How therapist's discourage client disclosure

MaxWig

Hi,

I'm looking for articles on obstacles to client disclosure in psychotherapy.

Specifically, I'm looking for material that covers how therapist attitudes can discourage clients from discussing certain topics.

I have in mind situations where certain behaviours are treated as symptoms, or presenting issues, regardless of whether the clients views them as such.

Any advice would be greatly appreciated.

Thanks

Odysseus

It maynot be what your looking for, but the first thing your post makes me think of was a paper I read a year or so ago by someone working in one of the historical abuse services.

The main message was that making reporting the abuse mandatory to the therapy was actually beneficial to disclosure of such material.

I don't actually agree with that, if the person wants to report then that is fine; however, I have found people to be reluctant to disclose such material if they feel they will be forced to report it.

I must try dig out that paper, as I said I don't think it is what you are looking for, butif it is let me know and I will sort out a link for you.

At the end of the day don't all limits we place on therapy prevent such disclosures, i.e. the big three for breaching confidentiality. I find clients may be reluctant to dicuss self-harm if they think I may inform their GP, the same with harm to others or child abuse. This is why if their are limits placed on confidentiality that they are named very clearly in the first sessions.

In my service they speak about confidentiality being limit to the multi-dis team; however, I explain very clearly what my understanding of that is to the client. All I may speak about is attendance/engagement I will not discuss personal historical stuff with the rest of the team.

Some staff feel agrevied that they discuss their interactions anf all I say is they are attending appointments and doing well, however, people need to know the can speak freely in my room, why come other wise?

MaxWig

Thanks for the reply Odysseus.

My main area of interest is how personal attitudes on the part of the therapist can influence client disclosure or concealment.

Your example is relevant indeed, as I am very interested in literature on how/if the therapist acts as an enforcer of social norms.

So for instance, whether the therapist is influenced to view certain behavious on the part of the client as issues that need to be addressed.

My specific area of interest is whether therapist's have adapted to the new form of substance use - recreational - for want of a better term. There is a growing consensus that illicit substance use has been subsumed into the normal leisure activity of youth culture i.e. it is no longer deviant. I'm interested in how therapist's make sense of this new activity - or whether, there is a tendency to identify certain behaviours as indicative of a 'typical' client. That is, if a client is in therapy, is their substance use more likely to be viewed as problematic than in the case of an individual who does not attend therapy.

So basically any literature on 'Therapist as agent of social control/Therpist attitudes and their effects on therapy etccc

Odysseus

I do a lot of work in the addiction area could you expand on your point a bit, I not exactly too sure what you are saying about substance use and it no longer been seen as "deviant".

Interesting points though.

MaxWig

Sure - The data suggests that drug trying rates among youth are such that substance us can no longer be termed 'deviant' - i.e the preserve of a sub-culture. More 16-24 year olds try drugs than do not.

One of the critiques of harm reduction in general, is that it targets children who have not yet encountered drugs, and addicts and/or problem users who have come into the medical and/or criminal justice system.

The rest of the drug using population are essentially invisible.

There are many reasons for this invisiblity, but prominent among these is the obvious legal risk of openly discussing one's drug use.

Psychotherapy should be a ideal arena in which to discuss and explore such drug use.

My interest is in whether therapist's (or psychotherapy in general) have come round to this new reality - Or whether a client's very status as a client implies to therapists that any/all of their substance use is problematic.

Furthermore, I am interested in the implications for disclosure or concealment, of such attitudes to the extent they do, or do not exist

JuliusCaesar

Drug use for many people will be problematic as they use drugs to escape anxiety or depression, or whatever unpleasant aspect of life they wish to avoid.

No, not everyone who attends therapy will have a problematic relationship with their drug of choice be it alcohol or illegal ones.

We do NOT have mandatory reporting of illicit drug use.

MaxWig

Thank you for your reply Julius Caesar.

I am well aware of both the points you make.

I may be unclear in my explanation/question.

My basic interest is in the link between personal attitudes on the part of the therapist, and their effect on the therapeutic alliance and/or client disclosure.

Whether or not the use of substances have an adverse effect or not is of no interest to me in this instance.

What is of interest to me, is the effect that this conviction will have on therapeutic alliance.
That is, If a therapist (rightly or wrongly) believes that drug use is harmful in most/every instance, what effect will this have on client disclosure?

Lbeard

JuliusCaesar wrote: »

Drug use for many people will be problematic as they use drugs to escape anxiety or depression, or whatever unpleasant aspect of life they wish to avoid.

To escape anxiety or depression. Do you mean to say these people are often self medicating?

Odysseus

MaxWig wrote: »

Sure - The data suggests that drug trying rates among youth are such that substance us can no longer be termed 'deviant' - i.e the preserve of a sub-culture. More 16-24 year olds try drugs than do not.

One of the critiques of harm reduction in general, is that it targets children who have not yet encountered drugs, and addicts and/or problem users who have come into the medical and/or criminal justice system.

The rest of the drug using population are essentially invisible.

There are many reasons for this invisiblity, but prominent among these is the obvious legal risk of openly discussing one's drug use.

Psychotherapy should be a ideal arena in which to discuss and explore such drug use.

My interest is in whether therapist's (or psychotherapy in general) have come round to this new reality - Or whether a client's very status as a client implies to therapists that any/all of their substance use is problematic.

Furthermore, I am interested in the implications for disclosure or concealment, of such attitudes to the extent they do, or do not exist

Are you talking about the therapist who see the clients drug use as something to be addressed in that if they are using drugs we need to get them to stop, rather than letting the client decide that, and instead use the space to allow the client to explore the role of drugs in their life?

MaxWig

Primarily, I am simply interested in the effect of such attitudes (to the extent that they exist) on therapy.

Julias Caesar's comment that "Drug use for many people will be problematic as they use drugs to escape anxiety or depression" is indicative of the areas i wish to explore.

These are the attitudes I would like to learn about, in terms of their effect on client disclosure.

TV, pornography, food, sex, cigarettes, cinema - pretty much anything can be used to 'escape' personal anxieties, and leave reality aside temporarily.

Growing literature suggests that young people increasingly view illicit drug use (of varying kinds) as a leisure activity (Normalisation). So while we may still make a distinction between illicit drug use and a sociable pint, the distinction is becoming blurred.

I am interested in whether Psychotherapy has room to contain such view.

Odysseus, I think allowing the client space is ideal of course, but attitudes and values come into the room, one way or another. And it is this phenomenon I would like to look at.

How and if attitudes effect the levels of disclosure or concealment on the part of clients

Surly that applies to every thing about the client and therapist, for example if the client was young and the therapist was middle aged, the client could ( consciously or unconsciously ) believer that the therapist would have different value/beliefs as regard to sexual behaviour, as sexual norms do change over time and thus be reluctant to disclose some behaviours to the therapist.

Or the client could look at the therapist and see what they perceive to be ( rightly or wrongly ) an educated middle class person who couldn't understand the milieu that the client lives in and thus be inhibited from sharing some information with them.

MaxWig

mariaalice wrote: »

Surly that applies to every thing about the client and therapist, for example if the client was young and the therapist was middle aged, the client could ( consciously or unconsciously ) believer that the therapist would have different value/beliefs as regard to sexual behaviour, as sexual norms do change over time and thus be reluctant to disclose some behaviours to the therapist.

Or the client could look at the therapist and see what they perceive to be ( rightly or wrongly ) an educated middle class person who couldn't understand the milieu that the client lives in and thus be inhibited from sharing some information with them.

Well, yes, I think the examples you give are all issues that would need to be addressed in the relationship.

Anything that interferes with client disclosure is damaging to the alliance.

However I am concerned with the relationship between actual (therapist) attitudes and client disclosure.

Odysseus

MaxWig, I know you are looking for articles, but do you have any links to articles which address this topic?

MaxWig

Hi Odysseus,

There is a vast literature on the effects of various attitudes in psychotherapy.

Homophobia, prejudice towards the overweight, religious prejudice, socioeconomic gaps etc.. all feature in the literature.
A google scholar search will result in many such articles

Regarding social control, everyone from Foucault through Laing, and the broader anti-psychiatrist movement speak about such issues, albeit with a broader scope.

I looking for any articles that deal specifically with drug-use.

There is literature on negative attitudes towards substance abusers - nursing and social care/doctors - and the effects of working with them.

If you search R.E.A.C.T and substance use, you will find a lot on it.
My interest is different though, in that I'm interested more in views on everyday use.

dar100

Hi Maxwig,

This paper may provide some information and add to your study

MaxWig

Thanks a million Dar100,

That is precisely the area I'm interested in.

And I had yet to come across this article.

dar100

Hi Maxwig,

Here is another article, I havnt read it but looks like it will contain some good info

MaxWig

Hi Dar100,

Thank you.

I have this article, but thank you very much all the same.

The REACT questionnaire gauges negative responses on the part of healthcare workers to the negative behaviour of substance abusers.

dar100

Hi Maxwig,

Final article I must get back to work, hope it can add to your collection

MaxWig

Thanks again Dar100,

Really appreciate it.

Kooli

Very interesting topic, although I'd be less interested in the drugs angle than the other ones you mentioned (i.e. when a client can sense a therapist's attitudes about sex & sexuality, overweight etc. and it causes them to shut down)

I've had concerns about this in group supervision when colleagues have automatically attributed a client's permissive sexual behaviour to a 'lack of self-care' or 'excessive risk-taking' or when a client has been raped and they pursue the angle of what the client could have done to prevent it happening (i.e. why it was their fault)

Lbeard

Kooli wrote: »

Very interesting topic, although I'd be less interested in the drugs angle than the other ones you mentioned (i.e. when a client can sense a therapist's attitudes about sex & sexuality, overweight etc. and it causes them to shut down)

There is a certain kind of person who should never be allowed become a therapist: The judgemental Irish conservative. Who will regardless of their training, fall back on their twisted conservative prejudices. Weight problems are very often pathological. A conservative who is neurotic in regards to their own sexuality should never be allowed near people who need therapy.

Middle-class Irish conservatives consider anyone not living the same life as themselves to be insane. They really shouldn't be allowed treat anyone.

I've had concerns about this in group supervision when colleagues have automatically attributed a client's permissive sexual behaviour to a 'lack of self-care' or 'excessive risk-taking' or when a client has been raped and they pursue the angle of what the client could have done to prevent it happening (i.e. why it was their fault)

It's the Just-World-fallacy. It's a very harmful belief many people have. The belief there is some kind of cosmic power that makes good things happen to good people, and bad things happen to bad people. Melvin Lerner has done a lot of work on this - it's very interesting reading, and maybe something everyone in care should be forced to digest. Lerner, found that in psychiatric hospitals he worked in, the staff blamed the patients for their conditions. And conseqeuntly treated them very badly.

For the bystander, it's far more comforting to believe that a victim, say a rape victim, brought the attack on themselves - this gives them a sense of security and comfort. Peversely, it leads to protecting the perpetrator, and attacking the victim. In some countries if a woman is raped, she runs the risk of being killed by her family. In Iran, if a woman reports a rape, the police decide if she did something to provoke the rape (like walking alone at night). If they decide she has, they put her in jail. In Ireland you have wealthy businessmen being let off with barely a slap on the hand for serious sexual assualt.

Your colleagues should not have their jobs. There is no way they can do anything but harm with their current perspectives. And it's possible further training would be completely wasted on them.

MaxWig

While your anger is probably understandable Lbeard, I'm not sure that prejudice is something that anyone can escape.

The examples given re rape victims are very disturbing, and I can't say I've some across anything so severe.

But I think your judgement re Irish Conservatives may be a little harsh.

Prejudice is the human condition - it is hardwired in to each of us.

It can be handled, examined and reflected upon, but I am skeptical that it can ever be transcended - simply bringing it to awareness should be enough.

Lbeard

MaxWig wrote: »

While your anger is probably understandable Lbeard, I'm not sure that prejudice is something that anyone can escape.

That's a very pessimistic view of the world. It may seem like a slow process, but in the overall context of human history it's been quite fast. Our societies are becoming less prejudice based. Homosexuals were being hung in England in the 19th century, women had virtually no rights, Bethlehem asylum in London was open to the public as a form of entertainment.

Prejudices can be overcome. Even in Ireland as a people we are less ignorant than we were. Illness in a family used to be considered a mark of shame for the family. And this is the ignorant pagan Just-World mindset. The family are being punished by God for some reason.

The examples given re rape victims are very disturbing, and I can't say I've some across anything so severe.

The situation in Iran is bad, but in Ireland we (at least Irish conservatives) used to do something that was nearly identical, except with less legal legitimacy than Iran. Rape victims and victims of incest, were locked up in institutions.

But I think your judgement re Irish Conservatives may be a little harsh.

Irish Conservatives have no problem dishing out the harshness.

Prejudice is the human condition - it is hardwired in to each of us.

It's something that is learned. And prejudice is pretty good if you're on the side benefiting from it. Conservatives experience positive discrimination. And then they negatively discriminate against all who are not their own kind.

It can be handled, examined and reflected upon, but I am skeptical that it can ever be transcended - simply bringing it to awareness should be enough.

Well it's as simple as this. Conservatives exclude people who are not conservative. I know conservatives, they believe they are entitled and deserving due to some inner goodness, their "personality". But it's the nasty, predatory and bigoted personality of Adorno's Authoritarian Personality.

Someone who is prejudiced against people with mental health problems should not be allowed work in mental health services - at any level. Someone who hates children, and is prejudiced against children from a lower social economic background should not be allowed teach them.

You would not let a pedophile work with children (though there was a stage in Ireland where conservatives protected pedophiles who were). Why would you let a personality that causes harm, work with any vulnerable person?

MaxWig

Certainly prejudice is not acted upon in the developed world as much as it once was.
That is not to say it does not exist. Homosexuality is not as prone to outward prejudice as it once was, and yet the prejudice remains I fear.

We are social animals, and as a result of that, we have a wonderful power to communicate, and build community.
Correspondingly however, those outside our community are often thought of in negative terms. This is ubiquitous.
I don't believe prejudice is learned, but i do think behaviour is learned.
Put another way, as humans we are suspicious of difference. This is a byproduct of evolution, and not easily avoided.

I think the psychologist/therapist who does not believe him/herself to be prejudiced may be fooling themselves.
Accepting that we are prone to prejudice, and remaining aware of it, I believe is the only way to avoid acting from it.

JuliusCaesar

You might find it interesting to google "therapist errors" or "mistakes in therapy". We are all human and yes we make mistakes often. The thing is do we recognise them and how we deal with them. This is a major reason for clinical supervision.

looksee

As an interested observer in this discussion, I wonder about the use of the word 'Irish' in the term 'Irish conservatist'. Surely the specific reference to Irish shows a prejudice in itself? The term conservative indicates attitudes, without which the person is not a conservative, but Irish just indicates a place of birth, within that an Irish person could have a whole range of attitudes and still be Irish. The term Irish Conservative carries a weight of generalised negative nuances reflecting the user's prejudices.

MaxWig

JuliusCaesar wrote: »

You might find it interesting to google "therapist errors" or "mistakes in therapy". We are all human and yes we make mistakes often. The thing is do we recognise them and how we deal with them. This is a major reason for clinical supervision.

Hi JuliusCaesar,
Thanks for that.

I agree, course of therapy could actually be viewed as one long course of errors and adjustments.

I'm more interested in attitudes and behaviours that are not necessarily viewed as mistakes.

Lbeard

looksee wrote: »

The term Irish Conservative carries a weight of generalised negative nuances reflecting the user's prejudices.

That's your interpretation. Irish Conservatives are very proud of their conservatism and Irishness.

Any characterisations of them I would make, they would see as essential virtues.

Or what do you want me to call them? Normal people? Or would you detect some negative nuance in my use of the word "normal"?

MaxWig

Lbeard wrote: »

That's your interpretation. Irish Conservatives are very proud of their conservatism and Irishness.

Any characterisations of them I would make, they would see as essential virtues.

Or what do you want me to call them? Normal people? Or would you detect some negative nuance in my use of the word "normal"?

I think the point is that we are discussing the 'Irish Conservative' as an homogenous group.

It makes very little difference what attributes we ascribe 'them'.

It is the idea that there is a 'them' that is prejudicial.

Its is an alienating gesture, that puts distance between 'you' and 'them'

Lbeard

MaxWig wrote: »

I think the point is that we are discussing the 'Irish Conservative' as an homogenous group.

Irish Conservatives are a very homogeneous group. Ultra conformity being an essential facet of the group.

It makes very little difference what attributes we ascribe 'them'.

It's called objectivity.

It is the idea that there is a 'them' that is prejudicial.

I believe for you, it's this particular 'them', and you wish to grant them a 'protected species' status.

Its is an alienating gesture, that puts distance between 'you' and 'them'

Alienation of others, who are different, is fundamentally at the core of Irish Conservationism. Central to their existence.

MaxWig

Like I said, we all have our prejudices

MaxWig

Lbeard wrote: »

Irish Conservatives are a very homogeneous group. Ultra conformity being an essential facet of the group.

It's called objectivity.

I'm afraid its the very opposite of objectivity. I understand your grievance. There is an attitude you dislike - you don't approve of it, and that's fine. But the Irish Conservative attitude is only different to your attitude in content. Your attitudes were created in the same way. You are a product of your environment in the same way as anyone else. Realising this can only be a good thing for you.



I believe for you, it's this particular 'them', and you wish to grant them a 'protected species' status.

I am talking about a stance you are adopting. I have no interest in the specific object of your hatred. I am simply trying to point out the similarity between your intolerance of Irish Conservatism, and their intolerance of whatever it is you hold dear.

Alienation of others, who are different, is fundamentally at the core of Irish Conservationism. Central to their existence.

I don't like small mindedness any more than you, I imagine. But you speak about alienation as though it is a one-way street. You can talk about parochial attitudes - racist, small-minded, deeply catholic - all you like, but it is wise to remain aware that there is a direct opposite to your conviction. There is your equivalent, talking about pinkie liberals, and anything goes lefties. Each subject claims knowledge and experience validates their position. Objectivity is realising that neither of you are right. We all want to believe that someone knows 'we' are right. But no one does

MaxWig

I'm afraid its the very opposite of objectivity. I understand your grievance. There is an attitude you dislike - you don't approve of it, and that's fine. But the Irish Conservative attitude is only different to your attitude in content. Your attitudes were created in the same way. You are a product of your environment in the same way as anyone else. Realising this can only be a good thing for you.

I am talking about a stance you are adopting. I have no interest in the specific object of your hatred. I am simply trying to point out the similarity between your intolerance of Irish Conservatism, and their intolerance of whatever it is you hold dear.

I don't like small mindedness any more than you, I imagine. But you speak about alienation as though it is a one-way street. You can talk about parochial attitudes - racist, small-minded, deeply catholic - all you like, but it is wise to remain aware that there is a direct opposite to your conviction. There is your equivalent, talking about pinkie liberals, and anything goes lefties. Each subject claims knowledge and experience validates their position. Objectivity is realising that neither of you are right. We all want to believe that someone knows 'we' are right. But no one does

Lbeard

MaxWig wrote: »

I'm afraid its the very opposite of objectivity.

I don't really believe in objectivity either.

I understand your grievance.

I don't think you do. Crucially it's about the ability of a certain personality type to provide care. That their rigid world view precludes them from being competent.

You don't understand my grievance. I've had personal experiences with doctors where they failed me terribly because of their prejudices; their Irish Conservatism. One doctor I went to several times with persistent pain. I requested to see a specialist, they wouldn't refer me. I requested tests, they wouldn't do them. They wouldn't give me pain killers. Eventually, after spending a lot of money on repeat visits, the doctor tells me they believe nothing is wrong with me, and I'm just a junkie trying to get painkillers. I'm not a junky. And I do know now the specific medical conditions causing me pain and other health problems.

Irish conservatives believe that anyone outside their group is either morally defective, and that their health problems derive from their moral failings. And likely a drug abuser.

There is an attitude you dislike - you don't approve of it, and that's fine.

No. It is not fine.

But the Irish Conservative attitude is only different to your attitude in content.

There is a substantial difference between how I treat and perceive others than an Irish Conservative.

Your attitudes were created in the same way. You are a product of your environment in the same way as anyone else. Realising this can only be a good thing for you.

Is this some kind of moral relativism?.....No objective truths, or objective morality. When Irish Conservatives do bad things, it's alright because ultimately there is no good or bad, within their cultural frame of reference they can do no wrong.

I have no interest in the specific object of your hatred. I am simply trying to point out the similarity between your intolerance of Irish Conservatism, and their intolerance of whatever it is you hold dear.

It's not hatred. It's simply about competence. A Irish Conservative care giver is maybe only competent to give care to other Irish Conservatives. And for others, they could be potent harm givers.

I don't like small mindedness any more than you, I imagine.

I couldn't care less how small minded people are. Small minds should just not be allowed do things, or be in positions of responsibility that really require big minds.

But you speak about alienation as though it is a one-way street. You can talk about parochial attitudes - racist, small-minded, deeply catholic - all you like, but it is wise to remain aware that there is a direct opposite to your conviction.

Wonderful. You're blaming me for the bigotry of Irish Conservatives.

There is your equivalent, talking about pinkie liberals, and anything goes lefties.

The anything goes lefty, folk devil, largely exists in the frightened little minds of the conservative. The kind who are opposed to same sex marriage, as they believe it will lead to people marrying their pet dogs.

Each subject claims knowledge and experience validates their position. Objectivity is realising that neither of you are right. We all want to believe that someone knows 'we' are right. But no one does

No this is not what I believe at all. I believe there is just different levels of uncertainty.