Zelik S. Mintz, LCSW, LP

As an analyst, I wrestle with myself about what stance will be most effective and helpful for my patients.  Being psychoanalytically trained, I was taught that the “blank screen” was a most effective approach.  After exploring and working in this way, I have abandoned the concept of the blank screen as ineffective and unrealistic.

While the theory behind the “blank screen” has merit and can be useful at times, psychotherapy is a two person psychology.  The “blank screen,” while theoretically tempting, is, in fact, illusory.  Inevitably, therapists and the people they treat affect each other in a multitude of ways, both verbal and non-verbal, that cannot be controlled by self-imposing an artificial neutrality.  As much as we may try to remain “blank,” patients pick up things about us, by transference, projection, deduction and/or exposure.

In the psychotherapeutic setting, we are often confronted with dilemmas about the most effective way to respond and meet the needs of our patients.  We continually make decisions about how best to offer empathy to our patients, including when to keep silent.  When listening to patients, how much do we self-disclose what we are thinking and feeling?  When do we keep thoughts and feelings hidden?

While to some analysts unorthodox, I offer my patients those aspects of myself that contribute to a holding environment.  For example, when a fearful and anxious patient chastises him/herself for not being “normal,” I may point out that such feelings or thoughts are common.  On rare occasions when I think that a personal example may ease a patient’s self-judgment, I’ll offer a personal detail that helps my patient feel less isolated.  One patient talked about how together and organized I am and how she suffers so in comparison.  I told her that this self-organization took a lot of time, work, and learning.  She was both grateful and hopeful.  My self-disclosure left her with the feeling that she too could accomplish positive change.

While such self-disclosure is uncommon, I have used it to offer hope to a despairing patient.  There are times as analysts when we can use ourselves as examples and hence ground patients and quiet their self-recriminations.  I once had a patient in his mid 30′s who talked at length about his lack of career achievement and focus.  He felt it was too late to have a satisfying career and furthermore he didn’t even know what he wanted to do.  He used his own expectations and the expectations of society to reinforce his feelings of worthlessness.  I told him that I had changed careers mid-life and went on to establish myself in another profession by going back to school for 12 years, an experience which at first was daunting but to which I had adjusted and succeeded.  My self-disclosure gave him hope and helped him work through the blocks he created by his self-recrimination and found motivation to explore what he might want to accomplish.

Non-verbal self-disclosure of our feelings can help convey empathy and caring.  If I am moved to cry by what I am hearing from my patient, do I hold back and hide my tears or gently let them be known?  Often when I tear up or cry, patients feel that I am empathizing with them and feel psychically held.  I am careful to let them know that it’s okay for me to cry when I am sad and I make sure they know I do not need to be taken care of.  Both my tears and my reassurance that I can still take care of them relieves patients and allows them to go deep into their sadness.

It is of the utmost importance that patients experience me as a human being with thoughts and feelings.  At times, self-disclosure can help create a warm and empathic relationship and provides a safe environment vital to the work.  It’s vital to let patients work though negative transference and rupture.  But to allow that to happen, careful self-disclosure can facilitate the safe holding environment necessary for the patient to freely express all that he/she is thinking and feeling.

The internet has dramatically changed how we interact and the way personal information is shared.  This is a particularly sensitive issue for psychotherapists and patients.  With just a simple click, people can find out many facts about their current or prospective therapist.  Analysts have to be particularly careful about what they make public and often perform a balancing act between what is available on Google and what needs to remain private.

Events both significant and benign are easily accessed on the internet and become a part of our public identity.  Social networks, particularly Facebook and Twitter, if not carefully controlled, can result in inappropriate and unwanted transmission of information.  It is vital to continually monitor privacy settings on all social media.  More insidious and difficult to control are what our “friends” and “followers” disclose about us.  It requires time and diligence to make sure private details about our lives are not disclosed.

Hence we are confronted with the task of managing our accounts so as little as possible become public. This can become particularly difficult when we’re celebrating life events such as marriage or a birth or when we publish travel pictures, photos from our past, or reveal what we do or whom we live with.  (When I Google my name, the second thing that comes up is an article in the New York Times about my marriage.)  Do we publicly celebrate events in our lives and run the risk that once this knowledge is disseminated, our patients will see it? And we must be careful to make no attempt at hiding this information from our patients once it has become public or we risk a rupture in the treatment.

Should we deprive ourselves of what’s available to others and avoid publicly celebrating events in our lives because of concerns about self-disclosure?  Do we take off our new wedding ring because it may disclose a newly attained status?  All of these questions must be addressed on a case-by-case basis—evaluating boundaries and degrees of self-disclosure is a vital and continuous process. Self-disclosure on the internet must be considered in the same way we make choices about what to wear, how we decorate our offices, and when we make physical contact.  This process presents us with an ongoing dilemma.

Touching may be the most intimate type of self-disclosure and is one of the most controversial subjects discussed by analysts.  Whether a pat on the back, a hug, a handshake or a comforting touch, therapists have a varied opinion about what is appropriate.

For many analysts, any physical interaction between analyst and patient is off-limits.  A handshake initiated by the patient is usually considered the most acceptable form of physical interaction while erotic interaction, at the other end of the spectrum, can result in the forfeiting of a professional license and possibly more. But what about physical interactions that fall between the two poles?  While some therapists consider that even a pat on the back exceeds acceptable professional boundaries, others tend to be more flexible about physical encouragement.

As analysts, comfort can serve as a barometer when we are faced with any form of physical interaction with a patient.  A physical response by the analyst that’s tentative, awkward or uncomfortable may cause a rupture in the treatment.  When I am presented with a physical request by the analysand that makes me uncomfortable, I explore the meaning of the overture with the analysand to disarm the awkwardness.  Although I do not feel uncomfortable with a handshake, if I did, I would articulate my hesitation rather than reveal any tentativeness in an awkward action.

With a physical overture, I always follow the patient’s lead.  Handshakes, initiated by male patients as a gesture of thanks, are not uncommon at the end of a session. Typically, I refrain from responding physically to other physical overtures or requests and instead tend to explore them in the course of the analysis.  One exception was when I worked with terminally ill patients in their homes.  In these instances, my therapeutic boundaries become much more fluid since any rigidity can feel unnatural and be experienced as non-empathic.

I once had a patient who for many years talked about the distance between us and about his strong desire to hold my hand.  He claimed that my holding his hand would help him feel connected and comforted.  At some point I realized that my declining his request was stalling the treatment.  One session, after talking again about the request, I agreed to take the risk.  I came and sat next to him and gently took his hand, but when I took his hand I immediately felt awkward and hesitant about how long to hold it.  When should I pull my hand away? Should I wait until he pulled his hand away?  I suddenly realized there would be a rupture when I took my hand away.  After about 30 seconds, I gently pulled away and sat back down in my chair.  What I thought would fulfill an aching need turned into rejection.  Although for years we had talked about and explored the need, the decision I made to satisfy that need, with the best intentions, backfired.  Eventually we recovered from the rupture the handholding had caused and I learned about the power and risk of satisfying even the most basic of physical requests.

The experience with my patient was illuminating.  And while I still have set ideas about the role physicality plays in treatment, I am open to the power of touch in the therapeutic setting.