Case Histories in Therapeutic Recreation: the Emergence of Ethical Issues

Case Histories in Therapeutic Recreation: The Emergence of Ethical Issues

Mark A. Widmer

This paper identifies and explores an ethical issue found in a case history reported in the Therapeutic Recreation Journal. Specifically, this paper examines the use of therapist self- disclosure to promote therapeutic relationships. Both the benefits and the risks of therapist self-disclosure in treatment are discussed. One philosophical perspective on how the issue of self-disclosure might be resolved is presented.

KEY WORDS: Self-Disclosure, Therapeutic Relationship, Ethics

Case histories provide knowledge from a consideration of ethical issues faced in prac- different perspective through real examples tice results in a unique type of knowledge of creative and innovative assessments, in- or insight that is essential to professionals terventions, and other programmatic tech- working in the human services. Since the niques. Beyond the programmatic informa- inclusion in 1991 of the case histories in tion presented, Therapeutic Recreation Jour- Therapeutic Recreation Journal, a number nal case histories bring to light real life of ethical issues have emerged. In some in- examples of ethical issues and challenges stances these issue have been ostensively faced by practitioners that are not typically identified by the case history authors. In addressed in papers reporting research or other instances, ethical issues have not be presenting conceptual content. Thoughtful identified by the authors, but are directly im-

Mark Widmer is an assistant professor and coordinator of the therapeutic recreation program in the Department of Recreation Management and Youth Leadership at Brigham Young University: 273 Richards Building, Brigham Young University, Provo, Utah, 84602. (801) 378-3381/FAX (801) 378-5254, e-mail: [email protected]

264 Therapeutic Recreation Journal plied in the content of the case history. The portant for the therapist to process her feel- purpose of this paper is to consider one of ings of loss and the need to let go. It is the many ethical issues found in the case difficult to know as a therapist how much histories. The particular ethical issue pre- self-disclosure is appropriate with a client" sented in this paper is taken from a single (p. 39). This passage identifies a dilemma case history. The issue will be explored in that arises naturally within a healthy thera- an effort to assist each of us to begin to pist-client relationship. The development of recognize and thoughtfully consider the im- a strong relationship or special bond between plications our work has for the people we the therapist and the client is often necessary serve. Specifically, this paper will explore for treatment to be successful. One theoreti- the use of therapist self-disclosure to pro- cal perspective suggests that relationships mote a therapeutic relationship as presented form the very foundation of all human devel- in a case history of particular interest. The opment and that some pathologies are the focus will be on both the positive and nega- direct result of dysfunctional relationships tive implications of therapist self-disclosure. (Fogel, 1993). According to Fogel's theory Finally, a philosophical perspective on how on co-regulation (1993), it is through rela- the issue of self-disclosure might be dealt tionships that we come to know and under- with will be presented. stand ourselves and our world. Relationships Negley (1994) describes the history of a also serve to form the core of our identity young woman suffering from major depres- and directly influence how the world is per- sion, suicidal ideation, and conversion disor- ceived. der. Outpatient treatment focused on helping Within relationships individuals regulate the client identify and communicate feelings, interaction with respect to the ongoing and increase self-worth, and improve leisure and anticipated actions of their partner(s) (Fogel, social functioning. Treatment continued over 1993). Participants set limits or borders on an extended period of time. According to the scope and setting of the communication Negley (1994), "Developing trust and build- within their relationships. The scope and na- ing a relationship became the most difficult ture of topics discussed and events shared and important aspect of treatment" (p. 37). directly influences the strength of the rela- Through a variety of experiential interven- tionship. Strong relationships, those charac- tions and considerable effort the therapist terized by a stance of openness (self-disclo- successfully built a relationship of trust with sure), dynamic interaction, and a willingness the client. This relationship clearly played a to enlarge the scope of our communication, critical role in the therapeutic process and result in the illumination of the self s rela- served to facilitate the successful attainment tionship to others and the world. Perhaps of treatment goals. even more important, strong relationships The necessary consequence of the attain- lead to a renewed self-understanding, the ment treatment goals was the termination of type of self-understanding that occurred in therapy. This meant a significant change in the present case study and the type of self- the therapist-client relationship. The process understanding that is critical to the therapeu- of termination proved to be emotional and tic process. Research in the area of self-dis- difficult for both parties. Upon reflecting on closure supports the position that the thera- the therapeutic process, Negley (1994) says peutic relationship is a central component of that' 'A special bond developed between the successful treatment (Cosby, 1973; Hen- therapist and the client.... Many intimate drick, 1988; Simon, 1988; Watkins, 1990; thoughts and events had been experienced Weiner, 1983). In other words, although together" (p. 39). Negley continues, "...clin- therapist self-disclosure is somewhat contro- ical supervision with the psychiatrist was im- versial (Cornett, 1991), both theory and re-

Fourth Quarter 1995 265 search suggest that a strong relationship can Beyond the natural emotional difficulty be a creative co-constructive process that is that accompanies termination, therapist self- therapeutic. disclosure can be problematic for other rea- The case history under consideration is sons. When attention shifts from the client an excellent example of the developmental to the therapist, the potential for role reversal process Fogel's theory describes. The mutual is introduced. Sometimes self-disclosure disclosure of intimate thoughts and the shar- may be misused in all ill-guided attempt to ing of intimate events is indicative of the gain a client's approval (Wells, 1994). In openness and the wide scope of communica- either instance the use of self-disclosure may tion necessary for the client to gain greater inappropriately burden the client, leading the insight and self-understanding. Self-disclo- client to feel angry, or otherwise damage the sure by both parties fosters this type of rela- therapist client relationship. Emotional dif- tionship. ficulty may also be experienced if intimate One reason the therapist in the case his- information disclosed by the therapist is tory under consideration found it difficult to taken lightly or mocked by the client. It is "know how much self-disclosure is appro- not uncommon for delinquent adolescents or priate with a client" (Negley, 1994, p. 39) individuals in correctional facilities to use is that self-disclosure is necessary for the sensitive personal information to antagonize therapist to build trust and enter a meaning- or psychologically assault the therapist. ful relationship. Yet, self-disclosure con- In other instances, as the therapist dis- comitantly exposes the therapist to consider- closes past feelings and experiences to "in- able emotional and professional risk. As il- crease perceived similarity" (Edwards & lustrated in the case history, empathetic Murdock, 1994), it is possible the client may disclosure tends to deepen relationships and lose confidence in the therapist's compe- create strong bonds. As the therapist and cli- tence. Or, when information is disclosed ent shared meaningful experiences, they be- about similar experiences (e.g., past drug ad- came closer and experience natural bonding ditions), the therapist may come to be per- or attachment. As Fogel's (1993) develop- ceived as a peer rather than a helping profes- mental theory suggests, this dynamic and sional. As demonstrated, self-disclosure may creative process results in greater self-under- be necessary to develop a meaningful rela- standing. In the present case history this un- tionship that facilitates the healing process, derstanding and insight played a primary role while on the other hand self-disclosure may in the client's recovery. jeopardize the therapist-client relationship or Patient improvement or recovery neces- put the therapist and the client at greater risk sarily leads to the need for termination of the of emotional or psychological trauma. therapist client relationship. Negley (1994) The fact that the therapist is paid to work points out that at the point of termination with the client presents another ethical di- both the therapist and the client suffered lemma. Should therapists, as paid profes- emotionally from the loss of the relation- sionals, use self-disclosure as a means to de- ship. Negley (1994) says that the client "ex- velop a therapeutic relationship when that perienced her childhood-like feelings of relationship will necessarily be terminated as abandonment, resentment, defeat and loss" treatment is completed or funding is de- (p. 39). The therapist also experienced feel- pleted? Does an inherent conflict exist when ings of loss and struggled with the need to the willingness of the therapist to use self- let go. It is important to note that in the disclosure is dependent either directly or in- history reported by Negley the therapist was directly upon the client's ability to pay? Is appropriately under the direct supervision of it appropriate to be paid to engage in self- a psychiatrist. disclosure? Fogel's (1993) theory of co-reg-

266 Therapeutic Recreation Journal ulation and other research (Cosby, 1973; in the client's recovery. Self-disclosure can Hendrick, 1988; Simon, 1988; Watkins, also result in emotional trauma for both the 1990; Weiner, 1983) suggests that the use of therapist and the client. The implications re- self-disclosure may enhance the therapeutic lated to being paid to engage in self-disclo- relationship and result in more effective sure and being used as a means to an end treatment. are also troubling. Is it possible that therapists would em- Negley (1994) is profoundly correct in ploy the use of self-disclosure believing that her observation. It is, indeed, "difficult to treatment will be more effective and that as know how much self-disclosure is appro- a consequence they will receive some sort priate" with a client (p. 39). Both benefits of political or financial gain? Further, is it and risks are associated with therapist self- possible that health care administrators disclosure. This particular dilemma is among would (perhaps they already do) promote the the most difficult because it deals with the use of therapist self-disclosure hoping to in- well-being of individuals and extremely per- crease revenue? In these types of situations, sonal information. when therapists seek to foster meaningful The 17th century philosopher, Immanuel relationships through self-disclosure, one Kant, provides an important perspective on might argue that therapists are essentially an issue central to this dilemma. Two princi- "selling" their intimate feelings and experi- ples identified by Kant are particularly help- ences. When the client's funding runs out, ful when considering this issue. First, Kant or when the client is discharged, the relation- (1964) posits that the only unconditional ship is terminated. The therapist's use of good is good will. For Kant, good will is the self-disclosure becomes the means to an end. ultimate and the only unqualified good. In The means in this circumstance is qualita- other words, an individual's will or intention tively different from the situation where the is more important than an individual's be- therapist uses skills, techniques, or tools as havior or the consequence of that behavior. the means to attain an end. In the first in- Second, Kant's formula of the end in itself stance, the therapist gives a part his or her states, "Act in such a way that you always "self" to facilitate change. The therapist's treat humanity, whether in your own person very essence, that which is intensely per- or in the person of any other, never simply sonal, is literally used (sold) to help another. as a means, but always at the same time as In the second instance, the therapist uses an end" (p. 96). Therefore, treating people skills, techniques, or tools to facilitate solely as a means to an end would be unethi- change in the client. These skills or tech- cal. Because people have inherent value, niques are not a part of the therapists inti- Kant argues that they should not be used mate and personal life or self. One might exclusively as a means to achieve an alterna- argue persuasively that the end of helping tive good, regardless of the value the good another person justifies the means of using might hold. self-disclosure as a therapeutic tool. It may From Kant's perspective, therapists ex- be somewhat more difficult to argue that the hibit good will when they have a sincere end of making money justifies the means of desire to help individuals with illnesses and self-disclosure. disabilities recover and experience a higher As can be seen, therapist self-disclosure quality of life. In this context the therapist has positive and negative implications. Self- might be considered not simply a means, but disclosure can enhance the therapist-client at the same time an end. The therapist be- relationship and increase treatment effective- comes a means through developing a thera- ness. In Negley's case history, self-disclo- peutic relationship that leads to recovery. sure appears to have played a primary role The therapist is at the same time an end if he

Fourth Quarter 1995 267 or she engages in the activity for the intrinsic In this paper, only one of many ethical value. When both of Kant's conditions are issues that have emerged in the recent Thera- met the use of self-disclosure would seem to peutic Recreation Journal case histories has be ethically acceptable and practically pru- been considered. This particular issue was dent. explored in an effort to assist therapeutic rec- If self-disclosure is used to develop thera- reation specialists recognize and thoughtfully peutic relationships in order to be more pro- consider the implications of their work. ductive, to shorten client treatment time, to Many other ethical issues of equal or greater increase revenue, or because it is perceived importance are to be found in the case histor- as part of one's job, then neither of Kant's ies published in the Therapeutic Recreation conditions would be met. Good will is lack- Journal. For example, what are the implica- ing and the therapist is not being treated as tions of changing the rules in a competitive an end. Although this use might be consid- game to facilitate the inclusion of one or two ered practically prudent, it would not be ethi- participants who use wheelchairs for mobil- cally acceptable based on the ethical princi- ity? Might this form of integration in com- ples applied. petitive sports discourage future participation Kant might suggest that therapists indi- among either disabled or non-disabled parti- vidually reflect on their intent when consid- cipants (Green & DeCoux, 1994)? Is it possi- ering the proper use of self-disclosure in ble that one might question the use of the clinical settings. If a sincere desire to help therapeutic recreation service model when the client exists and the therapist finds the working with patients in their declining work fulfilling, then the use of self-disclo- years? Is the goal of functional independence sure to develop a therapeutic relationship appropriate for client's whose physical ca- may be ethically justified. pacity is degenerating. "What level of func- Admittedly, the issue of therapist self-dis- tioning is realistic to aim for with an individ- closure is more complex than described in ual with a progressively debilitating disease'' this paper. Other important factors related to (Voelkl & Hermann, 1993, p. 51-56)? therapist self-disclosure and the therapeutic As these issues are considered, knowl- relationship deserve attention. Certainly the edge and understanding is expanded. This issue of professional competence is critical. knowledge and understanding adds a won- One may legitimately question whether the derful and rich dimension to the practice of training a therapeutic recreation specialist re- therapeutic recreation. Each of us should ceives is at the requisite level to be engaging seek to identify and reflect on the ethical in self-disclosure with clients. If the educa- implications of our work as we read the case tional and/or clinical background of a thera- histories and as we strive to improve the peutic recreation specialist is not sufficient to quality of life experienced by the individuals be engaging in self-disclosure, then perhaps we serve. Perhaps as our knowledge and un- self-disclosure should not be use, or only derstanding grows we will gain the wisdom used when clinical supervision is available needed to resolve the difficult questions we as illustrated in the case history discussed face in practice. in this paper. Another issue that deserves attention is the difference between self-disclosure in personal relationships and professional relationships, and the very real danger References of the therapist-client relationship pro- gressing from a professional to a personal Comett, C. (1991). The "risky" intervention: twin- ship self-object impasses and therapist self-dis- relationship as the result of therapist self- closure in psychodynamic psychotherapy. Clin- disclosure. ical Social Work Journal, 19(1), 49-61.

268 Therapeutic Recreation Journal Cosby, P. (1973). Self-disclosure: A literature re- morals. (Trans. H.J. Paton) New York: view. Psychological Bulletin, 79, 73-91. Harper & Row. Edwards, C. & Murdock, N. (1994). Characteris- Negley, S. (1994). Recreation therapy as an outpa- tics of therapist self-disclosure in the counsel- tient intervention. Therapeutic Recreation ing process. Journal of Counseling and Devel- Journal, 28(1), 35-41. opment, 72, 384-389. Simon, J. (1988). Criteria for therapist self-disclosure. American Journal of Psychotherapy, 3, Ellis, G. & Robertson, T. (1991). Editors com- 404-415. ments: Case histories. Therapeutic Recreation Journal, 75(3), 60. Voelkl, J. & Hermann, C. (1993). Therapeutic recreation assessment and intervention with an Fogel, A. (1993). Developing through relation- older adult displaying symptoms of dementia ships: origins of communication, self, and cul- and depression. Therapeutic Recreation Jour- ture. Chicago, 111: University of Chicago Press. nal, 27(2), 126-130. Green, F. & DeCoux, V. (1994). A procedure for Watkins, C. (1990). The effects of counselor self- evaluating the effectiveness of a community disclosure: a research review. The Counseling recreation integration program. Therapeutic Psychologist, 18, 477-500. Recreation Journal, 2S(1), 41-47. Weiner, M. (1983). Therapist self-disclosure. Bal- timore, MD: University Park Press. Hendrick, S. (1988). Counseling and self-disclosure. Journal of Counseling Psychology, 66, Wells, T. (1994). Therapist self-disclosure: Its ef- 419-424. fects on clients and the treatment relationship. Smith College Studies in Social Work, 65(1), Kant, I. (1964). Groundwork of the metaphysic of 23-41.

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