I’m on a flight to Frankfurt sitting next to a Colombian woman who is married to an Englishman. She’s complaining about his lack of passion, his reserve, his failure to satisfy her physical needs. “I have a psychotherapy patient from Latin America. She has an English husband and says a lot of the same things as you,” I say. My patient is clear in my mind—her words and mannerisms are so familiar to me—and yet I feel I shouldn’t be talking about her to this stranger on a plane, even though I say no more than this and haven’t even identified her country of origin.
In the NHS, confidentiality means you can’t identify a patient such that someone else would recognise them. But what is in a way the most personal material—dreams, fears, the inner world—is discussed in well-attended seminars.
The trouble is, patients are part of the family—the mind’s family, at least. Therapists often see them in their own home. Mine—though as a trainee they are few—are always in my thoughts. I’ll read an essay by Sigmund Freud and apply it to them (as well as to myself). I mention them to my children, though I know I shouldn’t. “I had a patient this morning who has a recurring dream about turning up for her GCSEs naked,” I tell my son on the way to an exam. He laughs and I hope he feels better. I changed finals to GCSEs and there are no identifying features. But was the patient’s session fully confidential? Not really.
For, although this kind of confidentiality is crucial for the therapist/patient relationship, it’s breached all the time. In supervision groups we discuss our patients in minute detail for hours at a time—up to 15 people might think and comment, the supervisor gives constant guidance. We disguise patients for these sessions, sure, but the life of their minds is described entirely openly, vividly. The disguises make the introductions and the clinical literature, incredibly dry: “X was born in Europe to a non-English speaking family. She is 32 years old and has worked in the service industry all her life.” Obviously, nobody could be identified from this kind of skeleton sketch. But X’s inner life, her relationships, addictions and even her precise turn of phrase will be talked about at length.
Then there are the scandals and secrets we might be dying to relate. So far, my own patients have not been high-profile figures, but many psychoanalysts do have eminent patients. “Oh, Cameron knows he won’t win the next election. He’s already told his kids they won’t be going to Chequers on holiday next year… I heard it from the couch.” This is an edgy but faintly acceptable way of sharing gossip gleaned from “the couch.”
The important issue for anyone training is that we have to be able to learn from the experience of others. If nobody ever related patients’ stories then this would be impossible. Melanie Klein is thought to have analysed and then disguised her own children. She wrote an essay whose subject was her disguised self (about grieving for her dead son). Freud psychoanalysed the child of a friend (“Little Hans”) via conversations with the child’s father. Freud’s most famous patients—the Rat Man and the Wolf Man (one traumatised by the idea of rats gnawing at his anus, the other by dreams of wolves in a tree outside his window)—did not remain anonymous postmortem if they did in life.
Thinking out loud about patients and writing about them is important. They can be heavily camouflaged and, my preference, then amalgamated so that my own analysis, things I have read, things friends tell me about themselves and real patients of my own are distorted beyond any recognition, but the essence remains real and, often, public.
Thinking out loud about patients and writing about them is important. They can be heavily camouflaged and, my preference, then amalgamated so that my own analysis, things I have read, things friends tell me about themselves and real patients of my own are distorted beyond any recognition, but the essence remains real and, often, public.
However, what patients dread, and what I have never heard, is derision. I have never mocked a patient even in private thought and I have never heard anyone else do so either. It’s odd in a way, since one would often find humour in public conversations and encounters. But the privacy of and respect for the session and patient and the real privilege of being witness to someone else’s mind is, it seems, very sacred, despite the fact that therapy is never as absolutely confidential as we might wish.
