Out On The Couch
How online self-disclosure benefits LGBTQIA+ therapists with lived experience
Self-Disclosure and Community Building
We know that LGBTQIA+ community members are resourceful and resilient. We also know about startling disparities in the mental health of queer and trans individuals v. that of cisgender and heterosexual ones. As a queer femme clinical social worker who has spoken openly and published about my own lived experience of major depression and trauma–thereby “coming out” many times over the years–I posit that normalizing such experiences through mindful self-disclosure benefits LGBTQIA+ therapists and can make for healthier workplaces. One way in which we can help de-stigmatize lived experience among clinicians, as I will explore in this article, is by building online community via social media. My hope is that, through establishing online outlets for support and authentic discussion with other lived-experience practitioners, LGBTQIA+ psychotherapists living with mental health conditions ourselves can build stronger and genuinely thriving communities of practice.
Self-Disclosure in Clinician Communities
Therapist self-disclosure (TSD) has been examined and categorized in specific ways in extant literature, and clinicians may be familiar with some terminology surrounding immediate v. non-immediate TSD; deliberate v. unavoidable TSD; and accidental, inappropriate, and client-initiated TSD (Alfi-Yogev et al, 2020, Zur, 2009) to clients. Some literature also explores disclosure to and identification with LGBTQ+ clients, and how this shows up both in queer and TGNB community as well as in relational practice (Hansbury and Bennett, 2014). But the possibilities for positive change when we share about our own lived experience with other practitioners, particularly via social media, have not been explored at length.
In other words, we can easily find commentary and research on the risks and benefits of TSD to clients. But what about the risks and benefits of disclosure within communities of practice, i.e. among therapists in a clinic or group practice setting–or between clinicians and workers such as certified peer specialists, whose lived experience is a requirement of their position because it is seen as a strength (Byrne et al., 2016, Marino & Child, 2015)? King et al. (2020) frame mental health professionals with lived experience as an underutilized resource, one whose presence and authenticity can help lessen stigma and foster healthier mental health service-oriented workplaces overall. At the same time, practitioners such as peer specialists face “the unique challenges of…being professionally isolated, feeling outnumbered and ostracised,” especially when few of them are employed in a given workplace (Moran et al., 2013, as cited in Byrne et al., 2016, p. 11).
Self-Disclosure and Resilience
First, we might consider here the stress induced by identity concealment, and how research has shown that the pressure of hiding our true selves as LGBTQIA+ people results in negative psychological responses associated with PTSD (Alessi & Martin, 2017). Support from online communities can potentially help mitigate these stressors for those of us who are both queer and living with mental health conditions, allowing for therapists with lived experience to be seen and valued for the unique gifts we bring to the workplace.
While self-help models have long been grounded in the principles of discussing lived and shared experiences, and peer models can indeed be enhanced by self-disclosure (Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001), it seems that few conversations are happening about how TSD among practitioners–LGBTQIA+ ones in particular–can benefit us. Yet I have found that my own self-disclosure has led to my sense of increased authenticity and even self-efficacy. This is especially salient considering that lived experience is a form of expertise, albeit one that is frequently undervalued in mental health care professions, unto itself.
In exploring the idea of online TSD, we may consider that some transparency is simply unavoidable, as it would be if we were living in a small town; in fact, Zur (2015) conceptualizes the Internet as a “global village.” This is particularly relevant to social media use–in addition to shared physical social spaces–among LGBTQIA+ community, which tends to be surprisingly small and deeply interconnected even in major metropolitan areas such as my hometown of New York City.
Both Zur (2015) and Longley (2021) caution that therapists may not be aware of the information clients have uncovered about them online, thus leaving them unable to appropriately address unintentional disclosures in session. Clinicians considering issues of disclosure around lived experience will want to bear this in mind. If we operate from the assumption that our clients as well as our colleagues have read any- and everything we have written for publication, online or off, we will be better prepared for the possibility of our authentic selves to show up in the therapy room as well as the conference room–or the Zoom rooms! Further conversations about self-disclosure from different intersections have been explored in previous articles published by The Affirmative Couch by Mandy Simmons and Jerry St. Louis.
Online Communities for Therapists
We might look to Facebook and Twitter for an idea of what intentional social media-based disclosures within communities of practice can look like. Both are homes to LGBTQIA+ mental health discussions in the forms of groups and chats, but it can be difficult to find dedicated space to share support around being a queer therapist with lived experience. Frustrated with the lack of such spaces, I started a small, private Facebook group in early 2020, inviting a few clinicians I knew who had openly shared their status as peers. The intention was to create a safer space in which we could discuss our work and lives. Some themes that have emerged include professionally navigating dual identities as clinicians and peers; potential over-identification with clients with similar lived experiences; and how much disclosure, and to whom, feels safe. With fewer than 20 members at present, the group is low-traffic, but an available and hopefully growing resource for LGBTQIA+ therapists with lived experience.
Risks and Benefits of Online TSD
The risks and benefits of TSD in terms of client impact is familiar terrain in the literature. Risks include violating boundaries and burdening the client with extraneous personal information that detracts from focus on the client, while benefits include potentially enhancing trust and strengthening the therapeutic alliance (Alfi-Yogev et al., 2020; Johnsen & Ding, 2021; Lehavot, 2010; Longley, 2021; Moody et al, 2021; Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001; Zur, 2009). Some psychotherapeutic modalities, including dialectical behavior therapy (DBT) and relational therapy, may better lend themselves to TSD than others, such as traditional psychoanalytic models (Hansbury and Bennett, 2014; Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001).
Worth noting, per Lehavot et al. (2010), is the tension of the generational divide between therapists born into an Internet-savvy world v. those born prior to the Internet’s omnipresence, and how this can factor into differing attitudes about online TSD. Generational and cultural differences persist, and different schools of thought on privacy-related values may clash. Traditional psychotherapeutic views on self-disclosure, online or off, may certainly err on the side of conservatism and eschew clinician authenticity; after all, in classical psychoanalysis, “self-disclosure was thought to result in gratification of patients’ wishes rather than analysis of them” (Psychopathology Committee of the Group for Advancement of Psychiatry, 2001, p. 1489).
Meantime, more modern viewpoints support that some self-disclosure can provide role modeling and confirm what is already publicly available online, thereby deepening trust with clients (Johnsen & Ding, 2021). Therapists who choose to disclose should be mindful about their rationale and have thoughtful responses at the ready, considering that revealing a diagnosis can elicit bias from clients, colleagues, and employers. This is why I encourage us all to reflect on the validity of lived experience as a form of expertise, and consider sharing pertinent literature–such as some of the articles in the below reference list–as tools for further learning.
Further education can help those who harbor bias and stigmatize individuals with lived experience unlearn harmful attitudes, and perhaps even their own internalized oppression. It is difficult to locate any data regarding the risks and benefits of LGBTQIA+ therapists themselves disclosing to each other, whether online or in person. What we do know is that LGBTQIA+ community members frequently use social media to discuss their mental health concerns and care. Interestingly, researchers have found social media usage to be both a risk factor for and a protective factor against depression for LGB people. Per Escobar-Viera et al. (2018), who draw on the Meyer minority stress model, social media can be conducive to the formation of social support and connection among queer folks, thereby encouraging stress reduction and forming protective factors against depression. At the same time, social media use can also foster social comparison and yield experiences of cyberbullying and stigmatization, leading to such negative outcomes as lowered self-esteem and symptoms of depression (Escobar-Viera et al., 2018).
Perhaps we can extrapolate some ideas from existing literature about the general benefits of sharing in alleviating self-stigma. Normalizing disclosure among not only “lived experience practitioners,” such as certified peer specialists, but also licensed mental health clinicians can provide both personal and community-wide benefits, eliminating feelings of isolation, being outnumbered and stigmatized in the workplace, and easing distress around identity concealment (Byrne et al., 2019; King et al., 2020). When we, as LGBTQIA+ clinicians, share about our lived experience and provide support to each other online, discussing our experiences of workplace challenges, we can make it more feasible for ourselves and each other to disclose to colleagues in our clinics, agencies, and organizations. This kind of effort can lead to further understanding of diverse experiences, identities, and states of mind, which ultimately benefits everyone.
Research on this topic moving forward should focus on the outcomes and benefits of disclosure in online communities formed specifically for this purpose–to provide support for queer and trans clinicians with lived experience. Worth noting is my own positionality in writing this article as a white cis femme for whom being doubly “out” as queer and having mental health-related diagnoses is, in some ways, relatively safe. Risks may be more significant for community members facing multiple forms of marginalizations; it is crucial to take an intersectional lens to the impact of self-disclosure and social media use on, for instance, LGBTQIA+ Black, Indigenous, and people of color communities (BIPoC) (Marino & Child, 2015). Future directions in research should address this when also examining how disclosure and authenticity in the workplace–i.e. outpatient clinics, group practices, and agency-based settings–benefits LGBTQIA+ clinicians with lived experience.
Learn more about working with LGBTQIA+ Clients
Alfi-Yogev, T., Hasson-Ohayon, I., Lazarus, G., Ziv-Beiman, S., & Atzil-Slonim, D. (2020). When to disclose and to whom? Examining within-and between-client moderators of therapist self disclosure-outcome associations in psychodynamic psychotherapy. Psychotherapy Research, 1–11.
Alessi, E. J., & Martin, J. I. (2017). Intersection of trauma and identity. In K. L. Eckstrand & J. Potter (Eds.), Trauma, resilience, and health promotion in LGBT patients (pp. 3–14). Springer. DOI 10.1007/978-3-319-54509-7_1
Byrne, L., Roennfeldt, H., Davidson, L., Miller, R., & Bellamy, C. (2021). To disclose or not to disclose? Peer workers impact on a culture of safe disclosure for mental health professionals with lived experience. Psychological Services. https://doi.org/10/gj7w6r
Escobar-Viera, C. G., Whitfield, D. L., Wessel, C. B., Shensa, A., Sidani, J. E., Brown, A. L., Chandler, C. J., Hoffman, B. L., Marshal, M. P., & Primack, B. A. (2018). For better or for worse? A systematic review of the evidence on social media use and depression among lesbian, gay, and bisexual minorities. JMIR Mental Health, 5(3), e10496. https://doi.org/10.2196/10496
Hansbury, G., & Bennett, J. L. (2014). Working relationally with LGBT clients in clinical practice: Client and clinician in context. In Relational social work practice with diverse populations (pp. 197–214). Springer.
Johnsen, C., & Ding, H. T. (2021). Therapist self-disclosure: Let’s tackle the elephant in the room. Clinical Child Psychology and Psychiatry, 26(2), 443–450. https://doi.org/10/gmvf8w
King, A. J., Brophy, L. M., Fortune, T. L., & Byrne, L. (2020). Factors affecting mental health professionals’ sharing of their lived experience in the workplace: A scoping review. Psychiatric Services, 71(10), 1047–1064. https://doi.org/10/gk87w8
Lehavot, K., Barnett, J., & Powers, D. (2010). Psychotherapy, professional relationships, and ethical considerations in the MySpace generation. Professional Psychology: Research and Practice, 41, 160–166. https://doi.org/10/btg4mw
Longley, H. (2021). A psychotherapist’s experience of self-disclosure, when practising in the digital era: A heuristic self-study [PhD Thesis]. Auckland University of Technology.
Marino, C. “Khaki,” Child, B., & Campbell Krasinski, V. (2016). Sharing Experience Learned Firsthand (SELF): Self-disclosure of lived experience in mental health services and supports. Psychiatric Rehabilitation Journal, 39(2), 154–160. https://doi.org/10/f8rkjh
Moody, K. J., Pomerantz, A. M., Ro, E., & Segrist, D. J. (2021). “Me too, a long time ago”: Therapist self-disclosure of past or present psychological problems similar to those of the client. Practice Innovations. https://doi.org/10/gmvf8x
Moran, G. S., Russinova, Z., Gidugu, V., & Gagne, C. (2013). Challenges experienced by paid peer providers in mental health recovery: a qualitative study. Community Mental Health Journal, 49(3), 281-291.
Psychopathology Committee of the Group for the Advancement of Psychiatry. (2001). Reexamination of therapist self-disclosure. Psychiatric Services, 52(11), 1489–1493. https://doi.org/10/bnhpwc
Zur, O., Williams, M. H., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the Internet age. Professional Psychology: Research and Practice, 40(1), 22. https://doi.org/10/bss28g
Zur, O. (2015). The Google factor: Psychotherapists’ intentional and unwitting self-disclosure on the net. Zur Institute. http://www.zurinstitute.com/onlinedisclosure.htm
Self Disclosure of the Polyamorous Therapist
As the mental health field makes inroads toward inclusive and equitable practice, efforts to understand the needs of polyamorous people are expanding beyond the basics (Johnson, 2013). Moreover, it is important to ensure polyamorous therapists are included in that discussion. As practitioners, we are examining ourselves for opportunities to better meet the needs of diverse people, including both the people we serve in a treatment capacity and ourselves. Therefore, polyamorous self disclosure is one part of these considerations.
When considering personal definitions of polyamory, most people emphasize ethics, emotional involvement, and sexuality in their relationship structures and practices (Cardoso et al.i, 2021). Therefore, definitions of polyamory are as diverse as the people who identify with consensual non-monogamy. More than 20 percent of adults have identified as practicing some form of consensual non-monogamy (Haupert et al., 2017), and around four out of 10 polyamorous people have experienced some form of discrimination related to their relationship orientation/style (Fleckenstein et al., 2012). Many mental health providers (MHP) practice polyamory in their own lives, and though their profession aspires to greater inclusivity, they are unlikely to be exempt from discrimination merely by virtue of assumed professional ethics of their peers.
Need for Inclusive Guidance and Practice for Polyamorous Therapists
Given the negative effects of minority stress experienced by marginalized groups (Meyer, 2003), it behooves the field to provide guidance on community-specific clinical and ethical dilemmas. Firstly, this will support the capacity of individuals with diverse relationship structures and practices to be able to provide and receive mental health services for the long haul. Secondly, this is especially important as the next generation of practitioners gains competency in affirming identities of the people they serve (Buche et al., 2017). Similar to how individuals within the LGBTQIA+ community are “deeply stigmatized and often invisible to outsiders” (Gibson, 2012), polyamorous therapists and the clients they serve may also benefit from proactive and thoughtful therapist self-disclosure.
Certainly, polyamorous therapists deserve support in navigating dating in the online age, especially given their unique needs as a smaller community. Since the onset of the COVID-19 pandemic, more dating is taking place online (Kluck et al., 2021). The virtual forum allows for safe distancing, speedy reviews of profiles, and informed consent before meeting in person. With such a small number of potential paramours making up the polyamorous community relative to their monogamous counterparts, there is likely to be overlap between polyamorous therapists and the people they serve, especially in online spaces. For the benefit of both therapist and client, it is worth considering whether to proactively address this issue in the therapeutic space through self-disclosure, or to address a potential encounter after the fact.
Therapist Self-Disclosure and Protecting Clients from Harmful Multiple Relationships
Therapist self-disclosure has been a hotly debated topic for some time, with so much of the conversation hinging on the particular therapist’s theoretical orientation (Levesque, 2018; Miller & McNaught, 2018). Some therapeutic approaches, such as the traditional psychodynamic lens, emphasize the therapist as a blank slate upon which the person receiving services projects their inner world (Dixon et al., 2001; Gibson, 2012; Sparks, 2009). As a result, these therapists also view self-disclosure of personal information as a limitation to projection. However, most contemporary psychoanalytic theory does not emphasis the blank slate as it is often experiences as cold or distant by the client (C. Cathers, personal communication).
Other approaches to treatment, such as the feminist-relational lens, take on a more egalitarian lens in which the therapist may disclose pieces about themself to normalize common human struggles and subvert the traditional power dynamic of therapist as expert (Gibson, 2012; Hill &Knox, 2002). Still others, such as cognitive behavioral therapy, de-emphasize the content of therapist self-disclosure and are more geared toward modeling the use of coping skills (Dixon et al., 2001). Regardless of a therapist’s orientation to treatment, there are certain pieces of information that go on display inadvertently. For example, details of the therapist’s personal life might become available to the client during encounters outside of the therapy room.
Insights Regarding Multiple Relationships for Polyamorous Therapists from Rural Providers
For the polyamorous therapist working with a polyamorous client, this poses a challenging situation where the probability of encountering one another outside the therapeutic space may obscure the boundaries. MHPs practicing in rural communities may have helpful insights to offer, as they too are likely to encounter the people they serve outside the therapy room given the smaller size and insular nature of the community (Boilen, 2021; Schank, 1998). Rural psychologist Dr. Sara Boilen urges practitioners to consider whether entering into a dual relationship will impair the therapist’s ability to provide adequate treatment, exploit the person receiving services, or cause harm to the client (2021). That is to say, in working with the polyamorous community, polyamorous therapists are ethically obligated to be proactive in navigating potential for multiple relationships. Many rural psychologists recommend viewing overlapping social spheres as inevitable and addressing this at the outset (Boilen, 2021; McDermott, 2007).
Challenges Unique to the Polyamorous Therapists
Certainly, the unique nature of the dual relationship for polyamorous providers and clients is likely to bring up ethical challenges related to sexual intimacy. Most ethical codes of conduct for mental health professionals specifically indicate that sexual intimacy between a therapist and client currently in treatment is never appropriate (American Association for Marriage and Family Therapy, 2015). Some professions may even provide guidelines as to how many degrees of separation away a therapist should remain in relationships with individuals associated with or related to their clients (American Counseling Association, 2014; American Psychological Association, 2016).
In all cases, our profession encourages therapists to reflect on their motivations for potential boundary-crossing, consider whether their actions will promote the well-being of the client, and consult with colleagues when their objectivity is compromised (Barnett & Hynes, 2015). Still, there is little guidance that directly addresses the concerns of polyamorous therapists who could end up seated in front of a client who is interested in dating one of the therapist’s partners.
Proactive Strategies for The Polyamorous Therapist’s Personal Life
One option for polyamorous therapists is to discuss a “veto” rule with their paramours to address these situations that pose a risk for boundary-crossing. As Franklin Veaux* and Eve Rickert explain in their practical guide to ethical polyamory, More than Two, a veto is an agreed-upon rule where one partner has the right to tell another partner to end a relationship (2014). To clarify, implementing this strategy in advance of encountering a potential conflict may provide the partner who is a therapist with the opportunity to circumvent the need for therapist self-disclosure. A veto rule can also reduce the risk of compromising confidentiality of the client with the therapist’s partner, while still communicating that the client is not an acceptable dating option.
However, the presence of a veto clause will inherently alter egalitarian power distribution in the dynamics of the therapist’s relationship structures. Many polyamorous folx do not practice vetos because they believe it can create coercion in the relationship. As a result, it may be necessary to make sure that the therapist discusses their professional ethics with each of their partners to reach a shared understanding, if using a veto strategy is not a good fit. These preemptive strategies will not prevent the therapist from encountering the client (and their previously prospective paramour) in a public setting, so it may be important to have this conversation regardless.
Polyamorous Therapist Self-Disclosure
Similarly, professionals in other fields disclose potential conflicts of interest at the outset of a professional engagement, therapists can use this lens with clients. One option would be to include language addressing relationship style in one’s intake documents, such as informed consent to treatment and in the demographic information completed by the client. Eliciting relationship statuses and structures in a client’s intake paperwork is both an inclusive practice that all therapists are encouraged to consider and may also help the polyamorous therapist to head off potential challenges before beginning treatment. The APA Division 44’s resource, “Inclusive Medical and Mental Health Care for People Engaged in Consensual Non-Monogamy,” provides guidance on inclusive paperwork practices (2019).
It is also important to consider that because the therapist has more power in the therapeutic relationship, the onus is on them to name and resolve the conflict. For example, a therapist might have to discontinue a relationship due to a potential overlap in the client’s network of relationships. Additionally, there may be a time where the therapist has to directly address the client attempting to start a relationship with one of the therapist’s paramours. This is where a veto-based arrangement may come in. Or a signed authorization to release information to the paramour, depending on the client’s preference, comfort level, and possibly clinically-relevant issues, such as social anxiety or attachment style. Above all, it is important to remember that the client’s wellbeing is at the core of each of these interventions.
Rife with Clinical and Emotional Richness
While all of these considerations may sound intensely complicated, polyamorous folx, especially polyamorous therapists, are no strangers to the rich dynamics of emotional intimacy and direct communication. In fact, these qualities are intrinsic to both polyamory and psychotherapy. Subsequently, these complexities need not have the aura of doom and gloom that many therapists experience when contemplating ethical dilemmas. Therapist self-disclosure can play an important role in developing trust, modeling vulnerability, normalizing diverse identity statuses, deepening the therapeutic alliance, and can constitute a culturally-responsive intervention in and of itself (Bitar et al., 2014; Levitt et al., 2016; Solomonov & Barber, 2019; Sparks, 2009), especially for polyamorous clients.
Though it is impractical to anticipate all possible dynamics, the research tells one story over and over again: that the therapeutic relationship is the foundation on which everything else stands (Asay & Lambert, 1999). In order to foster the working alliance, some guidelines for therapist self-disclosure have been proposed (Henretty & Levitt, 2010; Hill & Knox, 2002). For instance, including timing, depth of content, low frequency, and checking in after the disclosure has been made to explore how the client received the information to refocus the session on the client’s experiences. Therapists are encouraged to examine the function of their intended self-disclosure, especially if it is experienced with urgency, as the goal of treatment should never be solely based on meeting the therapist’s needs (Hill & Knox, 2002).
Looking to the Future
To sum up, the aim of this article is to arm polyamorous therapists with practical tools for negotiating the intersection of personal and therapeutic dynamics, knowing that this in no way will address every possible scenario the therapist will encounter. As sources of information and guidance for polyamorous mental health providers and clients emerge, some organizations and resources to keep an eye on include the American Psychological Association’s Division 44 Consensual Non-Monogamy Task Force and the Institute for Relational Intimacy’s recent publication, Polyamory: A Clinical Toolkit for Therapists (and Their Clients), by Martha Kauppi. As with much of the norms and knowledge for polyamorous people, wisdom emerged from within the community. Additionally, polyamorous therapists are encouraged to find or form consultation groups with colleagues who share their experiences of consensual non-monogamy in order to discuss ethical and clinical dilemmas as they arise.
*Please note that we do not condone or support abusive or coercive behaviors alleged by victims of abuse.
Learn more about working with polyamorous clients
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Solomonov, N., & Barber, J. P. (2019). Conducting psychotherapy in the Trump era: Therapists’ perspectives on political self‐disclosure, the therapeutic alliance, and politics in the therapy room. Journal of Clinical Psychology, 75(9), 1508-1518. http://dx.doi.org/10.1002/jclp.22801