Fiction: “Confidentiality”

I get them a lot, twenty-somethings who can’t keep their hair or clothes or face the same for a month without getting restless. Maybe they’re just out of college and have been students too long to know how to do anything else, and now they don’t have that to string their identities to. Maybe they’re feeling cheated by the promise that these are the best years of your life. Maybe they’re working, envious of their peers who aren’t—or aren’t working, ashamed at not being real adults yet.

I ask, “So what made you want to try counseling?”

They say, “I don’t know what to do with myself.” Or, “I don’t feel like I have a purpose anymore.” Or, “I don’t have motivation to do anything.” Or, “I’m not doing what I should be.” Variations on the same themes, familiar and predictable.

Now, Peter Lawrence sat perched on the edge of the client chair like a sprinter waiting for the pistol while I read over the new client form he’d filled out in the waiting room. He was twenty-four, a graduate student and piano tutor on the side. No medications. No chronic health concerns. No emergency contact, either, so perhaps no one close.

“So, Peter,” I said, looking for a way to calm his tension. First-time patients sometimes fear questions like, Do you ever have sex dreams about your mother? “What are you studying?”

“Composition,” he said. “Music, I mean. Orchestral stuff, mostly.”

“Interesting.” I made a note of it. “You enjoy music?”

He nodded. “Yeah.”

“You play piano?”

“Yeah. And viola. Other things, sometimes, but those are the ones I’m best at.”

“What sort of music do you write?”

“Mostly small things.” As if this was a shortcoming he was confessing. Never having worked with a composer before, I had no idea. “Sonatas, that sort of thing. I’m writing a symphony for my thesis.”

“Impressive. Your first symphony?”

He shook his head. “First in a while, though.”

“So,” I said, because his posture had relaxed slightly—still erect, but I’d worked with a classical pianist who’d sat the same way, and this was probably what at ease looked like for him, “what made you want to try counseling?”

“I have to,” he said.

This is a reason I don’t work with teenagers. Adults can choose to come to counseling; teenagers are often sent by their parents, and resentful of it. They’re there to placate someone, and that’s it. They’re not unreachable, but I do better with the people who start off wanting to be reached.

“Okay,” I said. “Why do you have to?”

“The university …” He scratched his brow. “They think I’m not stable enough for the ‘rigorous academic environment.’ That’s how they put it, at least. So I have to get a therapist to talk to them and tell them I’m okay.”

Not only was he here out of obligation—he was here with active incentive to lie.

“Do you know why they’re concerned about you?” I asked.

“I was talking to my thesis advisor about the symphony I’ve been working on.”

“Okay.”

He nodded, silent, as if his explanation ended there. I have an unwritten policy: if a client hasn’t spoken after three mental recitations of the alphabet and doesn’t seem to be composing thoughts, I give another nudge. It allows enough silence to begin to get uncomfortable, which often prompts speech, less shaped by guidance. But after the third w-x-y-z, when he hadn’t continued, I said, “What were you talking about?”

“He said my second movement sounds too much like the overture from Swan Lake.”

“Did that upset you?”

He shrugged. “No. I mean, it makes sense. I feel a lot like I did writing Swan Lake.”

“When was that?”

He shifted in the chair, as if the once-soft seat had turned lumpy and hard. “A while ago. I don’t know.” He stared past me, eyeing the abstract painting on the wall at my back. It’s a cluster of figure eight swirls, blues and greens, tranquil and unimposing. I don’t like it, but I don’t have to see it, and it gives people something to look at other than me without angling their heads away, hiding their facial reactions.

“Tell me more about Swan Lake,” I said, looking to return to something a little safer before he could shut down.

“It’s a ballet. There was a movie about it a few years ago. You’d recognize parts of it, probably.”

“Is yours an adaptation?”

His face hardened to the blankness of a mannequin. I gave him three alphabets.

“You seem upset, Peter,” I said. “Can we talk about why?”

“My advisor,” he said, “is worried I’m snapping under the pressure of working on this piece. He didn’t believe me when I told him, so I just need you to tell him I’m not crazy.”

“You’re not crazy,” I said. “Everyone gets stressed sometimes. We just need to find ways to handle it. How do you deal with stress now?”

He shook his head, finally looking away from the painting and back at me. “That’s not … I mean, it’s not just that. He does think I’m crazy. I told him something, but he didn’t believe me.”

“What did you tell him?”

“I wrote Swan Lake. I remember doing it. I remember growing up here, but I remember before that, too. I died once in 1893, in Russia. Now my name is Peter Lawrence, but then, I was”—his voice took on a Slavic accent as he said the name—“Pyotr Ilyich Tchaikovsky.”

No post-graduate malaise here, or thesis anxiety. This was the sort of thing they tell you from the start not to expect—that if you’re going into clinical psychology hoping to work with the paranoid schizophrenics and much-hyped dissociative identity cases, you should reconsider, because you’re likely to be disappointed.

Likely.

“Okay,” I said, giving him a gentle smile. Hoping to convey compassion, not, Yahtzee!

*

Peter signed a confidentiality waiver for both his thesis advisor, Dr. Randolph Jackson, and the student counselor, Greg Michaels. I spoke with Dr. Jackson first, then with Greg. They agreed on most points. Peter did well in his classes, got along with his peers and professors, didn’t have any academic or behavioral problems on record. His work was consistently good, never brilliant. He was reserved but friendly if approached. Both claimed to be shocked by the apparent psychosis.

“It’s just,” Dr. Jackson said, “that he seemed so normal. It never occurred to me that there could be something wrong with him. He isn’t even the odd genius type. Just … normal.”

“He’s a good student,” Greg said. “It would be terrible to have to send him home, but our concern is obviously that the academic environment is too stressful for him when he’s troubled like this.”

It was, they agreed, a recent revelation. Peter had told Dr. Jackson, who had consulted with Greg, and then the three of them had met, and now they wanted to hear what I thought.

“I’ve only met with Peter once,” I said. “He has another appointment later this week. In the meantime, I’d strongly advise allowing him to continue as a student. Just keep an eye on him.”

“If I can do anything else,” Dr. Jackson said, “please let me know. Peter is a fine student. I’d hate to lose him.”

“Thank you,” I said. “For now, just let me know if you see anything concerning. Actually”—the question just occurring to me, although it was obvious in retrospect—“what can you tell me about the real Tchaikovsky?”

*

“The second movement,” Peter said, “is weird. Most people like it fine when they hear it. Reading it, though, gives a bad impression of it. It’s a waltz”—he tapped out a three-beat waltz rhythm—“but it’s in five-four. Do you know much about music?”

“Tell me.” I don’t know much about music, but more than that, I wanted to hear how he would present it to me.

“Well, a normal waltz has three beats per measure—one two three one two three, like that. But my second movement has five beats per measure. It’s harder to feel. Doesn’t seem as natural. It gets sort of broken down into two uneven parts. One two three four five one two three four five. It’s awkward. People dance to two-four and three-four and four-four and six-eight and twelve-eight and four-two and just about every other time signature. Nobody dances to five-four. I wasn’t trying to be revolutionary or buck the norms of society or anything that dramatic. It was just about … I don’t know, doing it wrong, I guess.”

“Why?”

He shrugged. “Why not?”

“Why do it wrong?”

“That’s the thing,” he said. “If you listen to it—just listen, it doesn’t sound wrong. It sounds right on the surface. It’s wrong on the inside, but all you’d ever see if you didn’t know to look is a normal waltz. It’s a little heavier still, but so is the whole symphony.”

I had started this conversation by asking, Tell me about your music. Since then, I hadn’t once started to go through the alphabet.

“The final movement of a symphony,” he said, “is always the big one. It’s loud. It’s climactic. It’s dramatic. It wraps everything up. Only mine wasn’t like that. It’s mourning. A dirge.”

“Why write it that way, then?”

“I wanted people to know why I killed myself. Or, at least, I wanted people to have the option of knowing. You leave a suicide note and spell it out, you’re forcing your angst on them. Leave them with a symphony, though, and they can do what they want with it. They can hear the”—he tapped one two three one two three again—“waltz if they want. But if they want to know, it’s there.”

Dr. Jackson had mentioned this. The real Tchaikovsky had died of cholera, likely contracted by drinking unsanitary water.

“On the one hand,” Dr. Jackson had said, “a lot of the water was unsanitary. On the other hand, people knew that and took precautions. So the question is, did he carelessly drink dirty water, or did he use it as a cheap alternative to cyanide?”

Now I knew which theory Peter subscribed to.

“Did you want people to know why you did it?” This question helps you get a sense of how other people factor into the equation in the client’s mind. A client who wants his mother to find his bloody corpse in the bathtub is driven by very different things than a client who wants to go on a business trip and make it look like an accident. There’s an implied judgment, though, in questions like, Are you doing this to make a statement to someone?

“I didn’t care, personally,” he said. “But people like to know. It seems like not having an explanation makes it more haunting. I didn’t want to sensationalize myself with mystery. If I had anything worth leaving to anyone, maybe a note would’ve been important. But I didn’t have much. Just music. I left what I had to whoever wanted it.”

“So why did you do it?”

He exhaled, turned his focus back to the painting. “It’s complicated. I just never fit quite right. I was in a lull for a while—couldn’t write anything. And then the symphony started, and it came so easily—it was like being on speed, or at least how I imagine speed. I was working on the second movement when I realized it was a suicide note. It’s not like I hadn’t thought about it before. It made sense, once I saw it. I don’t know. That probably sounds weird.”

It did, but there was a more pressing question. “Are you suicidal now, Peter?”

He shook his head, said, “No. That was different. I was more messed up then. Things are pretty good, as long as I don’t tell people about Russia. Hiding is hard sometimes, but last time, it was just … everywhere. No matter where I was, I felt wrong. Now, I know people think I’m wrong, or would, if they knew … but I feel okay.”

“That’s good,” I said. “I’m glad.”

*

I have not stayed in contact with many people from my past, some for good reason, some for no reason beyond out of sight, out of mind. Dr. Madeline Stangler is an exception. She served as my doctoral advisor, supervised my early sessions, assured me that therapists can have their own struggles without being hypocrites. Even after I became licensed, I consulted her on the occasional stubborn client—no names, of course, and no identifying details, to preserve confidentiality. The first time she sought my insight on a case of her own terrified me. Although I’d been in practice for three years, it was only then that I realized I no longer had a mentor, just a peer. I should’ve felt proud, I think, or honored; instead, I felt adrift, like the gravity tether keeping me from flying out into space had suddenly been severed.

After my third session with Peter, I left her a voicemail message: “Hey, Madeline, it’s Rachel. I have a new client I’d really like your thoughts on. It’s one I just don’t know how to approach. When you get a chance, give me a call. Thanks.”

Two days later, we met for coffee after her evening lecture.

“And as far as I can tell,” I said after giving her a summary of Peter’s situation, “he functions fine in his daily life. He just also thinks he’s a dead composer. So my question is, what do I tell the school? They want to know if he’s ‘troubled,’ and he probably is, but I get the sense that if I say he’s suffering from a psychotic disorder, they won’t hear anything after that, no matter how much I say he seems fine to be in school.”

“So you’re wondering if you should be honest about his degree of psychosis or just about his capacity to function in a university setting?”

“Basically.”

“What do you think?”

Having therapists as friends is a great thing. It’s also irritating.

“I think he’s a good student,” I said. “I need to keep working with him to be more confident, but right now it seems like he has a delusion disorder—maybe grandiose, but it’s hard to tell—and is highly functional. I haven’t seen any reason that he shouldn’t be in school. It’s probably good for him to have the structure, too.”

“You don’t want to put the university in the position of a treatment provider. Their job isn’t to give him structure.”

“I know,” I said. Madeline raised an eyebrow. Her approach differs from mine in this regard. I never know if she’s challenging me on something because she thinks I’m wrong or because she wants me to be confident I’m right. “I think if he hadn’t said anything to his advisor, he’d be no worse off than he is now.”

“So you think he doesn’t need any sort of psychiatric treatment?”

I had posed myself this question several times already. It’s a point of debate, one that leaves both sides calling into question the ethics of the other: are there times when someone’s disorder is like a piece of shrapnel, embedded and placed in such a way that removing it would be more damaging than leaving it in place—and if so, what’s our obligation? We can’t do X-rays, after all, or consult anatomical models, or run computer simulations. Do we always seek to return a person to a physician-approved mode of being, or do we try to find the best way for them to get by in the world?

I said, “I don’t know. Some sort of counseling, at least, would be good. Just to give him some guidance on how to manage this. But honestly, pushing the delusion issue right now seems more destructive than productive.”

Madeline tapped a finger on the table, said, “So if that’s your position, what’s in his best interests?”

“Not getting kicked out of school for being crazy.”

“What options do you have?”

Two hours later, Starbucks closed, and in the parking lot, she paused by my car. “You aren’t in an easy position. When it comes to it, though, your client is Tchaikovsky, not the university. Your obligation is to him.”

*

Standard 9 of the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct addresses Assessment, and although I never administered a standardized test to Peter, the school was seeking a general assessment. Section 9.04a states, “Psychologists may refrain from releasing test data to protect a client/patient or others from substantial harm or misuse or misrepresentation of the data or the test, recognizing that in many instances release of confidential information under these circumstances is regulated by law.”

“There are a few things you need to understand, Peter,” I said at the outset of our next session. “If you’re comfortable with them, I’ll tell Greg Michaels that I see no reason you shouldn’t be in school. Okay?”

“Yeah,” he said, although his eyes went wide, wary. “Okay.”

“I mean it when I say I see no reason you shouldn’t be in school,” I said. “But you have some things that make you unique, and not everybody is going to understand that. Think of it like a color you can see but other people can’t. It doesn’t mean you’re wrong for seeing it”—some people call this embracing neurodiversity, which strikes me as a bit too PC, though the sentiment is nice—“but a lot of times, you’ll be better off not bringing it up.”

“The Tchaikovsky thing,” he said.

I nodded. “That’s not to say you can’t tell anyone, just that you should be discreet about it, particularly in professional settings.”

“So what are you going to tell them?”

“What would you like me to tell them?”

He stared at me for a moment, as if the question had snuck up on him.

“There are a couple options I thought of,” I said. “Maybe you have others. I could tell them you hadn’t slept for a few days—staying up cramming work, or maybe because of something going on in your personal life—because that can explain a lot. Or I could tell them you didn’t mean it, like you felt overlooked and were looking for attention, or just that you wanted to see what would happen. Or I could just tell them that you’re fine to be in school and leave it at that. Or—”

“That,” he said. “Just that I’m okay.”

“They’ll probably have more questions. I won’t have to answer—that’s not an issue. But they will wonder, and they’ll probably keep a closer watch on you.”

“That’s fine,” he said. “I don’t want to be there just because you lied.”

I made the call with Peter in the office, just listening. Greg Michaels prodded for details, and I cited confidentiality restrictions while giving Peter my full endorsement, and eventually he said, “I think I speak for Dr. Jackson and myself when I say we’d be more comfortable keeping Peter on if he remained in counseling.”

I glanced at Peter, who was perched in the same anxious position he had been when I’d first met him, and cocked my head. He shrugged, nodded.

“I think Peter would be open to that,” I said.

“You’ll keep us in the loop, I trust,” Greg said.

“No, I won’t.”

“You must understand the university’s concern in this situation.”

“There’s no reason Peter is unfit to be a student,” I said for maybe the fifth time. “That should be the extent of the university’s concern.”

It wasn’t the first time I’d had the conversation, or the last. Eventually, they always realize they can’t sway me and give up, some more bitterly than others. My conversation with Greg ended with his reluctant surrender and my request that he not take his ethical frustration out on Peter. It might not help—Greg’s intentions seemed good, but sometimes the well-meaning ones are the most destructive. I would need to explain to Peter where the school might overstep its bounds, what recourse he had if it did.

After Peter scheduled his next appointment, he said, “It’s okay that you don’t believe me.”

“It is,” I said, resisting the inappropriate impulse to assure him that I did believe him. “I’ll see you next week, Peter.”

But I didn’t. He left a message at 9:34 two nights before to cancel. I called him three times, hoping to reschedule, but the third time it went to voicemail, I said, “Hi, Peter. This is Rachel Sommers. You have my number, in case you decide you want to come in. Take care.”

I kept his file open. I didn’t expect him to return, but it meant I could, without too much discomfort, tell Greg that Peter was still a client of mine, and that that was as much as I was able to say.

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