The Curious Case of Therapist Self-Disclosure During Pharmacotherapy Visits in an Autism Center

An endearing school-aged autistic boy with specific skill in calendrical counting liked to know exact information about me. “How many children do you have? Where are they now? What are they learning? When is your birthday?” Once given the date, he told me what day of the week I had been born and what day my birthday would be next year and in subsequent years. He had new questions for me each time I greeted him in the waiting room of our autism center, asking for more information than I had been taught to share. At each visit, I had to think about how much to reveal, how sharing might help us work together, and what the impact of not answering his questions might be. He is a fact collector, and I tried to acknowledge his needs and humanity by sharing some of my facts. With every disclosure, I was mindful of the small breaches I was carving in my privacy and hoped they were helping build our bridge of connection.

We are taught in residency and fellowship—and learn even more so through experience—that there are many types of therapist self-disclosure (TSD) in the practice of psychiatry. TSD is a social offering that occurs in the context of a conversation. Some disclosures are unavoidably revealed by one’s appearance or accent. Some are unintentionally revealed through a reaction or the choice of holidays taken off, for example. Other disclosures are intentionally spoken or demonstrated in one’s clothing or accessories. Context can influence the thought process about disclosure. Different types of disclosures, associated with different meanings, may occur during diagnostic assessments, parent sessions, therapy, or pharmacology appointments. The rhythm of the therapeutic relationship also impacts these decisions. Disclosures might occur initially to establish rapport. Later, disclosures may allow for deepening of the relationship around shared interests or information or be an attempt to help overcome barriers in the treatment.

In the general pediatric population, TSD has been described as a therapeutic tool for rapport building, facilitating sharing, and reducing anxiety about the therapy relationship (Johnsen and Ding, 2021). To be appropriate, TSD requires mindfulness of the individual patient, including their age and developmental stage, the therapeutic relationship and its dynamics, timing, the treatment modality, and its goals. Disclosures should not cross the therapist-child boundary, fulfill the therapist’s need, remove attention from the child’s concerns, or cause the child to censor themselves or worry about the therapist (Johnsen and Ding, 2021).

One of the defining features of autism spectrum disorder (ASD) is difficulties with social interactions. Therefore, self-disclosure when working with autistic youth has considerations that extend beyond what we teach in general child psychiatry fellowship. To date, there are no published studies about TSD in ASD. A description of a psychotherapy treatment course with an adolescent autistic boy with intact cognitive and language skills mentions therapist self-disclosure of shared interests early in treatment for alliance building (Hull, 2020). And a single qualitative report on rapport building with autistic adults briefly mentions TSD as an indication of the therapist’s authenticity, supporting client experiences of trust (Hume, 2022).

Working as a child psychiatrist in an autism center allows a perspective on the ways that TSD varies across services. In the autism evaluation, TSD is used to create shared experiences and generate conversational topics. Contrary to other types of evaluations, providing personal information and assessing the recipient’s response is one of the hallmarks of the diagnostic assessment in autism. Specific tests, such as the Autism Diagnostic Observation Schedule, create conversational situations with opportunities for clinician disclosure of personal information such as vacations, attractions visited, or preferred foods to promote and assess social interactions. An evaluator might offer a statement that invites a response such as “I like reading too, I read a lot…” to give the child an opportunity to ask what books the evaluator reads and share what books they enjoy themselves. Whether the recipient picks up the social bid for reciprocal conversation and the quality of the response are informative.

Comprehensive treatment in ASD is individualized and multidisciplinary and focuses on building communication, social, play, and positive behavioral skills, alongside appropriate medical care. Families may seek related services including social skills, speech/language, and occupational therapy in addition to working with behaviorists, psychotherapists, and psychiatrists. Self-disclosure is sometimes incorporated in speech/language therapy for pragmatic language skills or in social skills therapy for teaching and practicing conversations. In these settings, my colleagues are often less measured and cautious about disclosures than in traditional psychotherapy.

In my experience as a child psychiatrist providing pharmacotherapy in an autism center, the psychotherapeutic components of medication appointments tend to be practically oriented and focused on concrete skills grounded in present reality because of the social communication needs and cognitive styles of many of my patients. I may introduce a personal experience into the discussion to provide a specific example of something the child is working on. If a child has social anxiety, briefly sharing an instance of my public speaking anxiety can serve as a concrete example for discussion while universalizing some of the experience and demonstrating empathy. If remembering to take medication is a barrier to treatment, verbal identification, without excess personal detail, coupled with practical suggestions, can demonstrate validation and empathy. I might share “I used to forget to take my medicine too, and now I keep it with my toothbrush so that I see it every time I brush my teeth. I’ve even thought about attaching the medicine bottle to my toothbrush with a rubber band.”

Similarly, identification can be a very powerful connector to parents and caregivers. Briefly disclosing an element of shared experience around proximity to neurodiversity, parenting, or other commonalities may help caregivers feel more understood and less isolated and can help build a trusting treatment relationship. A hint that I understand some of the difficulties of navigating the special education system, of parenting a child with special needs, parenting multiple children with a special needs child in the mix, balancing work, parenting, etc., can help parents feel that they are not alone. It’s never about the details of my situation. It’s an acknowledgment that I see the parent and their triumphs and trials and that I understand something about their victories and worries. My goal with the disclosure is to validate how hard they are working to support their loved one.

Some of my colleagues with close relatives on the spectrum will occasionally speak with caregivers more directly about their experiences. One colleague shared with me that she sometimes discloses her child’s diagnosis to connect with patients’ families through the disclosure. In her experience, the response to disclosing has generally been positive. While it is also sometimes neutral, it has never been negative. The disclosure often puts families at ease and seemingly allows them to relax during the parent interview or feedback session. She has found it helpful in parent appointments to give examples of what she has experienced. Some families ask questions and share more information with her after her self-disclosure, seeking clarification of their child’s symptoms with questions phrased as “have you experienced this?” Another colleague has a sibling with ASD and shares that information with certain patients’ parents who are concerned about how the other children in the family perceive and interact with the autistic sibling. As child psychiatrists, we work with families to support the care of our patients. We must be careful to consider how disclosure to identify with the caregiver may change the relationship with the child, our identified patient. To this end, we must be aware of whether the patient or other children are in the office when speaking with the caregivers and think about how the shared information may be discussed after the visit.

Some of my patients do not communicate through spoken language, and others are more articulate than I am. I predominantly use TSD to try to build rapport with youth with whom I have limited ability to converse. My attempts to engage over a mutual interest pictured on a t-shirt (“I see Pikachu on your shirt; Pikachu is my favorite Pokemon. Who is your favorite?”) or snack box contents (“I love Nutella too!”) may sound superficial, but this is a way to communicate that I see them as a whole person, beyond the difficulties that are being reported, often by their caregiver. Many patients cannot tell me their deeper feelings, worries, frustrations, joy, and pride. Therefore, I comment on what they or their families do tell me: the toys, animals, musicians, shows, and games they like, as a way to say, “I am interested in you, all of you, the parts you can tell me and show me, and the parts that you cannot.” This is what I hope to convey with these small personal revelations, though I sometimes cannot tell if this is accomplished because reactions vary from a follow-up comment to a nod or no acknowledgment.

I think of these forms of TSD as being on a continuum with some other approaches I use to connect with patients. Spoken TSD, even if brief with simple word choices and gestures, relies on the recipient’s receptive language skills. For children with weaker receptive language skills, I may pull up and print online images of a preferred character or activity. There is less self-disclosure in nonverbal actions of this type, though the intention to demonstrate caring and the aim to generate a moment of connection are the same. Some patients will bring an assistive communication device to appointments. Personal disclosure: my skills in this have significant room for improvement, but together with the caregiver, I will try to use the device to explore the individual’s interests and connect with them.

With those patients who communicate through spoken language but are not prone to asking questions, a different type of disclosure sometimes occurs. Rather than my telling something about myself to deepen the relationship, a shared moment arises when I listen and let my patients teach me. I ask about their interests and learn about them in my free time. In this way, I have learned about Cosplay, celebrities, Magic the Gathering, and TV shows such as The Good Doctor and Speechless. Then in a later session, I can share what I read, watched, or listened to and engage more meaningfully. Conversing in this way feels more connected than my uninvited identification comments about characters on t-shirts, weekend activities, preferred foods, etc., though the intention is the same. I am trying to indirectly say that in my personal time, “I followed up to look into what you care about because I care about you.”

Even with good intentions, TSD is hard to navigate. Knowing what to say and when to say it is difficult. Disclosing has come at a cost in some cases, and not disclosing has also come at a cost. I lost a neurodiverse adolescent patient in pharmacotherapy because I did not disclose living in the neighborhood where she worked. One day she saw me walking with my family on that block and came out of her store to ask if I lived there. I imagine she felt betrayed, but I never saw her again and thus never had the chance to speak with her about her feelings. Afterward, I deeply regretted not telling her that I was familiar with the area when she first brought up her new job and navigating whatever personally uncomfortable questions might have ensued. I wish I had something along the lines of, “I’m familiar with the area and go there sometimes. I might even bump into you. Let’s talk about if and how you would like me to greet you if I see you there.” In the moment I chose to protect my privacy, but in retrospect, I realized this came at the cost of her feeling that I had not honored her with truth or trust.

Through these experiences, the successes, the misses, and the in-betweens, I have learned valuable lessons about using TSD as a treatment tool. Some of the considerations I guide myself with are to be mindful of my boundaries and the context, to have clarity regarding what information is and is not being disclosed, and the reason for the disclosure or lack thereof. I try to carefully observe and listen before and after speaking and match the type and depth of the disclosure to the developmental, cognitive, and communication level and style of the patient, when and as appropriate. I aim to be comfortable with the information being revealed and to be brief, ensuring the focus remains on the patient and the disclosure facilitates rapport or communication about them. And I remind myself to be authentic, humble, and open to learning because no matter how mindful and well-intentioned we are, self-disclosure decisions are difficult and may not go as we anticipate or hope.