Perspectives: Private Faces in Public Places

By Kramer, Peter D. | Family Therapy Networker, November/December 1994 | Go to article overview

Perspectives: Private Faces in Public Places


Kramer, Peter D., Family Therapy Networker


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. …

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