Building a Therapeutic Relationship: How Much is Too Much Self-Disclosure?

Abstract

Therapeutic relationships are foundational to nursing practice. Nurses use self-disclosure as means of connecting with their patients. But, how is this done effectively, how do nurses learn self-disclosure, and what is the effect of self-disclosure on the nurse/client relationship. An exploratory qualitative research design was used to gather information to help improve nursing's understanding of self-disclosure within the context of a nurse/patient relationship. The following research questions were addressed: What are the reasons nurses self-disclose? How do nurses learn about using self-disclosure? When nurses do self-disclose, what effect on the therapeutic relationship? Data was collected through qualitative interviews with Registered Nurses, who reported using self-disclosure to enhance their relational practice. Recommendations include utilizing Nursing Professional Development Practitioners to implement educational guidance to self-disclose effectively.

Headnote

Abstract

Therapeutic relationships are foundational to nursing practice. Nurses use self-disclosure as means of connecting with their patients. But, how is this done effectively, how do nurses learn self-disclosure, and what is the effect of self-disclosure on the nurse/client relationship. An exploratory qualitative research design was used to gather information to help improve nursing's understanding of self-disclosure within the context of a nurse/patient relationship. The following research questions were addressed: What are the reasons nurses self-disclose? How do nurses learn about using self-disclosure? When nurses do self-disclose, what effect on the therapeutic relationship? Data was collected through qualitative interviews with Registered Nurses, who reported using self-disclosure to enhance their relational practice. Recommendations include utilizing Nursing Professional Development Practitioners to implement educational guidance to self-disclose effectively.

Keywords: therapeutic relationship, self-disclosure

Introduction

A therapeutic relationship is foundational to establishing an effective and efficient nursing practice. Nortvedt (2001) has identified that moral responsibilities and professional duties are generated from within this relationship. Yet, being in a therapeutic relationship demands that nurses respond to vulnerability. This vulnerability is generated from both the patient's and the nurse's personal and contextual elements. Both the nurse and the patient bring their own histories to the context of the interaction. In contrast to a decontextualized view of establishing a therapeutic relationship, which requires a nurse to have a caring attitude but not to be mutually engaged, a contextualized view of the therapeutic relationship requires that "one is always assuming and looking for the ways in which people, situations, contexts, environments, and processes are integrally connecting and shaping each other" (Doane & Varcoe, 2007, p. 198). Nurses use self-disclosure as a means of connecting and engaging with their patients, but how is this done effectively, how do nurses learn what the boundaries are to selfdisclosure, and what is the effect on the therapeutic relationship when a nurse discloses experiences that are similar or connected to what the patient is experiencing? To answer these questions explorative qualitative research methods were used.

Literature Review

There is little agreement on the meaning of selfdisclosure, and whether it is an appropriate means of establishing a therapeutic relationship. There are two primary discourses regarding the appropriateness of self-disclosure. The first, is the product of psychoanalysts. Psychoanalysts train with the mantra "do not self-disclose" (Edwards & Murdock, 1994). They believe it destroys the sacred professional boundary between client and practitioner (Nillson, Strassberg, & Bannon, 1979). Psychoanalytic theory requires the therapist to maintain a neutral position to foster client wisdom and self-knowledge (Maroda, 1999). Within the psychoanalytic tradition, it is believed that therapist self-disclosure results in the therapeutic focus shifting away from the patient. Thus, reducing the efficacy of treatment. Consequently, many psychoanalysts have concluded that selfdisclosing poses too great a risk of disrupting or disturbing therapeutic equipoise, without any accompanying therapeutic gains (Nillson et al., 1979). The canonization of "do not self-disclose" had been relatively unchallenged within the psychoanalytical literature. Psychoanalysts suggest that therapist self-disclosure leads to role reversal and subsequent role confusion, blurring professional boundaries, and feeling overwhelmed (Audet & Everall, 2010).

However, this notion has been challenged by researchers outside of psychoanalytical schools. For example, Hanson (2005) found that therapist non-disclosure was detrimental to the establishment of a therapeutic relationship; if the therapist doesn't self-disclose, client selfdisclosure is inhibited. Two possible effects of this inhibition are: 1) a decrease in the accuracy of clinical assessments, and 2) a decrease in the effectiveness of treatment plans.

The other discourse, on the appropriateness of selfdisclosure, has been developed by therapists who use a feminist ideology to guide their clinical practice. These therapists, "proactively disclose information about their professional background, personal values, and beliefs" (Audet, 2011, p. 87). In doing do it is an attempt to mitigate power differentials between client and therapist (Mahalik, Van Ormer, & Simi, 2000). Proponents of this approach emphasize that self-disclosure must be utilized in an appropriate context to establish a culture of egalitarianism, and therapeutic connections with clients (Mahalik et al. 2000). It is within these connections that client wisdom and self-knowledge are developed or enhanced. The connections are built by establishing therapeutic alliances (Audet & Everall, 2010; Hanson, 2005; Mahalik et al. 2000).

Very little nursing research has been conducted on the effects of self-disclosure on the nurse/patient relationship. Therefore, many nurses use evidence shared by other disciplines whose epistemological underpinnings are congruent with the five metaparadigms of nursing (person, environment, health, nursing, and justice). This includes feminist theorists and researchers who have contributed to the knowledge development related to the appropriateness of self-disclosure within the context of a therapeutic relationship. Feminist researchers have identified the following benefits of therapist/professional self-disclosure: enhancing therapist engagement, increasing client engagement, humanizing the client's experience, reducing of power differentials, normalizing experiences, focusing of advocacy strategies, and a decreasing of social inequities through emancipatory activities (Audet & Everall, 2010; Hanson 2005; Mahalik et al. 2000).

Psychoanalytical theory, and feminist theory have opposing perspectives on self-disclosure. More research is needed concerning the effects of nondisclosure on clients. Limited research was found regarding when, and how Registered Nurses (RN's) learned how to effectively self-disclose using the CINAHL, Academic Search Complete, Medline (EBSCO version), or Education Research Complete. There is a gap in research regarding the effects of self-disclosure from client perspectives in a nursing environment. Although, the literature focused on single therapist with a single client interactions, this was deemed applicable to the current research questions as there is a similar pattern of interaction within many nursing settings.

Methods

Design

An exploratory qualitative research design was used to gather information to help improve nursing's understanding of self-disclosure within the context of a nurse/patient relationship. The following research questions were addressed: What are the reasons nurses self-disclose? How do nurses learn about using self-disclosure? When nurses do self-disclose, what effect on the therapeutic relationship?

Sample

The sample consisted of 5 RN's who ranged in age from 22 years old to 60 years old. Study information was shared with potential participants working in direct care areas of large tertiary care centre. The first and second research participants were identified by responding directly to the researcher. The remaining participants were identified using snowball sampling strategies. Everyone met the following eligibility criteria: ability to give informed consent, practicing as an RN and responsible for providing direct patient care, at least 18 years old, and ability to participate in an English language interview. Potential participants were excluded if they believed they could be negatively impacted by talking about their experiences.

Data Collection

The following questions were used to guide a semi-structured interview. Describe a time in which you decided to share information about yourself with a patient? What information did you share about yourself? What does self-disclosure mean to you? What factors influenced your decision to self-disclose? What was your goal in sharing this information? What were the results of your self-disclosure - for yourself/the patient, positive/negative if any? How did you learn about professionally using self-disclosure? What advice would you give students learning to use selfdisclosure as a therapeutic tool? The interviews took place at a location that was mutually agreeable to the participant and the researcher. The length of the interview ranged from approximately 20 - 40 minutes. All the interviews were audiotaped. Then transcribed. The transcripts were then compared to the audiotapes to ensure transcription accuracy. Recruitment continued until thematic data saturation was achieved.

Data Analysis

Data analysis occurred throughout the research process. "The process of critical scholarship is one that rests on the reflection and insight" (Thompson, 1987, p. 33) therefore, the data analysis was not a distinct stage of the research process, but rather began in the literature review and continued until the conclusion of this project.

A thematic analysis began with a longitudinal listening to the interview. This allowed the researchers listen to the whole interview. Particular attention was given to decision-making processes related to the self-disclosure, how these were learned, and then to the assessment of the effects of this self-disclosure on the therapeutic relationship.

Data collected was analyzed using a three-part process: first coding, analytic coding and journaling (Lofland, Snow, & Anderson, 2005; Miles, Huberman, & Saldana, 2013). First level coding was used to describe the attributes of rationale used to determine the appropriateness of self-disclosure. Values regarding the appropriateness of self-disclosure, and the effect that self-disclosure had on the therapeutic relationship were identified. Data was organized and indexed according to the questions used in the semi-structured interview.

In the second step of analysis the researcher moved beyond description to inference thereby establishing pattern or analytic codes. The constructs that that emerged were decision, purpose, information, location of learning, and advice.

The third component was journaling. This is a technique captured the researcher's thoughts and ideas that occur while analyzing the data. Journals were made up of conceptual notes and provided insight into the evolving themes/constructs that are emerging from the data. They were reflective comments comprised of a few words or sentences that recorded hypothesis, links, and interpretations seen in the data. These ideas generated propositions that lead to the proposed recommendations.

Data analysis concluded when no new analytical codes were found, and when the categories reach saturation. Data from all sources - transcripts, field notes and reflexive journal were analyzed and provided a total picture of the research and responded to the posed research questions. Although these steps are outlined in a linear fashion they were not tidy. All of one step was not be completed before moving on to the next step. This was at times messy and sometimes a confusing process, characterized by false starts, regroupings, and doubt.

Results

Our results will begin by a discussion of what the participants meant by self-disclosure. Then we will explore the influences on nurse's self-disclosure decision-making and what types of information they share. This section concludes with reporting on how the participants learned about selfdisclosure appropriateness and techniques.

Definition

All participants had an individual definition of self-disclosure. However, self-disclosure, as summarized by the current participants, is a planned intervention with the goal of enhancing the nurse-patient relationship through the RN sharing personal information. Each participant operationalized how they self-disclosure differently. For example, one identified that selfdisclosure included sharing information "above the general context" of a nurse-patient relationship, versus simply sharing personal information. Everyone used self-disclosure as a means of improving mutual engagement within the context of a therapeutic relationship.

Decision to Self-Disclose

A variety of factors determined the RN decision to self-disclose. Most participants described a sense of intuition, or common sense from learned experiences, as one of the prominent factors of deciding to self-disclose with patients. Similarly, others chose to self-disclose with patients to establish rapport to improve communication between the RN and patient; in other words, the RN would disclose with the patient, in hopes the patient would reciprocate sharing information about themselves. Other factors identified by participants included whether the patient was a "regular" - meaning a patient and/or family had been on the unit for an extended time, or was frequently admitted - as the RN was more comfortable sharing with patients they were familiar with. The context of the nurse-patient relationship (ie. inpatient vs outpatient, or family member presence) also impacted the decision to self-disclose. One participant stated reading the patients chart and assessing their readiness for selfdisclosure impacted her decision to share her experiences with clients. Conversely, the same participant identified the importance of determining the RN's readiness to share with patients; the RN should assess whether it is in their "realm of nature" to self-disclose, as it may not comfortable for them to do so.

Purpose of Self-Disclosure

Participants unanimously stated the purpose of self-disclosing with patients is to establish a connection. Self-disclosure is viewed by participants as a means to show understanding, increase rapport, and empathize with their patients. One felt that it "humanizes" the nurse-patient relationship. Self-disclosure minimizes barriers to therapeutic communication, contributes to the development of relational space, and promotes a patient's willingness to self-disclose. Variability amongst participants included, describing selfdisclosure as a method to give hope to their patients; while another stated humanizing the relationship allowed them to give control back to their patients. The same participant also utilized self-disclosure to distract her patients from stressors encountered during her time with them such as painful, or invasive procedures. In contrast, one participant stated she viewed self-disclosing with her patients as a technique to stay "present" with her patients; which is supported by another who found self-disclosure promoted the holistic care of patients - treating not just the physical, but the mental, and spiritual aspects as well.

Information Shared

Participants varied with what types of information they shared with patients. Almost all stated they shared personal information including common hobbies/interests, and information about their families. Others used context to determine what information they would share; for example, sharing information related to the patient's diagnosis. One participant highlighted that self-disclosure could be non-verbal as well, that a RN shares information about themselves by how they dress, how they talk, how they present themselves.

Where Self-Disclosure Learned

The majority of participants did not learn about self-disclosure in school, but rather through clinical experiences after graduation. They observed fellow RN's using self-disclosure with their patients, and modeled their practice. One participant stated a level of "common sense" is necessary to practice self-disclosure in a safe manner. This participant also believed nursing school was boundary driven regarding nursepatient interactions, meaning education regarding nurse-patient relationships focused on definitive professional boundaries, rather than on the relational attributes. Another described feeling reluctant to self-disclose at first; suggesting her internal conflict could be from the lack of education regarding self-disclosure. In contrast, a participant who did not describe experiencing an internal conflict, was provided education on selfdisclosure in nursing school. This education included discussions about self-disclosure, and students were encouraged to practice appropriate self-disclosure as it was viewed as therapeutic to patients.

Offering Advice

Participants offered varying advice. Most based their advice focusing on maintaining professional boundaries, such as "do not given out [your] address or phone number", or "never over share". It was suggested by a few participants that keeping the best interest of patient in mind is one way to keep students from over sharing, as stated "only tell enough to benefit [the patient's] situation".

Discussion

Self-disclosure is a form of treatment; it is an intervention strategy that can be used to achieve specific patient outcomes. Feminist ideology can be used to guide RN evidence-informed decisionmaking related to self-disclosure. Decisions about self-disclose are based on attempts to enhance therapeutic relationships. This is done by reducing power inequities between the client and professional, normalizing the client's experience, and building trust between the nurse and the patient (Edwards & Murdock, 1994).

Two factors that must be taken into consideration when deciding to self-disclose are context, and power. Power in this circumstance is related to taking treatment action without seeking input of the patients that are trusted to our care (Gedge & Waluchow, 2012). In a nursing setting, patients are vulnerable. They are in an environment where RN's, along with other HCP's, are in positions of power. The vulnerability that is generated from a relational interaction can be mitigated through respectful and responsive relationships (Bergum, 2004). One component of a respectful and responsive relationship is the ability of the nurse and the patient to engage in a collaborative process where each has the ability to participate, choose, and act. This includes decisions about the use of self-disclosure. Nurses in this study implemented self-disclosure strategies in different ways that were dependent on context, and on individual nurse characteristics. It has also been suggested that patient populations vary in their perceptions of health care professional self-disclosures depending on context, and role expectations (V andeCreek and Angstadt, 1985)

Participants in this study only reported having positive experiences self-disclosing with their patients; no participants recounted a negative experience, or recalled patients negatively commenting on the RN self-disclosing. Further study is required to understand the experiences of nurses self-disclosing from the patient perspective. Additionally, further research is needed to determine if patients receiving care from an interdisciplinary team in a hospital/acute setting, differ from clients receiving care individually from a single therapist in a one-on-one setting.

Recommendations for Nursing Professional Development Practitioner's Practice

The use of self-disclosure is a contextually bound ethical decision. Developing the professional sensitivities needed to effectively use selfdisclosure to advance positive patient outcomes requires support and guidance. Nursing Professional Development Practitioner's (NDP) can develop educational resources, utilizing the client's perception, and professional motivation as the foundational elements for training RN's to selfdisclose effectively. Guiding the RN's behaviours to match client perspectives will enhance favourable outcomes (VandeCreek & Angstadt, 1985) and empower nurses (Kretzschmer, et al., 2017) which has the potential to enhance the RN's workplace satisfaction, and patient health care outcomes.

Creating a structured program, and providing opportunities for debriefing (Ziebert, et al., 2016) will also promote the treatment efficacy of self- disclosure. A framework for self-disclosure that guides decision-making related to this nursing care strategy could develop clinical competencies and facilitate the adoption and appropriate use of selfdisclosure techniques.

The educational program could have the following learning objectives. One, participants will assess the of use self-disclosure strategies. Two, participants will use two different methods to evaluate the effectiveness of self-disclosure. Three, participants will describe at least two potential advantages to using self-disclosure as a nursing care intervention. Four, participants will describe at least two ways of reducing the risks to patients when self-disclosure is used.

Limitations and Future Research

Consistent with qualitative research sampling the sample size was a convenience sample. Participants were chosen because of the expertise associated with the research questions. As such the data gathered has richness and depth, and specifically describes the experiences of 5 nurses.

The conclusions identified in this paper should be used as a basis for inductively informing decisions. Efforts to use this information by sweeping broad generalizations and applying to all nurses, would be misguided. There is also the potential of researcher bias influencing the analysis of the data. However, this risk was mitigated through the use of an audit trail and peer de-briefing.

The results of this study and the available literature suggest that self-disclosure is an intervention that affects the therapeutic relationship. This study contributes to better understanding self-disclosure in nursing, however further research is needed. Priority research areas include understanding the experiences of nurses self-disclosing, and nurses not disclosing, from the patient perspective. Finally, evaluation of the therapeutic effect of selfdisclosure and a better understanding of the internal conflict experienced by health care professionals engaging in self-disclosure vs perceived crossing of professional boundaries are needed.

Conclusion

Therapeutic use of self-disclosure aligns with feminist theory. This theoretical grounding guides nurses to implement self-disclosure strategies in ways that reduce the risk of harm to patients. The findings of this study shed light on the varying aspects of RN's self-disclosing with patients; including: defining self-disclosure, why RN's choose to self-disclose, purpose of self-disclosure, information shared with clients, where participants learned about self-disclosure, and advice they would give to others. Participants identified the answer to the question "How much is too much sharing?" was too much sharing is when it no longer is for the benefit of the client. It is critical that nurses can assess the therapeutic value of selfdisclosure. Therefore, the guidance and support offered by NDP is critical in developing selfdisclosure clinical competencies.

Sidebar

Correspondence: Paige Steuber, BScN, RN, Pediatric Intensive Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada E-mail [email protected]

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