Looking Out the Patient's Window Redux:
Self-disclosure and Genuineness

​by Irvin Yalom

THEORY PSYCHOLOGY
​
How much should therapists reveal? When to reveal? When not? The guiding in answering such questions is always the same: What is best for the patient? Nancy was a patient I had known for a long time and I had a strong intuition that my genuineness would facilitate her work. Timing was an important factor as well: Self-disclosure early in therapy, before we established a good working alliance, might have been counterproductive
​ Nancy

In my fifteen-minute break—before seeing Nancy, my last patient of the day—I checked my voice mail and listened to a message from a San Francisco radio station. "Dr. Yalom, hope you don't mind but we've decided to change the format of our program tomorrow morning: We've invited another psychiatrist to join us and, instead of an interview, we'll have a three-way discussion. See you tomorrow morning at eight thirty. I assume this is all okay with you."

Okay? It wasn't okay at all and the more I thought about it the less okay it felt. I had agreed to be interviewed on the radio show in order to publicize my new book, The Gift of Therapy. Though I'd been interviewed many times, I felt anxious about this interview. Though the interviewer was extremely skilled, he was highly demanding. Furthermore, it was an hour long, the size of the radio audience was enormous and, finally, it was in my hometown with many friends listening. This voice mail message further fueled my anxiety. I didn't know the other psychiatrist; but to juice up the interview they had, no doubt, invited someone with an opposing point of view. I brooded about it: The last thing I, or my book, needed was an hour-long hostile confrontation in front of a hundred thousand listeners. I phoned back but there was no answer.

I was not in a good frame of mind to see a patient but the hour struck six and I escorted Nancy into my office. Nancy, a fifty-year-old nursing school professor, first came to see me twenty years before following the death of her older sister who had died of a brain malignancy. I remember how she began: "Eight sessions. That's all I want. No more, no less. I want to talk about the loss of the dearest and closest person in my life. And I want to figure how to make sense of life without her." Those eight sessions clicked by quickly: Nancy brought an agenda to each session: important memories of her sister, their three fights—one of which initiated a frosty silent four-year era which only ended at the funeral of their mother, her sister's disapproval of her boyfriends, her deep love for her sister—a love she had never expressed openly. 

Nancy was smart and quick: A self-starter in therapy, she worked hard and appeared to want or need little input from me. At the end of the tenth session she thanked me and left, a satisfied customer. I wasn't entirely satisfied, however. I would have preferred more ambitious therapy and I had spotted several areas, especially in the realm of intimacy, where further work could have been done. Over the next twenty years she called me two other times for brief therapy and, repeating the same pattern, used the time efficiently. And then, a few months ago, she phoned once again and asked to meet for a longer time, perhaps six months, in order to work on some significant marital problems.

She and her husband, Arnold, had grown increasingly distant from one another and for many years had slept in different rooms on separate floors of their home. We had been meeting weekly for a few months and she had so improved her relationship with her husband and her adult children that, a couple of weeks previously, I had raised the question of termination. She agreed she was getting close but requested a few additional sessions to deal with one additional problem that had arisen: stage fright. She was awash with anxiety about an upcoming lecture to a large prestigious audience.

As soon as Nancy and I sat down she plunged immediately into anxiety about her upcoming lecture. I welcomed her energy: it diverted my attention from that damn radio show. She spoke of her insomnia, her fears of failure, her dislike of her voice, her embarrassment about her physical appearance. I knew exactly what to do and began to escort her down a familiar therapeutic path: I reminded her of her mastery of her material, that she knew far more about her topic than anyone in the audience. Though I was distracted by my own anxiety, I was able to remind her that she had always sparkled as a lecturer and was on the verge of pointing out the irrationality of her views of her voice and physical appearance when a wave of queasiness swept over me.

How hypocritical could I be? Hadn't my therapy mantra always been "it's the relationship that heals, it's the relationship that heals." Hadn't I always, in my writing and teaching, beat the drum of authenticity? 

The solid, genuine, I-thou relationship—wasn't that the ticket, the significant ingredient in successful therapy? And yet here I was—riddled with anxiety about that radio show and yet hiding it all behind my pasted-on compassionate therapist countenance. And with a patient who had almost identical concerns. And a patient who wanted to work on intimacy to boot! No, I could not continue with this hypocrisy.

So I took a deep breath and fessed up. I told her all about the voice mail message I received just before she entered and about my anxiety and anger for my dilemma. She listened intently to my words and then, in a solicitous voice, asked, "What are you going to do?"

"I'm considering refusing to go on the program if they insist on this new arrangement."

"Yes, that seems very reasonable to me," she said, "you agreed to another format entirely and the station has no right to make the change without clearance from you. I'd be really upset about that, too. Is there any downside of your refusing?"

"None that I can think of. Perhaps I won't be invited back for the next book but who knows when or if I'll write another."

"So, no downside of refusing and lots of possible downside in your agreeing to do this?"

"Seems that way. Thanks Nancy, that's helpful."

We sat together in silence for a few moments and I asked, "Before we turn back to your stage fright, let me ask you something: How did that feel to you? This has not been our everyday hour."

"I liked your doing that. It was very important to me," she replied, paused for a moment to collect her thoughts and added, "I have a lot of feelings about it. Honored that you shared so much of your self with me. And ‘normalized': Your performance anxiety makes me more accepting of my own. And I think your openness will be contagious. I mean, you've given me the courage to talk about something I didn't think I'd be able to bring up."

"Great. Let's get into it."

"Well," Nancy looked uncomfortable and squirmed in her chair. She inhaled and said, "Well, here goes . . ."

I sat back in my chair, eager with anticipation. It was like waiting for the curtain to rise on a good drama. One of my great pleasures. A good story in the wings ready to make an entrance is like no other anticipatory pleasure I know. And my anxiety and annoyance at the interview and the radio station? What interview? What radio station? I had totally forgotten it. The power of the narrative drowned all cares.

"Your mentioning your book, The Gift of Therapy, gives me the opportunity to tell you something. A couple of weeks ago I read the whole book in a single sitting, till three a.m." She paused.

"And?" I shamelessly fished for a compliment.

"Well, I liked it but I was . . . uh, curious, about your using my story of the two streams."

"Your story of the two streams? Nancy, that was someone else's story, a woman dead these many years—I described her in the book. I've used that story in therapy and teaching for more years than I can remember."

"No, Irv. It was my story. I told it to you during our first therapy, twenty years ago."

I shook my head. I knew it was Bonnie's story. Why, I could still visualize Bonnie's face as she told me the story, I could see her wistful eyes as she reminisced about her father, I could still see the violet turban around her head—she had lost her hair from chemotherapy.

"Nancy, I can still see this woman telling me the story, I can . . ."

"No, it was my story," Nancy said firmly. "And what's more, it wasn't even my father and me. It was my father and my aunt, his younger sister. And it wasn't on the way to college—it was a vacation they took in France."

I sat stunned. Nancy was a very precise person. The strength of her assertion caught my attention. I turned inwards searching for the truth, listening to the trickling of memory coursing in from outposts of my mind. It was an impasse: Nancy was certain she told me this. I was absolutely certain I heard it from Bonnie. But I knew I had to remain open-minded. One of Nietzsche's marvelous aphorisms entered my mind and served as a cautionary tale: 

"Memory says, I did that. Pride replies, I could not have done that. Eventually memory yields."

As Nancy and I continued to talk, a new and astounding thought dawned. Oh, my God, could there have been two stories? Yes, yes, that's it. There must have been! The first story was Bonnie's story about her father, her yearning for reconciliation, and their unsuccessful drive to college; the second story was Nancy's two-stream story about her father and aunt. Now, all at once, I realized exactly what had happened: My gestalt-hungry, story-seeking memory had conflated the two stories into a single event.

It's always a shock to experience the fragility of memory. I've worked with many patients who have been destabilized when they learned that their past was not what they had thought it was. I remember one patient whose wife told him (at the breakup of their marriage) that, throughout their three-year marriage, she had been obsessed with another man, her previous lover. He was shattered: All those shared memories (romantic sunsets, candlelit dinners, walks on the beaches of small Greek islands) were chimerical. His wife was not there at all. She was obsessing about someone else. He told me more than once that he suffered more from losing his past than from losing his wife. I didn't fully understand that at the time but now, as I sat with Nancy, I could finally empathize with him and appreciate how unsettling one feels when the past decomposes.

The past: wasn't it a concrete entity, unforgettable events etched indelibly into stone-like leaves of experience? How tightly I clung to that solid view of existence. But I knew now, I really knew, the fickleness of memory. Never again would I ever doubt the existence of false memories! What made it even more confounding was the way I had embroidered the false memory (for example, the wistful look on Bonnie's face) which made it entirely indistinguishable from a real memory. All of these things I said to Nancy along with my apology for not having obtained her permission for the story of the two streams. Nancy was untroubled by the issue of permission. She had written science fiction stories and was well aware of the blurring of remembrance and fiction. She instantaneously accepted my apology for publishing something of hers without her permission and then added that she liked her story being used. She took pride in it having prove helpful to my students and other patients.

Her acceptance of my apology left me in a mellow mood and I told her of a conversation a few hours previously with a visiting Danish psychologist. He was writing an article about my work for a Danish psychology journal and asked whether my intense closeness with patients made it more difficult for them to terminate. "Given the fact that we're near termination, Nancy, let me pose that very question to you. Is it true that our closeness interferes with your ending your meetings with me?"

She thought about it for a long time before responding, "I agree. I do feel close to you, perhaps as close as with any other person in my life. But your phrase, that therapy is a dress rehearsal for life, which you said so many times—I think you overdid it by the way . . . well, that phrase helped keep things in perspective. No, I'm going to be able to stop soon and keep a lot from here inside me. From day one of our last set of meetings you did keep focusing on my husband. You did keep focusing on our relationship, but scarcely an hour passed without your moving over to the intimacy between me and Arnold."

Nancy ended the hour by giving me a lovely dream (remember Nancy and Arnold slept in separate rooms).

"I was sitting on Arnold's bed. He was in the room and watching me. I didn't mind his being there and was busy with makeup. I was taking off a makeup mask, peeling it off in front of him."

The dream-maker inside of us (whoever, wherever, he or she is) has many constrictions in the construction of the finished product. One of the major constrictions faced is that the dream final product must be almost entirely visual. Hence, an important challenge in the dream work is to transform abstract concepts into a visual representation. What better way to depict increased openness and trust with one's spouse than to peel off a mask?

Discussion

Let's review the major points conveyed in this vignette. First, let's consider my self-disclosure of my personal anxiety evoked by an event that occurred just before the start of the therapy hour. Why choose to share this? First, there was the consideration of genuineness. I felt too phony, inauthentic, sitting on my anxiety while trying to help her deal with anxiety about a very similar issue. Second, there is the matter of effectiveness: I believe that my preoccupation with my personal issues was hampering my ability to work effectively. Third, there is the factor of role modeling. My experience over decades of doing therapy is that such revelation inevitably catalyzes patient revelation and accelerates therapy.

After my self-revelation there was, for a few minutes, a role reversal as Nancy offered me effective counsel. I thanked her and then initiated a discussion of our relationship by commenting that something unusual had just happened. (In the language of therapists, I did a "process check.") Earlier I made the point that therapy is, or should be, an alternating sequence of action and then reflection upon that action.

Her response was highly informative. First, she felt honored by my sharing my issues with her—that I would treat her as an equal and accept her counsel. Second, she felt "normalized"—that is, my anxiety made her more accepting of her own. Last, my revealing served as a model and an impetus for her further revealing. Research confirms that therapists who model personal transparency influence their patients to reveal more of themselves.

Nancy's response to my disclosure is, in my clinical experience, typical. For a great many years I have worked with patients who have had an unsatisfactory prior experience in therapy. What are their complaints? Almost invariably, they say that their previous therapist was too distant, too impersonal, too disinterested. 

I believe that therapists have everything to gain and nothing to lose by appropriate self-disclosure.

How much should therapists reveal? When to reveal? When not? The guiding in answering such questions is always the same: What is best for the patient? Nancy was a patient I had known for a long time and I had a strong intuition that my genuineness would facilitate her work. Timing was an important factor as well: Self-disclosure early in therapy, before we established a good working alliance, might have been counterproductive. The session with Nancy was an atypical session and I do not generally reveal my own personal disquiet to my patients: After all, we therapists are there to help, not to deal with our own internal conflicts. If we face personal problems of such magnitude that they interfere with therapy then obviously we should be seeking personal therapy.

That said, let me add that on countless occasions I have gone into a session troubled with some personal issues and, by the end of the session (without having mentioned a word about my discomfort), felt remarkably better! I've often wondered why that was so. Perhaps because of the diversion from my self-absorption, or the deep pleasure of being helpful to another, or the boost in self-regard from effectively employing my professional expertise, or the effect of increased connectivity that all of us want and need. This effect of therapy helping the therapist is, in my experience, even greater in group therapy. All of the reasons noted above are in effect but there is an additional factor in group therapy: A mature, caring therapy group in which members share their deepest inner concerns has a healing ambiance in which I have the privilege of immersing myself. 


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From The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients (updated edition) © 2002, 2009 by Irvin D. Yalom. Courtesy of HarperCollins Publishers.

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