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Psychotherapy

Review of "Confiding"

By Susan Baur
HarperPerennial, 1994
Review by Christian Perring, Ph.D. on Mar 31st 1998
Confiding The literary genre of therapists' tales is by now well established. Case histories of abnormal psychology have always had plenty of intrinsic interest because of the strange ideas or behavior of the patients. Then there is the search for the cause and the cure, which often gives a story of therapy the flavor of a whodunit. Generally we are led to admire the wisdom and ingenuity of the therapist, and one of the principle dangers of the genre is that the author-therapist comes off looking smug and self-important. This is not a danger that Susan Baur succumbs to, since most of the cases in Confiding end with either no obvious progress or downright failure.

 Baur's approach is also unusual in that she includes much more abstract discussion than most therapists' tales. The structure of the book is basically that the odd numbered chapters are stories, and the even numbered chapters, which have all the footnotes, are discussions of themes that emerge in those stories. It's an effective way of making theoretical discussion more approachable to a wider public, sandwiching it in between the details of people's troubled lives.

 The main theme of the book is the importance of telling the narratives of people's lives. This is a well worn idea when it comes to health people and the worried well, but Baur argues that stories are also important for people with serious mental disorders such as schizophrenia. She develops a subtle view as she bridges the traditional divides between nurture versus nature and psychotherapy versus drugs. She is sympathetic to some recent innovations in psychoanalytic theory, yet she does not pretend that talk therapy can cure serious mental illness. Nevertheless, she passionately argues that the effort to understand the threads of patients' lives is an essential part of good health care, and she roundly condemns the trend of managed care's reduction and rationing of talk therapy for the seriously ill.

 This theme makes it fascinating to compare Confiding with Carol Austad's Is Long-Term Psychotherapy Unethical? (See review below). Both Baur and Austad believe that our current system of health care is failing, with too much bureaucracy and too many people getting no treatment. But Austad argues that long-term talk therapy is a luxury that we cannot afford in a rational prioritizing of psychiatric treatments unless it can be proven to be effective, and that the value of most such therapy is unproven.

 Since Baur is not claiming that talk therapy cures, we might wonder what value it has. Baur does bring in some scientific studies, such as those which have shown that when therapy begins, use of medical facilities drops. But her focus is on less quantitative studies and ideas. She is interested in how our self-perception relates to the stories we tell about ourselves, and how the exchanges and repetition of stories between two people changes their self-understanding. She argues that awareness of the details of stories helps us to understand people, and helps prevent our behavior towards patients be dictated by the diagnostic labels they have been given. Through a wider understanding of stories of people with severe mental illness, the public could come to fear them less, and so have less need to insist on a black and white divide between crazy and sane. Baur emphasizes that we can only understand a person through understanding his or her family and social context; sometimes the context dictates the course of the person's life, and individual therapy is almost powerless to change the unfolding of that family story. But the stories we tell of ourselves are what make us who we are, and it is ultimately only through changing those stories that we can change.

 These ideas are profoundly interesting. They help us see how even when we can't measure the benefit of talk therapy, high quality treatment may require us to see the patient as a person to be engaged in conversation. True care involves deep interaction between the patient and the therapist. Baur's tales of her patients illustrate her claims well. But of course they don't prove her claims. It is all too easy to imagine Austad saying that such commitment is admirable, but that we need to face today's realities. The quality of life issues on which Baur focuses are not measurable through statistical surveys, and right now we are not even managing to give half-way decent care to millions of the mentally ill.

 Even though I tend to agree with Austad's requirement of provable effectiveness in therapy, work like Baur's is indispensable. These days it is rare to see a popular book discuss any treatment apart from psychotropic drugs for people with serious mental illnesses. Baur's tales of people struggling with their lives and her discussions of the implications of her experience as a therapist don't promise any easy solutions, but they remind us what ideals of therapy we should aim for.

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