Disquiet in the consulting room: everything/nothing that is said here is confidential

Writing from experiences in the consulting room in private practice in Australia, the author refers to the layered complexity of a conflict of ethical duty which has legal and social implications. The paper explores how the ethics that are congruent with creating a safe vas bene claustrum can be diametrically opposed to the social and legal structures and processes on which we all rely. It is suggested that within the vas, analysts and analysands engage in a shared process of emotionally connected, layered, symbolic thinking. Subpoenas directed at analysts are seeking concrete evidence that will stand up in court. The paper argues that this is a category error based on ignorance and misconceptions of what analytic work entails. The intrusion of a subpoena into the vas has the potential to cause havoc in the mental health and the lives of already vulnerable, possibly traumatized and isolated individuals. It can undermine a fundamental human right and undermine the profession of psychotherapy as a whole. The paper proposes that analysts have an ethical obligation to protect the work contained within the vas from these category errors and to educate other professionals as to why we cannot provide the kind of evidence that the courts require.     

Working Online During the Contemporary COVID-19 Pandemic1

Within the psychoanalytic school there has been substantial and ongoing debate about the efficacy of teleanalysis. However, as a result of the current COVID-19 pandemic and the online work with which the Jungian analytic community has now had to engage, this paper initially focuses on analysts’ actual experiences of working by teleanalysis. These experiences highlight a range of issues like “Zoom fatigue”, “online disinhibition”, dissonance, confidentiality, the frame and working with new patients. Alongside these issues, there were ample experiences by analysts of both productive psychotherapy apace with analytic work involving transference and countertransference phenomena, all indicating that a genuine and good enough analytic process can occur with teleanalysis. An overview of the research and literature both prior to the pandemic and as a result of it, confirms the validity of these experiences so long as analysts are cognizant of the specifics of such an online modality. Conclusions to do with the question, “what have we learned?”, alongside training, ethics and supervision issues are subsequently discussed.     

Confidentiality, privacy, and the facilitating role of psychoanalytic organizations

Burgeoning external threats to confidentiality by claims to clinical information create unprecedented challenges for psychoanalysts. Internal threats arise from the use of clinical material for educational, scientific and historical purposes. Traditionally, confidentiality is considered a patient's right and an analyst's obligation; privacy is not usually stated as a professional requirement. Little consideration has been given to the impact of the confidentiality and privacy dilemmas that analysts encounter throughout their careers. There has been no systematic examination of the confidentiality policies of psychoanalytic organizations, nor has their role in facilitating maintenance of patient confidentiality and analysts' privacy been made explicit. The research reported here was undertaken to address these issues and to obtain baseline information about the current confidentiality policies and practices of psychoanalytic organizations in three English-speaking countries (Britain, Canada and the USA). The author discusses survey results in the light of the challenges which arise at each phase of the analytic career. She makes suggestions as to how psychoanalytic organizations can and should facilitate analysts' resolutions of contemporary confidentiality and privacy dilemmas.     

Commentary on Steven H. Cooper’s Paper “Blurring Boundaries or Why Do We Refer to Sexual Misconduct With Patients as ‘Boundary Violation’”

In this commentary on Steven H. Cooper’s paper, the author acknowledges that the term boundary violation presents a vexing problem when we try to integrate it with the traditional use of the term boundary in psychoanalytic thought. He suggests that the two discourses represent two separate but somewhat related levels of discourse and that overlap occurs in some areas but not in others. While the use of “boundary violations” to describe ethical misconduct presents problems, the author suggests that it may be useful for some analysts who have experienced a collapse of analytic space and can no longer “play” in a symbolic realm. He also suggests that we may be stuck with the term because of the unconscious function it serves for the analytic community.     

Psychologists' perceptions of legal and ethical requirements for breaching confidentiality

This paper outlines the legal and ethical duties of psychologists in relation to preserving as well as breaching confidentiality in therapeutic relationships. It analyses the results of a questionnaire examining psychologists’ perceptions of the legal and ethical constraints on confidentiality and their likelihood of breaching confidentiality in different situations. The vast majority of participants indicated that the law permits them to disclose confidential information and that there is an ethical duty to disclose information to a third party when the patient is perceived to be dangerous. The results suggest that there is some uncertainty as to when confidentiality should be breached in practice and it is argued that the law is overly complex in this area and that guidelines are needed to assist psychologists in their clinical practice.     

Working online due to the COVID-19 pandemic: a research and literature review

Given the contemporary situation of many analysts in the world now being forced to work online due to the effects of the COVID-19 pandemic, it is important to review the working online issue. Substantial debate over previous years has questioned whether a genuine analytic process can unfold through online work. This debate is reviewed with the conclusion that such a process is not necessarily precluded. Research outcomes are then reviewed to highlight those things that can facilitate positive outcomes when working online. These cover the ‘online disinhibition effect’, the therapeutic alliance, particular ways of using the screen, focussing on trauma, the importance of self-awareness, knowing the predictors of mental health, certain potential positives of isolation/quarantine and psychotherapy interventions that may be currently needed. Final recommendations and suggestions are then presented as in the diagnosis issue, professional development and guidelines to do with practical and ethical considerations.     

Informed consent as a prescription calling for debate between analysts and researchers(1)

This article is a review of the international scientific literature on informed consent and its use in some of the constituent organizations of the International Psychoanalytical Association (IPA). Because psychoanalysis comprises a theory based on practice, the dearth of clinical material for study, training and research purposes is a serious problem for analysts. Supervisions, presentations at scientific societies and congresses, publications and teaching material involve patients to an extent that goes beyond the work done in their sessions. Should consent be requested in these cases? This contribution addresses controversial and long‐standing issues such as informed consent and confidentiality, audio recording of treatments, knowledge production, the ambivalence of participating subjects over time and the perspective of analysts and patients respectively. The authors consider the various alternative approaches available for the handling of these ethical dilemmas without losing sight of the patient’s dignity and personal rights, while also taking account of the position of the analyst.     

Keeping and sharing: confidentiality in ministry

What ethical norms regarding confidentiality are applied by ministers in their professional practice? In this essay conventional ethical assumptions about confidentiality in ministry, taken from the work of Gaylord Noyce, are compared with the experiences, attitudes, and expectations of ordered and lay members of the Anglican Church of Canada and the United Church of Canada in two Canadian regions. The similarities and differences are then compared and contrasted with more contemporary theories. The study concludes that most people in the two denominations studied borrowed their ethical norms from the counseling context. Most subjects thought of confidentiality in terms of the beneficial therapeutic effects of keeping the secrets but they also articulated alternative theological grounds for maintaining confidences. Different expectations about how information is to be handled also reveal deeper theological and ecclesiological conflicts over the appropriateness of debriefing with members of the congregation. Differences between rural and urban congregations were revealed in the example of public prayer as an occasion for the breaking of a confidence.     

Seeking an Analytic Identity

Abstract

Rothstein has stimulated all analysts to rethink how we can better commit ourselves to our analytic work. In this paper I focus on factors in analysts' personalities and experiences in their training and practice that contribute to or distract from establishing an analytic identity.

First, I explore analysts' background and motivation. In admissions to psychoanalytic institutes we look for candidates who can see psychoanalysis as an intellectual puzzle to be solved and an emotional involvement to be experienced. We look for earlv conflicts that the candidate can sublimate in the service of analytic functioning. We assume that the capacity to sublimate is only partial and that analysts in their development continue to recognize conflicts in transference—countertransference reactions.

Second, I give some examples of experiences from analysts' training that stimulate the formation of their analytic identities. These include transient identifications and counter-identifications with the training analyst, supervisor, seminar leader, and favorite analytic authors.

Third, I discuss more external factors that influence the development of analytic identity. These include the climate in training and continuing education at the institute. How much does the institute support its members in immersion in psychoanalysis? Economic factors continue to he an important factor in determining individual choice in this immersion.

Finally, I review studies on the effectiveness of psychoanalysis. Dedicated analysts with considerable experience believe that analysis works despite some limitations. Part of high motivation to continue analytic work includes understanding how analytic results differ from the simpler solutions achieved by nonanalytic therapies.     

What comes out of the consulting-room? The reporting of clinical material

The author addresses the difficulties inherent in reporting clinical material. These fall into two main categories, the ethical problem of upholding confidentiality, and the technical problems which include the definition of analytical data, and the numerous ways in which truth can be distorted in the analytic context. It is advocated that consent be obtained from patients before publishing their material. It is also suggested that clinical reports should contain enough detail of the analytic interaction, including the analyst's thoughts and feelings, to convey the analytic process, and to enable the listener/reader to consider the evidence for himself and to draw his own conclusions. It is concluded that an analyst's anxiety about exposing a patient might obscure an anxiety about exposing himself.     

The educational boundary1

In this contribution, the authors defi ne and discuss the educational boundary in analytic training, which they believe is an often neglected and useful concept in psychoanalytic education. The framework on which their discussion rests includes the recent attention of psychoanalysts to issues of boundaries and ethics. Their understanding of how clinical work affects the mind of the analyst educator, as well as the ways the personalities of various analysts affect their dealings with faculty peers and students, are the other cornerstones of their discussion. The authors contend that many of the institutional problems encountered in the training of analysts can be better understood when viewed through the prism of the educational boundary. They present examples which illustrate several of the ways psychoanalytic educators complicate the training experience of candidates, offer specifi c explanations as to why analysts struggle as they try to manage their educational interventions, and indicate in a discussion of potential remedies that those behaviors might be avoided if the educational boundary is in focus. They also provide an example of how the educational boundary can be more effectively managed.     

Ferenczian Elasticity in the Analysis of an Adolescent

Psychoanalytic work with adolescents poses a challenge for analysts who adhere to standard analytic technique as many adolescents who need analytic intervention resist such a structured approach to analysis. The author finds that elasticity of technique is currently widely used by analysts when working with this difficult age group even though they may be unaware that this is, in fact, a Ferenczian technique. Clinical examples are presented to illustrate how frequently the technique is used in cases of resistant, troubled youth. The author outlines an approach that is sensitive to these resistances and makes compromises in technique based on the principle that engaging a troubled youth in a therapeutic venture is preferable to refusing treatment based on the patient’s not being able to adhere to standard analytic technique. In this sense, Ferenczi was an early herald of the type of contemporary analytic work that is practiced currently especially with a difficult population of patients.

     

Origins of the ethical attitude

This paper seeks to explore the genesis of the capacity for an ethical attitude, personally and professionally. As analysts working in intimate clinical settings, ethics is at the foundation of our professional lives, as it is at the foundation of our humanity and what it is we struggle towards in our own personal development. The ethical attitude presupposes special responsibilities that we choose to adopt in relation to another. Thus, a parallel situation pertains between caregiver and child and between analyst and patient: they are not equal partners, but nevertheless are in a situation of mutuality, shared subjectivity, and reciprocal influence. The basic premise of this paper is that the analytic attitude is an ethical attitude, and that the ethical attitude is a developmental achievement, and as such it may reach beyond the depressive position.     

Cultural considerations in release of information

In most mental health professions, confidentiality is probably the most important ethical principle in psychology, aside from nonmalfeasance. However, confidentiality is embedded in the Western values of individuality and autonomy. This creates a moral and ethical dilemma for clinicians working with clients from other cultures. This article presents 3 cases to highlight the conflict that many clinicians are likely to face with regard to confidentiality when working with clients from South Asia and similar cultures. The importance of understanding how cultural values may contradict professional ethics and some ways in which the clinician can address them are also discussed.     

Cultural Considerations in Release of Information

In most mental health professions, confidentiality is probably the most important ethical principle in psychology, aside from nonmalfeasance. However, confidentiality is embedded in the Western values of individuality and autonomy. This creates a moral and ethical dilemma for clinicians working with clients from other cultures. This article presents 3 cases to highlight the conflict that many clinicians are likely to face with regard to confidentiality when working with clients from South Asia and similar cultures. The importance of understanding how cultural values may contradict professional ethics and some ways in which the clinician can address them are also discussed.     

The Analyst's Secret Delinquencies

Despite a burgeoning literature on major analytic boundary violations, there has been little investigation of what might be called analytic delinquencies or misdemeanors—the small and virtually ubiquitous ways in which analysts deliberately withdraw from the therapeutic endeavor. I consider the impact of professional misdemeanors on patient and analyst and compare both with more serious analytic “crimes” and enactments. Professional delinquencies may reflect a therapeutic reenactment, an expression of the analyst's split-off or disavowed need, or an unconscious attempt to self-regulate or to negotiate space within the constraints of the treatment setting. Because the professional ideal leaves so little room for the analyst's humanity, it is often difficult for us to address and work with evidence of our own need when it clashes with what we regard as the analytic contract.     

Protecting confidentiality rights: the need for an ethical practice model

All psychologists must uphold the same ethical standards about confidentiality even though each state imposes different legal limits on their ability to protect clients' confidences. The resulting ethical-legal confusion is exacerbated by legally based confidentiality training that treats legal exceptions as if they were the rule and fosters the impression that attorneys are now the only real experts about this aspect of practice. This article provides an ethics-based confidentiality practice model that clarifies the ethical rule and puts its legal exceptions into ethical perspective. Like the Confidentiality section of the American Psychological Association's (2002) Ethical Principles of Psychologists and Code of Conduct, this outline would apply to all psychologists regardless of state laws, but the details of its implementation would vary according to role and setting. It can be used as a universal training outline, a consultation and supervision tool, a guide to professional practice, and a basis for clearer ongoing conversation about the ethics of "conditional confidentiality." Psychologists can use this practice model to regain their status as experts about the confidentiality ethics of their own profession.     

Confidentiality issues in psychological research

There has been increased attention in recent years to the importance of individual privacy and professional confidentiality both in Australia and overseas. At the same time, psychologists' growing research interests in areas such as AIDS, child sexual abuse, and domestic violence have led to new ethical dilemmas over the contract of confidentiality between researchers and their research participants. The present paper discusses a number of issues regarding the ethics of confidentiality in psychological research. Following Bok (1989), the issues are highlighted within the context of four ethical principles that underlie researchers' obligations to preserve confidentiality. These principles are derived from considerations of privacy, loyalty, the pledge of silence, and professional codes of ethical standards. Each of these principles is illustrated with examples taken from recent research. We devote special attention to instances that appear to provide a clash between moral principles.     

The Politics of Relational Psychoanalysis

Given the foundational premises of relational psychoanalysis, the lack of attention to the social and political world on the part of analytic writers who identify with this orientation is curious. Perhaps relational psychoanalysis itself, particularly in its democratizing impulses (e.g., emphasis on mutuality, concern with questions of authority and self-disclosure), has become a replacement for politics, an effort to provide for patients (and analysts) in the consulting room an experience of a world that no longer seems attainable outside it. The analytic situation thus created would represent a recasting of the world as analysts wish it could be, projected into therapeutic space.

This development in the analytic field is part of a more general cultural shift away from a belief in the possibility of social transformation and a redirection of energies into ameliorative projects. This discouragement dispirits the work of those relational writers who do engage a political aspect in their thinking. The author argues that the recovery of a sense of political efficacy would vitalize analysts' endeavors inside and outside the therapy office and could help to balance the overinvestment of the clinical dimension of psychoanalysis that has accompanied the ascendance of the relational perspective.