What is a characteristic of self disclosure?

Self-disclosure

Self-disclosure was identified as a key strategy for forming, as well as maintaining, friendships. Perhaps not surprisingly, when a friendship begins to deteriorate, the decline is reflected in the friends' self-disclosure. According to one program of research, friends tend to avoid personal, intimate self-disclosure when their relationship is deteriorating. For example, in one of study, participants recorded their interactions with a friend over a 2-week period. Disengaging friendships were characterized by less effective and less personal communication than growing friendships. It is unclear whether the avoidance of intimate self-disclosure is a cause of friendship decline or whether friendship deterioration causes people to restrict the intimacy of their disclosures. This is an issue that can only be addressed by longitudinal data in which patterns of self-disclosure and reports of deterioration are tracked over time.

Self-Disclosure

Self-disclosure, or the sharing of personal information with another person, is a central feature of many friendships, particularly in adolescence. This is consistent with a major concern that arises at this stage of development, namely self-exploration and the development of identity. Sharing high levels of intimate information can be risky unless the friend can be relied upon to treat information as confidential and not share it with others. Through reciprocated self-disclosure, children form a sense of emotional closeness and acquire extensive knowledge about one another. Part of a shared history of a friendship is not just the activities or events that friends share together but the detailed and intimate knowledge they have of the other person. As a result, friends know far more about one another than do nonfriends.

One interesting complexity about self-disclosure deserves comment. Although friendships that are high in self-disclosure are more likely to be close friendships, co-ruminating with friends, or excessively discussing problems and focusing on the negative feelings associated with those problems, may have negative emotional consequences for children and adolescents, especially girls. To illustrate, although co-rumination is associated with higher-quality friendships for boys and girls, it is also associated with higher levels of anxiety and depression for girls.

2.1 Basic Findings in Self-Disclosure Research

Self-disclosure involves sharing personal information with someone else. When we use the term self-disclosure in this chapter, we do not refer only to verbal content, but also to nonverbal expressivity (e.g., facial expressions, tone of voice) and actions (e.g., slamming doors, hugging). As Reis and Clark (2013) noted, “people reveal themselves in diverse ways, and [self-disclosure refers to] all of these varieties of self-revelation” (p. 402).

Self-disclosure is seen as vital to the development of relationships and to the happiness of established relationships. As Jourard and Whitman (1971) put it, “if we want to be loved, we must disclose ourselves” (p. 83). Experiments have shown that gradually escalating self-disclosure between strangers generates closeness (Aron, Melinat, Aron, Vallone, & Bator, 1997). Emotional disclosures (as opposed to disclosures of facts) are considered to be most important for the development of intimacy (Derlega, Metts, Petronio, & Margulis, 1993; Morton, 1978; Reis & Shaver, 1988). Willingness to disclose negative emotions predicts forming more relationships and establishing more intimacy in close relationships (Graham, Huang, Clark, & Helgeson, 2008). People disclose more to people they like, and people who self-disclose more tend to be better liked than people who disclose less (Collins & Miller, 1994). (There are exceptions; for example, people who self-disclose too much too early in a relationship are viewed as inappropriate; e.g., Wortman, Adesman, Herman, & Greenberg, 1976.) In established relationships, couples who self-disclose more are more loving, more satisfied with their relationships, and more likely to stay together than couples who self-disclose less with each other (Sprecher, 1987; Sprecher & Hendrick, 2004).

Certain individual differences predict self-disclosure (see Berscheid & Regan, 2005; Miller, 2015). Women are generally more self-disclosing than men. People who have a secure attachment style self-disclose more intimately than people who are insecure, and as we will describe, HSEs tend to be more open than LSEs. However, we must acknowledge evidence that self-disclosure depends less on personality factors than on relationship characteristics and on the principle of reciprocity, whereby people typically disclose to each other at equal levels of depth (Miller & Kenny, 1986).

The most prominent model of self-disclosure is Reis and Shaver's (1988) seminal model of intimacy. According to Reis and Shaver (1988), self-disclosure and responsiveness are both necessary components in the development of intimacy. When people self-disclose, they provide an opportunity for the listener to show validation and caring for the discloser—that is, to behave responsively. Whether or not listeners do, in fact, behave responsively shapes the discloser's decisions about future disclosure. If Nora perceives Nick as highly responsive, she should disclose more often and more deeply in the future, and intimacy will grow. If Nora perceives Nick as unresponsive, she should limit future disclosures, thereby stifling intimacy development. Research has supported Reis and Shaver's model (e.g., Forest & Wood, 2011; Laurenceau, Barrett, & Pietromonaco, 1998).

Self-disclosure is considered to be essential for developing closeness, but at the same time, interpersonally risky. Rather than drawing closer, the other person may dismiss one's concerns, disapprove, betray one's confidences, or even end the relationship. Baxter and Montgomery (1996) identified additional risks of disclosing: reduction of one's autonomy and personal integrity, loss of control or self-efficacy, and the possibility of hurting or embarrassing the listener. Disclosing negative emotions or unfavorable personal experiences is considered to be riskier than disclosing positive emotions and experiences. Disclosing unfavorable information about oneself may lead to others’ disapproval and dislike. In their summary of self-disclosure research, Howell and Conway (1990) concluded that, compared to negative emotional disclosures, “positive emotional disclosures are more likely to be made, are considered more appropriate, and are reciprocated to a greater extent” (p. 468), at least in Western cultures.

Ways of improving our sexual communication

Self-disclosure—This can create an atmosphere of understanding and mutual understanding. What people know about us may not be the whole picture. Sharing who we really are contributes to closeness and encourages the other person to self-disclose as well, and through self-disclosure we nurture forgotten aspects of ourselves by bringing them to the surface. The contribution of such disclosure to a closer relationship is obvious (MacNeil & Byers, 2009). Men are traditionally not as good as women are in self-disclosing (Lips, 2007). Since they have been taught to be “macho” (i.e., strong and silent), they experience more difficulty in expressing feelings of tenderness or vulnerability. It is easier for women, generally, to disclose their feelings because they have been conditioned from childhood to express themselves (Tannen, 2016). These differences can result in distancing of the partners. Little or no interpersonal contact between partners can result in feelings of loneliness. It is the most painful loneliness to feel alone when you are with someone with whom you want to feel close.

Trust—intimate relationships are mostly concerned with love and trust. Trust is a belief in the reliability and integrity of a person. Trust is considered a critical factor in close relationships for two reasons. Obviously, one cannot self-disclose without trust, since such disclosure makes us vulnerable. Second, the degree to which we trust a person influences how we interpret ambiguous or unexpected messages from that person. So again, trust is of prime importance in a close relationship.

Providing feedback—is another critical element in communication. Providing feedback requires, first of all, active listening in which we listen intently, question what is unclear, rephrase what we understood and, if self-disclosure occurs, there is an expectation that no mocking, criticism, or distaste be expressed. Constructive feedback is the most important type, as it helps strengthen relationships (Yarber & Sayad, 2019).

Reflections on clinicians’ self-disclosure

In the past, self-disclosure by clinicians to clients was not recommended. Now it is acknowledged that such self-disclosure may have therapeutic benefits. While the issue of self-disclosure is a complex one that cannot be discussed fully here, in this section we hope to simply provide some food for thought.

The choice of whether or not to self-disclose (about sexual or gender identity and many other topics) should be spontaneous and premeditated at the same time. Clinicians should not naively believe that they do not leave telltale signs about their private life, and they cannot ignore that hiding their own sexual and gender identities may generate cognitive and affective dissonance in clients who realize that their therapist holds these identities.

While the decision of whether or not to self-disclose is a relational issue, clinicians should make every effort to ensure that it is also therapeutic. It is fundamental for clinicians to understand the urges and goals behind it—whether it is useful for the therapeutic alliance or arises from a need of the clinician—as well as why and when it is elicited by the client and on what grounds. Finally, clinicians should be aware that their reluctance to communicate their own sexual and gender identities may suggest unresolved concerns, shame, or embarrassment, especially if it follows from specific questions or hints made by a client.

2.4.2 Self-disclosure

A large research literature exists on self-disclosure in conversations and, in particular, gender differences in self-disclosure. Dindia and Allen (1992) conducted a meta-analysis of these studies. Across 205 studies, women self-disclosed more, but the difference was small (d=−.18). Patterns of self-disclosure depend on the sex of the target. There is no gender difference in self-disclosure to a male target (d=.00), whereas the gender difference is more substantial for a female target (d=−.35). Patterns also depend on the relationship between the two people engaged in the conversation. The gender difference in self-disclosure is trivial when the conversation is between strangers (d=−.07) and is found mainly when the conversation is with a friend (d=−.28), a spouse (d=−.22), or a parent (d=−.26).

Communicating About Oneself to Others

Sharing information about oneself, or self-disclosure, is a central avenue of interpersonal communication and another way to create intimacy in relationships. Self-disclosure is defined as personal information about oneself that is communicated to another. Disclosure differs in terms of its breadth, depth, and duration. Breadth refers to how many different topics are covered in the disclosure, depth to how personal or intimate the level of disclosure is, and duration to the length of the actual disclosure.

A common way for people to disclose information about themselves is to construct an account. An account is a package of impressions, perceptions, attributions, emotions, and description, formed into a story. Someone would develop an account about an event in his or her life in order to gain a sense of control and meaning around the event. Sharing that account with others is a way of giving out information about yourself, helping others to understand you, or influencing others' impressions of you. People may construct accounts about other people's behavior as well and share those accounts for the same reasons: to give out information about the leading players in those accounts or to influence others' impressions of either the account maker or the actors in the story.

Self-disclosure is a key concept in social penetration theory. Social penetration theory describes the process by which people develop relationships. As two people get to know each other, there is usually a social exchange as people take turns disclosing. One person's mild disclosure often triggers this exchange. The second person in the interaction can then choose to disclose in return or not. If so, there may be a continuing spiral of increasing intimacy between the two people. These disclosures gradually become more intimate and involve more depth. Through this process, the communication partners uncover information about each other, developing a multilayered understanding of the other that serves as a foundation for the relationship. Thus, one major purpose of disclosing personal information is establishing friendship or intimacy with another.

A second use of self-disclosure is as a social strategy, revealing or withholding information in order to obtain a goal. For example, you might share a sympathetic story about yourself in order to get someone to assist you in a task or to talk your way out of a negative consequence of some kind. In contrast, you might disclose your pride in a success in order to make a good impression at a job interview.

Disclosure can also be used as a catharsis, or a venting of emotion. There is research demonstrating that disclosure of this kind can be therapeutic, if an empathetic listener receives it. Early theories of self-disclosure assumed that this type of disclosure was always beneficial and that the willingness to self-disclose was a sign of mental health. Now, however, it is clear that disclosure is more complex than this, and that there are several risks involved in the decision to self-disclose. There is a risk of rejection by the listener, loss of personal control over the information shared, and of embarrassing the listener.

Self-disclosure is a discretionary behavior; that is, people control how much, to whom, and when they wish to disclose. Self-disclosure can also be a goal-oriented behavior; it can be used for different purposes in different situations. There is risk attached to self-disclosure. For all of these reasons, perceptions of others are crucial to decisions about disclosure. The impressions and attributions we have formed regarding others affect the extent of our willingness to disclose to them and the circumstances under which we are willing to disclose. We may be more likely to disclose to people who appear warm, receptive, and trustworthy. We may also disclose more to those who appear to have advantages to offer us in return for our disclosures. For example, someone is likely to self-disclose more readily to a prospective romantic partner who is both attractive and congenial than to one who appears to be either cold or personally unappealing.

Individuals manage their communication and disclosure with others to further their social goals. A major theoretical perspective related to this idea is that of self-presentation or impression management. This research assumes that people take on different roles in their daily lives, much like actors on a stage. Individuals select certain appearances or behaviors intended to convey a particular image for others.

One person may have a variety of roles or images he or she can portray, depending on the situation or the social goal of the moment. Some strategic methods of self-presentation that have been identified by researchers include emphasizing one's strengths or accomplishments, advertising one's moral superiority, portraying oneself as a helpless victim, ingratiating oneself through flattery and admiration, and appearing aggressive or intimidating. Individuals may rely on one particular self-presentation method in most of their interactions with others, or may vary their self-presentation based on the needs of the situation.

Different people are more or less motivated to change their self-presentation to suit the social requirements of different situations. Self-monitoring is a term used to describe the awareness of changes in social situations and the desire to alter one's self-presentation in order to better fit into those situations. People who are high self-monitors have many different images they are able and willing to present; people who are low self-monitors are more consistent in their self-presentation across many different situations. People also vary in how anxious they are in social situations; this can affect how well they manage their self-presentation. Extroverted people are generally more at ease with self-presentation strategies than are introverts; however, this appears to be mainly due to some introverts' anxiety over social interactions rather than a lack of skill in impression management.

The growing use of technology as a communication medium creates new questions about person perception and self-disclosure. In the past decade, much research has focused on the increasing use of the Internet as a medium for interpersonal communication. Because these types of communications tend to be relatively brief and made at a distance, communication partners often do not have the benefit of nonverbal or emotional expression in order to reduce uncertainty or help form judgments about the other. Early studies seemed to confirm that communicating through media such as e-mail, chat rooms, or cell phone text messages had the expected negative effect on communication effectiveness and social intimacy.

However, newer research findings are more equivocal. Some research indicates that communication via Internet increases openness in self-disclosure, promotes positive feelings about communication partners, and allows frequent interaction with friends and family. It is possible that as these technologies have become more established and accepted as useful communication tools, people have adapted their patterns of communications and social judgments as well. One hypothesis is that people who suffer from anxiety in face-to-face social encounters may be more at ease communicating by computer and thus able to have more satisfying social interactions. Social scientists have only begun to explore the effects of technology on interpersonal perceptions and communication. It is not clear as yet what the full impact of newer technologies will be on patterns of interpersonal communication.

How much one communicates to others about oneself is a complex social decision. This self-disclosure may serve several purposes: social penetration, social manipulation, or emotional catharsis. People often build accounts about themselves to use specifically in telling their stories to others. They may also strategically balance how much they reveal in order to maximize social benefits through self-presentation while minimizing the inherent risks in disclosing personal information. To do this well, people must make judgments about the receptivity, trustworthiness, or helpfulness of others. Thus, disclosure decisions are linked to the process of interpersonal perception.

Gremlin Number Five: Self-Disclosure

If this book had been written 10 years ago, a discussion of self-disclosure would have been relatively straightforward. There is a professional principle involved; it is the ethical requirements of every professional group to distinguish between a practitioner’s professional and private lives (see American Counseling Association, 2005; American Psychiatric Association, 2001; American Psychological Association, 2002; National Association of Social Workers, 2008). All these professional groups identify which behaviors on the part of the practitioner conform or violate their ethical standards. They also specifically state that these ethical requirements do not apply to one’s private life. Pipes, Holstein, and Aguirre (2005) state this distinction clearly (and colorfully) when comparing a practitioner’s private life as compared with her or his professional one.

Outside their roles as psychologists, they may … break confidences, be verbally abusive to their romantic partners, lie to their friends, evaluate others unfairly, and generally act like a louse. (p. 326)

The question of self-disclosure was never a problem in the old rigid days of Freudian psychoanalysis. The neat inviolate rule was never to disclose anything about the therapist, or to answer any question posed by the patient. The theory behind it was that the analyst was supposed to represent a “blank screen” upon which the analysand could project his or her transference. Of course, no one is ever a blank screen, although it took orthodox psychoanalysis half a century to figure that out.

There have been two new dimensions to self-disclosure that have changed the discussion immeasurably: the first are the changes in therapeutic theory, and the second is the powerful influence of the Internet on clinical practice. Modern schools of psychotherapy (like the ones represented in this book) are more relaxed and allow the personality of the therapist to be present in the counseling room. That advance in technique is a two-sided coin that has advantages and disadvantages for the progress of psychological treatment. It has the advantage of aiding in the development of empathy and therapeutic rapport between the therapist and the patient. But the potential disadvantages are awesome. It was easy to know how to behave as a Freudian analyst—just say “No.” Because we have opened the door to personal questions from our clients, might we also be opening a Pandora’s box, unleashing an entangled web of transference and counter-transference? What questions do we answer, and when do we retreat to the safety of therapeutic boundaries? A story from my past illustrates this dilemma.

I was trained as a clinical psychologist in the psychology department of the City College of New York. In the second year of the program we worked part-time at the college counseling center. I was assigned to do an initial interview with an undergraduate student. He was to be the first client of my career. I arrived at the center with a fresh pad of paper and an outline for conducting the interview. I introduced myself to the student and we walked into the counseling room and sat down. Then before I could say anything, he said, “I want to know how you feel about the Vietnam War.” I was dumbfounded. This was not supposed to happen! I was supposed to be in charge! While I sat in turmoil, he said, “I’ll only work with you if you agree with me that the war is immoral and should end.” For those too young to remember, the Vietnam War was extremely divisive in America, and the war in Southeast Asia was matched by demonstrations on our streets, many arrests, and in a few cases students were shot and killed.

Like other students, I was also against the war, and I had demonstrated on the streets challenging our government to put an end to it. But that was not the point. Did I, a neophyte (tadpole?) therapist have the right to introduce my values into this young man’s therapy—and at his demand, to boot? Flying by the seat of my pants, I made my decision based upon how important shared values were to this young man. I said that I was against the war. He responded by thanking me for my answer and began to tell me why he wanted to enter psychotherapy.

Immediately after the session, I ran to my supervisor in order to confess my sin and to ask for absolution. My supervisor was the best on the faculty; he was almost a legend at City College, and I respected his judgment enormously. “He has a right to know about your values,” said Dr. Hertzman. He discussed this issue in my supervision class the next day and argued that shared values aid in forming a therapeutic alliance. In the 45 years that have transpired since that day, I have learned that my supervisor was right. Shared values between counselor and counselee represent a fertile foundation for a successful treatment. On the other hand, I have also learned that expressing them carries significant risks. Which values should we share, how often, and when do we stop? This problem of shared values and other personal questions does not come up often during an initial interview, but as I’ve stated earlier, it is only a matter of time before the neophyte counselor will be handling both short- and long-term clients.

As already mentioned, the patient is entitled to an explanation of the process that she or he is undertaking. In a clinic setting there may be a written procedure; in private practice the therapist usually makes a statement about what she or he is doing and why. Personal questions about the interviewer, on the other hand, are best left unanswered because one cannot in so short a period of time understand what meta-message it will convey to your client.

The only exception I make is to answer a question about my sexual orientation—but only if I am asked. Self-disclosure of one’s sexual orientation has often been discussed in the professional literature because it is of importance to LGBT people (Gartrell, 1994; Herek & Greene, 1994; Kooden, 1991; Perlman, 1991). Gay and lesbian therapists have argued the advantages and disadvantages of “coming out” to their clients, and the general consensus is that they should when asked. It is easy to do this in large metropolitan cities, but harder to do so if working in rural clinics, especially those that are religiously funded. Lawyers have a good saying for the problem. It is, “The camel’s nose is in the tent,” meaning that once you answer (in this case) one question, you may not be able to curtail other client questions that may become more intrusive. Always remember to think in terms of meta-communications; what is the underlying meaning of the question?

While I will divulge my sexual orientation, my client is not entitled to know whether I have a lover, when I came out, where I live, or anything else about my life. One humorous example in my practice was the patient who frequently wanted to put food in my refrigerator during his session, so that he could look over my apartment and learn what kinds of foods I eat (and whether I kept a neat kitchen). In this day of the Internet, a client may do a search in order to inquire about me, and many of my patients have done so. That is their prerogative. I will not feed the underlying fantasy that motivates the questions, and I do not have enough time to find out about it during an initial interview. The patient who persists in asking personal questions may have serious problems with ego boundaries and that should be noted in a written report. Answering personal questions during the initial interview delivers a meta-message that the future therapist will meet the patient’s dependency or control needs. The assigned therapist will not thank you for making her or his work more difficult. These questions relating to the line between one’s professional functions versus private life are relatively easy to identify.

Of all the contributors to this book, Nichols (Chapter 4) is the most revealing to her clients about her life, background, and her goals for psychotherapy. Her point of view is passionate and far from the traditional boundaries of psychotherapy. While some colleagues may hail her as courageous, others may feel as if she has strayed too far from traditional boundaries. I admire her ability to self-disclose but to never cross ethical boundaries.

The Internet, however, has changed everything about professional versus private life in clinical practice. Unfortunately professional schools and ethics boards have not yet caught up with the explosion of technology and its implications for practice. This may be due to the fact that students and young practitioners are better versed in these techniques than their instructors. A simple Internet search will reveal many aspects of our lives. Many of us now have professional web pages in which a potential applicant may learn about our education and background, and we construct this source of information in order to advertise our expertise in ways congruent with the ethical guidelines of our discipline. But the same Internet search may also turn up considerably more personal information than we would voluntarily give to a patient.

There is a generation gap here. Prensky (2001) has described “Digital Natives” as a younger generation that has been born to the Internet and views its communication like a second language, while “Digital Immigrants” are considerably older and have (at best) an ambivalent attitude toward modern technology. At least 85 percent of college students own their own computer, some of them having begun to use them between the ages of 5 and 8, and they check their email every day (Lehavot, 2009). Twenty percent of psychology graduate students have Internet profiles, and many of them post photos and information that they would not want their clients to see (Lehavot, Barnett, & Powers, 2010). Almost all of these graduate psychology students were conducting psychotherapy under supervision at their respective schools. A high percentage of them also have profiles on MySpace, Facebook, and other social networking sites, and these are available to other members of the social network community.

But many established psychotherapists are also members of social networking sites, and they too post photographs and personal information for others to see, including current or potential clients. Since this form of technological communication is so new, we do not yet know its implications for professional practice. For instance, should a therapist remove a photograph of himself or herself at the beach wearing a skimpy bathing suit and hoisting a bottle of beer? Should a therapist do a computer search for information about a client in therapy, and is it helpful to the client’s therapy if we find a photograph of her or him in a skimpy bathing suit and hoisting a bottle of beer? The normally identified boundary between personal and professional becomes highly permeable under these circumstances.

It has gotten even more controversial with the development of sexually oriented websites on the Internet. We can pose the question this way: Is it a violation of ethical standards for a therapist (male, female, gay, or straight) to join a website whose purpose is to meet another person for a sexual liaison and publish a profile graphically discussing preferred sexual activities, together with nude photographs including their genitals? And is it a violation of ethics for the therapist, knowing that a patient has such a website, to access it and look at his or her physically revealing photos together with other sexual and nonsexual information? Might it be okay for the therapist to do so, if she or he asks for permission? And if that is okay, exactly how would the therapist ask?

These are not theoretical problems because they have already appeared on professional list servers. Some therapists have argued that a therapist has the right to a private life, including membership in sex websites. Others, and here I will count myself among them, argue that once the information and photographs are placed on a public website for all members to see, it is no longer private.

Pipes and associates (2005) state the case well when discussing the issue of ethics for members of the APA.

Professional associations such as the American Psychological Association (APA) have a vested interest in the behaviors of their members for a number of reasons, including the reputation of the profession, the desire to enhance the education and competency of members, and the aspiration to protect the students, clients, supervisees, organizations, and research participants with whom members work. When individuals enter a profession, a question arises as to what behaviors, if any, they agree to modify or give up as a result of becoming a member of the profession. (p. 325)

They go on to say that by joining the APA, members voluntarily agree to constrain their behavior. They were only discussing social networking sites, not sexual web pages. Within the next few years, all professional organizations and training institutions will be required to come to terms with the ethics of their members participating in sexually oriented websites. Simple participation in social networking sites has already created problems in psychotherapy, even when they conform to ethical standards. Patients viewing naked pictures of their therapists or therapists calling up naked pictures of their patients will unquestionably destroy a therapeutic relationship and could possibly lead to charges of unethical conduct against the therapist by state licensing boards and litigation against the therapist. Advertising for romance, in contrast to sex, while less inflammatory, may create as much havoc in psychotherapy as sexually revealing photographs.

Sophisticated users of these web pages say that privacy controls are available to limit those who see the information posted. While that may be true of sites such as Facebook and MySpace (or may not), it makes no sense to use privacy controls when one is advertising for romance or sex. If you are training to serve the public as a therapist of whatever school of psychotherapy, you will have to give up some of the freedoms that are available to ordinary “civilians.” That includes advertising for romance and sex on the Internet. You will have to find other ways to find likely partners.

Treatment

The eliding of distinctions between profession and personal social media use raises the question of to what degree self-disclosure facilitates or hinders the therapeutic process with patients. Given the pervasiveness and accessibility of social media, a patient or would-be patient may have access to knowledge about a clinician’s hobbies, music tastes, interests and pastimes, political leanings, family members, vacations, and as many personal details as have been made publicly available. Such knowledge may potentially lead to negative, split decisions. A patient may choose in a moment to not work with a physician for any number of reasons (e.g., personal details are misaligned) and thus decide to not work with a competent clinician for reasons unrelated to the clinician’s potential effectiveness. Moreover, Applebaum and Kopelman raise concerns about “unreflective and excessive self-disclosure by psychiatrists,” sometimes unwittingly (Appelbaum & Kopelman, 2014). While psychotherapy has shifted from the Freudian model of a “blank slate” therapist who never discloses any personal details, it is now widely agreed on that some level of personal disclosure may be appropriate, as long as this is rare, careful, and likely to have a positive therapeutic impact on the treatment process (Henretty & Levitt, 2010). However, online social media disclosures typically lack these characteristics. A psychiatrist may not even be aware of the extent of Internet disclosure and so unable to address such disclosure and its significance in the clinical encounter.

Sabin and Harland describe four major ethical challenges for the use of digital technologies in patient care: managing of clinical boundaries, maintaining privacy and confidentiality, establishing realistic expectations regarding digital communications, and upholding professional ideals (Sabin & Harland, 2017). New technologies offer both technical challenges (e.g., privacy settings and encryption) as well as psychological challenges (e.g., boundary confusion regarding the concept of “friending” on Facebook or unrealistic expectations about digital communication with a provider). In their summary of boundaries on clinical practice, Gabbard and Gutheil discuss a number of areas critical to the therapeutic process that can also be applied to the ethics of treatment in social media: roles, time, place, payment, and self-disclosure (Gutheil & Gabbard, 1993). The landscape of social media invites new boundary-confusing challenges into the framework in which a therapeutic relationship is conducted. Sabin and Harland offer as an example the concept of how clinicians might respond to “friend requests” on Facebook (Sabin & Harland, 2017). Because responses are binary—one can either accept the request or deny it—any action undertaken has potential to confuse and introduce ambiguity into the relationship. An acceptance might be understood as the establishment of a “friendship” that supersedes the patient-therapist relationship; likewise a Facebook rejection might be understood as rejection of the patient as person, i.e., “my therapist doesn’t like me.” For these reasons, 85.8% of psychiatry residents when polled state that they just ignore such “friending” attempts from patients (Ginroy, Sabatier, & Eth, 2012). Rather, such scenarios should not be avoided, but regarded as opportunities to discuss and explore motivations for “friending” activity, and clarify misunderstandings. Discussion of such boundaries between patient and therapist may provide useful grist for the mill of helping the patient understand one’s behavior and identity and a citizen of the digital age, navigating the relational ramifications of social media use in their rest of their life.

Zur offers a number of practical tips for exploring the range of clinical and relational dynamics at work in patient-therapist social media interaction and how they affect the therapeutic process (Zur, 2015). Professional boundaries should be regularly and consistently maintained and clarified whenever potential confusion occurs, and explicit protocols for emergencies should be discussed and preferably made explicit in a patient contract at the onset of treatment. Once a consistent online treatment presence has been established on social media, websites and platforms should be regularly reviewed and modified with most current updates for how online communication is best conducted (with attention paid to times when the clinician is not available). Despite potential ethical issues, social media technologies provide a useful tool for promoting mental health treatment and distributing accurate information, especially for technology-savvy younger generations that are familiar with searching for, finding, and sharing information online (Frankish, Ryan, & Harris, 2012).

Client Responses to Online Therapy

Client reactions to online group therapy have been similar to those of f2f groups with regard to pacing, self-disclosure, bonding, conflict, and transitions. However, participating in online therapy requires that clients have a minimal level of computer literacy. Therapists must have an optimal level of skill in order to provide safe and confidential services online and handle any technological contingency. Online therapists and clients must write reasonably well and express themselves effectively (Rochlen et al., 2004). However, our experience has been that the level of sophistication in our groups has remained high over the years. Group members write very well and are able to express themselves without any difficulty. Members are also very computer-savvy and there are very few instances when a group member needs help with accessing/using the group. In fact, the most frequent help requested by PainAid members is to be reminded of their user names and passwords; those with pain often have difficulty with concentration and memory due to their pain conditions, medications, or associated anxiety. Advances in technology have helped PainAid’s groups to run better with little to no technical interruptions.

PainAid groups have no beginning or end; members are able to join through “rolling admissions” and may participate as much or as little as they wish in both chats and discussion boards. An email address is publically posted so that members can ask for individual help with any technical issues at any time, but otherwise they use the groups to get support or discuss their concerns. There is no screening process by PainAid moderators; the community regulates itself and moderators review all posts, deleting any that are grossly inappropriate and otherwise facilitating discussions so that accurate information and helpful support are shared. CancerCare does have a screening process for its time-limited groups, which the staff facilitators have found helpful. There are structured breaks in the groups and group members are encouraged to share email addresses with each other before each group ends. Group members are provided with a contact at the organization along with a toll-free telephone number should they need support while the group is on break. Over the years, more and more group members have shared their disappointments and frustrations with their online support group taking a break. Many do not remember reading about the group’s end date in the Welcome folder when they first joined.

Members have raised their difficulties in dealing with large groups featuring active ongoing posting strings; it can be difficult to read so much and keep track of everyone’s names and situations. When this occurs, the facilitators invite group members to talk about this further and have validated members’ feelings, which they have found to be helpful.