Prior to 1990, the psychiatric literature often contained detailed clinical case descriptions. These descriptions allowed us to communicate important and nuanced aspects of our psychotherapeutic work. Providing detailed descriptions of interactions that occurred between patient and therapist moved our field forward by both honing our technique and considering more effective ways to help our patients.
Today, the vast majority of professional publications are available to anyone with access to the internet. Perhaps as a result, the number of detailed descriptions in journal articles have decreased, and some have even stopped publishing case reports. In turn, this deprives our field of the opportunities to provide optimal stewardship of our unique and valuable knowledge base. (Of course, presentations to exclusively professional audiences continue; these seminars and conferences remain viable options that can offer this same rich clinical material.)
To maximize our continued progress, we need to retain our practice of presenting detailed clinical reports. Only detailed narratives provide the actual, in-the-moment, give and take of clinical work. Unfortunately, using composite or disguised cases, now a common practice, creates fiction that may fall short of guiding us to the answers, and even to the questions, about real psychotherapeutic process. For example, to achieve anonymity, we may consider changing a refugee from Sudanese to Armenian. That may seem a small detail with no obvious impact until we consider the huge difference between the trauma these two diverse cultures experienced.
There is an inherent dilemma when we publish detailed clinical material. On the one hand, we commit ourselves to providing confidentiality to our patients. On the other hand, we need to consider how to continue moving our field forward by publishing meaningful, detailed clinical material.
Before the internet, there were three generally accepted ways to accomplish this:
• Publish the material and hope the patient would never find it;
• Disguise the identity of patients and change the details of the case so the patient is not recognizable;
• Inform the patient of an intent to publish and obtain the patient’s consent.
Prior to the internet, journal articles were much less accessible to the public. Now, published material can be retrieved rapidly by anyone with internet access and the thought that patients will not find their therapist’s published work is simply naive.
Since clinicians who participate in educational activities are sworn to maintain the same confidentiality as the treating clinicians, teaching and professional presentations are not considered violations of patient confidentiality. Even in these situations, though, we customarily provide only de-identified material to reduce the chances of accidental disclosure.
Group for the Advancement of Psychiatry Committee on Professionalism and Ethics: Philip J. Candilis, MD, Interim Director of Medical Affairs and Director, Forensic Psychiatry Fellowship, Saint Elizabeth’s Hospital, Washington DC; Theodore Fallon, Jr, MD, MPH, FABP, Clinical Associate Professor of Psychiatry, Drexel University College of Medicine, Philadelphia, PA; Karen G. Gennaro, MD, MBA, Director, Online Intensive Psychotherapy Program, William Alanson White Institute of Psychiatry, Psychoanalysis and Psychology, New York, NY and Department of Psychiatry, St. Vincent’s Hospital, Harrison, NY; Sheila Hafter Gray, MD, Adjunct Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda MD; Edmund G. Howe, MD, JD, Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD; Robert Nesheim, MD, Executive Medical Director Emeritus, Hamm Memorial Psychiatric Clinic, St Paul, MN and Consulting Psychiatrist, Sawtooth Mountain Clinic, Grand Marais, MN.
The committee reports no conflicts of interest concerning the subject matter of this article.
1. Gabbard GO. Disguise or consent: problems and recommendations concerning the publication and presentation of clinical material. Int J Psycho-Analysis. 2000;81(Pt 6):1071.