Confidentiality: Ethical Perspectives and Clinical Dilemmas

CHARLES LEVIN, ALLANNAH FURLONG, MARY KAY O'NEIL, (EDS.): Confidentiality: Ethical Perspectives and Clinical Dilemmas. Hillsdale, NJ: The Analytic Press, 2003. 352 pp., $55, ISBN 0-88163-355-0. Psychotherapy happens in the privacy of a privileged space, a quiet room away from the eyes and ears of the world. By stark contrast, psychotherapy is also a profoundly social contract, defined by professional, legal, and societal norms regarding technique, oversight, fees, pedagogy, licensure, and proper conduct. Protecting privacy within the boundaries of a socially defined space continues to be a controversial and critically important ethical activity for psychotherapists, patients, and the democratic societies that support their practices. At the beginning of a new century, many forces threaten the confidentiality of psychoanalytic psychotherapy. Some, like managed care insurance, are new, arrogant third parties on the scene. Others, like professional boards and psychoanalytic institutes, have always hovered above the therapy room, providing guarantees of propriety while also threatening to subvert the process. From time to time, the juridical system has compelled psychotherapists to disclose privileged communications in the interest of national security, child welfare, or civil dispute. So what exactly does confidentiality mean in the 21st century world of psychoanalytic psychotherapy? Confidentiality: Ethical Perspectives and Clinical Dilemmas is a carefully edited multi-authored volume that provides the widest possible range of competing answers to this question. Like any excellent text about ethics, this work raises many more questions than it resolves, and provides no definitive guide to personal practice. In fact, the authors leave few assumptions unchallenged regarding the privacy of psychotherapeutic discourse. Chapters are broadly divided into several themes: the interface between clinical privacy and the pursuit of training and knowledge within the field, dilemmas in clinical confidentiality, and the interface between the clinical world and legal systems. Even as the privacy of the analytic space has been a core value of psychoanalysis from its beginnings, the world of the analytic institute (its courses, supervisory meetings, training analyses and case-based publications) has systematically abridged that privacy. Who owns the narratives emerging in the therapeutic process? At one pole, Jonathan Lear argues that confidentiality is not merely one value among many that apply to the practice of psychoanalysis; confidentiality is the bedrock upon which psychoanalytic practice is based. Its infringement eliminates the very possibility of the practice. In particular, Lear argues that displacing a patient's narrative into the professional literature or the pedagogic activities of a psychoanalytic institute irreparably harms the therapeutic relationship. He challenges the idea of informed consent for such dissemination, doubting whether patients are ever in the position of freely agreeing or disagreeing with their therapist's request for permission to write about their work. By contrast, Allannah Furlong proposes a more flexible approach to confidentiality in view of the legitimate aims of pedagogy and scientific discourse. She worries about the "concretization" of confidentiality when too strictly defined. She prefers to regard confidentiality as a "flexible skin" rather than a straightjacket, designed to offer protection but also capable of being expanded for the needs of learning, clinical intervention, and research. With respect to the intrusions of juridical authority, this volume includes Anne Hayman's reflections regarding her courageous defiance of a court order to testify about an analysand 36 years ago before a British court, even to the extent of confirming that she had treated this patient. She articulates the necessity of absolute privacy in the analytic setting, and the requirement that analysts be willing to risk legal retribution to preserve their clinical commitment to nondisclosure. …