Perspectives

Peter D. Kramer

The ethics of writing about our clients

IN RECENT YEARS WE HAVE WITNESSED AN OUTPOURING of popular writing by psychiatrists. Robert Jay Lifton, Irvin Yalom, Robert Coles, Sue Chance, M. Scott Peck, Paul Wender, Robert Klitzman, George Valiant, Donald Klein, J. Allan Hobson, David Hellerstein, Edward Hallowell, Stephen Bergman, Salvador Minuchin, Lenore Terr, Leston Havens, John Marshall and John Ratey have produced books for a general audience, and this list is far from comprehensive. But treating and writing do not mesh easily.

One issue is case vignettes. Freud felt free to describe his patients, so long as he changed identifying details. It was Freud (winner of the Goethe Prize for literature but never the Nobel Prize for medicine) who noted the paradox, so frustrating to writers who know the value of accurate detail, “that it is far easier to divulge the patient’s most intimate secrets than the most innocent and trivial facts about him; for, whereas the former would not throw any light on his identity, the latter, by which he is generally recognized, would make it obvious to everyone.” Today, doctors fret more about divulging intimate secrets without consent. The impetus is less fear of lawsuits, which are rare, than a sense of responsibility that arises from the increasingly collaborative relationship between doctor and patient.

Some psychiatrists show patients whole chapters and obtain written permission. This procedure intrudes on treatment and is not without its pitfalls. In their eagerness to please, patients may agree to depictions they later regret. Having obtained permission, doctors may feel free to publish hurtful characterizations. I know of a patient who signed an authorization and later distraught sought treatment with a new therapist over the humiliation she felt when she saw her portrait in print.

Some psychiatrists build psychotherapies around their writings, showing patients drafts as a way of sharing their associations and assessments. This strategy is daring it exposes the narcissism of both participants but, in the right hands, it can work.

How best to approach consent remains unanswered in my mind. Any discussion, however respectful, is intrusive and invites the patient to display a false self. My standard has evolved over time. For my book Moments of Engagement, where vignettes often concerned people with whom I had lost touch, I sought general consent for most longer stories, none if describing a single intervention. (Knowing I would write, I had asked some families for permission as early as the middle 1970s.) On publication, I received one objection, from a woman who thought I had assessed her with more accuracy disturbingly so on the page than in the office. Complaints did come from Complaints did come from patients I had not written about: Weren’t they interesting enough?

The popularity of Listening to Prozac has added an additional complication the psychiatrist as public figure. One Washington Post Outlook contributor recently depicted himself as squirming when he saw my face on television and then riffling through Listening to Prozac, hoping and fearing to find himself described in a case study, perhaps with a moniker like Freud’s “Wolf Man.” The author (his story appeared on July 3, 1994) gives a comical account of our meetings. I come off as a strict, intrusive Freudian with a bad haircut. What is worse, he says he ended up a graduate student at Harvard with a fiancee named Jennifer. This revelation generated a flock of calls from parents who wanted psychotherapy for their college-age sons. Parents will put up with anything, even a disheveled Freudian, if the result is Harvard and a fiancee named Jennifer.

Professional standards, as I interpret them, preclude even my confirming whether this young man was a patient. But I can say something about my current approach to the dilemmas of the psychiatrist-writer. Listening to Prozac is built around a dozen detailed vignettes. Though I took a different tack in each instance, I had one organizing principle: the dictum that consent is not a moment but a process. Typically, I discussed what I hoped to write and why with a patient repeatedly, four or five times over the course of a year or two even though the patient had given consent immediately. Beyond my case notes, there was no document, just talk and reliance on one another’s trustworthiness, an approach I find consonant with the rest of psychotherapy.

EVEN SO, NO TREATMENT AND NO PATIENT IS LEFT untouched by the doctor’s writing. Most often, the effects are minor and positive a sense that one’s therapist has listened attentively, that one’s story has significance. But having been written about can induce feelings of specialness, entitlement or, at the worst, violation.

Beyond the revealing individual vignette, there is a problem of the psychiatrist’s being a writer. Knowing their doctor writes, will patients feel inhibited? Or narcissistically stimulated, exhibitionistic? And what if they do not know? Happening upon my books in a store/one patient became overwhelmed with feelings of abandonment. She cried off and on for days, without knowing why. Did the moment arouse memories of neglect by gifted parents? Feelings of inadequacy vis-a-vis a talented brother? Awareness that her psychiatrist had another life, fears that he might leave practice altogether? (Even in these few sentences, I have altered details no moment of writing is protected.)

Since that episode, I have taken care to tell prospective patients that I do write, and that I may come to want to write about them. Willingness to be a subject of a clinical inquiry my idiosyncratic inquiry is a price people pay entering my practice. Since it is what they have anticipated anyway, new patients are not disturbed by my request. But I remain unsure whether early warning is the best approach. The analogy with clinical research studies, ones that entail both treatment and data-gathering and that call for advance consent, offers only imperfect reassurance. There are still colleagues who never seek permission on any level, just write discretely and cross their fingers; having chosen a different, complex route, I can see the virtues of the old ways.

And then there is the question of publicity. Should a psychiatrist do the book tour? How not, if he or she is an author? The book contract may be predicated on the tour. To have a public voice at all, toward the end of the millennium, is to agree to CNBC, “Good Morning America,” “Oprah.” I feel privileged to have been given the chance.

I WAS A WRITER LONG BEFORE I WAS ever a psychiatrist first knew I was a writer at age 7. We want, as a culture, for some writers to become psychiatrists, and for some psychiatrists to become writers want the humanism of writing to illuminate the technology of healing. The writer-doctor is an outsider within the guild; his or hers is the voice not just of information but of conscience. Moreover, in an era of narrow technicality in medical journals, the popular doctor-writer is sometimes an original synthesizer for the profession.

And yet the doctor like the politician, is suspect. Every news-at-noon anchor is an investigative reporter: How do you respond to your critics? Daytime talk shows pit patients against doctors: “Doctor Kramer, meet the regional head of the Prozac Survivors’ Group.”

I do not say that commercial television is a good place to convey psychiatric information. Too often, on TV, issues are framed by controversy. Standard storytelling genres prevail: Jekyll-and-Hyde, the Frankenstein monsters, the hero reviled and rehabilitated. But TV is a good place to show how egalitarian our culture is. The doctor’s voice breaks, he look sheepish or glib, his hair, yes, could be better cut.

The demystification of the public psychiatrist accords well with current models of psychotherapy, in which the humanity of the doctor is ever apparent. The public may not appreciate how much psychotherapy has changed in recent years: Even within psychoanalysis, the analyst as blank slate is an ideal only to a small rear guard. The therapist is no longer neutral and characterless but rather present and empathetic. The doctor’s is only one perspective among many possible useful, we hope, and respectful, and based on wisdom and technical skill, but subject to change and alteration.

Part of my medical training was on Martha’s Vineyard, off-season, under the psychiatrist-writer Milton Mazer. On a small island, there is little choice of plumber, school principal or psychiatrist. Everyone knows everyone else’s business. It is possible to do good psychiatry under these circumstances. The psychiatrist can be country doctor, family doctor, community doctor to a degree, I model my practice on Mazer’s, am unafraid to have my quirks apparent to patients.

Psychiatrists are also subjects of writing witness the Outlook piece. The Wolf Man submitted to a book-length interview by an Austrian journalist. Not long ago, Jeffrey Moussaieff Masson, the Kitty Kelly of psychoanalytic historiography, published a devastating portrait of his training analyst, Irvine Schiffer. The problem with critiques by patients is that doctors cannot reply. Except in certain legal proceedings, the content of treatment is covered by doctor-patient privilege even when the doctor is under attack. (For technical reasons related to a Canadian television release form, Schiffer may have been free to respond to Masson, but so far as I know he did not.) A colleague of mine squirmed when a former patient vilified her, I believe on false grounds, in an article in a serious magazine. The patient had suffered brain damage and was impulsively irritable and impaired in his judgment, but not so impaired as to be unable to write convincingly.

There is no cure, nor should there be one, for this asymmetry. Patients must be free to criticize their doctors, and doctors must be forbidden to respond. I can imagine a diatribe so extreme in its viewpoint that a scrupulous editor ought, as a condition of printing it, to ask the patient-author for a waiver of confidentiality on behalf of a doctor under attack, but I doubt such an event has ever occurred. Nor would most doctors respond to the offer. Doctors just have to take their licking. More than one of my patients has said jokingly, but therapists make a living by noting aggression in fact that she is keeping a diary for Listening to Kramer: The Expose. Patients are so vulnerable in the psychotherapeutic setting that whatever tips the balance in their favor is for the good.

At least, I believe this truth some of the time: that doctor and sometimes patient can be public figures without excessive harm and with potential benefit. There are also days when I despair utterly and vow to forsake writing. Or, since that seems unlikely, to turn to fiction.

THERE IS, I AM CONVINCED, NO IDEAL way to combine psychotherapy and writing. Every question is too invasive, every unasked question too paternalistic, the whole process too distorting to the encounter. And yet I think we are right as readers to want to hear from those who deal daily with practical issues of the mind and as patients to want to work with doctors who think synthetically and struggle to put their thoughts into words. Fortunately, both patients and psychotherapy are hardy and resilient. Fortunately, just as the “good-enough” mother strengthens the child through her occasional lapses, the good-enough therapist can catalyze growth. No relationships are exclusive; we see parents, lovers, spouses and colleagues in a variety of roles. We can probably stand to see our psychiatrist on television.

Copyright 1994 by Peter D. Kramer. Reprinted with permission from The Washington Post, Outlook, Sunday, September 25, 1994. Peter D. Kramer is the author of Listening to Prozac and Moments of Engagement: Intimate Psychotherapy in a Technological Age.

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