The Mood Disorders Support Group of New York City

	M O O D S
Newsletter of the Mood Disorders Support Group of New York City
February 2003	Table of Contents (all articles are on this page) From the Chair   by Betsy Naylor More Web Sites on Mental Health  How Much Should Psychotherapists Tell About Themselves?     by Michael Craig Miller, M.D. From Ask the Doctor  with Dr. Ivan Goldberg  Lecture Tapes Available     We Get By with a Little Help from Our Friends . . . About MDSG	When printed, this page will automatically re-format itself. Formatted for Printing

Dear Members and Friends of MDSG:

Heads up: Some changes are coming about, and I want to tell you what will be different and why.

For example, this newsletter is the first to be sent as an open mailing. Until now, newsletters have been sent in an envelope. Open mailings will save MDSG thousands of dollars per year. Those who do not want to be on the open mailing list may get the newsletter from our website or from one of the discussion group sites.

Our organization is one that grows and contracts and we often have to be flexible to the changing needs of our sites. Right now, we are growing at a rapid rate, our lecture series is highly attended, the west side site now has weekly numbers that match that of the Friday site and we stretch our resources to maintain excellence in the services we provide. 

Since we do not have a large paid staff to help, from time to time we must adjust according to the ebb and flow of our organization. As of March 18th, our Brooklyn site will close for the foreseeable future and we hope that you will visit us at our other sites after that date. In the meantime, I am very grateful for the hard work of the volunteers at the Brooklyn site who have kept it running for the past few years.

Also, a word about our lecture series. . . At times, I think the lectures are taken for granted, although a lot of skill goes into setting up this program. Some speakers are selected because they are known experts, and also dynamic and interesting. Other times a subject particularly interesting to our audience leads to the expert speaker selected. All the speakers receive only a small honorarium. We have the chance to hear the latest on what works in helping us get better. I'd like to see more of us in the audiences.

And lastly, if you are already on the mailing list, may we have your e-mail address? Certain announcements could then go out to many people at once, and MDSG could save on mailing costs. You can give us your e-mail at any discussion group site or lecture, leave it on the phone line, or e-mail us at info@mdsg.org. 

Changes mean that we are paying attention to what works, what doesn't work, and what would bring improvement. Look for more change as MDSG gets better and better.

In our last issue, we began a feature to help bring order to the often chaotic flurry of information related to mood disorders. In this modern age, many people rely on the Internet for data. Last time, we listed some helpful websites. Here are a few more that we think can be informative. As usual, be careful when you surf the Internet. You never know who may be on the other end acting as an authority, especially in chat rooms. 

1. www.nimh.nih.gov  National Institute of Mental Health
2. www.narsad.org  National Alliance for Research on Schizophrenia and Depression
3. www.save.org  Suicide Awareness Voices of Education
4. www.miminc.org  Madison Institute of Medicine-Lithium Information Center/Bipolar Disorders Treatment Information Center
5. www.aacap.org  American Academy of Child and Adolescent Psychiatry
6. www.stepbd.org  Systematic Treatment Enhancement Program for Bipolar Disorder
7. www.chadd.org  Children and Adults with Attention-Deficit/Hyperactivity Disorder
8. www.mentalhealthscreening.org  Screening for Mental Health, Inc.
9. www.nationaleatingdisorders.org  National Eating Disorders Association
10. www.suicidology.org  American Association of Suicidology 

We have a web page devoted to links about Mood Disorders. 

By Michael Craig Miller, M.D.
Editor in Chief, Harvard Mental Health Letter

“Doctor, enough about me. Now I have a few questions for you.” In years past, the typical psychotherapist might have put up a stop sign labeled therapeutic anonymity or neutrality. But today many therapists are willing to answer questions about themselves, and an increasing number think it’s not only acceptable but a good idea.

The stereotype of the therapist as a blank screen onto whom the patient can project thoughts, feelings and fantasies is becoming outdated. Although therapists still have good reasons not to answer certain questions, decades of observation, research, and debate have called into question the value of anonymity.

It depends, of course, on what kind of psychotherapy is being conducted. Psychotherapists who perform supportive or cognitive-behavioral therapy often regard self-disclosure as enhancing the therapeutic relationship. But even psychoanalysts, for whom anonymity and neutrality have been fundamental rules, are now considering the uses of self-revelation instead.

Why is this an issue? Most physicians, lawyers, accountants, and other professionals consulted by clients about personal matters do not avoid friendly conversation about their children or their last vacation. It’s not seen as interfering with the service they provide.

By contrast, many psychotherapists—especially those from the psychoanalytic tradition—have felt obliged to conduct their business according to the stringent guidelines proposed by Sigmund Freud almost a century ago. Dr. Freud, however, was not always so reserved with his own patients. He answered questions about his family and discussed his own feelings about patients. From time to time, he lent books to patients, gave them gifts, or provided financial support. But in the early days of psychoanalysis, he worried that some colleagues were overstepping boundaries and having improper relationships, including sexual relationships with their patients. He wanted them to be careful not to take advantage of their patients’ vulnerability, so he instructed them to be more detached. The analyst was to be precise and objective, like a surgeon.

The need to maintain boundaries is certainly a compelling reason for therapists to be careful of what they say about themselves. Professional ethics discourage the use of patients for the therapist’s emotional gratification. And all successful psychotherapy depends on keeping the focus on the patient’s problems, rather than deflecting attention to the therapist’s feelings or experiences.

Anonymity and neutrality also have specific roles to play in the psychoanalytic process. A central feature of that process is analysis of the transference, the patient’s responses to a therapist that reflect feelings about important people from early life, especially parents. In theory, every personal relationship is touched by transference. The aim of psychoanalysis and psychoanalytic psychotherapy is to encourage the transference to grow and flower so that early relationships can be re-experienced and newly understood.

It’s assumed that personal information about the therapist would interfere with that process of discovery. The less the patient knows about the therapist’s life, the more their thoughts and feelings about the therapist can be the result of transference alone. Instead of answering personal questions, a therapist explores the patient’s wish to know about the therapist’s personal life.

Like a surgical procedure, this approach can be difficult for both the therapist and the patient. Some have always objected to the surgical analogy, and even within psychoanalysis, the debate about therapeutic neutrality is almost as old as Freud’s writings. An argument in favor of self-disclosure can be made in the name of common sense. Forty years ago, the analyst Leo Stone expressed doubt whether the evolution of the transference was disturbed by a patient’s knowing whether the therapist prefers golf to sailing.

In any case, the surgical analogy is unrealistic. Therapists reveal things about themselves, not just by what they say, but also by what they don’t say, their facial expressions, the way they conduct their practice, and the way they dress and decorate their offices.

From neutrality to “humanness”

If Freud’s century-old prohibitions are impractical, what guidelines make sense for modern therapists? First, they must recognize that there are several kinds of self-revelation:

• Non-verbal communications, facial expressions, and spontaneous reactions
• Personal style—for example, whether the therapist is naturally serious and formal or playful and informal
• Answers to direct questions or volunteered descriptions of personal experiences, images, memories or feelings.

These three forms of self-disclosure are distinguished by the degree to which the therapist exercises control over them. Controlling nonverbal communications, which are usually outside the therapist’s awareness, is difficult, perhaps impossible. Modifying personal style is challenging, although possible. Therapists are freer to choose how to use active self-disclosure to further the goals of therapy.

It is not clear how far a therapist should go. Disclosures can range from the simplest yes or no to extensive narratives or confessions. The focus may be a publicly known fact (Yes, I graduated from Columbia), a straightforward acknowledgement of preferences (I like baseball, too), or a far-reaching description of personal experiences and feelings. Common sense is a poor guide, since one therapist may regard as a boundary transgression what another sees as simply imparting harmless information. But the psychotherapy literature gives some indication of current practice.

Studies of self-disclosure

Cognitive behavioral therapists and professionals who practice supportive therapy, interpersonal therapy, and counseling have traditionally taken a more flexible approach to self-disclosure than psychodynamic (psychoanalytic) therapists. Psychiatrists who provide mainly medication and support to their patients are also less likely to withhold personal information from them. 

A growing literature favors some self-disclosure by therapists. For many decades, some psychoanalysts have suggested that insisting rigidly on personal distance may discourage patients from becoming engaged in treatment. Some psychologists go further and advocate “transparency.” They believe that a therapist’s disclosures can promote therapeutically valuable disclosure by the patient.

Research has shown that the effectiveness of psychotherapy depends largely on the bond between therapist and patient---and a therapist’s disclosures can have a strong influence, both positive and negative, on that bond. Patients are most comfortable when therapists show that they have the experience and skills needed to cope with patients’ problems. Disclosing professional experience serves that purpose. Studies also show that therapists with an informal manner seem more trustworthy, but if they discuss negative personal experiences (such as depression) they are likely to appear less attractive and less expert.

In a recent study, 18 therapists worked with two clients each. With one client, the therapists were instructed to tell more about themselves in response to self-disclosure by clients. With the other client, they put up that stop sign and kept their distance. When the therapists told more about themselves, clients reported less distress and regarded the therapists as more “friendly, open, helpful, and warm.” The researchers concluded that some self-disclosure is helpful, although they cautioned against too much of a good thing.

Surveys indicate that in practice, most psychotherapists do talk about themselves, while remaining mindful of the risks as well as the benefits. A survey of 342 therapists in Colorado revealed that they used self-disclosure to promote the idea that human problems are universal and to offset clients’ distortions of reality. They tried to be careful to avoid inappropriate revelations that might remove the focus from the patient or interfere with the emerging transference.

In another survey, eight experienced therapists were interviewed. Those who used self-disclosure did so strengthen the therapeutic bond and provide a “context for growth.” They wanted to be “real” and “honest,” but also respectful, warm, and attentive, in order to provide a model for the patient, develop a working relationship, and encourage the patient to be more realistic and independent.

Beyond warmth to a new way of working?

Therapists of any era may have championed respectful and professional informality and warmth, but these qualities are not defined today as they were in the turn-of-the-century Vienna. Cultural contexts vary, too, from the warm and physically expressive Latin cultures to more reserved Northern European or Asian ones. And therapists cannot ignore regional differences within the United States.

Today attitudes are changing in psychoanalytic psychotherapy, where the barrier to self-disclosure—understood as essential to the treatment—has been the most stringent observed.

Psychoanalytic therapists are taking a new look at self-disclosure in connection with their own reactions to patients, a phenomenon usually called countertransference. Until recently, countertransference was seen only as a problem to be worked out by the therapist alone, perhaps with the help of a colleague or supervisor. In the last 20 years, however, some analysts have become interested in what they call “intersubjectivity,” the interplay of the patient’s psychology with the therapist’s. Some now openly discuss their own experience of the therapy or analysis with the patient to further the patient’s self-understanding.

Owen Renik, a psychoanalyst and outspoken advocate of self-disclosure, describes the advantages of “playing his cards face up” with the patient. He writes, “I’m consistently willing to make my own views—especially my own experience of clinical events, including my participation in them---explicitly available to the patient.” He believes that this open approach demystifies the analyst and promotes rather than impedes the emergence of transference.

Generalizing about these issues is difficult. Because each case is different, therapists must always exercise clinical judgment. They can reconcile conflicting aims and needs (including their own need for privacy) by explaining their technique and negotiating an approach that balances the patient’s need for a genuine response with the therapist’s idea of how best to be helpful. Most good therapists have a professional attitude that includes some warmth and flexibility along with a firm sense of technique. This approach avoids the hazards of being too rigid on one hand or crossing boundaries on the other.

The research suggests some practical guidelines for therapists that may require modification depending on the therapeutic technique employed.

• Do not try to hide the obvious. A curious patient can always track publicly available information about a therapist.
• Self-disclosure is not necessary for a therapist to seem “real” or “human.” Many patients prefer not to know too much about their therapists. Decisions can be governed by the patient’s needs and not by a theoretical conviction about the risks or benefits of openness.
• Analytic therapists can be explicit about their interest in encouraging and making use of transference feelings. Unless the patient understands this, analytic neutrality may damage the therapeutic bond.
• Strict neutrality or anonymity may not be necessary for examining and resolving the transference. There are persuasive arguments both for and against it.
• Patients have a right to know what they are getting into. They are entitled to ask about the therapist’s methods, experience, and professional qualifications. Questions about such matters as ethnicity, sexuality, and religious or political convictions are more negotiable.
• The more therapists reveal, the greater the danger that patients will see them as violating a boundary. Therapists must take care that any disclosures about themselves have a therapeutic justification.

A physician friend tells the following story. He and his own doctor work in the same hospital. During a recent appointment, the doctor tried to establish a friendly relationship with him by light gossip about people and events in the hospital. My friend didn’t like this; it made him uneasy. So it is not only psychotherapy that professionals have to read the preferences of their patients or clients with respect to self-disclosure. Those preferences are different for each person, so slavish adherence to a single rule is not sensible. Therapists and patients may find it useful to discuss this issue openly during psychotherapy. The patient will be the final judge of whether the therapist’s choices are helpful.

Note: Dr. Miller will speak at the June 2, 2003 lecture.

Excerpted from October 2002 issue of the Harvard Mental Health Letter © 2002, President and Fellows of Harvard College.

The Harvard Mental Health Letter is an excellent monthly publication. The usual subscription rate is $72 per year. Special introductory rate made available for our readers is $29 per year. (Note: In the printed newsletter, this was mistakenly reported as $59 for our readers).  

Harvard Mental Health Letter
Dept. HMDS
P.O. Box 420448
Palm Coast, FL 32141-0448
      or call
(800) 829-5379 and ask for Dept HMDS

Barret, M.S., and Berman, J.S. “Is Psychotherapy More Effective When Therapists Disclose Information about Themselves?” Journal of Consulting and Clinical Psychology (2001): Vol. 69, No. 4, pp597-603. 

Jacobs, T. “On the question of self-disclosure by the analyst: Error or Advance in Technique?” Psychoanalytic Quarterly (1999): Vol. 68, No. 2, pp. 159-83.

Mathews, B. “The Role of Therapist Self-disclosure in Psychotherapy: a Survey of Therapists,” American Journal of Psychotherapy(1988)): Vol. 42, No.4 pp. 521-31.

Renik, O. “Playing One’s Cards Face Up in Analysis: an Approach to the Problem of self-disclosure,” Psychoanalytic Quarterly (1999): Vol. 68, No.4, pp. 521-39.

Stone, L. The Psychoanalytic Situation. International Universities Press 

From Ask the Doctor       with Dr. Ivan Goldberg

Top Of Page

J Affect Disord 2003 Jan;73(1-2):123-31 The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account sub-threshold cases. Judd LL, Akiskal HS. Department of Psychiatry, University of California, San Diego. 

RESULTS: As originally reported nearly two decades ago by the primary investigators of the ECA, the lifetime prevalence for manic episode was 0.8%, and for hypomania, 0.5%. What is new here is the inclusion of sub-threshold SSM subjects, which accounted for 5.1%, yielding a total of 6.4% lifetime prevalence for the bipolar spectrum. All three (manic, hypomanic and SSM) groups had greater marital disruption. There were significant increases in lifetime health service utilization, need for welfare and disability benefits and suicidal behavior when the SSM, hypomanic and manic subjects were compared to the no mental disorder group. Suicidal behavior was non-significantly highest in the hypomanic (bipolar II) group. Otherwise, hypomanic and manic groups had comparable level of service utilization and social disruption. 
  
    

Did you miss a lecture of great interest to you? 

Most of the people who come to hear these experts speak, tell us how helpful the information has been. Not only do we find out about the latest scientific breakthroughs, but we also learn new coping skills from these cutting edge researchers, clinicians and authors. 

Tapes of these popular lectures are now available through the mail. Below is a listing of some of the most recent presentations. 

To order by mail, simply write a letter requesting any tape by number. Tapes are $13 (including postage and handling) or $25 for two tapes, $35 for three tapes. You should receive your tape(s) in two weeks. Include a check payable to MDSG and send it to:

MDSG provides award-winning services to New York’s entire mental health community---over 800 individual support groups a year, the distinguished lecture series, our telephone information service, this newsletter. And all at the lowest possible cost, through volunteers.  The $4 contribution for meetings doesn’t cover all our expenses. We need your help to pay the phone bill, print the newsletter, promote MDSG in the media, and meet other needs.

Annual membership is $35 for individuals, $50 for families. Your membership card is a free ticket to support groups and most lectures. Contributions are tax deductible. So be a friend of MDSG--support us as we support you!

Memberships and contributions to MDSG are tax-deductible to the extent allowed by law. MDSG is an IRS-recognized 501(c)(3) organization..

MDSG/NY sponsors a series of  lectures on various aspects of mood disorders. Anyone can attend our lectures. More information is available on our lectures page. Our next lectures are:

Questions for the Psychiatrist
Monday, April 7, 2003 
David Hellerstein, M.D. 
Find out about Rapid Cycling, Chronic Depression, Hypomania or anything about mood disorders, including Atypical Depression.

Interactions Between the Police and the Mentally Ill
May 5, 2003 
James J. Fyfe, Ph.D.
Dr. Fyfe, Distinquished Professor at John Jay College of Criminal Justice, will discuss: What does the average cop know about mental illness? This is a fund raising lecture. 

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