Contemp Fam Ther (2014) 36:417–425 DOI 10.1007/s10591-014-9308-4
ORIGINAL PAPER
Therapist Self-disclosure and Culturally Competent Care with Mexican–American Court Mandated Clients: A Phenomenological Study George W. Bitar • Thomas Kimball J. Maria Bermu´dez • Cora Drew
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Published online: 9 May 2014 Springer Science+Business Media New York 2014
Abstract Therapist self-disclosure (TSD) is a skill with numerous potential benefits and risks for the therapeutic alliance. While its effects have been established, little empirical research has examined the impact of TSD in cross-cultural treatment settings with court-mandated clients, a context with unique considerations. In an effort to help fill this gap, results of a phenomenological study examining the effects of TSD on Mexican–American men working with Anglo American therapists in a mandated treatment setting are presented. The results of this study indicate that TSD is a culturally competent intervention with several benefits for mandated clients, including strengthening the therapeutic alliance, normalizing client problems, lessening the therapist-client hierarchy, and modeling the acceptability of self-disclosure. Clinical and marriage and family therapy educational implications are also discussed. Keywords Therapist self-disclosure Court mandated treatment Cultural competence Mexican–American men Cross-cultural counseling Masculinity
G. W. Bitar (&) C. Drew Marriage and Family Therapy Program, Pfeiffer University, 4701 Park Rd., Charlotte, NC 28209, USA e-mail: george.bitar@pfeiffer.edu
Therapeutic self-disclosure (TSD) has received increasing empirical attention over the past decade. Defined as the ‘‘… revelation of personal rather than professional information to a client by a therapist,’’ (Zur 2009, p. 21), research suggests that TSD is a powerful skill that can strengthen the therapeutic alliance (Hanson 2005; Knox and Hill 2003) and normalize universal human experiences (Henretty and Levitt 2010), while enhancing client trust and engagement in the treatment process (Audet and Everall 2010). While there are several potential benefits of TSD, there are also risks to this skill, including blurred client-therapist boundaries and the loss of therapist credibility (Audet and Everall 2010). Additionally, there are important ethical issues when considering the use of TSD that must guide therapists in determining how self-disclosure is utilized (Gibson 2012). While research is generally supportive of the use of TSD, there are few studies examining the use of this skill as a component of culturally competent care or as a method of strengthening the therapeutic alliance with court-mandated clients. The purpose of this study is to fill this gap by exploring the impact of TSD on the therapeutic alliance within a cross-cultural, mandated treatment context.
Literature Review
C. Drew e-mail: cora.drew@pfeiffer.edu
A Brief History of TSD
T. Kimball Texas Tech University, Lubbock, TX, USA e-mail: thomas.kimball@ttu.edu
The role of TSD has evolved over time. Farber (2006) explains that the emergence of client-centered therapy (and other humanistic and existential approaches), in the late 1950s and the women’s movement have had a profound impact on how the therapist’s role is conceptualized. Carl Rogers and the humanistic movement in therapy moved the
J. M. Bermu´dez University of Georgia, Athens, GA, USA e-mail: mbermude@uga.edu
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perceived role of the therapist away from traditional psychodynamic/psychoanalytical orientations, where therapists are trained to be neutral and non-disclosing, toward more humanistic roles, where therapist openness, genuineness, and empathy are viewed as central to the therapeutic process. In this shift to a more humanistic focus, there has been increased attention on the therapist’s use of self and, more specifically, on the use of TSD during the course of treatment. Knox and Hill (2003) consolidate much of this research in their classification of the seven types of TSD, including disclosures of facts, feeling, insight, strategy, reassurance/support, challenge, and immediacy. TSD can also be avoidable or unavoidable, intentional or unintentional, and verbal or nonverbal (Zur 2009). Audet and Everall (2010) take this research one step further by capturing specific functions of TSD that facilitate the therapeutic alliance, including early connection to the therapist (Audet and Everall 2010). Bedi et al. (2005) also found that TSD was identified as one of the critical events that clients identified as contributing to the therapeutic alliance, even as therapists themselves tended to minimize the impact of this skill. Given the influence of the therapeutic alliance on clinical outcomes (Blow and Sprenkle 2001; Lambert and Bergin 1994; Miller et al. 1997), it is reasonable to assume that TSD may have a direct effect on the efficacy of treatment, though research is needed to directly examine this link. With this said, the literature is also clear that the ‘‘the degree of intimacy in therapist self-disclosures… must be carefully calibrated’’ (Knox and Hill 2003, p. 534) and focused on the needs of clients (Roberts 2005). In the field of marriage and family therapy (MFT), TSD is conceptualized in markedly varied ways across different theoretical orientations. Roberts (2005) describes these differences across six prominent MFT models; structural/ strategic, symbolic experiential, Bowenian, feminist, reflecting team, and narrative. While each model creates some space for TSD and transparency, the level, type, and purpose for disclosing varies considerably across models. For example, from a structural/strategic perspective, therapist disclosure is viewed as a technique that is used in a limited way for the purpose of joining (Roberts 2005). From a feminist perspective, however, TSD is viewed as playing a central role in increasing collaboration, decreasing hierarchy, acknowledging power differentials, and affirming shared experiences (Roberts 2005).
TSD and Culturally Competent Care While the potential benefits of TSD have been established in general, there are few studies examining its use within the context of culturally competent treatment. Despite the
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minimal amount of research in this area, there seems to be some theoretical consensus related to the usefulness of this skill. Constantine and Kwan (2003), for example, explain that TSD can be used in developing the therapeutic alliance, addressing cultural mistrust, exhibiting cultural competence, and establishing therapist expertness. In one of the few empirical studies in this area, Burkard et al. (2006) found that European American therapists who disclosed their thoughts related to oppression and racism, at appropriate moments, enhanced the therapy process in a cross-cultural treatment setting. Sue and Sue (1999), furthermore, speak to the centrality of TSD when Anglo American (non-Hispanic) therapists are working with clients from diverse cultural backgrounds. In multicultural counseling, the culturally different client is likely to approach the counselor with trepidation: ‘What makes you any different from all the Whites out there who have oppressed me?’ ‘What makes you immune from inheriting the racial biases of your forebears?’ ‘Before I open up to you (selfdisclose), I want to know where you are coming from’… In other words, a culturally different client may not open up (self-disclose) until you, the helping professional, self-disclose first. Thus, to many minority clients, a therapist who expresses his/her thoughts and feelings may be better received in a counseling situation. (p. 93) These thoughts are also consistent with a feminist perspective that views TSD as an effective way of lessening the client-therapy hierarchy while building a collaborative therapeutic relationship (Simi and Mahalik 1997). In describing culturally sensitive work with men, Wexler (2009) states, ‘‘therapist self-disclosure, carefully calibrated, can be effective in fostering this alliance and helping to bring men out of their shell’’ (p. 84). Molina and Franco (1986) echo this point in emphasizing the importance of therapist self-disclosure when working with Mexican–American men, more specifically. TSD and Court Mandated Treatment In the same way that limited research exists at the intersection of TSD and culturally competent care, there is minimal research examining the use of TSD with courtmandated clients. While the centrality of the therapeutic alliance in mandated treatment contexts has been established (Brown and O’Leary 2000; Taft et al. 2003), a review of the literature found a dearth of articles examining the use of TSD within these settings. The use of TSD in court-mandated contexts may require an additional level of sensitivity, given the unique power dynamics with involuntary clients.
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Clinicians working with mandated clients are often faced with ethical dilemmas inherent in their role as therapist and social control agent. The dual-role nature of this relationship creates complexity in the alliance beyond that which is present with non-mandated clients (Skeem et al. 2007). On the one hand, the clinician’s goal is to foster improved functioning and self-determination within clients (role as therapist), and on the other hand, the clinician is often required to report client compliance and progress in treatment to authority figures (role as social control agent). Burman (2004) speaks to the bind that can often arise as a result of the different and sometimes conflicting roles:
419 Table 1 Interview guide Question Number
Question
1
Please tell me about your experience of individual counseling
2
Please describe your experience of talking about your personal issues in individual counseling. How do you feel after you talk about your personal issues?
3
What does your therapist do or say that makes it easier to talk about emotional experiences and personal issues? How could a therapist make it even more comfortable to talk about personal issues?
4
How do you decide what to share and what not to share? What personal issues are the easiest to discuss in counseling? Explain. What topics are the most difficult? Explain. (Topic prompts if necessary: substance use, criminal activity, struggles with family members, sexual, physical, and emotional abuse)
5
How does talking about your personal issues in counseling affect how you talk to people outside of counseling? Explain
This dual role may create a greater power disparity between client and therapist that can hinder the formation of a strong therapeutic alliance (Skeem et al. 2007). It may be that the appropriate use of TSD is even more critical within these mandated settings, in order to lessen the therapist-client hierarchy and create a more collaborative therapeutic alliance.
6
How have you learned to express your thoughts and feelings as a man? In counseling, are there emotions or personal issues that you feel more comfortable sharing as a man? Explain. How about less comfortable? Explain.
Purpose of this Study
they met inclusion/exclusion criteria. This is an appropriate technique for a phenomenological study, when the researcher is establishing the essential structure of a specific experience within a specific population (Creswell, 1998). Each client’s intake/assessment information was gathered at the same community mental health agency and was used to determine if they met the inclusion/exclusion criteria for participation in the study. To participate in this study, participants had to self identify as a Mexican– American adult male, to be currently in a psychotherapy community mental health agency, and on probation for a federal offense. After determining if their participation was appropriate, clients were recruited in-person and asked to sign the IRB-approved consent documents.
Combining roles and allegiances places the [treatment provider] in a double-bind- being simultaneously accountable to the client and the criminal justice system, with varying objectives and focal points. These can interfere with developing rapport and a trusting relationship that are so instrumental in facilitating the goal of client progress and treatment effectiveness. (p. 2)
The general benefits and risks of TSD have been established in the literature, with many of the benefits directly relating to the therapeutic alliance. The impact of TSD in cross-cultural counseling settings, however, has not been examined in-depth, nor has the impact of TSD with courtmandated clients. It is critical to analyze the use of TSD within these settings given the unique dynamics that are present within these contexts related to culture, identity (e.g., gender, ethnicity, sexual orientation, client-therapist differences), and power (e.g., the dual-role nature of a therapist working in mandated settings)—all of which may impact the manner in which the therapeutic alliance and TSD are experienced. It is at the intersection of cultural competence, mandated treatment, and TSD where this study contributes to the existing body of literature.
Methodology Procedures A criterion sampling technique was used for this study. Participants were selected based on the extent to which
7
8
Is there anything else you would like to say related to what we have discussed today?
The Interview Process Consistent with phenomenology, (Colaizzi 1978) and for credibility considerations (Lincoln and Guba 1985), two indepth interviews were conducted with each participant. The first interview lasted between 60 and 90 minutes. The questions during this interview focused on the participants’ general experiences of talking about their personal issues in counseling (e.g., ‘‘Please tell me about your experience of individual counseling’’). Though questions specifically
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Participant
Age
Education
Time incarcerated (months)
minimize any role confusion, the interviewer did not include any of his clients in this study.
1
59
9th Grade
168
Data Analysis
2
22
High School
34
3
60
9th Grade
98
4
24
9th Grade
14
5
45
GED
89
6
32
GED
108
7
30
10th Grade
240
8
34
10th Grade
72
9
35
8th Grade
39
10
31
GED
60
Table 2 Participant demographic information
asking about TSD were not included in the interview guide, all participants initiated discussions around this topic when addressing Question #3 of the interview guide (see Table 1). The authors plan to use the data gathered from the other questions in the Interview Guide for future publications. The second interview served the purpose of confirming and revising emerging themes in the data analysis process. During this interview, themes and data summaries were reviewed and participants were given an opportunity to revise and further clarify the themes. These interviews lasted between 30 and 60 minutes and were spaced between 2 and 4 months following the first interviews. Sample Ten (n = 10) participants were selected, the maximum number suggested for phenomenological research (Creswell 1998). This was also the number where data saturation was reached, based on the first and second interviews, data analysis, and the peer review process. All of the study participants were volunteers and were given a gift card for their participation in this study. The following table provides an overview of participant demographic information: Table 2. The clients who were interviewed for this study were in treatment with a total of three different therapists: one female and two males. All three therapists were Anglo Americans, did not speak Spanish, although one was fluent in Portuguese. The therapists were provisionally licensed MFTs who identified with an ‘‘integrated’’ approach to treatment and were the colleagues of the interviewer. The interviewer for all the participants was the first author of this article. He is an Arab American and Licensed Marriage and Family Therapist with an interest in the social construction of masculinity across cultures and its therapeutic implications. During the time of the interviews, he was conducting individual and group therapy at the agency where the participants were receiving treatment. In order to
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Consistent with the descriptive phenomenological approach of Colaizzi (1978), data analysis included the following overlapping steps: (1) The participant’s descriptions were read in order to obtain a sense of what was being expressed, (2) Significant statements were extracted that related directly to the phenomenon of TSD. Repetitive statements were eliminated, (3) The meanings of each statement were formulated to ‘‘discover and illuminate those meanings hidden in the various contexts and horizons of the investigated phenomenon which are announced in the original protocols [transcripts]’’ (p. 59). In this step, we moved from what the participant said to what they seemed to mean, based directly on the descriptions. The ‘‘investigated phenomenon’’ for the purposes of this study was the client experience of self-disclosure. The reference to meaning being ‘‘hidden,’’ then, refers to the larger themes that emerged across participant responses that the investigators helped highlight. Steps 1–3 were repeated for each transcript and the formulated meanings across transcripts were clustered into themes. The clusters of themes were referred back to the original descriptions for validation purposes. This was achieved by examining whether there were important descriptions that were not included in the themes or whether the themes implied what was beyond the descriptions. The results to this point were integrated into an exhaustive description of the experience. The exhaustive description was then formulated to include the fundamental structure of the experience (i.e., a brief statement that captures the main themes). Finally, an additional interview was conducted with each participant to obtain feedback and ensure accuracy in the findings (i.e., member checking) (Lincoln and Guba 1985). In order to minimize bias, peer debriefing was also utilized in order to establish the credibility of the findings (Lincoln and Guba 1985). This process involved the interviewer meeting regularly with the second and third authors of this study to explore potential interviewer bias and to clarify methodological issues. The debriefers were selected for their expertise in providing culturally competent treatment to Latinos and their experience working with mandated populations. The debriefers are also Licensed Marriage and Family Therapists who are employed in academic settings. Findings Four main themes emerged when analyzing the effect of TSD on participants in this study. TSD had the effect of:
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(1) building the therapeutic relationship, (2) modeling selfdisclosing behaviors, (3) lessening the therapist-client hierarchy, and (4) normalizing client struggles. The following section provides interview excerpts illustrating each of these themes. Theme I: Building the therapeutic relationship—‘‘We’re Bonding.’’ The majority of participants described the initial challenges of attending therapy and the discomfort they felt in being expected to disclose to a stranger. When asked to describe the transition toward greater comfort in the therapy process, participants stated how critical therapist-self-disclosure was in creating a more relaxed, open, and connected environment. The following excerpts provide examples of this point: Yeah, when he’s talking, you know, I know it just ain’t about me. You know what I mean? We’re talking too—we’re bonding, man. You know what I mean? We’re getting to know each other. It’s not just me—he getting to know me. I’m getting to know him. And that helps out a lot, too, you know. I don’t think I could just lie there or sit there and just talk away. If I don’t know anything about you, I’m not gonna tell you my whole life’s story. (Participant 4). Ya’ll make people feel comfortable. And that right there is what makes people open up. Like you said, too, by [my therapist] telling me about his family that helped me out, too. (Participant 3). Yeah, I mean he made me feel like I knew him, you know [through disclosure]. And that’s what helped me a lot— helped me out a lot, too, just by him being my friend more than being—I mean being my friend like that but he kept it to a professional, you know. (Participant 7). Theme II: Modeling—‘‘So that makes it easy.’’ Several of the participants explained how their therapists’ disclosure made them feel more comfortable with their own disclosures and served as a model of how to open up. This theme appeared more often with the participants who were working with male therapists. The following participant highlights this point: He shares his life experiences with me too. He talks about his family. He talks about his kids, about how he’s got one on the way, stuff like that. He showed me pictures of the sonogram or whatever, where they take pictures of the baby, and that’s personal. That’s personal stuff, and so that in exchange just loosened me up, and I started talking about my personal life. So that makes it easy. (Participant 5). The counselor got a good personality and he opened up, too, about his life- so that helped. (Participant 8). Some participants perceived their therapists as taking a certain risk in opening up, which then helped them feel more comfortable in taking their own disclosure risks:
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So, you know, because I, personally I don’t think that very many people do that [disclose]. I mean I haven’t really been to things like this, but if I was in his shoes, I don’t know if I would do that, but he does and he feels comfortable with it. So if he feels comfortable doing that well then I feel like I should feel comfortable enough to open up to him… (Participant 10). Theme III: Lessening the Hierarchy—‘‘We are both human beings.’’ This theme addressed an important dynamic that emerged across several of the interviews. Therapist disclosure seemed to humanize the therapist, thus leveling the hierarchy and facilitating a more egalitarian relationship. This was especially important to the following participant who was accustomed to being in a position of power prior to his incarceration: And he’s a counselor. He’s got a degree. And he’s having problems and issues. It made me feel at that level with him because before I’d be like down here and I used to see other people up here. Especially when I got out of the game, because when I got out of the game, I was up here. (Participant 2). Several participants also used similar wording that appears in the following excerpt in describing this lessening of hierarchy through the use of TSD: The counselor ain’t way up here and I’m way down here. We’re both the same- we’re both human beings. (Participant 1). Theme IV: Normalization—‘‘I wasn’t the only one.’’ TSD also served the purpose of normalizing client struggles and softening feelings of shame: To me, I mean, people—I don’t know, it’s just people that got good jobs and stuff like that, they seem to be a little better than a Mexican working his butt off, but to me it was just like he was just normal. I mean he was good, he was good people. He told me about his life. He’s got struggles, too, like all of us. That made me feel good. That I could open up to him and to let him know about my life. (Participant 9). And he told me a lot of things a lot of other people won’t. That’s how I felt. Personal stuff. He also endured some of his problems in life. So it made me feel like I wasn’t the only one. He was—‘‘Even though I have a degree and I have skills—I have the skills to talk to other people; that doesn’t mean I don’t have problems.’’ And so he’d always also talk about his family. So it made me feel comfortable. (Participant 6). It’s crazy because, I mean, [therapist’s name] is good people; I can’t see him getting a divorce or anything
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like that. So, I mean, it showed me that he’s good people, so I mean I can be good people. (Participant 7). All 10 of the participants described the importance of TSD in making therapy a more comfortable place to disclose. Participants explained that their therapists discussed issues related to past and current struggles, in addition to more casual personal topics (e.g., number of children, pets, etc.). Participants also discussed the importance of trust, advice, listening, care, and therapist personality characteristics (e.g. friendliness, good character) in helping to foster the therapeutic alliance. In sum and consistent with a phenomenological approach (Colaizzi 1978), the following sentence is intended to capture the essence of participant experience related to the TSD phenomenon: TSD humanized both participants and their therapists, creating a more collaborative therapeutic alliance that allowed for greater comfort in the client’s own disclosures and the normalization of client experience.
Discussion The findings of this study lend additional credence to Jourard’s (1968) statement, ‘‘to a shocking extent… real self-disclosure begets real self-disclosure’’ (p. 64). These results also lend support to the theorizing of leading scholars in the disclosure and multicultural counseling literature. Sue and Sue (1999), for example, explain, ‘‘… a culturally different client may not open up (self-disclose) until you, the helping professional, self-disclose first’’ (p. 93). In discussing how to engage Mexican–American men in therapy, Molina and Franco (1986) state ‘‘… it might be that counselors need to self-disclose to the Mexican– American man to get the client to reciprocate’’ (p. 161). Given the results of this study and the current literature, TSD might be viewed as one of the critical events in crosscultural mandated care that establishes and strengthens the therapeutic alliance.
Clinical Implications Learning when and how to self-disclose can also be viewed as serving one of the goals of becoming a culturally competent therapist: developing a helping style that is appropriate for the population served (Sue and Sue 1999). The following section presents principles for using TSD in a culturally appropriate manner, extrapolated from the results of this study. Given the potential benefits and risks of TSD, it is recommended that these principles be used in conjunction with those presented by Knox and Hill (2003);
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Denney et al. (2008); Zur (2009); and Roberts (2005) and not be generalized without caution. These principles likely have relevance with other marginalized populations (e.g., disabled, poor) and with Latino populations more generally. Be Authentic Instead of viewing TSD as an intervention or technique, it should be viewed as an expression of authenticity and genuineness. This is consistent with the work of Fife et al. (2013) and their emphasis on the therapist’s way of being as the foundation for effective clinical practice. One of the reasons that TSD seemed to have a positive impact on the alliance was due, in part, to the participants perceiving the disclosures as a natural part of connecting, as opposed to an ‘‘intervention’’ that might be experienced as scripted or forced. This point is also consistent with Latino values that emphasize equality, dignity, mutuality, reciprocity, and respect (Falicov 2000). A lack of pretense in the use of TSD is likely critical to its effective use. Maintaining authenticity and openness, however, can be challenging in mandated criminal justice treatment settings where clients might not be forthright with certain problematic behaviors (e.g., substance use), a percentage of clients (although small in our experience) have antisocial personality characteristics and might attempt to take advantage or manipulate therapist openness, and where its not uncommon for clients to violate probation requirements and be reincarcerated, even after perceived progress in therapy. While some of these risks are present in any treatment setting (e.g., a client might manipulate a therapist to gain some advantage in a divorce hearing), therapist awareness and use of self within mandated criminal justice settings may require an additional focus in order for therapists to maintain an authentic stance and not retreat to a more ‘‘protected’’ emotional distance, absent of appropriate selfdisclosures. Be Collaborative TSD should be used to soften the client-therapist power differential and create a more collaborative alliance. The need for therapists to actively create a more collaborative alliance may be particularly critical in treatment contexts where power differences are accentuated even beyond the norm. In this case, the fact that participants were mandated to attend treatment and were working with members of the dominant group (i.e., Anglo Americans, educated, middleclass) may have made TSD even more critical to lessening the hierarchy and strengthening the alliance. Respect for hierarchy in Latino culture may have further added to this power difference (Bermu´dez et al. 2010). Nonetheless, a skilled therapist will be able to balance their hierarchical
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position with personalismo traits that soften the power imbalance to create a bi-directional open stance of respect. Therapists in mandated treatment contexts, furthermore, often serve dual roles as helpers and, at times, enforcers (e.g., having to inform a probation officer if a client missed an appointment) (Skeem et al. 2007). This dual-role nature of mandated care further adds to the importance of therapists actively tending to the hierarchy within these settings. This emphasis on collaboration is consistent with several culturally sensitive approaches to treatment, including Relational-Cultural Therapy, which works to engender mutuality, authenticity, and mutual empowerment (Sparks 2009), feminist family therapy (Roberts 2005), and the bidirectional nature of non-colonizing practices (McDowell and Hernandez 2010). As one participant explained, ‘‘I thought that my experience of counseling in prison was going to be like my present counseling experience… more people just pushing you down.’’ The likely expectation for many participants was that therapy would be one more oppressive experience of social control. TSD, however, seemed to help alter these perceptions and created an empowering context for client growth. Model Through TSD Many men view personal disclosures as a sign of weakness. Others simply may not have the experience or have had a model for how to disclose (Wexler 2009). A context, such as therapy, that is predicated on personal disclosures can therefore feel intimidating and awkward for many. This is especially relevant given that Mexican–American males might have a tendency to internalize dominant social norms that equate certain levels of self-disclosure as a feminine act of weakness. During TSD, then, the therapist provides a model for how to disclose, thereby providing an example of how clients can move from negative aspects of machismo (e.g., being emotionally restrictive) to more positive conceptions (e.g., being connected and more open) (Bitar et al. 2008; Hernandez and Curiel 2012). Normalize Through TSD Participants in this study also emphasized how TSD helped them feel more comfortable about their own problems. This is consistent with Wexler’s (2009) assumption that ‘‘therapists create an atmosphere of increased trust and intimacy by acknowledging that some of the same struggles and conflicts have taken place in their own lives and in their own relationships’’ (p. 74). The process of normalizing client struggles through TSD may also foster the experience of client self-cohesion—where people experience greater internal emotional integration through the connection to another person with a shared experience (Wexler,
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2009). It is also important to note, however, normalizing client’s struggles through TSD can risk minimizing the client’s unique experience and should be used with sensitivity (Roberts, 2005). Remain in the Moment and Client-Focused Participants highlighted a range of therapist disclosures that proved helpful, including more casual disclosures at the beginning of sessions (e.g., ‘‘My wife and I went to a concert this weekend and had a great time.’’) to more personal disclosures (e.g., ‘‘I too have struggled with depression and know how desperate life can feel.’’). The common denominator across therapist disclosure types was that they were all of a personal nature and fit the needs of the client in the moment. The disclosures also tended to be brief, with the therapist returning the focus back to the client in a timely manner. Training Implications Given the growing body of literature describing the benefits of TSD on the treatment process, there is also a growing rationale for integrating this skill into MFT training and supervision in a systematic manner. TSD can be included across several content areas, including the study of common factors and the therapeutic alliance, culturally competent treatment, and in discussions of the therapist’s use of self in treatment. The effective use of TSD is a high level clinical skill in many ways, requiring significant selfknowledge, intuition, and, at times, vulnerability. This skill likely does not come naturally, even for therapists who are actively engaged in personal counseling and ongoing supervision. Trainees, therefore, need specific guidelines and supervision on the appropriate use of TSD and the use of self (Cheon and Murphy 2007; Roberts 2005).
Limitations and Future Research There are several limitations that need to be acknowledged in relation to this study. First, given the qualitative nature of this study and sample size, the results of this study should be applied to other populations with caution. Second, while participants were informed that their interview responses would remain anonymous, there may have still been a tendency not to disclose information that may have been viewed as critical of the therapist, TSD, or treatment process, thus potentially affecting the credibility of the findings. Future research might focus on the impact of TSD in other cross-cultural settings. For example, how do issues related to the intersection of therapist and client age,
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ethnicity, race, gender, and socioeconomic status shape the experience and impact of TSD? For example, how does the client experience of TSD differ when working with a female therapist instead of a male clinician? This study touched on this question but this dynamic was not explored in-depth to draw any meaningful conclusions. Researchers might also explore whether the use of this skill is even more critical in building the therapeutic alliance when there is a greater therapist-client power differential, such as within the context of court-mandated treatment, and interview therapists about their experience of TSD in working with mandated populations. There is also a need to explore how the experience of TSD might differ when used across modalities (e.g., individual, couple, family). Finally, researchers might explore how TSD training can be integrated into MFT programs in an ethical manner.
Summary The results of this study suggest that TSD is a critical component in facilitating client self-disclosure and establishing the therapeutic alliance within cross-cultural counseling environments with mandated clients. TSD also has several other benefits (e.g., normalizing client problems) and is proposed as a key component of culturally sensitive treatment. Future research might examine the impact of TSD on therapy outcomes more directly and establish evidenced-based strategies to train interns in the effective use of this skill.
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