Confidentiality and Its Discontents: Dilemmas of Privacy in Psychotherapy

Confidentiality and Its Discontents: Dilemmas of Privacy in Psychotherapy

Confidentiality and Its Discontents: Dilemmas of Privacy in Psychotherapy

Confidentiality and Its Discontents: Dilemmas of Privacy in Psychotherapy


Freud promised his patients absolute confidentiality, regardless of what they revealed, but privacy in psychotherapy began to erode a half-century ago. Psychotherapists now seem to serve as "double agents" with a dual and often conflicting allegiance to patient and society. Some therapists even go so far as to issue Miranda-type warnings, advising patients that what they say in therapy may be used against them.
Confidentiality and Its Discontents explores the human stories arising from this loss of confidentiality in psychotherapy. Addressing different types of psychotherapy breaches, Mosher and Berman begin with the the story of novelist Philip Roth, who was horrified when he learned that his psychoanalyst had written a thinly veiled case study about him. Other breaches of privacy occur when the so-called duty to protect compels a therapist to break confidentiality by contacting the police. Every psychotherapist has heard about "Tarasoff," but few know the details of this story of fatal attraction. Nor are most readers familiar with the Jaffee case, which established psychotherapist-patient privilege in the federal courts. Similiarly, the story of Robert Bierenbaum, a New York surgeon who was brought to justice fifteen years after he brutally murdered his wife, reveals how privileged communication became established in a state court. Meanwhile, the story of New York Chief Judge Sol Wachtler, convicted of harassing a former lover and her daughter, shows how the fear of the loss of confidentiality may prevent a person from seeking treatment, with potentially disastrous results.
While affirming the importance of the psychotherapist-patient privilege, Confidentiality and Its Discontents focuses on both the inner and outer stories of the characters involved in noteworthy psychotherapy breaches and the ways in which psychiatry and the law can complement but sometimes clash with each other.


Confidentiality matters. We all define ourselves by those aspects of selfhood that we have shown to others and by those other aspects of selfhood that remain private and hidden. in fact, it is the latter part of selfhood, our “private” self, that sets us apart from other people, giving us a sense of uniqueness and difference. No one, not even in the most brutal totalitarian society, can control what we think and feel so long as we choose to keep those thoughts and feelings to ourselves.

Confidentiality matters even more to those of us who, in seeking the help of another person with our inner or interpersonal difficulties, choose to expose our inner world to that “other” in the hope of coming to a better understanding of ourselves. This is the goal of psychoanalysis and similar forms of psychotherapy, where we drop the barrier of personal secrecy and risk making intimate disclosures to a person we trust. the quality of help we derive from such an experience depends on our willingness to place our trust in such a person.

But beyond that, confidentiality matters even more when we engage with another person in a process of self-discovery and through that process discover aspects of our inner lives that even we have never been able to access. Those aspects of ourselves have been walled off from us because they are in one way or another so unacceptable in our role as civilized beings that an active psychological process causes them to be unconscious.

When Sigmund Freud abandoned the use of hypnosis as a method to discover the unconscious inner lives of his patients and adopted instead new methods of psychological treatment, eventually to be called psychoanalysis, the most significant change he made was the introduction into the clinical situation of a device called “free association.” in this method of treatment, the patient is instructed to look inward at his or her stream . . .

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