OPED Blog (Optimizing Psychology for Eating Disorders) By Sandra Wartski, Psy.D., CEDS
Bananas, Boxers and Being Bare Naked: Inadvertent Advancing of Therapist Authenticity
By Sandra Wartski, Psy.D., CEDS
Psychotherapy is generally assumed to be based on an honest exchange of information and a focus on mutually developed goals. Our work is often geared towards exploring and processing feelings, sensations, thoughts, behaviors in open, authentic ways. We hold a foundational belief that the work is more effective when clients remain truthful in their disclosures. In the domain of Eating Disorders (EDs), this focus is sometimes made even more complex due to the fact that the often long-standing ED has distorted and twisted various parts of an individual’s life experience amidst a culture that also includes much “fake news” about bodies and food.
Interestingly, research shows that dishonesty exists more globally than previously realized (Ariely, 2013; DePaulo, 2018) and also exists in the context of therapy at a much more frequent level than is often assumed (Farber, Blanchard & Love, 2019; Kottler, 2010). Despite therapists being well-versed in understanding human behavior and trained in orienting carefully to non-verbal cues, they can still be blindsided and baffled when deception or intentional distortion present in a treatment relationship.
Therapist Disclosure and Authenticity
But the onus of the honesty does not only apply to the client. Clinicians, too, are expected to be earnest and authentic in their therapeutic relationships. Most therapists would claim they are indeed truthful in their verbalizations, though it turns out that therapists, too, have common topics about which they sometimes lie (Jackson, Crumb & Farber, 2018). A clinician being open within a treatment relationship is inherently different from other interpersonal connections and is not expected to involve the same type of exchanges that might occur with a friend or family member, though the general expectation of honesty still exists.
One aspect of therapist honesty involves direct therapist self-disclosure. While generally discouraged in the psychotherapy of Freud’s era, most more modern therapies do allow and even encourage some degree of self-disclosure which is believed to potentially assist therapeutic effectiveness. How much a therapist reveals and shares depends on training, orientation, and experience, but most clinicians do titrate some personal information to be helpful to clients. In fact, there is research to show that clients find therapists more likeable and sincerer if they engage in some self-disclosure periodically (Zur, 2007), and many clients report feeling validated and more normal to learn that therapists too are imperfect or need to sometimes use skills for coping. Clients clearly aren’t looking for a therapist to use their therapy hour to talk about their own struggles, but a therapist sharing authentically about having been late due to bad planning, being tired because of a stressful event, or indeed potentially feeling frustrated about something being discussed in session can make a positive impact.
There are naturally many nuances to direct self-disclosure that must be considered in order to maximize benefit to the client, including level of detail, timing, and purpose (Kenosi & Cartwright, 2019); however, the therapeutic field does seem to be moving towards increased use of disclosure in thoughtful, intentional ways. There are also a wide variety of therapeutic application branches being utilized for further enhancement, such as clinicians trained in Somatic Experiencing or Sensorimotor Psychotherapy incorporating mindfulness of their own somatic sensations while with a client to further inform the work. Degrees of self-disclosure continue to be a somewhat controversial area, but there is agreement that most therapists are not properly trained in this arena (Magaldi & Trub, 2018) and increasing awareness that technological developments have changed the nature of therapist transparency as well (Somers, Pomerantz, Meeks & Pawlow, 2013; Zur, Williams, Lehavot, & Knapp, 2009).
Sometimes, however, there are indirect therapist disclosures that are unintended but can still end up becoming a source of potential benefit. This is a realm of authenticity that goes beyond the words, beyond the body language and even beyond the mindful processing of somatic sensations. There are the small details that say something about us, from office decorations to shoes, but occasionally there are much more significant serendipitous events that occur within and outside of our offices which allow opportunities for meaningful processing and progress.
Some of the work with clients with EDs, particularly early on, is often centered around food and eating. While it is usually the nutritionist on the team who delves into this area in a much more in-depth way, food and eating are naturally being explored by therapists as well. While residential facilities, partial programs or experiential groups naturally have opportunities for clients to sometimes eat with clinical staff, outpatient therapists don’t have this opportunity quite so often.
Keeping a banana (or a granola bar or seasonal candy) on my desk (or discarded packaging in my trashcan or post-lunch smells in the room) has become one way I have become more authentic. There was a time in the past when I would carefully put away my snacks in a drawer for fear of triggering a client or over-disclosing something personal to them, but then there was that time when I left by mistake (or at least, unconsciously) a banana on my desk after lunch which led to a rich and interesting discussion with a client who was struggling to allow more variety into her limited intake. She had spent the prior session lamenting about various foods that are “bad,” including bananas, and felt stuck but comfortable in her limited eating. Bananas – like many unsafe foods for individuals with EDs – are an example of a food which have, unfortunately, gotten a bad rap because of various mythical rumors such as them being too calorie-dense, having too much sugar, or simply too starchy. (I happen to really like bananas, not only for the taste but also especially appreciating their portability and room temperature accessibility.) When I saw her raised eyebrows as she glanced at my banana in the first few moments of our early afternoon session, I leapt on the opportunity to process her seeing this fruit there, to understand the impact of her learning that I do indeed eat bananas and to us being able to approach “forbidden” foods from a new angle.
There are many challenge foods that one might allow to remain exposed in the therapy room, not necessarily with targeted intention for certain clients but because therapists can role-model natural, normative eating of all type of foods and drink, all ones hopefully in non-diet arena. I don’t always leave out a food or drink item, and not all clients care or notice, but a furtive glance or a momentary hesitation often is the signal of it being a potentially informative area to at least explore briefly. This sort of natural “disclosure” can be a way to share benign-but-maybe-meaningful personal information which could assist in some steps forward.
Baring Belly Rolls and Boxers
Most of us are aware of how clients with EDs scrutinize bodies – including their treatment team’s bodies – as they delve into their own work about their own bodies. Some individuals are less concerned about others’ shape and size, yet many are very vigilant. Many clients report having thoughts about various team members’ bodies in both upward or downward comparisons. Clinicians who experience thin privilege in their body often have interesting conversations with clients about weight gain and about allowing their setpoint weight to unfold, with some of their clients struggling, for instance, to accept that one of their team members may be smaller in size and question whether this is truly their setpoint weight. On the other hand, clinicians in larger size bodies sometimes experience clients who are nervous that the clinician is biased towards pushing for larger size bodies or even sometimes worry that there is competition between clinician and client. Various suppositions, projections and assumptions can present, and all of this naturally warrants and deserves open communication whenever possible to allow for more learning and growth.
There are, however, other unintended ways that sometimes a clinician’s body ends up serving as a source of psychoeducation. There may be minor incidents, such as when a therapist burps or her stomach gurgles, worthy of momentary attention and allowance of acknowledgement of normal body function. There may also be other more significant events, such as when a therapist has a physical injury or is pregnant, which may merit more processing in relation to physical changes. And then there are moments related to normal body functionality to be potentially shared by a therapist, such as boldly accepting one’s own belly rolls. Clients often report that they are distressed by belly rolls when they sit down and often use all kinds of tactics, ranging from baggy clothes to pillows, to cover the natural folding of the skin. There can be psychoeducation around this sort of topic (such as explaining how when humans are seated, the torso shortens and the midsection is compressed), but sometimes straight-forward role modeling of acceptance can be even more powerful.
I recently had another unintended authenticity moment which involved a client seeing my boxers under my skirt – which turned into a pivotal moment in a session. Lest this sound somewhat inappropriate, I will explain. This particular client had spent much of her life engaged in disordered eating and living in a malnourished body but had over the recent years made progress in overall eating, well-being and functioning. She came in to one particular session, however, suddenly appearing to have regressed to some of her old thinking patterns and talking about missing the ED. After a bit of explorative detective work together, we were finally able to discover that she had been triggered by chafing of her thighs when she wore a dress at work, “something that hadn’t ever happened when I was thin,” she explained. She had then assumed that this must mean she had gained too much weight and needed to lose weight again because she no longer had that infamous “thigh gap” currently touted in various social media circles as ideal.
We went on to discuss how most any woman running around in a skirt or dress for long periods of time experiences repetitive friction that causes painful irritation on the inner thighs. We ended up having a fairly frank discussion about different kinds of underwear women use to prevent chafing, such as women’s boxer shorts. She had never heard of this, found this difficult to believe that “normal women” really would wear them and assumed this was a signal of her needing to be accommodating for her body having gotten out of control. Given that I happened to be wearing a skirt that day, I made a sudden decision to hike up my skirt slightly above my knee to show her my long boxers. We laughed as I explained how I would rather do something rather unusual to provide some validation about a normative female experience than to have rubbing thighs potentially send her spiraling back into eating disorder behaviors. This is not an intervention I’ve ever done before with a client nor one that I am necessarily advocating, but I share it as a way in which a moment of thinking outside of the box allowed one client to step back and regroup in a positive way.
Being Bare Naked
Sometimes the form of authenticity comes in much more exposed and humbling ways. There can be silly moments of therapist authenticity – like the time when I locked myself in the waiting room for a later evening appointment and had to pull up a chair and not-so-delicately scoot my way through the small, receptionist sliding-glass window in order to get into the main offices; this was likely an awkward optic but did, I think, help to make me more human. Unexpected events like attending the same party as a client also shift the boundaries around privacy and later leads some additional conversation around social events with clients. When explaining more personal events, like a black eye (due to getting hit by a softball) or a sudden cancelation of an appointment (due to a death in the family), a therapist may also end up sharing personal information which allows opportunity for more genuine connection.
Being seen naked had not been the type of authentic exposure I had ever anticipated as a therapist, yet I have now amassed 3 occasions when I have encountered clients or parents of clients in the women’s locker room at the gym when I have been in various stages of undress (but closer to naked than dressed). On the occasions when I am able to go to the gym before work, I am often rushing to take my shower, resulting in my generally choosing expediency over careful cover-up. Those few times of encountering clients naturally led to tongue-tied moments. I quickly wondered if I should acknowledge the encounter by saying something clever like “This is awkward!” or perhaps simpler like “See you tomorrow!” I ended up blurting out a quick “Hi” in all 3 instances and moved along quickly. Only 1 of the 3 sightings episodes has resulted in any significant processing back in the office. As might be expected, with the one client whom there did seem to be appropriate need to more acknowledge the event in some depth, we were able to delve into a different kind of discussion about the varied, functional, and perfectly imperfect body shapes seen in most locker rooms. Bare bodies also allow highlighting of how we all have human bodies that really are much more similar than different.
Embracing moments where I can be more authentic and exposed with clients not only provides excellent opportunities for bidirectional growth but also reminds me of how we clinicians expect authenticity from our clients. I am continually asking my clients to be honest, brave and bold by doing uncomfortable things, ranging from eating food they have avoided for years to facing a scary emotion to finally having a long-overdue conversation. Making the most of day-to-day life experiences can end up spontaneously providing another way to work on increasing authenticity in more subtle, indirect ways of interaction that might nonetheless be appreciably meaningful for our clients.
Ariely, D. (2013). The (Honest) Truth About Dishonesty: How We Lie to Everyone – Especially Ourselves. New York: HarperCollins.
Blanchard, M. & Farber, B. (2016). Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship. Counselling Psychology Quarterly, 29:1, 90-112.
DePaulo, B. (2018). The Psychology of Lying and Detecting Lies. CreateSpace Independent Publishing Platform: Scotts Valley, CA.
Kenosi, L., & Cartwright, D. (2019). Clients’ experience of therapist-disclosure: Helpful and hindering factors and conditions. Indo-Pacific Journal of Phenomenology, 18(2), 51-62.
Kottler, J. (2010). The Assassin and the Therapist: An Exploration of Truth in Psychotherapy and in Life. London: Routledge.
Magaldi, D. & Trub, L. (2018). (What) do you believe?: Therapist spiritual/religious/non-religious self-disclosure. Psychotherapy Research, 28:3, 484-498.
Somers, A., Pomerantz, A., Meeks, T. & Pawlow, L. (2013). Should psychotherapists disclose their own psychological problems? Counselling and Psychotherapy Research, 14, 4, 249-255.
Zur, O. (2007). Boundaries in psychotherapy: Ethical and clinical explorations. Washington, DC: American Psychological Association.
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), 22-30.
Sandra Wartski, Psy.D. completed her undergraduate degree at the University of Rochester and received her Doctorate in Psychology from Widener University. After interning at Media Child Guidance Clinic and The Renfrew Center, Dr. Wartski moved to Raleigh and joined Silber Psychological Services in 1993. As a licensed psychologist in North Carolina, Dr. Wartski has been conducting individual, family and group therapy, as well as psychoeducational evaluations, with special interests in mood disorders, anxiety, eating disorders, relationship issues and crisis intervention. She is also a Certified Eating Disorder Specialist (CEDS). One of her favorite parts of being a therapist is the opportunity to build relationships allowing room for positive growth and change. Dr. Wartski also enjoys providing presentations and writing articles on a variety of mental health topics for both community groups and other professionals. Her primary professional volunteer activities have related to disaster mental health responding, serving as Disaster Response Network Coordinator for North Carolina and as Mental Health Lead at the Triangle Red Cross; more recently, she has served as President of the North Carolina Psychological Association (NCPA) and is now serving as President of the North Carolina Psychological Foundation. Dr. Wartski has been honored to have received the North Carolina Psychological Foundation President’s Award, The Exceptional Volunteer Service Award from the American Red Cross and the “Heroes in the Fight” Award from the Coalition for Persons Disabled by Mental Illness.
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