Psychological inflexibility prospectively predicts client non-disclosure in outpatient psychotherapy

Highlights

• Psychological inflexibility longitudinally predicts client non-disclosure.

• Psychological inflexibility more robustly predicted non-disclosure than shame.

• Forty-eight percent of outpatient clients reported non-disclosure in therapy.

Abstract

Psychological Inflexibility (PI) is reliably associated with adverse psychological outcomes but little research has explored how PI may affect therapeutic process in psychotherapy. The current study examined the longitudinal influence of PI measured at pre-treatment on likelihood of client non-disclosure of treatment-relevant information at 15-week follow-up and evaluated PI against an empirically supported predictor of non-disclosure, internalized shame. Sixty clients in outpatient psychotherapy at an evidence-based treatment center (M_age = 35.38; 62% female) completed self-report measures of PI and internalized shame at initiation of therapy, 3- and 9-week follow-up and a dichotomous assessment of non-disclosure at 15-week follow-up. We hypothesized that pre-treatment PI and internalized shame would uniquely and positively predict likelihood of non-disclosure at 15-week follow-up. Results indicated that, when tested simultaneously, only pre-treatment PI predicted likelihood of non-disclosure at follow-up (OR = 2.96). This is the first study to test the influence of PI on client non-disclosure and implicates PI as a relevant pre-treatment individual difference variable for identifying clients at higher risk for non-disclosure in psychotherapy.

Introduction

Client disclosure of distressing thoughts, feelings, and experiences is an integral part of psychotherapy. Therapists depend on clients to accurately and candidly disclose relevant material to develop their case formulation and direct therapy (Blanchard & Farber, 2016). In return, many clients turn to their therapists for support in facing deeply personal and distressing experiences they may have kept private for much of their lives. Indeed, disclosure of secrets in psychotherapy has been associated with affirmative therapy experiences for clients including strengthened therapeutic alliance (Hall & Farber, 2001), positive in-session emotional experiences such as authenticity, relief, and connection with one's therapist (Farber et al., 2006), and enhanced perceptions of session quality (Marks et al., 2019).

Despite the potential benefits of disclosure, a significant portion of clients in outpatient psychotherapy endorse non-disclosure, defined here as the intentional concealment or omission of information relevant to therapy, including life experiences, personal information, and relevant psychological experiences (adapted from Baumann & Hill, 2016). Research indicates that approximately 28–53% of clients in outpatient settings report having intentionally kept a secret from their therapist.¹ Commonly withheld topics include relationships and intimacy, distressing internal experiences or mental health symptoms, and stigmatized behaviors and experiences including sexual behavior, substance use, insecurities, past abuse, and non-suicidal self-injury and suicidal thoughts (e.g., Baumann & Hill, 2016; Hill et al., 1993; Love & Farber, 2019; Marks et al., 2019; Pope & Tabachnick, 1994).

Concealment of this type of therapeutically rich material may impede therapeutic progress due to incomplete understanding on the part of the therapist or missed opportunities for intervention. Approximately one-third of individuals who withheld relevant information from their therapist in a large online sample reported they believed non-disclosure hurt their therapeutic progress while only 4% of the sample believed non-disclosure helped their progress (Love & Farber, 2019). Similarly, client non-disclosure of salient personal information, such as important aspects of one's cultural identity and distressing psychological symptoms, has been prospectively associated with reduced symptom improvement at termination (Drinane et al., 2018; Hook & Andrews, 2005). Identifying factors that predict non-disclosure may inform how therapists can compassionately and effectively promote disclosure to inform treatment planning and intervention among clients who have difficulty sharing personal or upsetting information.

Non-disclosure in therapy has been associated with trait self-concealment (SC; Larson et al., 2015). SC is characterized as the broad predisposition to consciously hide intimate and negatively-valanced personal information (Love & Farber, 2019) and has been conceptualized as a form of psychological inflexibility (PI; Masuda et al., 2017). Described in the context of Acceptance and Commitment Therapy (Hayes et al., 2012), PI refers to a rigid pattern of behavioral responding that prioritizes the control of psychological reactions over the pursuit of one's chosen values (Bond et al., 2011). Applied to SC, it is theorized that some people endeavor to avoid sharing potentially embarrassing personal information, at least partially because disclosure often evokes aversive affect (e.g., Farber et al., 2006). PI significantly correlates with trait-level SC (r = 0.54, p < .01; Masuda et al., 2017). Qualitative research on barriers to in-session disclosure also implicate PI, with one study reporting 80% of clients who withheld secrets from their therapists did so to avoid discomfort (Baumann & Hill, 2016). However, no study to date has examined the influence of PI on non-disclosure in outpatient therapy.

In addition to PI, shame has been identified a key contributor to client non-disclosure in therapy (e.g., Hill et al., 1993; Hook & Andrews, 2005; Love & Farber, 2019; Macdonald & Morley, 2001; Swan & Andrews, 2003). Large scale studies have found that 64–75% of clients in outpatient therapy endorse shame as the primary reason for withholding secrets (Baumann & Hill, 2016; Love & Farber, 2019). Similarly, shame-proneness (i.e. the dispositional tendency to experience shame) predicted fewer retrospective reports of disclosure among clients treated for eating disorders (Swan & Andrews, 2003) and depression (Hook & Andrews, 2005), as well as lower self-reported willingness to disclose a potentially shameful secret to a counselor (DeLong & Kahn, 2014). This pattern of findings suggests that withholding secrets in therapy may be better understood as a behavior used to avoid shame specifically, rather than indicative of the broader pattern of affective avoidance in PI.

The current study extends the present literature through two primary aims. First, we empirically tested the prospective relation between PI at baseline and clients’ likelihood of endorsing non-disclosure at 15-week follow-up. To our knowledge, this is the first study to examine this association. Second, we tested whether internalized shame or PI was a stronger predictor of non-disclosure at follow-up. We did not make a priori hypotheses about the relative strength of PI and shame variables on non-disclosure as no longitudinal studies were available for comparison. However, we did predict inverse associations between PI and shame and non-disclosure.

As exploratory aims, we examined whether changes in PI and shame over the course of treatment predicted non-disclosure based on the idea that improvements in these variables may index meaningful shifts in the therapeutic alliance and thereby facilitate increased disclosure. Additionally, we assessed ten reasons for client non-disclosure identified in prior research (Hook & Andrews, 2005) to contextualize findings from this sample in the broader literature.