What We Do, What We Say, What We Don’t Say: Confidentiality In The Publication Of Clinical Writing

Abstract

Questions concerning analysts’ publication of material from the analyses of their patients have troubled the field of psychoanalysis since its inception. Disguise inevitably distorts the clinical material and is often insufficient to protect the patient from recognition. Asking the patient’s consent for publication intrudes upon and alters the analytic process. While analysts have largely reached a consensus about the need for anonymity in published material, there is still considerable debate about the necessity for obtaining patients’ consent when using their material for publication. In this paper, I will trace the evolving meanings of disguise, and particularly of consent, in the analytic literature. I will place a particular emphasis upon the differing theoretical belief systems that underlie the analyst’s decision to ask consent from her patient or not to do so, and I will argue that, although decisions on asking consent remain a complex matter, such coherent belief systems should play an important part in analysts’ decisions regarding consent. I will illustrate my thought processes and some clinical situations with brief examples, and I will conclude with some practical recommendations, with the hope that these will stimulate further discussion in the analytic community.

Keywords:

• Confidentiality
• disguise
• consent
• clinical writing
• clinical vignettes
• publication of clinical material

Disclosure statement

No potential conflict of interest was reported by the author(s).

DISCLAIMER

Potentially personally identifying information presented in this article that relates directly or indirectly to an individual, or individuals, has been changed to disguise and safeguard the confidentiality, privacy and data protection rights of those concerned, in accordance with the journal’s anonymization policy https://www.tandfonline.com/journals/upaq20.

Notes

1 Writing and publishing, of course, are here representative of a more general issue. The analyst’s wishes, both conscious and unconscious, have a shaping influence upon all his thoughts and decisions related to the analysis. Whether or not he publishes, the analyst’s wish to construct a new theory, or to confirm an old one, shapes his listening. If he does intend to publish patient material, unconscious greed and the wish for fame may play a part, along with the generally more accepted conscious wishes to share material, learn, and enrich the field. As with all decisions regarding an analysis, an analyst must be attentive to his motivations, exploring in his self-analysis underlying wishes to write a vignette about this patient at this time and the countertransference themes that shape what he hears and writes. There is no short-cut. All this requires ongoing self-analysis, and perhaps, as Aron (2016) suggests, the seeking of a consult to understand more fully the less conscious elements of the decision to write and publish.

2 The Wolf Man, for example wrote: “From the beginning, I had the impression that Freud had a special gift for finding a happy balance in everything he undertook. This characteristic expressed itself also in the appearance of his home in the Berggasse. I can remember, as though I saw them today, his two adjoining workrooms, with the door open between them, and with their windows opening on a little courtyard. There was always a feeling of sacred peace and quiet here….A few potted plants added life to the rooms, and the warm carpet and curtains gave them a homely note. Everything here contributed to one’s feeling of leaving the haste of modern life behind, of being sheltered from one’s daily cares” (Wolf Man 1958, pp. 351-352).

3 Ms. P’s analysis was conducted four times a week on the couch.

4 Anecdotal reports, however, yield many examples from this era of patients’ discovery that they had been the subjects of published clinical accounts. These include numerous accounts of patients in the field who have recognized themselves in the literature.

5 Ms. A’s analysis was conducted on the couch three times a week.

6 Among the questions raised is the significance of Stoller’s report that none of his patients refused consent for publication. My own experience differs. Following Stoller’s model for the past twenty-five years, I have found that most patients agree to publication; others refuse publication from the start or change their minds when they read the clinical material; if this occurs, I withhold the patient’s vignette, or the entire paper, from publication.

7 Orgad (2014) uses scenes from the movie “Secrets and Lies” to demonstrate how this silent avoidance plays out between characters. He argues convincingly that this is the way Bion’s minus K plays out in action.

8 My impression is that often analysts wait until after termination to write vignettes and get consent at least partly to foreclose the possibility of hearing the patient’s response. There is also a sense that the truth of an analysis is better established at the end, but our theory tells us that this is not so. As Schafer (1983) argues, the essence of the psychoanalytic process is continuing curiosity for new truths. Termination is an interruption rather than an ending to this search.

9 My impression is that this is frequently a part of the patient’s transference from the beginning, as patients often seek out an analyst’s publications before beginning analysis.

Additional information

Notes on contributors

Lucy Lafarge

Lucy LaFarge is a Clinical Professor of Psychiatry at Weill-Cornell Medical College. For many years a training analyst at the Columbia University Psychoanalytic Center, she is now a member of the affiliate faculty at Austen Riggs. She is currently the Editor in Chief of the Psychoanalytic Quarterly and was previously the Editor for North America of the International Journal of Psychoanalysis. She is in private practice in New York City.