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Abstract

Under-reporting of concussions is a well-known public health problem. Unfortunately, concussion researchers and practitioners do not have an explicit theoretical foundation for understanding the psychology of concussion non-disclosure. We used interdependence theory, a theory based on the structure of social relationships, to develop a social dilemma model of personal information non-disclosure and apply it to the concussion domain. Self-disclosure becomes problematic when individuals perceive a need to report their concussions but also perceive that disclosure could be detrimental in some way. Individuals who experience these disclosure dilemmas can evaluate the value of concussion self-disclosure using direct outcomes (e.g. losing scholarships, improved recovery), self-concept outcomes (e.g. viewing disclosure as “weak” or “sensible”), and social status outcomes (e.g. being perceived poorly or favorably by teammates). These immediate, personal outcomes are integrated with relationship-specific motives and ethical considerations ultimately leading to disclosure or non-disclosure. Providing an explicit theoretical basis for self-disclosure dilemmas is critical for understanding concussion non-disclosure and mitigating its corresponding harm. Our social dilemma model highlights (a) the foundational psychological basis for concussion non-disclosure, (b) possible reasons that initiatives designed to increase concussion disclosure have been ineffective, and (c) the need to consider the decision-making autonomy of concussed individuals. Although we explain our social dilemma model using concussion self-reporting, we believe that this model is applicable to any domain where individuals are reluctant to disclose personal information to others who need it.

Keywords

Concussion brain injury dilemma disclosure non-disclosure reporting athletes

Why do individuals conceal personal information that others need to know? On the surface, the answer seems obvious. Individuals withhold personal information because they believe that disclosure will do more harm than good. Yet, researchers and practitioners would benefit from a deeper examination into this issue. In the present paper, we describe the interpersonal conditions that create disclosure dilemmas. These conditions provide a theoretical foundation, rooted in interdependence theory, for understanding and managing information non-disclosure. We demonstrate the utility of this social dilemma model of personal information disclosure by applying it to concussion self-reporting.

Disclosure dilemmas

The term “self-reporting” lacks clarity. Social scientists generally refer to any information that participants provide about themselves as self-reported.¹ Accordingly, individuals are self-reporting any time they provide personal information to others. The common use of self-reporting is more limited. People use the notion of self-reporting to refer to situations where individuals disclose personal information despite the apparent costs of doing so. Consider individuals reporting their charitable donations on income tax returns. Methodologically, this type of self-disclosure is a form of self-reporting; individuals are providing personal information rather than concealing it or allowing others to disclose the information for them. However, people generally would not describe this behavior as self-reporting, because the information disclosure is expected. Individuals typically have no reason to conceal their charitable donations; they might even benefit financially from disclosing them. This stands in contrast to individuals reporting earnings that the government would not otherwise detect. Reporting earnings, unlike reporting charitable donations, can create a financial cost for self-reporters. In such cases, people more readily perceive earnings disclosure as a form of self-reporting because it occurs despite contextual factors that might inhibit it.²

The common use of “self-reporting” gravitates towards situations where individuals divulge information even when circumstances might discourage self-disclosure. For clarity, we use the term “disclosure dilemma” to describe this particular type of social dilemma. Disclosure dilemmas have two basic principles. First, disclosure dilemmas always have a potential discloser and at least one potential recipient. The potential discloser is the person who has important personal information (e.g. a criminal could self-report his or her crime). In some cases, there are others who are aware of the personal information and would also be potential disclosers (e.g. a friend who is aware of the crime). Nevertheless, the person withholding the self-relevant information is the potential discloser in the context of a disclosure dilemma. Potential recipients are persons who have some justifiable need to obtain potential disclosers’ personal information. There can be multiple people who serve as potential recipients. For instance, an embezzler could self-disclose the crime to police or to the organization where the embezzlement occurred. Second, disclosure dilemmas occur when potential disclosers have some motivation to conceal personal information despite potential recipients’ legitimate need for that information. For instance, HIV-positive individuals sometimes experience a tension between a perceived responsibility to disclose their HIV-positive status and the perceived costs associated with doing so.³

Disclosure dilemmas can be understood using the lens of interdependence theory.^4,5 Interdependence theory is an adaptation of social exchange approaches to interpersonal relationships;⁶ it follows the basic social exchange premise that individuals attempt to maximize rewards and minimize costs in their relationships. However, interdependence theory places a particular emphasis on understanding how individuals coordinate their behavior with others’ behavior to achieve personal and interpersonal goals over time.

Consider, for example, the prisoner’s dilemma game. In this game, two participants receive better outcomes for mutual cooperation than for mutual non-cooperation, but each participant achieves the best individual outcome by betraying the other participants’ cooperative behavior. Individuals think, feel, and behave differently in the context of the prisoner’s dilemma game than they do in other situational contexts. The prisoner’s dilemma game breeds suspicion because the situational context causes partners to wonder whether they can really trust each other. In other situations, individuals might clearly benefit from mutually cooperative behavior, such as romantic partners who would prefer to dine together than dine apart. By describing how the cost-benefit structure influences relationships, interdependence theory ultimately “advances a taxonomic model of social situations” (Rusbult and Van Lange,⁴ p. 353). Put differently, interdependence theory describes how individuals make choices in an interdependent world and examines specifically how individual psychology and behavior tends to follow particular types of situations.

Interdependence theory is useful for understanding disclosure dilemmas because disclosure dilemmas represent a particular type of social situation. Specifically, potential disclosers recognize that others want them to disclose, but they believe that disclosure might not be in their own self-interest. In interdependence terms, potential disclosers think, or at least suspect, that they do not have aligned covariation of interest with others. This type of social dilemma requires potential disclosers to integrate their personal concerns about disclosure with a broader motivation to influence others and with ethical considerations. The interpersonal structure of disclosure dilemmas sets the stage for the motivations, cognitions, and behavior of individuals who are conflicted about disclosing personal information.

Concussions and disclosure dilemmas

We can demonstrate the utility of considering personal information non-disclosure as a social dilemma by examining concussions. Concussion treatment depends upon honest self-disclosure. Medical professionals need accurate concussion symptom reporting to assess and manage recovery.⁷ Concussion self-disclosure is also a critical component of creating policy that might reduce the frequency of concussions.⁸ Organizations can more successfully mitigate concussions with complete and accurate data about their occurrence. Yet, research demonstrates that individuals will knowingly conceal concussions. Concussion non-disclosure can occur in different ways. Individuals might conceal the entirety of their concussions,⁹ downplay the severity of concussion symptoms,¹⁰ or delay concussion self-disclosure.¹¹ Thankfully, researchers and practitioners have recognized the importance of concussion self-disclosure and have provided dozens of published studies devoted specifically to this topic.^12,13

Despite this attention, research has not led to an explicit model regarding the nature of disclosure dilemmas in concussion reporting. This likely causes researchers and practitioners to neglect or underappreciate important aspects of concussion disclosure decision making and behavior. To illustrate, individuals should be motivated to self-disclose concussions to receive the benefits that accompany treatment designed by a medical professional. In some cases, the desire for proper medical treatment will align with other personal interests, such as avoiding poor performance that might occur during recovery or gaining social approval for seeking treatment. Why then, would individuals decide to conceal their concussions and forgo the benefits that might accompany disclosure? They do so because something about the disclosure dilemma has convinced them that they would be better off not reporting. Because concussion disclosure dilemmas are rooted in this situational context, it makes sense to examine the reasons individuals believe that concussion self-disclosure could be more punitive than rewarding, and the reasons that individuals might disclose concussions despite believing that doing so will be personally costly.

Personal outcomes

Potential disclosers can evaluate concussion self-disclosure by examining how it influences them directly, without considering how disclosure might influence others. Interdependence theory considers this immediate, hedonistic perception of the situation as the given situation.⁴ These personal outcomes that might inhibit concussion disclosure can be placed into conceptually distinct categories.

Self-disclosure might create direct, personal outcomes that do not involve the self-concept or the perceptions of other people. Athletes commonly report that they do not disclose concussions because they do not want to be taken out of a game.^14–16 It seems safe to assume that being taken out of a game is a direct personal cost because athletes do not want to lose the enjoyment of competing. Likewise, athletes and non-athletes might conceal concussions because they perceive disclosure as being financially or occupationally harmful.^17,18 Employees, for example, might conceal concussions if they believe that disclosure will result in lost earnings. Disclosure also creates emotional outcomes depending on whether self-disclosure violates or supports potential disclosers’ conceptions of their ideal selves.¹⁹ Athletes who identify with being an athlete or with being brave might perceive disclosure as violating that identification.^20–22 Disclosure also influences personal outcomes when disclosers believe that it will influence their social status;²³ concussed individuals might think that others will perceive them more negatively, or more favorably, if they self-disclose.^24–26

Relationship-specific motives

Individuals do not necessarily consider only their own needs. They recognize that their decisions influence the outcomes of other people. Thus, individuals often adjust their immediate, personal outcomes to include their motivation to influence the goals and desires of other people. In the parlance of interdependence theory, this adjustment is a transformation process where the personal outcomes associated with the given situation are interpreted in the context any number of relationships that could be influenced by the disclosure decision. The desire to influence others’ outcomes is obviously related to the self-relevant concerns that individuals might experience about social status, like believing that self-disclosure looks unfavorable to teammates. Individuals can manage their social standing by engaging in behaviors that are favorable to other people. However, relationship-specific motives can also include a more selfless desire to influence others’ outcomes, often for the better.

Clearly, individuals consider how concussion self-disclosure will influence others. Individuals sometimes express concern that self-disclosure would be costly to specific people they care about; in such cases, potential disclosers are exhibiting at least some concern for maximizing outcomes for close others. For example, athletes might believe that they would be better off disclosing, but worry that disclosure will be costly to teammates or coaches.^25,27,28 Athletes who believe that their participation is critical for team success are presumably less likely to disclose, even independent of their own personal interest in playing. In contrast, athletes are presumably more likely to disclose concussions if they believe that playing does not appreciably influence the team’s success or that the concussion has compromised their ability to play effectively and help their team. A less likely scenario involves the possibility that potential disclosers conceal concussions to create costly outcomes for specific others. Athletes could, for instance, avoid concussion disclosure because they want a bitter rival to experience defeat – a “minimize others’ outcomes” strategy.²⁹

Ethical responsibilities

Individuals are also willing to override immediate personal consequences in order to fulfill ethical obligations.³⁰ Concussed individuals might consider their perceived responsibility to support formal or informal self-reporting policies, particularly if they made a corresponding promise to support.³¹ Feelings of formal or informal obligation could increase concussed individuals’ motivation to disclose as they proceed through the transformation process of evaluating a given situation. To this end, the NCAA (i.e. the National Collegiate Athletic Association in the United States) requires student-athletes to receive mandatory concussion education and to acknowledge their responsibility to report concussions.³² Potential disclosers could believe that they have an obligation to self-disclose even when disclosure creates immediate negative outcomes for themselves and close others. In so doing, potential disclosers might consider explicitly how self-disclosure supports a policy that helps people generally, as opposed to being concerned about specific others like teammates, coaches, and family members. These ethical concerns are conceptually different than concerns about self-disclosure influencing personal outcomes or the outcomes of specific others. Instead, they represent perceived obligations possibly created by formal rules or promises. In this way, concussion self-reporting policies could increase the perceived costs of concealment and encourage disclosure even when disclosure appears otherwise detrimental.

Consider, for instance, a superb American football kicker who has minimal concussion symptom load and only a remote likelihood of receiving a successive concussion in an upcoming game. The kicker might believe that self-disclosure would be costly to self and teammates in a manner that is not commensurate with the situation, but he or she might nevertheless feel a responsibility to uphold a pledge to self-disclose. The kicker might also recognize that failing to self-disclose contributes to a slippery slope where athletes, rather than policy, determine whether they disclose concussions. This slippery slope introduces self-disclosure as a social dilemma akin to that of the tragedy of the commons.³³ Non-disclosure might benefit the self and known others, but if many people violate concussion self-disclosure responsibilities, the result will be collectively harmful. Athletes would not receive proper concussion care. Public health officials or institutional administrators might be forced to consider more drastic policy measures to manage undiagnosed concussions.

Integration

These varied influences on disclosure dilemmas are integrated into a more sophisticated cost-benefit analysis, called an effective situation in interdependence theory.^4,5 The effective situation is an amalgam of the immediate personal outcomes of the given situation, often adjusted by relationship-specific motives and ethical responsibilities. Figure 1 shows how these different facets of a disclosure dilemma can be integrated into an overall cost-benefit analysis. Figure 1 begins with the immediate, self-relevant outcomes that commonly initiate a disclosure dilemma: direct outcomes (e.g. loss of income), self-concept outcomes (e.g. perceiving disclosure as a sign of personal weakness), and social status outcomes (e.g. looking positively or negatively to teammates). These outcomes create a given situation where concussion self-disclosure can appear favorable or unfavorable. Figure 1 then shows how relationship-specific motives (e.g. improving the outcomes of close others) and ethical concerns (e.g. following a pledge) contribute to a general transformation process. This process leads to a revised appraisal, called the effective situation, that integrates immediate, personal outcomes with the need to manage broader issues with human interdependence – specifically, the fact that disclosure influences the outcomes of other people. Potential disclosers are more likely to engage in disclosure/non-disclosure behavior as the effective outcomes associated with concussion disclosure appear more rewarding than costly.

Figure 1.

A psychological model of decision making and behavior in disclosure dilemmas.

This social dilemma model of understanding concussion self-disclosure is not intended to suggest that concussed individuals are necessarily rational or deliberate when deciding whether to disclose.³⁴ Individuals can misperceive the costs and rewards associated with disclosure or non-disclosure. For instance, athletes might overestimate the benefits of playing while concussed and simultaneously underestimate the consequences of poor concussion management.³⁵ Concussed individuals will also vary in their levels of deliberation about whether they should self-disclose. Individuals might exhibit low levels of deliberation when they are not motivated to consider the matter or they do not have time to consider the matter properly.³⁶ The disclosure decision-making process can be further complicated when concussions cause executive dysfunction that disturbs effective decision-making.³⁷ The social dilemma model describes the broad structural-social factors that individuals must navigate in determining whether to disclose. Within this broad social dilemma model, individuals can certainly make decisions that are selfish or altruistic, thoughtful or thoughtless.

Implications for researchers and practitioners

Interest in concussion disclosure has gravitated towards areas where concussed individuals seem likely to experience disclosure dilemmas. Concussion disclosure researchers have focused on athletes because athletes have known reasons to inhibit concussion self-disclosure and forgo treatment.^12,13 More to the point, the NCAA and the United States Department of Defense jointly awarded several grants for research and educational initiatives devoted to concussion self-reporting. Their shared interest in encouraging concussion self-disclosure is sensible because military and athletic populations are vulnerable to concussions and both populations experience socio-cultural factors that inhibit self-disclosure.^38,39 This point can be further illustrated by contrast. Researchers are not attentive to concussion self-disclosure in retired adults with outstanding health care because this population presumably does not struggle systematically with situational factors that discourage disclosure. Thus, it is clear that researchers and practitioners have at least a tacit understanding that problems with concussion disclosure occur primarily when there are external factors that inhibit disclosure. Nevertheless, explicitly recognizing the nature of concussion disclosure dilemmas can benefit researchers and practitioners in several ways.

The psychological foundation of concussion non-disclosure

Understanding concussion disclosure as a particular type of social dilemma provides an important theoretical basis because it frames self-disclosure around the interdependence issues that concussed individuals must resolve psychologically.^4,5 The foundation of disclosure dilemmas is fairly straightforward. Individuals who know or suspect that they have been concussed can engage in different degrees of deliberation about whether concussion disclosure is worthwhile. Individuals might perceive benefits to self-disclosure, such as receiving professional medical treatment and avoiding having to perform under compromised circumstances; they could even operate in a culture that genuinely supports concussion self-disclosure. Individuals might nevertheless conceal concussions because they believe that disclosure will result in disappointing outcomes. This alone clarifies the importance of identifying potential disclosers’ perceptions of the cost-reward structure as a predictor of self-disclosure.

In more straightforward disclosure dilemmas, potential disclosers might only consider the direct, self-relevant outcomes (e.g. losing time competing) or the perceived association between self-disclosure and the self-concept (e.g. self-disclosure means I’m weak). Self-disclosure, however, becomes increasingly complex as disclosure dilemmas become increasingly interdependent. As interdependence increases, concussed individuals are likely to be concerned about how self-disclosure could influence their social status and influence others. Accordingly, potential disclosers incorporate their desire to create positive outcomes for people they care about (e.g. teammates, coaches, parents) and negative outcomes for people they dislike (e.g. rival opponents). In such cases, self-disclosure can also be influenced by interpersonal factors, such as perceived levels of social support,⁴⁰ perceived social norms,^20,26 the perceived influence of concussion disclosure on others’ outcomes,^25,27,28 and so forth. This process can be further complicated when concussion self-disclosure policies are in place that make individuals feel like they have a responsibility to self-disclose.³⁰

To summarize, disclosure dilemmas are always created by potential disclosers perceiving a responsibility to provide personal information to another person or persons while also perceiving that it might not be in their best interest to do so. The disclosure decision-making process is therefore influenced by a set of particular social-cognitive considerations – direct outcomes, self-concept (or identity) outcomes, social status outcomes, relationship-specific motives, and ethical concerns. Within this overarching model, however, concussion disclosure dilemmas have their own qualities. Disclosure dilemmas will vary in terms of which categories of considerations are creating the dilemma (i.e. direct outcomes, self-concept outcomes, social status outcomes, relationship-specific motives, and ethical responsibilities). The specific outcomes that create disclosure dilemmas will also vary by population and domain. For example, athletes and HIV-positive individuals both inhibit self-disclosure for direct personal reasons, even though the nature of those personal costs differ (e.g. potential playing time versus concerns about non-confidentiality of health records).⁴¹

Personality and individual differences can also influence how individuals navigate this decision-making process. Personality could influence the perception of the immediate, personal cost-benefit structure. For example, individuals high in neuroticism might have different perceptions about the direct costs associated with playing through concussions.⁴² Individual differences in self-concept beliefs influence the affective costs associated with reporting;¹⁹ individuals who more strongly identify with being an athlete or brave might view concussion disclosure as being more emotionally costly due to the self-concept violations.^20–22 Personality could influence the evaluation of social costs; individuals with low self-esteem might place greater emphasis on the perceived social costs associated with disclosure or non-disclosure.⁴³ Personality could also influence individuals’ willingness to transform the immediate self-relevant costs in the given situation into the effective costs that ultimately guide decision making; altruistically oriented individuals might care more about how their decision making can benefit others.⁴⁴ Finally, personality could influence the perceived responsibility to follow concussion-disclosure policy; conscientious individuals, in particular, presumably perceive a greater responsibility to disclose when they believe that policies or pledges require them to do so.⁴⁵

Finally, the social dilemma model also provides a theoretical complement to the socio-ecological model of concussion disclosure. The socio-ecological model emphasizes four levels for understanding health behaviors: (1) An Intrapersonal Level examining the specific characteristics of the potential discloser (e.g. concussion knowledge, gender); (2) An Interpersonal Level examining the potential influence of others (e.g. peer pressure, peer support); (3) An Environment Level that examines broader cultural influences (e.g. access to medical coverage, general attitudes toward injury); and (4) a Policy Level examining administrative procedure related to potential reporting (e.g. legislation; mandatory education).¹² The social dilemma model integrates the broad considerations offered by the socio-ecological model and places them into the specific interdependence issues that individuals are trying to resolve.

For instance, the socio-ecological approach provides a broad emphasis on the role of environment and access to educational materials.^12,46 Framing concussion self-disclosure as a social dilemma reveals that education could encourage self-disclosure through conceptually distinct mechanisms. Concussion education might increase awareness of the personal costs associated with successive concussions⁴⁷ and thereby increase concussion disclosure. Educational material might encourage a more supportive interpersonal climate that reduces the social costs of disclosure.^24,48 Concussion education might make individuals feel more obligated to follow policies enacted to enhance disclosure.³⁰ Generally speaking, the socio-ecological model suggests that providing educational material to encourage concussion self-disclosure is broadly sensible. The social dilemma highlights the specific ways that educational material could help individuals resolve their concussion disclosure dilemmas.

Gender is another variable that can help illustrate fundamental differences between the socio-ecological model and the social dilemma model. There is some evidence that women are more willing than men to disclose their concussions,^49,50 although this gender effect varies depending on context.⁵¹ The socio-ecological model organizes gender into a broader context by identifying it as an important intrapersonal variable in concussion disclosure. The social dilemma model provides specific mechanisms for understanding how gender might influence concussion self-disclosure. Men and women could perceive different levels of direct costs for reporting. Subpopulations of men and women might differ, on average, in terms of their self-concept beliefs. Subpopulations of men and women might also experience different levels of social support, different relationship-specific concerns about their behavior influencing others, and different ethical concerns about disclosure. A study involving United States Air Force Academy cadets provides a nice example.¹⁷ Women reported greater willingness to self-disclose concussions than did men. A subsequent analysis revealed that this gender effect occurred because a greater portion of men intended to become pilots, and these future pilots were concerned that disclosure could influence their careers.¹⁷ In other words, there was a gender effect, but it was rooted in the perceived direct costs associated with wanting to become pilots.

Researchers and practitioners can therefore view concussion disclosure using two complementary models. The socio-ecological model provides a framework for organizing broadly the different variables that encourage or discourage disclosure.¹² The social dilemma model provides a framework for understanding how individuals resolve concussion disclosure dilemmas and disclosure dilemmas psychologically. These models can be understood in conjunction to one another. The socio-ecological model provides a holistic analysis of the person, interpersonal relationships, culture, and policy, while the social dilemma model integrates these broad variables into a disclosure decision-making process at the individual level.

Improve initiatives aimed at increasing concussion disclosure

The interdependence-based social dilemma model can also explain why, from a social psychological perspective, existing interventions designed to increase concussion disclosure have achieved limited success⁵² or no noteworthy levels of success.^53–55 Collectively, these interventions have attempted to elevate athletes’ awareness of concussion symptoms, the consequences of concussions, concussion guidelines, and return-to-play recommendations. These types of interventions have possibly been ineffective because they do not resolve the reasons that athletes decide to conceal their concussions (e.g. missing game time). In particular, teaching athletes to recognize concussion symptoms might help athletes recognize when they have been concussed, but that will not change concussion disclosure behavior if athletes believe that concealing their concussions is still the most rewarding course of action.⁵⁴ Highlighting the long-term costs of concussions is intuitively sensible, but this approach has probably been ineffective because athletes who are strongly motivated to play engage in delay discounting⁵⁶ and other forms of rationalization.⁵⁷

Kurowski et al. developed a lecture-based intervention that covered symptoms, concussion guidelines, second impact syndrome, and chronic problems that follow concussions. This intervention might have created “minimal benefits” (Kurowski et al.,⁵² p. 7) because the strength of manipulation in terms of long-term consequences was sufficiently strong and was combined with widely distributed guidelines that provided a sense of social support. Even so, the majority of athletes who received this education and were later concussed reported that they had played while concussed. The intervention also did not seem to meaningfully prevent athletes from returning to play too quickly. There is some evidence that concussion reporting has increased with the implementation of new NCAA policy, but it is unclear whether this is due to increased concussion self-disclosure or improved external monitoring of player concussions.⁵⁸

We speculate, based on our social dilemma model, that interventions would be more effective by placing greater emphasis on the perception of the immediate outcomes that create disclosure dilemmas. This approach might appear challenging at times, particularly when concussed athletes feel strong desires to continue playing and help their teams. However, even in these cases there might be effective solutions. For example, evidence suggests that playing while concussed can hurt performance,⁵⁹ increase the likelihood of injury,⁶⁰ and delay recovery.¹¹ Athletes might legitimately consider these types of immediate consequences in making disclosure-non-disclosure decisions. Additionally, a recent movement among five powerful collegiate American football conferences to guarantee that athletes cannot lose their scholarships due to injury reduces at least one potential cost associated with concussion self-disclosure.⁶¹ Alternatively, organizations like the NCAA and high school districts could make efforts to decrease the perceived importance of sports where concussion rates are high and increase the perceived importance of sports where concussion rates are low. This approach might seem draconian, but researchers and practitioners should at least consider whether it might provide an effective way to reduce concussion non-disclosure.

The social dilemma model also clarifies the importance of identifying the specific outcomes that are creating disclosure dilemmas. Consider, for example, research demonstrating that athletes will conceal concussions in order to stay in games.^14–16 This information is important, but it does not identify the more specific concerns that athletes might have. Wanting to stay in the game could occur because of direct personal costs (e.g. losing the enjoyment of competing). Yet, wanting to stay in the game could also reflect anticipated costs to self-esteem (e.g. violating self-perceptions of being brave), anticipated costs in social status (e.g. teammates being disappointed with the discloser), or costs to known others (e.g. teammates and coaches would be disappointed if the team loses). From one perspective, the reasons underlying athletes’ desire to stay in the game do not matter. Leaving the game is a cost regardless of its underlying etiology. However, the reasons for wanting to play while concussed do matter. Practitioners would presumably develop different interventions depending on whether individuals want to stay in the game to receive the direct enjoyment of competing, to behave consistently with self-perceptions, or to please others.

Respecting human autonomy

Considering disclosure as a dilemma should also remind administrators that self-disclosers can experience real costs. Individuals who want to encourage self-disclosure should consider how they can do so without violating potential disclosers’ autonomy to decide whether disclosure is worthwhile. Interested parties generally have some justification for encouraging disclosure. Concussed individuals might be at an age where legally and ethically they do not have complete control over their medical decision-making. Concussed individuals might also misjudge the consequences of non-disclosure, thereby requiring others to intervene to encourage effective decision-making. Disclosure dilemmas become more ethically complicated as the consequences of non-disclosure become more interdependent. As non-disclosure has a greater influence on others, like parents and coaches who care about the individual’s well-being, interested parties have a stronger basis for encouraging disclosure, even if disclosure appears costly to concussed individuals.

There are ways to navigate these foggy self-disclosure waters. One method involves changing the given cost-benefit structure associated with disclosure.^62,63 For example, the aforementioned movement among collegiate American football conferences to guarantee that athletes cannot lose their scholarships due to injury⁶¹ does not encourage athletes to make costly decisions, but instead creates an environment where concussed individuals are more likely to disclose volitionally. Likewise, organizations can develop policies to ensure that individuals continue to receive pay if they are prevented from working due to a concussion. Another method of encouraging self-disclosure is to provide honest information that allows potential disclosers to make more informed decisions. If individuals are overestimating the costs and underestimating the rewards of self-disclosure, providing accurate information could increase potential disclosers’ willingness to self-disclose without violating their personal autonomy.

Conclusion

Self-disclosure occurs regularly in social relationships. Much of the personal information people share with others is benign, so people do not think of it as self-reporting. Self-disclosure becomes a compelling social problem when it is a part of a broader dilemma where potential disclosers are reluctant to provide information to others who have some need to obtain it. The nature of these disclosure dilemmas indicate that individuals’ perception of the cost-benefit structure surrounding disclosure is critical to understanding why potential disclosers might conceal concussions even when they know or suspect that they have been concussed. Interdependence theory is a particularly useful theory for understanding disclosure because it accounts for how individuals make personal choices in an interdependent world.^4,5 In the case of concussion disclosure dilemmas, individuals assess perceived rewards and costs from a self-relevant standpoint, but integrate these potential outcomes with broader relationship-specific motives and with ethical considerations.

We focused on concussion disclosure because of our research in this area and our desire to help individuals receive better concussion care. Nevertheless, disclosure dilemmas clearly take place in several other domains such as sexual assault,⁶⁴ HIV-positive status,⁶⁵ medication error reporting,⁶⁶ criminal activity,⁶⁷ and so forth. Recognizing explicitly the nature of disclosure dilemmas in any of these domains could reveal the variables that are likely to be relevant. Thus, a social dilemma model of information disclosure provides a foundation not just for concussion disclosure, but for understanding and addressing self-disclosure more broadly.

Footnotes

Acknowledgements

The authors thank Emily Jones and Jennifer Clarke for their assistance in the development of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by an NCAA-Department of Defense Mind Matters Challenge grant to study and improve concussion disclosure.

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A social dilemma model of information self-disclosure,applied to the concussion domain

Abstract

Keywords

Disclosure dilemmas

Concussions and disclosure dilemmas

Personal outcomes

Relationship-specific motives

Ethical responsibilities

Integration

Implications for researchers and practitioners

The psychological foundation of concussion non-disclosure

Improve initiatives aimed at increasing concussion disclosure

Respecting human autonomy

Conclusion

Footnotes

Acknowledgements

Declaration of conflicting interests

Funding

References