Supporting limits to disclosure
• Maximising verbal production can be unhelpful
• Support the person to take up agency in limiting disclosure

Traditionally clinicians have advocated maximising verbal disclosure via the use of empathy, for instance Shea (1998). However, management of verbal disclosure can be much more sophisticated than this. Talking about traumatic events can re-traumatise. One of the aspects of injury experienced by people who have survived abuse is a transgression of personal boundaries by someone in a position of trust. This can be repeated in the context of a conversation with a mental health clinician and is the origin of the play on words of 'therapist' as 'the rapist'. A common strategy people use to manage distressing memories is to put them out of their minds and so maximizing verbal disclosure can undermine this strategy and expose them to further distress. From the expert position monitoring comfort levels can be done whereby the clinician can monitor distress and manage it, perhaps suggesting the conversation be deferred.

Alternatively the client can be offered the opportunity to self monitor:

“I am going to ask a lot of questions. Some of these may be difficult to answer. Nobody can make you talk. If there is something you don’t want to talk about just let me know.”

This can be helpful in developing rapport, but depends on the person to identify the concern and feel able to state it. We all exercise agency and have considerable personal knowledge an experience which we exercise on a daily basis in deciding how much to disclose to whom. Engaging in a mental health assessment requires different decision making processes from those required in everyday life and few people have much experience of them. This lack of experience, the vulnerable state of the person at the time of seeking help from us and the power differential all contribute to the risk that the person may push past their comfort zone and feel exposed in a way they find diminishing.

It is part of our responsibility, in holding the power we hold in the clinical interaction to support the person in taking up a role in negotiating their boundaries. Thus identifying a sense of unease a person is experiencing around limits to disclosure becomes a prioritized activity. Rather than seeking to dissolve, or support the person to push through, the sense of unease, it becomes important to let people know we value hearing about the hesitations or unease they experience. We can support this communication by exploring how unease is likely to come into awareness and what we can do to support them to communicate it. By making explicit what we are noticing in the present moment we can support that process. For instance:

“I notice a change in your expression and the amount you are talking in this conversation. I’m wondering if you are experiencing a level of discomfort and how it is likely to be for you if we keep talking about this.”

Identification of unease around speaking about an area can be the beginning, rather than the end of the conversation. The unease identified needs to be valued, clarified and understood:

“I find it helpful for you to let me know what areas we need to take special care around. I would like this conversation to be helpful rather than just causing necessary distress. I am getting the idea, from what I have noticed and what you have told me, that talking about the illness your mother went through and her death bring up strong feelings for you. Is that right?”

There are a range of possibilities as to how it might be helpful to proceed and these can be negotiated with the person. They may be put aside in the short term, discussion as to how the person usually manages these feelings and how that works for them may be helpful, negotiation preparation for having the conversation or exploration around how the person is making the decision:

Some people have found it easier when tough questions come up to leave the room and have a break and come back. On returning:

"I’ve noticed that you chose to take a break. Is there anything you can let us know which might be helpful in understanding Johnny in what was difficult about the conversation when you chose to leave?"