Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?

Saturday, January 17, 2009

A monstrous ethical dilemma

I just finished reading Stephen White's first novel, Privileged Information (Viking, 1991; 363 pp.). I'm surprised I'd never heard of him before, because I love murder mysteries and I particularly love those written by or about psychologists. But somehow I'd missed this one: A friend, in town for the holidays, turned me on to it. "Be sure and start with the first one," she said, and I did.

At first, I didn't like it. It wasn't all that well-written, in the beginning at least, and I thought the ethical problem was kind of contrived. But it picks up along the way.

Here's the dilemma. The novel opens with the suicide of a patient. The patient unfortunately wrote up her sexual fantasies about her therapist, the protagonist of the novel, in her diaries without identifying them as fantasy. The executor of her estate reads them, and thinking that the protagonist, Dr. Alan Gregory, not only may have been sleeping with his patient but may have precipitated her suicide by doing so, files a complaint.

Gregory certainly is in a bit of a pinch here, because the complaint hits the papers and of course the therapy community is abuzz about it as well. Gregory can say nothing in his defense, publicly at least, due to patient confidentiality. He of course can defend himself before the licensing board, but that is not the problem here. What felt contrived to me was that he seems to think he can't talk to his colleague and business partner, his lawyer, or even his clinical supervisor about the case, which is completely incorrect. He can. And should.

But this is a relatively minor flaw in the book, because as it turns out the privileged information of the title primarily refers to another patient altogether, one whom Gregory begins to suspect of murder. Now he really is in a bind, because he cannot reveal what the patient is up to without a more clear and convincing threat to a specific person. Which the patient is smart enough not to give him. So the rest of the novel turns around how to stop a killing without giving away privileged information.

Along the way, Gregory, who is completely innocent of the boundary violations with which he is charged, does manage to rationalize some other, serious ethical breaches. And his final solution is not ethically perfect, either. It's creative, though, and it does solve the problem.

White is himself a psychologist who practices in Boulder, CO. In his writing he gives a good picture of the life of a psychologist. But ethical issues not addressed in this novel include (1) Gregory seeing 38 people a week when his caseload is its usual size, and (2) Gregory continuing to work while his personal and professional life crumble around him. He also takes on a patient who represents a clear conflict of interest. He should have referred this guy on during the first session--but then, if he had, there would have been no novel, so I guess we're stuck with that.

Gregory makes boodles of money seeing 38 people a week, but my God. When does he do anything else? Like billing, charting, reading, eating lunch, going to the bathroom... He books people back to back, referring once to "my 3:00 and my 3:45" so he's not doing any of this between sessions. I once interviewed for a job with a psychologist who claimed to see 50 to 55 patients a week: My first instinct was to run like hell. That can't be healthy. You can't possibly, in my humble opinion, maintain a high standard of performance at that level.

He is also working with a couple while his own marriage is breaking up, and one has to wonder if how he sees his own relationship troubles is biasing his view of what the couple he's treating "should" do with theirs.

And finally, he takes on a client who had an affair with a former client. I wouldn't touch that with a ten-foot pole. Or as a former colleague of mine used to say, a 12-foot Russian.

So we hope White doesn't practice like that. And while the book gives a better portrayal of the profession than, say, Prince of Tides, I'd still warn you to take it with a grain of salt (it is, after all, fiction). The Alex Delaware novels by Jonathan Kellerman are much better in that regard. I've read them all and the worst thing I can recall Dr. Delaware doing is having a drink at lunch when he has a patient to see in the afternoon.

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