In this series we consider ethical dilemmas and concerns that come up in CBT and think about how we might respond to them. These articles are intended to stimulate reflection and discussion, without necessarily providing a definitive answer.
Thank you to members who have contacted us to ask questions and share dilemmas they face. We will include some of these as anonymised examples in future editions.
As CBT psychotherapists, wellbeing practitioners, researchers, teachers and supervisors and related practitioners, we are expected to hold ourselves to high standards of conduct. This means to protect the public, act in the best interests of our clients and uphold the reputation of the profession.
In many situations, it can be very clear how to act in accordance with ethical principles. In this column, we look at issues that have come up for our members – perhaps where it seems that ethical principles may conflict with each other, or where it may not be obvious how to apply them in the circumstances. We also consider themes from complaints that have been brought about members – or where decisions made by our members have been questioned on professional or ethical grounds. There are some questions to reflection at the end of the article.
The question: How much should I tell a client about myself in therapy, and what do I do if a client asks for personal information about me?
This question has come up in clinical supervision, when a CBT psychotherapist was asked if they had children during a therapy session. The client had been experiencing intrusive thoughts about possibly harming their own children, with high levels of anxiety about experiencing these thoughts because they very much did not want to harm their children. The therapist had done a thorough risk assessment, and there were no identified safety concerns. The CBT psychotherapist wasn’t sure that they made the best response to the question, wondered how this fitted with the formulation they were developing together with the client- and wanted to reflect on it in supervision.
Self-disclosure at the client’s request is just one of a number of different ways that a therapist may reveal personal information to a client The therapist’s appearance, visible differences or personal items in the room can also give information about the therapist. Even when sessions are by telephone, the therapist may speak with an accent, for example. CBT training includes reflecting on our own emotional responses in sessions, and how much disclosure is part of the therapeutic encounter, and when it is more about the therapist than the client.
It is also possible that unintended disclosure happens. The client and therapist could see each other outside the therapy context – while out with a partner or family, when at an event, a social or religious gathering for example – which would reveal information that the therapist may not have chosen to share.
Clients may also search for an online presence or social media to find out more than the therapist has told them directly. In addition, needing to rearrange sessions due to caring responsibilities, bereavement or illness may also reveal some information, and the therapist will need to consider how this is approached.
Other self-disclosure may happen because the therapist has deliberately chosen to offer information which is intended to help with the area being worked on, such as ‘I used to get very anxious about going to the dentist, and found CBT really helpful’.
The therapist may work in a setting which is offering specific services to a group, in a particular language, or being affirmative for a particular protected characteristic. Clients may assume shared diversity with the therapist and a discussion about whether this is the case may be seen as relevant to meeting the client’s specific needs.
In CBT, there is some evidence that a limited amount of self-disclosure is seen as additional ‘genuineness’ by the therapist. It can help to build the therapeutic relationship and contribute to positive outcomes. Careful use of self-disclosure can contribute to specific therapeutic interventions to bring about change, such as modelling, feedback, ‘normalising’ a reaction or for reinforcement. (Goldfried et al., 2003; Metcalf, 2011; Miller and McNaught, 2020; Jung et al., 2015). Therapeutic interventions such as behavioural experiments or accompanied exposure away from the clinic room may also result in more self-disclosure.
The therapist would be expected to answer any questions which are about their training, qualifications, professional experience or specialities for example. They are relevant to the client and the therapy work, rather than being personal disclosure The therapist can be open and transparent when answering these.
There are some key themes for making decisions on self-disclosure which are informed by ethical principles. In general, the therapist can do good and avoid harm if there is a clear rationale which fits with the work being done. Any disclosure should be for the benefit of the client – and still be consistent with keeping appropriate boundaries. Reflecting on self-disclosure when it does happen will help the therapist to ensure that their work meets these expectations.
Self-disclosure that over-steps these boundaries is more likely to do harm. For example, if the therapist shares something which is important in their personal life, but this shifts the focus to the therapist or their needs, rather than those of the client. If the therapist finds themselves wanting to share more personal information than is appropriate to these boundaries, they should reflect and take this to supervision to consider how to manage this well.
The reasons that a client may ask for personal information are often positive, such as wanting to get to know the therapist as a person, and feeling that they can trust them. The client may also be testing out whether the therapist has the experience or background to help them. Also, the client may not be used to the difference between a personal and a professional relationship, especially when they are disclosing deeply personal information about themselves. The therapist can help by maintaining clear boundaries in the therapy relationship, and may need to discuss these overtly.
It is very unusual, but occasionally a client may deliberately try to obtain personal details about the therapist, or may engage in ‘stalking’ or harassing behaviours. If the therapist believes this may be happening, safety and wellbeing are priorities, and the therapist should seek supervision, practical support and legal advice.
When the client asked the therapist if they have children, the therapist could use these points to make a decision on how to respond:
- The therapist will decide whether to ask for more information about the reason for asking, as well as whether they do wish to tell the client. Some may never share this information, and some may decide that it is appropriate in some
- If they decide not to share this, then they can consider any potential impact on the therapy relationship, and how to manage this. For example, when first establishing the therapy relationship, the response may be different from when they have already built trust, decided on goals and worked together for a while.
- The therapist can demonstrate that they have heard the request, and respond empathically to the question without necessarily giving the information asked for.
- They may ask how it might help the client to know – and make a decision after that discussion.
- The therapist can emphasise that the work is about the client, not them – or – if this is the case – that the request may be reassurance-seeking or avoiding some difficult content that is the focus of the session. There may be other therapy-related reasons why the answer may not be Observing this and working together on the reasons can help to re-focus on the work they are doing together.
- If the therapist decides to make a self-disclosure, it would be more likely to enhance the therapy relationship and the therapy work if it is overt that it is relevant. It is also important to notice the impact of the self-disclosure on the client.
- It would be expected that any self-disclosure would be brief, and used in moderation.
- The therapist can then reflect and take this to clinical supervision, considering any learning opportunities and reviewing the decision in relation to this particular client and in the light of our Standards
For reflection
- What is your own response to the scenario, and how does it relate to how you would handle a client asking for personal information about you, or if there was an unintended disclosure?
- Are there any relevant personal experiences to reflect on?
References
Barnett, J. E. (2011). Psychotherapist self-disclosure: Ethical and clinical considerations. Psychotherapy, 48(4), 315–321
Goldfried MR, Burckell LA, Eubanks-Carter C. Therapist self-disclosure in cognitive-behavior therapy. J Clin Psychol. 2003 May;59(5):555-68. doi: 10.1002/jclp.10159. PMID: 12696131.
Jung, E., Wiesjahn, M., Rief, W. and Lincoln, T.M. (2015), Perceived therapist genuineness predicts therapeutic alliance in cognitive behavioural therapy for psychosis. Br J Clin Psychol, 54: 34-48. https://doi.org/10.1111/bjc.12059
Metcalf, L. (2011). Marriage and family therapy: A practice-oriented approach. Springer
Kingdon, D, Maguire, N, Stalmeisters, D and Townend, M (2017) CBT Values and Ethics. Sage
Miller (nee Johnston), E., & McNaught, A. (2018). Exploring Decision Making Around Therapist Self? Disclosure in Cognitive Behavioural Therapy. Australian Psychologist, 53(1), 33–39. https://doi.org/10.1111/ap.12260
Jung, E., Wiesjahn, M., Rief, W. and Lincoln, T.M. (2015), Perceived therapist genuineness predicts therapeutic alliance in cognitive behavioural therapy for psychosis. Br J Clin Psychol, 54: 34-48. https://doi.org/10.1111/bjc.12059
To share your thoughts and reflections about this, or to ask an ethical question for a future issue – contact communications@babcp.com with ‘CBT Today – Ethics’ in the subject line
Further reading and reference:
Kingdon D, Maguire N, Stalmeisters D, & Townend M (2017). CBT Values and Ethics. Sage Publishing
Ethical decision-making in practice (Kingdon et al 2015)
- When we are putting values and ethics into practice, there are some considerations that help with making an informed decision
- Identifying the issue, and reflecting on whose problem it is- considering who we owe an obligation or alliance to in the situation concerned
- Putting it into context-
- are there laws, organisational policies or ethical codes which apply in this situation?
- If this situation involves a client, what do I understand about their values?
- Reasoning – what ethical theories and principles can be used to help with this decision?
- Who can I consult with? – Clinical supervisor, or senior member of my team, my professional body- other?
- Processing and reflecting the information gathered so far – using discretion and judgement to consider the most appropriate options
- Deciding – making a decision which has a rationale, and is sensible and justifiable
- Evaluating – is there anything to learn from this situation? Can I or my colleagues do more to ensure that situations like this are resolved helpfully? Does anyone including me need more training or other professional development to help in the future?
