Cultivating a Culture of Concern Regarding Confidentiality in Writing About Child and Adolescent Psychoanalysis

It has been five years since the International Psychoanalytical Association (IPA) accepted the comprehensive report of the Confidentiality Committee providing contemporary perspectives on preserving confidentiality of patients’ clinical material in training, professional exchange through presentations and publications, and in the use of telecommunications for treatment, teaching, and supervision. An overarching recommendation of the committee was to “foster a culture of confidentiality in which protection of the patient’s privacy and dignity becomes a paramount concern at every point in the development, sharing, and presentation of clinical material” (2019, 11). We believe such a “culture of concern” can develop within the psychoanalytic community worldwide as a manifestation of a shared commitment to helping one another ensure that patients’ rights and expectations for confidentiality are honored in our scientific literature. Challenging oneself to ask the following questions is a start: Why am I writing? About whom? For whom? When is an appropriate time to write about a case? What is the context or where is the setting? How is the material being used and for what purpose? Consulting with trusted colleagues before publication of clinical material is one step in monitoring how an analytic author’s unconscious may lead to blind spots in writing. During the publishing process itself, having several pairs of cautious eyes on the content – including those of each author, editor, and reviewer – is another level of safeguarding. Details that may seem precious to the writer may be unnecessary for the reader. Being transparent about the fact that steps have been taken to protect confidentiality provides an ongoing reminder about the necessity of doing so. The aim is to build a sense of mutual responsibility for the welfare of all patients.

Confidentiality in publishing child and adolescent case histories

Although the IPA report did not specifically address child and adolescent psychoanalysis, during a webinar sharing their findings in June 2019 members of the Confidentiality Committee did acknowledge that there are special circumstances that pertain in working with children, adolescents, and their families. Notably, the reference section and lists of further reading do not contain resources from the child literature on the topic of writing about case material, nor does a PEP search under the subject “confidentiality” turn up titles regarding writing from the major child journals.

Freud, in his introduction to his “Analysis of a Phobia in a Five-Year-Old Boy,” wrote that he had permission to publish the father’s notes on his treatment of his own son Hans. In a postscript added in 1922, Freud notes the remarkable fact that:

When [Hans] read his case history … the whole of it came to him as something unknown; he did not recognize himself; he could remember nothing; and it was only when he came upon the journey to Gmunden that there dawned on him a kind of glimmering recollection that it might have been he himself that it happened to. So the analysis had not preserved the events from amnesia, but had been overtaken by amnesia itself. (Freud 1909, 148–149)

In his preface to the analysis of 18-year-old Dora, he wrote:

… in my opinion the physician has taken upon himself duties not only towards the individual patient but towards science as well … [and] the many other patients who are suffering or will some day suffer from the same disorder. (Freud 1905, 8)

Ápropos of the questions posed at the outset of this communication, Freud described measures he took to protect Dora’s right to confidentiality: He chose to write about a patient who was not from Vienna, whose identity he had only disclosed to Fliess; he waited four years after the treatment ended and her life circumstances had changed before publishing; he did not reveal any names; and he relied on the scientific nature of the journal in which he was publishing to limit the risk of exposure.

In my (DB) role as the editor-in-chief of the journal Child Analysis: Clinical, Theoretical, and Applied, I wrote two editorials addressing the inherent conflict Freud identifies between protecting confidentiality while at the same time contributing to the knowledge base of the profession. In the first of these, “Publish or Perish: An Editorial on Confidentiality in Child Analysis,” I reflect on some of the points Freud made.

Can a parent give “informed consent” on behalf of a child patient? Can a developing child give informed consent on his own behalf? Is a child able to comprehend and appreciate the meaning and implications of consent not only in the present, but at future points in his life? If so, at what age? Is a child patient any less affected than an adult by the transference ramifications of being asked to give consent? Is he less affected by the effects of countertransference when the analyst is writing about – or even thinking of writing about – an ongoing case (regardless of whether permission is obtained)? Should one contact a former child patient, his parents, or both, to request permission to publish? Should one state at the outset of treatment that one may write or present aspects of the analysis or work with the parents? What devices, if any, should one use to disguise the identity of the child, parents, siblings, and other family members who may figure in the analytic material? … Does the repression which occurs at developmental junctures – postoedipally and at the end of adolescence – affect a child’s memories of his analysis?¹ (Barrett, June 2001, 6)

In that editorial I conclude that we must publish clinical papers in order to survive as a vital force contributing to the ongoing psychoanalytic understanding and treatment of children and adolescents.

The illusion of informed consent in psychoanalysis

During the last decade of the 20th century and early years of the 21st, a number of psychoanalysts addressed themselves to confidentiality in the presentation of clinical material (Aron 2000; Furlong 1998; Gabbard 1997, 2000; Klumpner and Frank 1991; Lipton 1991; Michels 2000; Tuckett 2000). In that era the idea of obtaining informed consent from patients reflected the practice in psychiatry and in medical research involving human subjects. Glenn Gabbard, in his 2000 paper “Disguise or consent: Problems and recommendations concerning the publication and presentation of clinical material,” explicitly states that if consent is obtained, its impact should be “thoroughly and unflinchingly analyzed” (Gabbard 2000, 1083). One practical problem with this is how it can be done if one is writing about a patient whose therapeutic work has ended (something he recommends as “preferable”). At the time, he considered consent to be necessary if the patient was in the mental health field – though there is no mention of a parent in the mental health field whose child might appear in a case study as a patient. Gabbard himself points to a problem with disguises when these may mislead readers into generalizing erroneously about specific details, e.g. medical conditions, jeopardizing scientific accuracy and integrity.

The IPA Confidentiality report recognizes that there is wide disagreement among contemporary analysts about asking patients for consent to use their clinical material outside of the analytic space, with some believing it is required and may be beneficial, some believing its potential for harming the treatment or the patient outweighs its benefits, and still others believing the decision should be made based on individual situations. The report states:

The object of analytic inquiry, the unconscious, complicates any notion of informed consent within the transferential field. Neither the analysand nor the analyst can be immediately aware of all the unconscious motives that impel permission for the sharing of clinical material and neither of them can predict the future après-coup impacts of such a decision. There is therefore an inherent ethical uncertainty about informed consent in psychoanalysis, given the always-only-partial knowability of transference and countertransference. (International Psychoanalytical Association, Committee on Confidentiality 2019, 10)

The psychoanalytic electronic publishing archive

The reliance on publishing in journals intended solely for a psychoanalytic audience as a form of protecting patients became obsolete with the appearance of The Psychoanalytic Electronic Publishing Archive (PEP) a quarter of a century ago. In preparing a second editorial in 2008, “Child Analysis – A PEP talk from the editor,” (Barrett 2007/2008) I spoke with Nadine Levinson, one of the original founders, about the implications for patient confidentiality. She replied, “Frankly, once you have published, your clinical material is accessible to someone, somehow” (N. Levinson, pers. comm., 2008). Her conclusion is all the more true today and potential legal ramifications of writing about patients are added to the moral and ethical dilemmas.

Anonymization – A sea change

Francis Grier, the current editor of The International Journal of Psychoanalysis, describes the status quo in many contemporary psychoanalytic journals (Grier 2023). Authors who seek consent from their patients may consciously or unconsciously take too few precautions about disguising details that may risk revealing an individual’s identity. Authors who do not want to intrude on the treatment process by asking for permission to publish may claim compelling reasons why their paper should be an exception to the rule requiring consent. Would-be authors may decide it is no longer safe to write about anyone. Grier’s editorial eloquently moves from the problems with consent to propose an “ethical shift” in which an author’s use of material from any patient becomes less about the patient as an individual and more about an analytic experience in which that person is transformed through the writing into an “exemplar” from whose work other analysts can learn. He reports on the recent efforts of a group of editors and publishing colleagues² who met to develop a revised policy and specific guidelines for making strong anonymization, rather than requiring patient consent, the fundamental principle and standard for authors to meet. In Grier’s words, “anonymisation is primary, and de rigueur” (2023, 983).

Psychoanalytic journals published by Taylor & Francis, including The Psychoanalytic Study of the Child, will soon be implementing a new policy that will include guidelines for anonymization and rigorous expectations for authors to provide details about the steps they have taken to comply with the specific journal’s requirements. Consent will no longer be mandatory, though any analyst may choose to ask it from their patient, and consent will not obviate the need for strong anonymization. How strong is strong? Authors will be required to stipulate that no third party would be able to recognize the patient or any other persons who may appear in the paper and, insofar as possible, patients would not recognize themselves. Authors will be advised that special care should be taken in cases that involve children and adolescents. Journals represented on PEP will soon be required to meet these same standards. Word is spreading among editors of journals with other publishers and there is hope for an enlarged “community of concern” that shares the principle of anonymization as the measure most protective of patients.

Guidelines for anonymization

To alleviate the anxiety that authors may feel reading about these changes, it should be emphasized that the “new” guidelines for anonymization are not so different than those most already employ in their writing. Details to be disguised or omitted include names, place of birth, exact ages, occupation or education, other affiliations, location, time frame, and exact length of the treatment, specific medical conditions, and identifiable family history and trauma. There will certainly be challenges that require creative solutions and vigilance. Closer scrutiny will help assure that implicit biases must be recognized when including, altering, or eliminating identifiers such as race, ethnicity, class, religion, nationality, and gender (Barrett 2012). As the new guidelines are implemented, questions and problems will arise. Grappling with these will allow for improvements and guiding best practices.

To our contributors and our readership

Those of us who write about psychoanalytic treatments of children, adolescents, and emerging adults will have to devise some new ways to convey the richness and unique aspects of work with patients at different ages and developmental moments. We will have to find ways to write about play, artwork, messes made in the office, as well as the physical closeness and action that working with children involves, in a way that reveals meaning and process while carefully protecting the identities of the patients themselves. In addition to changes in the way we write, we will be changing the way that we read as we become less focused on concrete details and more invested in tuning in to what the patient and analyst have to teach us in the story being told. We believe this can be done and that we can help one another write better and write more, to the benefit of our patients and their families – and the community of child and adolescent psychoanalysts.

Notes

1. The question as to what, if anything, patients who were in analysis during their childhood or adolescence remember of their treatments is an important and interesting one. Midgley (2012) writes about Peter Heller’s adult recollections of his childhood analysis with Anna Freud, published after she sent him notes from their work. Luepnitz (2017) interviewed Winnicott’s “The Piggle,” after the former-patient-now-adult contacted her. She did not remember the treatment with the exception of one session about which she felt guilty for having killed Winnicott with a rolling pin in fantasy. When she heard a CD of Winnicott giving a BBC lecture, his distinctive voice was not familiar to her. One of us treated a patient in latency and adolescence who as an adult reached out with questions about why the parents insisted on treatment. The patient had little memory of the analysis and when given the opportunity to read something the analyst had written about the treatment, did not recognize themselves as the patient described. Additional anecdotal information and research on this topic is needed to validate or dispute our hypotheses about the effects of amnesia.

2. Stephen Seligman, former Editor of Psychoanalytic Dialogues; Francis Grier, Editor of The International Journal of Psychoanalysis; Denia Barrett, Co-Editor-in-Chief of The Psychoanalytic Study of the Child; David Tuckett, CEO of Psychoanalytic Electronic Publishing; and Adam Burbage, Global Head of Portfolio in the Behavioural Sciences at Taylor & Francis.