Couch is a series about psychotherapy.

Photo

When it came time for the pre-publication legal review for my most recent book, I had an idea of what to expect, or so I thought. The book was highly critical of the American Psychiatric Association, a deep-pocketed, fiercely self-protective organization. I took particular aim at its most lucrative product, the Diagnostic and Statistical Manual of Mental Disorders. So I figured the review would rigorously investigate whether my account was fair and accurate enough to withstand any legal challenge.

I was right about one thing: The review was a veritable inquisition. But I was wrong about the subject of the lawyer’s concern. It wasn’t the A.P.A. Instead, she was worried, nearly obsessively, about my accounts of interactions with my therapy patients.

I’d told such stories before. My previous book was full of descriptions of therapeutic encounters, and I’d taken the industry-standard precautions. For detailed case studies, I obtained written consent. In cases where that was not possible (for instance, if the therapy had taken place long ago and I’d lost touch with the patient), I changed all the identifying information; a woman became a man, a doctor became a truck driver and so on. And sometimes I would assemble composite characters, golem-like, out of many people I had seen — a physical characteristic here, a verbal tic there — in order to illustrate a clinical point with a brief anecdote.

These techniques had easily passed muster with the lawyers for my previous book, so this attorney’s focus on the few, lightly sketched case studies in the new book caught me off guard. It also made me cranky. Who was she to doubt my commitment to protecting people with whom I had such intimate relationships, who had taken me into their confidence, whose foibles and troubles I had learned to accept and even to love? But doubt she did.

“This one,” she would say, “the strapping beauty with the wild hair — does she really have broad shoulders and wild hair?”

“Well, like I told you,” I would reply, “she is a composite. The person in the book doesn’t exist. But if you’re asking me if I’ve really seen a broad-shouldered woman with wild hair, then I guess the answer is yes.”

“And that one,” she would go on, “the psychotic woman with the hotel fixation — is she really a woman, and was her fixation on hotels?”

“Yes,” I would say, “but she’s not Chinese-American and she’s not close to 53 years old.”

“So why does she have to be a woman? Can’t you make her a man?”

No reason, I supposed.

“And the other one, the college girl?” she would continue. “Did she really go to an Ivy League school? If so, can’t you say she went to a state university?”

And on and on. In the end, the wild-haired Amazon became a blond waif and the psychotic Asian-American became a man from California, and the college girl (who in real life had already graduated), aged 10 years and became a Chinese-American executive. I married her off to a playboy banker who, until the lawyer’s review, had been a divorced scientist with no connection to the student.

I will admit to thinking that some of the adjustments I made were pretty clever, although I was a little troubled by how easy (and even fun) it was to turn the ethical imperative to disguise patients into poetic license. Not to mention how much more smoothly an argument could go if you were free to change the details to suit it.

It took a couple rounds of edits before the lawyer was finally satisfied that my subjects were sufficiently disguised. I was in high dudgeon most of that time. If I’d wanted to write a novel, I protested, I’d have written one. And even when I tried to make up details, how could I escape the fact that most of what I know about people, most of my sense of what constitutes a plausible fiction, comes from my work as a therapist? It seemed as if she was asking for the impossible — characters and situations plucked out of thin air — in service of the unnecessary. Hadn’t I already rendered the patients unrecognizable in my original manuscript?

I kept most of this to myself until the last day of the review, when I made an offhand, passive-aggressive comment to the lawyer about how ironic it would be if my new characters were mistaken for real people other than the originals.

“You mean by readers?” she asked.

“Of course,” I said. “Who else?”

“The question isn’t whether someone else will recognize your patients,” she said “It’s whether or not they would recognize themselves.”

I was flabbergasted. We’d apparently been operating in parallel universes, each assuming that we knew and shared the other’s goal. I had thought we were trying to protect the patients’ privacy; she was worried about their well-being. She may have been doing her job, making sure that no one would sue us, but she was also doing mine, wondering what it would be like to encounter yourself, however deeply disguised, on the page of a book written by someone who has encouraged you to show yourself completely, on the promise of not being judged or exposed, and whom you trusted to keep your intimacies between you.

That violation is almost as unfathomable as the fact that I missed it, that it took, of all people, a lawyer to point it out. Nor would it have been any less had I sought and obtained consent. After all, does a patient really have the option of denying a therapist? Can such a request be made without altering the course of therapy, and even perhaps the patient’s life?

My moment of self-reproach might have passed. I might have gone on to find some justification for continuing to write about patients. After all, hasn’t the world benefited from the beautifully rendered case studies by such masters of the craft as Sigmund Freud and Irvin Yalom?

But then I got busted.

I’m not going to tell you the details, not the real ones or the fake ones or even the lawyer-approved doubly deceptive ones, except to say that one day, after the book was published, an irate patient came to an appointment with my book in hand, read a page out loud, and said: “I know this is me. I can’t believe you would do this.”

Not a single detail in the passage identified this person. Anyone else reading the offending passage would conclude that the patient’s accusations were paranoid or narcissistic ravings. My lawyer would have been able to persuade any judge or jury of my innocence. I had plausible deniability. But the patient was right. Buried in the page, like a telltale heart, was that person’s story. I knew it, the patient knew it, and we both knew in that moment that I had caused a wound beyond healing. I had used the patient for my own purposes. Our relationship was over.

In his last novel, “The Confidence-Man,” Herman Meville noted that novelists typically pluck their fictional characters from real life. “Every great town,” he wrote, “is a kind of man-show, where the novelist goes for his stock as the agriculturist goes to the cattle show for his.” It’s an unflattering comparison, and one that applies equally, if not more so, to therapists who use their patients as characters. At least novelists aren’t typically betraying confidences.

Therapy is not a man- (or woman-) show. The world is already too full of confidence men, which is part of the reason that people are willing to pay for the refuge we therapists offer: an hour of freedom from being treated as the means to someone else’s end. Those of us who take their money should consider the possibility that when writing about them, no matter how effective our disguises, we are betraying them. When it comes to the stories they have given us, perhaps we should just keep silent.



Gary Greenberg, a psychotherapist in private practice in Connecticut, is the author, most recently, of “The Book of Woe: The DSM and the Unmaking of Psychiatry.”