Angry

 

 

 

 Angry is one of the most common search words that people use to find my blog. I did not know that I spoke about being angry so much, but now that I think about it, anger is certainly one of the negative feelings which propel folks into psychotherapy. Like all pain, anger is a clue to internal distress, sometimes rising to the point of needing medical attention. Betrayal makes people angry as I spoke about in my previous posts involving the Monte/Marla drama: https://shirahvollmermd.wordpress.com/2010/01/24/betrayal/   https://shirahvollmermd.wordpress.com/2010/06/30/more-betrayal/. Susie, sixty-one, was angry today when she came in, not at me, but at her employee, Tony. Tony did not do his work, and when confronted, he took the opportunity of this negative exchange to attack Susie on a personal level. Susie handled it professionally, but internally, she felt dismantled. “It seems that Tony honed in your vulnerability; on the parts of yourself that you do not feel sure about.” I said. “Well, obviously,” Susie replied. “So that is helpful to us to understand what this vulnerability is all about.” I say, highlighting that getting hurt, although painful, is also an opportunity for self-exploration. “I guess,” Susie says, dismissing the opportunity, but at the same time, understanding that maybe when the pain subsides, she might be able to examine her sensitivity. Susie was angry when she walked in; she was calm when she walked out. Sharing the experience, thinking about her feelings, seems to have diffused them. Immediate gratification happens in psychotherapy, along with the long-term kind. Being angry can be part of a helpful internal journey. Susie reminded me of that.

Comin’ Back

   “Where have you been?” “That man with the hat has been up there too long.” Those are two of the many flattering comments I received while I took my hiatus. The truth of the matter is that I cannot really answer why I took a break, nor can I answer why I am coming back. I continue with my same tension. I want to describe the human struggles through a fictionalized version of my patient encounters, while at the same time, maintaining deep respect for the confidential relationship. This struggle continues to perplex me in ways that gets more intense as time passes along. Patient stories, even though I  fictionalized them, are deeply personal experiences. They cannot leave my office, since the personal price to my patient, would be massive. The bedrock of my work, privacy, is the foundation on which we build trust and respect. At the same time, so much of what I hear are universal issues about relationships, be they spouses, friends, children, siblings or parents. These issues lend themselves to a general audience without revealing personal, or private, information. The internet allows me to cast these stories around the world, which sometimes, not often, open up a world-wide conversation which feels to me to be both helpful and interesting. The surprise of these “conversations” inspires me to continue  to walk this very narrow path between sharing conflicts, while guarding privacy. I thank my readers for encouraging me to return. I am excited to be back.

Confidential Blogging: An Oxymoron?

     Confidentiality is the bedrock of my field. Patients need to know that what they say will be protected from their loved ones, their families, their employers and their friends. Without confidentiality, psychotherapy would  become a relationship fraught with fear and anxiety. As a physician, it is my job to protect patient privacy except when I have evidence of child abuse, domestic violence, elder abuse, imminent self-harm, danger to others or grave disability. In these cases, the law mandates that I intervene to protect the safety of my patient or the safety of others. These rules are clear and helpful.

   My blog has raised challenging issues of confidentiality. My home page states I fictionalized my patients. Many of my current patients read my blogs and see themselves represented in my stories. Sometimes I was not thinking of them when I wrote them, but sometimes I did use that particular patient as my inspiration for my post. There is no identifying information in my blog, which is to say that if a friend of one of my patients read the post, he would not know who I was talking about. Having said that, it is true that,  at times, a patient can identify himself.

    Where does this dilemma fall in the need to protect privacy? My patient reads my blog, he immediately thinks that I was basing my vignette on something that happened in our session, he feels violated, but also flattered. Is he violated if he feels violated? I  say the answer is yes. If my patient told me his feelings, I would immediately take down the blog. I do not want to cause my patient to feel violated. However, is this too late? Should I not write about my patients if I risk that they will feel violated, even though I am quite certain that they are not recognizable to anyone other than themselves? This is my question. 

     The internet can be a scary place. I do not know who reads my blogs. I try to disguise my patients by changing identifying features, but I could work harder on this obfuscation. Still, I am talking about patient information as a springboard to my ideas about human behavior and human interactions. The examples help me to describe my point. The particulars of the patient are not important, but because I am using the words of some of my actual patients, then those patients know that I am writing about them. Almost all of my patients know I have a blog, so they know that there might be times when they spark a blog. Many times, I tell patients that a particular interaction has given me so much pause that I want to blog about it. Many get a little nervous when I say this, but they all tell me it is fine with them.

         New patients are a bit trickier. I think it is wise  not to use new patients as a stimulus to a blog entry, as I think we should form a relationship first, before  we enter into the internet world. My new rule: all new patients have to stick with me for six months before they enter into my blogosphere. Our doctor-patient relationship must gel, such that if they read about themselves on the internet, then we will have a chance to talk about it, and if they remain uncomfortable, I will immediately take it down. If the relationship is too young, then a new patient might feel that nothing they tell me is safe. That is a dreadful feeling and I want to avoid that at all costs. How does waiting avoid this problem? I think that once a patient and I have bonded, then they will get a feel for my blog, and they will understand that the patients in my blog serve to illustrate an idea. The blogs are not venues to expose harmful personal information. Further, as I stated above, no one, besides the patient, will be able to recognize the springboard to the blog. Further, the time that we take to establish our relationship, will hopefully reassure the patient, that although I make mistakes, I do not intend to harm anyone. A new patient may not have that trust in me.

   Am I rationalizing unethical behavior? I do not think so. It is ethical to write about patients when they are disguised. The nature of the disguise is subject to debate, but suffice it to say, I need to think carefully about  that disguise. That is a work in progress. It is ethical to discuss clinical issues as long as patient privacy is not violated. I am not allowed to give identifying information (eg this patient is the top tennis player in California). I have not done that. On the other hand, I have worried patients who have read my blog and they have felt exposed. I do not think this makes my behavior unethical, but it does give me pause,  a long pause, about which patients I choose to write about, and how I write about them. This is a delicate situation, and as I mentioned in an earlier blog, https://shirahvollmermd.wordpress.com/2010/01/28/my-audience/, if I see that  this blog is harmful, then I will stop  blogging immediately. So far, I have hit some bumps, but I can get back on course. The tension between wanting to express my clinical dilemmas and fearing that I will hurt my patients is strong. My hope is that being mindful of this tension will serve me well. Each obstacle that I have met has helped me. I am now more mindful of the difficulties presented when a patient reads about himself, even if no one else can identify him. I  have learned  this the hard way, and although the hard way is never pleasant, this knowledge will change how I write my blogs. Unethical is not the word to describe my blogs; the word is naïve. I am naïve no longer.