So, What Can Therapists Write About?
By: Sara Nash, Phd
Tags: Psychotherapy, Psychology, Counselor As A Person, Counseling, Mental Health

So, What Can Therapists Write About?

A response to Gary Greenberg’s op-ed, Should Therapists Write About Patients?

In an op-ed for the New York Times, psychotherapist and author Gary Greenberg recounts a recent mishap in writing about his patients. After obtaining consent and/or taking elaborate attorney-approved steps to render his patients’ stories unrecognizable even to themselves, Greenberg published about some of his work with patients. Despite his meticulous efforts, one patient identified himself in the book — not in any obvious characteristics but in the story’s essence. The patient felt violated, and the therapeutic relationship never recovered.

In addition to honoring patient confidentiality, therapists have an ethical aspiration to do no harm. Although Greenberg did his due diligence, he learned that — at least for this patient — he should have done more. I suppose he made (as we all do) a mistake. Perhaps if he’d asked this patient’s permission, the patient would have declined and Greenberg could have avoided the fiasco. Or perhaps — and I say this with great trepidation, not knowing what or how Greenberg wrote about his patient — the patient was being a bit over-sensitive. Whatever the case, Greenberg then concludes that not only is it unsafe to write about patients after thoroughly disguising them, but because of the power dynamic inherent in therapy, therapists should never write about patients— even with their informed consent. He suggests that to publish about patients at all is to alter and potentially damage the therapeutic relationship.

Like Greenberg, I am a psychotherapist, and I am a writer who loves reading about and reflecting on the therapeutic endeavor. Psychotherapy — often more art than science — is about being human, from which no amount of professional experience exempts me. I have also been a client plenty (I prefer the word “client” to “patient”), and today in addition to full-time psychotherapy practice, I teach and supervise counselors-in-training. My students have complained that their training is too technical and impersonal — that it doesn’t connect to the actual practice of therapy — and I agree. When I went through school, most of my professors hadn’t worked with clients in decades, and they’d lost touch with what it was really like. Thus, books about actual therapy relationships by real therapists remain among the most instructive teachers.

Irvin Yalom, Rachel Naomi Remen, and Annie Rogers are but a few therapists who have safely written about their clients, in candid detail at that. Yalom even co-authored and co-published a book with a client about his therapy with her. It is simply not true that writing about clients is always bad. Of course, the trusted confidence of the counseling contract is sacred. But some clients may actually welcome living on through their therapists’ writings. While they may not want a friend or employer to recognize them in the text, some people may be proud of their counseling work, touched that their therapist cared enough to write about them, and honored that de-identified versions of their stories could help others.

In terms of asking for consent, power differentials undeniably exist in therapy. But we can navigate this by openly working to share power with our clients; indeed, the good counseling I’ve received has left me feeling far more empowered than when I started it. When we ask for consent, we can time our requests thoughtfully, waiting until our clients are on stable ground. Some folks may never be appropriate for such requests — those who continuously struggle with self-advocacy and healthy boundary-setting, for example. When we ask, we should give people plenty of space to think about it, and offer compelling reasons why they might want to say “no thanks.” We can take care to explore how our writing might impact the therapeutic relationship. Best case scenario, we can even offer to share what we write and get their final okay before publication.

Consent is great where possible, but let’s face it: Often, it’s just not. Clients move away and lose touch, and the essence of their stories may not pop up in our memory or our well-disguised book characters until 20–30 years later. Also, we work with the same themes over and over again — trauma, depression, sexual assault, existential concerns, family issues, relationships, addictions…the reality is, these are archetypal issues with which we all struggle, and if we happen to recognize ourselves in our therapists’ carefully disguised writing about us, maybe it’s not just us they’re writing about. And if it is, maybe it’s not such a big deal.

Of course, what we write about our clients matters, too. For example, I would be hurt if I learned from my counselor’s book that she didn’t like me; when I sit with her, I feel bathed in a warm, accepting love. Or, I’d feel shocked and saddened if she’d reduced me to a set of symptoms rather than respecting me as a whole human being.

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While it’s not clear in the op-ed, I can imagine Greenberg may be facing a lawsuit. So I thank him for sharing his experience, and I plan to take heed. That being said, how are we to learn the art and practice of a complicated interpersonal profession without hearing stories from those who practice it? How are we to practice well if we can’t read about and learn from the triumphs and troubles that happen behind the closed doors of therapy offices — indeed, about the very kind of mishap Greenberg recounts?

And What About Ourselves?

To Greenberg’s question I would add one more: Should therapists write about ourselves? How much should we reveal about ourselves in blogs, articles, memoirs, and books? Because if it’s tricky to write about clients, it’s even trickier to write about ourselves.

Frankly, I’ve always wished for more honest narratives about what it’s like to be a therapist as a person. Such narratives are important because effective therapy is more about who we are than what we know. Sure, prescriptive instructional books fill the marketplace — trust me, I’ve read a lot of them. In my experience, most tout the benefits of stuff like mindfulness and self-care, but in a personally distant way. There are few vulnerable accounts about the personal realities of becoming and being a therapist — I mean, raw open stories by therapists about who we are on the inside, not just the clients we serve in our professional roles.

Counselors are conditioned to pay attention to others, after all, and taught to share very cautiously about ourselves. We rarely expose ourselves in the ways we ask our clients to expose themselves. Yet I suspect that how therapists work with our own difficult stuff may be as or more instructive as prescriptive books or books focused on our clients.

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Nothing in my training prepared me for the practical long-term reality of spending the bulk of my relational life behind closed doors, keeping the secrets and stories of hundreds if not thousands of people, people with whom I’ve connected more deeply in an hour than I may connect with my partner in several days’ time. (No offense to my partner; it’s just that therapy is its own milieu, the intensity of which is not easily or even desirably reproduced in daily personal relationships.) My clients move me and inspire me to grow in myriad ways, yet I can’t talk about them openly, can’t say who they are or how I know them when I see them in public, can’t talk about their impact on me without being extremely careful about what I say. Beyond that, I can’t even share about myself in the written word without wondering if I’m “over-disclosing” or will lose my credibility as a therapist, or be judged by my colleagues for struggling like a regular person with life, relationships, and my own limitations.

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In formal graduate training, counselors receive the message to hide our personal selves while also being genuine and vulnerable with our clients. It’s a confusing and ongoing dance in which we will misstep, sharing too much of ourselves here and not enough there. But it can be learned only through practice, which is why my mentor Marshall Knudson taught me to ask for clients’ permission to be clumsy up front, since if I was really engaging myself in the process, clumsiness was inevitable. If we can’t be clumsy, we can’t be real. To be of any value as a therapist is to be fully invested in relationships, and to be fully invested in relationships is to make mistakes.

For as much as graduate school lacked, now that I’ve been in full-time practice awhile, I realize that my training years were actually my most connected. My peers were still eager to process clients with each other, and we were all under constant supervision. I could always find a colleague or mentor whose door I could knock on and say, “Something intense/hard/beautiful just happened with a client and I need to process— can you listen and give me some feedback?”

Technically speaking, I still have this kind of support in my professional setting, but we’re all so busy. And tired. And sometimes, yes, emotionally burned out. It’s not just the hard stuff, like the life-and-death decisions I make on a near-daily basis with clients who are suicidal. There are times when something amazing happens, something good and real and maybe even life-changing. My client can walk out and tell his friends and family about the connection, the insight, if he so chooses. I, however, am alone with it. Sure, I can go summarize it to a colleague in a couple of rushed minutes,or even carefully tell a non-counselor friend about the basic theme, without giving away any potentially identifying information. But much gets lost in that kind of telling, and everyone’s so busy. And tired. And sometimes emotionally burned out. So instead, I wipe my tears. I use the bathroom. I stare at the wall, or I check Facebook. Then, I go get my next client, and open myself to the next connection.

I’d like to know how other therapists deal with this (and no, I don’t want to hear about your fabulous, empirically validated meditation practice). I want to hear the grit, the rough edges — because trust me, we all have them. I recently launched a podcast series, The Counselor as a Person, to talk to therapists about these very questions. How do we go home at night after talking people off of ledges and respond to the question, “How was your day, honey?” How do we fight with our spouses? How do we manage at cocktail parties where the conversation feels superficial and hollow, and we’ve just come from the trauma trenches? How do we work with our own tendencies to get depressed and anxious and self-doubting and — who knows — maybe even a little suicidal? How do we try to practice “self-care” and — you know — fail at it?

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Holding my clients’ confidence is just part of the job, a job I love and feel honored to have. But sometimes doing therapy is a lonely business. The important people in my personal life will never know much about the countless powerful human connections and characters I encounter at work, and thus, there’s a big part of who I am and what impacts me that my partner, friends, and family will never see. Most of my clients — about whom I care so much — will finish therapy and we’ll never talk again.

And of course, there’s the lopsided interpersonal reality of knowing many people deeply, while being deeply known by just a few.

For some therapists, then, it may be vital that we are able to write — that we can communicate beyond our isolated work environments about the complexities of what we do, how it impacts us, and who we are. Therapists are people, too, after all, and we need connection, need to be known by others just as much as our clients need to be known by us. As any therapist or client knows, being known as we are for who we are works best when it extends well beyond the secrecy of the counseling office.

Also, some therapists may just happen to be writers. And writers need the relief of a writing outlet.

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Of course, when we write about our clients, we should do so only with great care, respect, and if possible, their fully informed and ethically-obtained consent.

When writing about ourselves, however, I believe that we may do well to consider using a little less care and a bit more courage.