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Lying on the Couch

Lying on the CouchWhat happens when a psychologist writes a memoir?

To tell the truth I have to lie.

To write a memoir these days you had better be telling the truth. When I met with the publisher about Confessions of a Former Child: A Therapist’s Memoir, she specifically asked me if what I wrote was true. I hesitated, and a worried look crossed her face. Finally, I insisted it was all true, except for the parts I made up. She told me I needed to explain.

I told her that in essence, as a psychologist and a memoirist I serve at the discretion of both disciplines — the first devoted to understanding the human condition, the second to the condition of being human. Both employ methods of nonfiction writing to achieve their goal, but with a major difference: A psychologist must follow strict guidelines published by the American Psychological Association on how to talk about case studies of patients.

The Publication Manual of the American Psychological Association, Fifth Edition advises three strategies to disguise case material without changing the variables of the phenomena being described. These suggestions may be helpful for other non-fiction writers as well.

  1. Alter specific characteristics
  2. Limit the description of specific characteristics
  3. Obfuscate case detail by adding extraneous material

One, two, or all of these techniques may be needed to achieve the goal. Depending on your choice you should inform readers that you have made these alterations. The Author’s Note for Confessions of a Former Child: A Therapist’s Memoir, reads:

Out of respect for their privacy I have changed the names of some of the people who appear in this book. When referring to individuals I have worked with in therapy, I have followed the American Psychological Association’s guideline to protect confidentiality.

In Confessions of a Former Child: A Therapist’s Memoir, I reflect on aspects of my life and how these experiences influence work with my patients. This is the life work of a therapist, called countertransference — how memories and feelings in our psyche often merge and intertwine with our clients.

When I write about events in my life, the truth, with creative enhancement through metaphor and description to tell the story, is fact. But when I write about my patients, I have to bend reality. To tell their truth I must change features such as names, dates, gender, location and other details about them. I often use amalgams to blend and blur details enough to mask identity, but preserve uniqueness; to do otherwise would be unethical. Because my story involves the story of others, the work is to extract the distinctiveness of their condition, but not specify it to the point confidentiality is breached. There is an essence to the encounter with a patient that can be brought forward even while changing the characteristics embedded in the experience. My goal is to tell the truth, and to quote Frank Lloyd Wright, the truth is more important than the facts.

Let’s talk about Steve.

In the essay “Kettle of Fish” I detail the story of my second cousin Gary (his real name) who managed the famed bar by the same name in Greenwich Village. I was with him at the bar the night he died from a heroin overdose. All the events surrounding the story are true and factually accurate. Here is the opening paragraph to “Kettle of Fish.”

On the back of his right hand the roots of a marijuana plant are growing between his fingers. The tattoo spreads over his knuckles, following his veins, until disappearing under the cuff of his blue-and-white striped Van Heusen. The purple stem and distinctive pointy green leaves scramble up under the sleeve and emerge above his collar. The leaves and stems cross under his neck and disappear into the other side of his shirt. On the back of his left hand, the intense purple-and-green plant is so lush no natural flesh tone is visible. The dark blue suit he wears provides an unlikely background for such a mural. The tattoo is ten years old, a memento of his eighteenth birthday. The suit is new, chosen by the mortician this morning.

Many of the essays in the book move back and forth between events in my life and the lives of my patients. In a typical essay, an experience during therapy will activate a recollection from my life. In “Kettle of Fish,” as the essay progresses the scene changes to my work with “Steve.”

Therapy had gone well for the first few sessions. We talked about a wide range of topics, but focused on the effect drugs had had on his life. During his band’s tours in Europe in the mid-’70s, he had spent time in prisons in Denmark and Paris for drug dealing. He knew friends who had died of overdoses and, of course, there was what happened in Harlem. Even though our sessions started in the summer, Steve, like most recovering junkies, always wore long sleeves. It wasn’t until nearly two months of therapy that I saw the leaf underneath his long-sleeved shirt.

“I see you’ve got a marijuana plant growing under that fine shirt of yours,” I said.

He rolled up his cuff to show me.

“A stupid idea for a tattoo,” he said.

“Let me guess, you used to shoot into the purple stems to keep track marks hidden,” I said.

“You are either one hell of a guesser,” he said, “or I ain’t the first junkie to grace this office.”

“I’ve seen it before,” I said.

“Was the person alive or dead?”

“Good question,” I said avoiding the answer. “What is it like to carry that reminder of your addiction with you?”

The link between my cousin and my patient was established through the true experience of them both being heroin addicts, both being charismatic, and both having similar tattoos. But telling the truth of the story had to be separated from the facts. Steve, of course, was not his real name, and the details of his life, being a Wall Street broker and studio musician, being a federal prisoner and being ambushed in a drug deal in Harlem, were all features either actually taken from his life, fabricated, or borrowed from the lives of other patients. This technique creates a character via an amalgam, yet allows the point of the story, that both were ultimately self-destructive, to be brought to the reader.

Then there is Enrico.

The connection between Gary and Steve could be brought into focus easily even while blurring the details of Steve’s life. But in the title essay “Confessions of a Former Child,” I describe my childhood concern that eating foods with seeds would get me pregnant. (Yes, although sad and bizarre it is totally true). Later in the piece I describe my work as a psychologist with an intellectually disabled adult, Enrico, who shared similar fears.

After I finished graduate school, to make extra money I signed up to administer psychological testing for the state. This type of testing was needed primarily for adults with what used to be called “mental retardation,” people whose intellectual disability caused them to function at the cognitive level of a child. Because I had training as a developmental psychologist, I thought I could deal with this. I believed I had the skills, the talent, the patience, and the desire. I was limited by only one small fact, a minor detail missing from my repertoire of personal and professional experience: I had never actually met a person with an intellectual disability.

Enrico was a big man, very big. He was six feet four inches tall, and two hundred and forty-one pounds. He spoke broken English and had a measured IQ of fifty-two. His family was from Italy, and he had never had the opportunity to get any special education or training back in his country. Enrico’s father was a wealthy businessman who shunned Enrico and only allowed him to work on their large estate. Enrico was an embarrassment. He was, however, used to doing lots of heavy physical labor. He was strong, but at the age of twenty-eight he knew nothing of the world. A simple, innocent man who knew only how to work hard.

His family moved to the United States for the business opportunities it afforded his father. The entire family—Enrico’s mother and father, two sisters, four brothers, aunt, grandmother, housekeeper, gardener, and family dogs (there were six of them)—moved into a large home in the west end of our county. Within two weeks Enrico was lost and victimized in the new world. He had been arrested three times for exposing himself in public; he was beaten by a gang of youths who mistook him for a rival gang member; and he announced to his family that a woman named “Mary” would become his wife and have sex with him if he gave her a thousand dollars.

Welcome to America.

Notice the number of Enrico’s identifying characteristics: gender, size, weight, ethnicity, IQ, education, family, socioeconomic status, work style, type and number of pets, sexual proclivity, legal record, gang connection, and issues with poor decision making. Some of these things were, indeed, part of the profile of the person I was writing about, and some completely extraneous detail designed to mask Enrico’s identity, and enhance the reader’s sense of character.

But the primary goal of the description is achieved: to introduce the reader to an individual who, because of his disability, will have thoughts that mirror the way children look at the world. This is the essential factual feature for the arc of the story: specific thoughts I had as a child reflected back to me by an intellectually disabled patient about how someone becomes pregnant.

The worried look on my publisher’s face softened and my debut memoir was sold for an advance of six figures. This is true. Just keep in mind that two of those figures were to the right of the decimal.

Lying on the Couch

Daniel Tomasulo, Ph.D.

Dan Tomasulo Ph.D., TEP, MFA, MAPP teaches Positive Psychology in the graduate program of Counseling and Clinical Psychology at Columbia University, Teachers College and works with Martin Seligman, the Father of Positive Psychology in the Masters of Applied Positive Psychology (MAPP) program at the University of Pennsylvania. He is Director of the New York Certification in Positive Psychology for the Open Center in New York City and on faculty at New Jersey City University. Sharecare has honored him as one of the top 10 online influencers on the topic of depression. For more information go to: He also writes for Psych Central's Ask the Therapist column and the Proof Positive blog.

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APA Reference
Tomasulo, D. (2018). Lying on the Couch. Psych Central. Retrieved on October 18, 2019, from
Scientifically Reviewed
Last updated: 8 Jul 2018
Last reviewed: By a member of our scientific advisory board on 8 Jul 2018
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