). When disclosing we also have to consider the support versus the stigma associated with psychiatric disabilities. For many of us with mental illness, self-disclosure might not occur in the workplace until after feeling confident about our job security and performance record. As one worker with a psychiatric disability stated, �You can disclose when you�re strong, but can�t disclose when you�re weak� (Mancuso, 1993, paragraph 19). Learning to pass also incurs interpersonal costs such as shame from hiding one�s psychiatric disability. The lack of close relationships with fellow co-workers can occur because of limited self-disclosure.
Another important issue for mental health workers is the potential effects of self-disclosing to the people whom we serve at our jobs. By disclosing our psychiatric disability, it is not known how the person whom we serve might react. Professional training has often discouraged personal involvement and self-disclosure, while maintaining rigid boundaries between staff and the individuals served (Sowers, 2005). By maintaining these rigid boundaries, a wedge is placed between the staff and individuals served who are seeking assistance, which result in �hindered collaboration, mutuality, and reality-based relationships� (Sowers, 2005, p. 11). Further, these rigid boundaries prevent us from deepening our relationships with people in trauma, mental health and addiction recovery disallowing us from being mentors, supporters, and role models.
Psychology of Self-Disclosure
Life satisfaction is often dependent on effective interpersonal skills. For instance, in times of crisis nearly half of us will seek help from a friend (Tucker-Ladd, 1996). Friends not only provide emotional support, but they help guide our behavior and opinions, provides us the opportunity to help them, and show us that our lives are worthwhile. Becoming intimate with another person requires willingness to make self-disclosures about one�s self. Self-disclosure is a sign of good mental health and healthy personality development. Researchers investigating individuals who self-disclose are shown to experience higher levels of self-contentment, adaptivity and competence, perceptivity, extroversion, and trust towards others, when compared to non-disclosing persons (Tucker-Ladd, 1996).
Telling others about you creates a healthy feedback loop, which involves self-disclosure, friendships, and self-acceptance. Discussing one�s intimate thoughts with another provides feedback to that person on how you are reacting to them and by sharing you are deepening your friendship. Gaining acceptance from others increases one�s own self-acceptance. Appropriate self-disclosure makes one feel better, which fosters more disclosure, leading to richer interactions. All of these factors are more conducive to greater self-reflection. Failure to self-disclose results in one�s hiding their real self from others, which contributes to a downward spiral of shame, less self-reflection, and becoming less effective in solving one�s problems (Tucker-Ladd, 1996).
For people living with serious psychiatric disabilities, often their interpersonal and social skills are impaired. Dealing with the additional stresses caused by their psychiatric disability can result in ineffective coping skills. All of these factors can result in increased isolation, withdrawal, and exacerbation of one�s symptoms.
Recovery for People with Psychiatric Disabilities and their Helpers
A study conducted by the World Health Organization (WHO) in 19 69, compared outcomes from different countries for persons with schizophrenia and highlights that recovery is possible. Follow-up at two-year and five-year intervals found patients in India, Nigeria, and Columbia had greater recovery outcomes, than patients in the United States and four other developed countries (De Girolamo, 1996; Whitaker, 2002). In a follow-up study completed in 1992, which used persons with one-episode schizophrenia, WHO obtained similar outcomes to the 1969 study (Whitaker, 2002). Research completed by Courtney Harding and colleagues concluded that the world-view of chronicity for serious mental illness is not the norm (cited in Anthony, 2000). Gagne (2005) cited further longitudinal research conducted by Courtney Harding, for the past 30 years the recovery rate from mental illness is between 49% and 68% for North America, Europe, and Asia.
The concept of recovery is greatly influenced by the writings of �persons with lived experience in recovery� (Anthony, 1993; Gagne, 2005; Mead & Copeland, 2000). Persons receiving services are critical of the mental health system because many of them view it as a one size fit all system, which denies the unique and individualized process of recovery (Sowers, 2005). Recovery is about helping people change and grow. Whereas the dimensions of ongoing support, housing and medical needs, and employment are closely related to wellness; however, it is the subjective byproducts of these needs that are conducive to the recovery process. Change occurs when people have a sense of hope, self-esteem, empowerment, self-determination, and self-awareness about aspects of their own behavior (Anthony, 2003). In addition to these factors, Copeland and Mead (2004) added personal responsibility, education, self-advocacy, and support.
Key dimensions in recovery include mutual relationships and support such as peer support, consumer run organizations, and leadership training. According to Mead and Copeland (2000), �Mutual support is a process in which the people in the relationship strive to the relationship to become fuller, richer human beings� (p. 319). Further, Mead and Copeland stress that mutual and appropriate support must extend into the clinical community. While clinical relationships can never completely be mutual or equal, they can be more reciprocal. Mental health workers can play a vital role in this vision of recovery by conveying this belief, while being hopeful and less pessimistic in their expectations (Gagne, 2005). Furthermore, it is essential that mental health workers create collaborative relationships with the individuals with whom they work.
The Therapeutic Relationship
In the therapeutic relationship, therapists are warned that boundary crossings are forbidden, unethical, and exploitative (Dixon et al., 2001; Roberts, 2005; Zur, 2004). Boundary crossing in psychotherapy involves departure from traditional analytic and risk management practices (Zur, 2004). Boundary crossings generally refer to the therapist�s self-disclosure, touch, exchange of gifts, bartering and fees, location of sessions, and contact outside of therapy. A closer investigation on the issue of boundary crossing reveals interesting insights. The belief that rigid boundaries are required in therapeutic relationships is a psychoanalytic principle dating back to Freud (Dixon et al., 2001). Therapeutic self-disclosure in clinical relationships is associated with dangers to the transference analysis, clinical work, and increased risk management (Zur, 2004). Further, Reamer (2003) has pointed out that social work literature abounds with ethical issues associated with professional boundaries, which are challenging and tricky to navigate. Concerns that boundary crossings can lead to boundary violations and exploitation are genuine; however, therapists and psychiatrists have concerns that therapeutic self-disclosure is underused or misused because it lacks a framework (Dixon et al., 2001; Roberts, 2005; Zur, 2004). Moreover, humanistic, feminist, existential, and other eclectic therapists actively advocate for free and open self-disclosure (Roberts, 2005; Zur, 2004).
Non-judicious use of self-disclosure by therapists can result in harm to the client. If a therapist of a different social class or culture self-discloses, the client might perceive the therapist as criticizing or placing them in a one-down position (Roberts, 2005). The therapist�s self-disclosure might infringe upon, over take, or overwhelm the client�s stories. Dixon et al. (2001) pointed out that therapist self-disclosure comes with the risk of shifting the inquiry from the client to the counselor. The client might misconstrue the therapist�s self-disclosure as wanting to enter a nonprofessional relationship. Therapist self-disclosure can silence the client out of fear of disapproval or perceived disagreement.
Zur (2004) noted, �boundary crossings are different from harmful boundary violations and, appropriately employed, can increase clinical effectiveness and therapeutic outcome� (p. 32). Similarly, Dixon et al. (2001) challenged instead of focusing on the possible harm from deliberate therapeutic self-disclosure, the therapist should consider whether or not is it helpful to the client and their treatment. Researchers and therapists also raise concern of maintaining rigid boundaries in the therapeutic relationship. For instance, Lazarus (1994) stated, �One of the worst professional or ethical violations is that of permitting current risk-management principles to take precedence over human interventions� (p. 260).
The interactions between mental health workers and people in trauma, mental health, and addiction recovery do not fit the typical client-therapist relationship. Therefore, it might make more sense to draw from the wealth of knowledge that exists on the positive effects of self-disclosure from the self-help community. Self-disclosure and mutual support contributes to the effectiveness of peer models: 12-step programs, Wellness Recovery Action Plan (WRAP), consumer run organizations, clubhouses, and self-help groups (Dixon et al., 2001). Lastly, the following theoretical models advocate for self-disclosure: cognitive, behavioral, cognitive-behavioral, feminist, group, humanistic, pastoral counseling, and existential as a way of modeling, creating authentic relationships, offering an alternative perspective, increasing therapeutic alliance, and decreasing the power differentials (Dixon et al., 2001; Zur, 2004).
Conclusion
Appropriate self-disclosure is a sign of good mental health and healthy personality development. Self-disclosure is a key component of life satisfaction. Research has shown that self-help groups, peer support, and peer-run organizations are key in helping form mutual relationships with people living with mental illness and aiding in their recovery process. For people living with mental illness, often their interactions are limited to only other people using mental health services. Mental health workers play an important role in helping form somewhat reciprocal and collaborative relationships with persons living with psychiatric disabilities. Creating authentic relationships in the larger community outside of the mental health system is still needed. Mental health workers who are also living with mental illness can also bring an added dimension to these relationships�their own recovery process. Mental heath workers can play a vital role as coaches, mentors, and role models in the recovery process of individuals served.
From the literature cited, self-disclosure can play an important role in a person�s recovery from mental illness and has an important therapeutic value. Mental health workers are placed in unique roles working with persons living with psychiatric disability. Our roles include facilitating groups like art, music, and yoga, medication delivery to their homes, doing one-on-one activities in the community, and transporting to appointments to only mention a few. Our associations with the individuals whom we serve are not the typical client-therapist relationship, which gives us greater latitude to form authentic, reciprocal, and reality-based relationships. Some might argue that these roles encourage dual relationships that might become exploitive boundary violations. However, if the roles we as mental health workers are limited to coaching, mentoring, and role modeling with plenty of supervision, boundary violations are less likely to occur. When misunderstandings arise due to boundary issues, they too, become a learning opportunity for everyone involved�client, staff, and supervisor (C. Stevens, personal communication, July 20, 2005). The literature suggests the following guidelines for therapeutic boundary crossings:
2. When boundary issues are discussed in supervision and staff meetings �there is a safety net or
healthy context in which to iron out difficulties, especially admitting mistakes, repairing
transgressions where both individuals coming away knowing more about one another and themselves than before they ever ventured into authenticity� (C. Stevens, personal communication, July 20,
2005).
3. The choice of whether to self-disclose should be an active decision that is balanced against the
risks, and the decision should always be based on the individual�s best interests (Dixon, et al., 2001).
4. Boundary crossings, like any other intervention should be part of a well-constructed and clearly
articulated treatment plan which takes into consideration the individual�s problem, personality,
situation, history, culture, etc. and the therapeutic setting and context (Zur, 2004).
For mental health workers living with mental illness, it is vital that we have the opportunity to self-disclose with fellow co-workers without fearing some type of consequence. We bring our unique experience and vision of recovery to the mental health field. Self-disclosure can aid in our own personal development. Support from our fellow peers (i.e., co-workers) can also promote our own professional development. Whereas peer support for mental health workers living with mental illness is extremely important, but currently only one peer-run organization of this type exists.
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