Tuesday, October 27, 2020

Therapists Writing Tell-All Books

It’s as old as Freud-- therapists writing about their patients. More recently, Irvin Yalom told fictionalized stories about his own patients in several books, most famously in Love’s Executioner. Recently, Lori Gottlieb wrote a best seller about her own experiences in therapy, adding accounts of her patients’ work with her. And one Esther Perel has done podcasts of couples therapy sessions in her office.

As it happens, for better or for worse, telling stories about your patients is an effective marketing tool. 

And yet, as Ellen Gamerman recently asked in a Wall Street Journal article, what happens to therapy when the patient has agreed that the therapist can write up the case for public consumption. Does it influence what is said and what is not said? Does it enhance the possibility for effective treatment-- because the patient wants to shine forth as a hero-- or might it even induce the patient to enact more drama, the better to be more interesting, to be a better story? What happens when a supposedly private conversation becomes a potential public spectacle?

Surely, there is a fundamental difference between confiding in an intimate and playing for a potentially large audience. We cannot imagine that anyone would present himself in the same way, would present his problems in the same way in these different circumstances. Encouraging patients to become exhibitionists does not seem to be very therapeutic, even if they want to do so.

We need also to mention that, as John Donne once said, no man is an island. No patient can tell his story, can lay out the minutiae of his misery without implicating other people, without betraying confidences that others have placed in him. The patient who allows his stories and his problems to become public might consent in the one sense, but can he consent to share the intimate truths of other people?

Better yet, is the therapist involved in a breach of professional confidence? Shouldn’t the therapeutic setting involve total and complete discretion? After all, modern therapy arose as a secular version of the Catholic sacrament of confession. And, the secrets of the confessional always remain secret. If I understand correctly-- and I am sure you will correct me if I do not-- priests are not allowed to share even confessions of criminal activity. A therapist however is duty bound to report instances, for example, of criminal behavior, as in, child abuse. 

Freud broke with the confessional tradition when he wrote up his cases. For the record, we know that he fictionalized them, even lied about his successes, the better to establish his bona fides as a therapist. Given his example we cannot preclude that therapists might be using their case studies to pretend to cure people they have not cured. There is no real way for a reader to know. 

With someone as famous as Freud, researchers have gone through the records and have unearthed the truth. It showed Freud to have been a serial prevaricator, dishonest to the core.

As happens in other aspects of human experience, consent is a very tricky concept. Can you legitimately consent to be abused? Can you consent to allow someone else to betray your confidence? If a patient has signed a waiver allowing the therapist to betray his confidence, does sharing the information with the public still constitute a betrayal of confidence? If it does, what moral example is the therapist setting for the patient?

Is the therapist still being indiscreet if the patient has agreed to it? And what happens when a patient, someone who consents to have his dirty linen exposed to public view, decides, after seeing it in print and after suffering the personal repercussions, that he would rather not have done so? What happens if he feels that he has been tricked? It is devilishly difficult to put the toothpaste back in the tube. 

Since I believe that we ought to have a position on a question of such moment, I will tell you that I am opposed to all such sharing, to all such indiscretion and to all such breaches of confidence-- even when a patient fulsomely consents. We might ask why a patient might consent, what it says about him and what moral example it sets. If we do, we will end up thinking that it is generally a bad idea.

As one therapist suggested, if the therapist is obliged to change all personal details in order to protect the patient’s identity, then perhaps he should just write fiction. Admittedly, it will not be as effective a way of marketing his service, but still?

Gamerman opens her article thusly:

Catherine Gildiner’s new book about her life as a psychotherapist stars her former patients, some of whom experienced strong reactions after seeing their lives exposed on the page. Ms. Gildiner said one patient, a woman who had been abused as a child, told her that reading the book brought up repressed memories of her sadistic father and briefly sank her into a depression. Another patient, a wealthy antiques collector, was mortified by the thought of anyone ever knowing the patient was her and vowed not to tell a soul about her literary turn, the author said. A third, Ms. Gildiner added, was a musician who felt so vindicated by the book’s portrayal of him that he showed the hardcover to everyone in his family.

“All of them were happy to be in it,” said Ms. Gildiner....

One wonders about Ms. Gildner’s definition of happiness, but surely none of these people impress you as having experienced joy for reading about themselves.

I would add that these patients would be within their rights to conclude that their therapists are telling the truth about their own feelings about their patients. And yet, fiction has a logic all its own, and a therapist will almost certainly be led to skew the details for dramatic effect. The therapist might believe that he is telling the truth, but the genre’s requirements can easily overpower even the most serious effort to be truthful.

Gamerman continues, to the effect that the doctor-patient confidentiality is being sacrificed to marketplace demand. These books sell very well indeed. And they seem to drive more patients to do therapy-- whether because they want to star in a therapist’s fiction or because they have a repressed exhibitionist tendency, we do not know:

Doctor-patient confidentiality is a cardinal rule for therapists, a legal and professional obligation that is considered essential for treatment. But therapists are turning their case studies into page-turners. The widening acceptance of mental-health care and the lucrative cachet of self-care in all its forms is fueling demand. 

She continues that when a therapist asks for permission to write about a patient, the gesture itself skews the process:

Professionals should not ask anything of patients beyond payment, some therapists say, adding that clients may not feel comfortable declining to be written about given how much power the therapist holds in the room. If patients don’t end up in the book, they may worry that the therapist finds them boring. If they do make the cut, they might regret it later.

It becomes a proverbial can of worms. Surely, some professionals feel compelled to write up case studies, because they are an excellent teaching tool. Such cases are often consigned to professional journals, to places where patients, their friends and family are unlikely ever to see them. Thus, they appear to respect the rules of professional confidentiality.

And yet, as long as these studies are written for a public audience, they will necessarily distort the relationship. As noted above, even if the patient consents to this form of public exposure, the act in itself is counterproductive. One does not quite see how the patient will gain any therapeutic benefit from having the intimate details of his life exposed on the public square or from being party to a betrayal of family secrets. 


Anonymous said...

It seems unethical and problematic for the reasons you describe. But what do you think of the academic articles that describe patients.

Stuart Schneiderman said...

See my post of two days ago about therapists writing about their patients. As for the academic articles, we would want to know what their criteria are. The British example of a proliferation of depression suggests that therapy does not do what it is supposed to do.