Book Review

The New Informants: The betrayal of confidentiality in psychoanalysis and psychotherapy

N Engl J Med 1996; 334:1141April 25, 1996

Article

The New Informants: The betrayal of confidentiality in psychoanalysis and psychotherapy
By Christopher Bollas and David Sundelson. 215 pp. Northvale, N.J., Jason Aronson, 1996. $22. ISBN: 1-56821-595-9

The practice of observing therapeutic confidentiality is so riddled with exceptions that it has all but disappeared. This book lucidly describes the disappearance of privacy, showing how the clinical effect of this loss has been destructive and how mental health professionals may respond constructively. The authors' critique extends well beyond psychiatry. Given the ubiquity of therapeutic relationships, observing a truly effective therapeutic privilege would buttress privacy norms in general.

The authors show that “the punitive arm of [the state apparatus] has entered the clinical space.” They describe the main ways the privacy of the therapeutic relationship has been infringed upon: by the threat of civil liability if therapists fail to warn of potential harm by patients, requirements that therapists report any reasonable suspicion of child abuse, and waivers of confidentiality whenever health insurers and managed-care providers are financially involved or litigation is pursued. Many are affected; more than half a million reports of child abuse are filed annually in California alone.

The authors largely fault psychiatry and psychology for the loss of confidentiality in psychotherapy, pointing in particular to the members of those professions who oppose analytic approaches on methodologic grounds and prefer drugs or other treatments. They also criticize the professional associations in these fields for failing to act on behalf of the therapeutic privilege.

For broader audiences, though, it would have been more helpful to focus on the larger social realities, as opposed to the complicity of some therapists. After all, the assault on therapeutic privacy comes largely from outside the health professions. For those seeking cost control, shifting from intensive therapy to drugs is simply good economics. For those who think the unconscious is metaphysical nonsense, the psychiatrist–patient privilege is trivial.

The authors could also profitably have contrasted the limited protection of privacy in psychotherapy with the venerable practice among Catholic priests of suffering imprisonment rather than breach the sacrament of confession. According to church doctrine, there is no exception to this form of confidentiality, notwithstanding sinners' revelations of either past child abuse or prospective criminal mayhem.

Secular exponents of the right to privacy, however, are often convinced by various legal “balancing” arguments that the need to prevent crime or fraud outweighs a patient's claim to absolute privilege. But as these authors correctly observe, this paradigm puts too little weight on the privacy side of the scale. It would be more appropriate to consider the total social value of the privacy privilege to enhanced mental health, including the fact that numerous patients might — if they enjoyed a confidential therapeutic relationship — ultimately refrain from wrongdoing.

The authors are at their most persuasive in discussing how the loss of assured confidentiality degrades the quality of psychotherapy for everyone. Free association, its classic technique, is fatally tainted. Scrupulous and law-abiding therapists must discourage their patients from lurid descriptions of improper sex and violence; else they “would be there to apprehend the patient.” Similarly, patients must censor themselves.

Although it is not addressed in this book, the intrusion of “therapy” into the legal process has also been of doubtful value for judicial outcomes. Tales of abuse do not translate well into the courtroom, which is ill suited to distinguish psychic from objective reality. (See, for instance, Satan's Silence: Ritual Abuse and the Making of a Modern American Witch Hunt by Debbie Nathan and Michael Snedeker [New York: Basic Books, 1995].)

Whether therapeutic confidentiality is viewed from the perspective of the law or that of psychology, it is entirely uncertain whether abrogating it “actually makes anyone safer.” Unless some overall benefit is demonstrated, the diminution of our constitutionally protected right to privacy would appear quite unwarranted.

Edward Greer, J.D., M.P.H.
Southern New England School of Law, North Dartmouth, MA 02747