“I don’t know what to do about this because we do have to use clinical material. It’s the best tried and true method in which to inculcate analytic thinking in our students and supervises. On the other hand, we are so indebted to our patients and their trust in us and our responsibilities as ethical practitioners not to divulge their privacy. Principles are what we’re trying to teach, we’re not trying to teach people, we are not trying to teach that person, the case is not what we are teaching, but the principles in the case.”
Barbara Stimmel, PhD
New York
Episode Description:
We begin by acknowledging the tension between our commitment to patient confidentiality and our need to learn, teach and advance our field through the sharing of intimate information. We discuss the difference between using clinical examples to reveal particular individuals as opposed to illustrating principles in psychoanalysis. Barbara describes the well-known case of a famous author whose analyst revealed identifiable details of his analysis in a publication. She shares why she feels that co-writing with one’s analyst about one’s treatment is problematic – “it stretches the concept of co-construction to a clinical breaking point.” We consider how presenting a patient publicly impacts the analyst’s interiority and lives on in the treatment. We close with recognizing the challenge of confidentiality and appreciating “the insuperable predicament posed by the mutually exclusive imperatives of protecting patient privacy and educating the next generation, as well as ourselves. Remembering that ego ideals are only approximations is our most effective balm.”
Our Guest:
Barbara Stimmel, PhD, is an adult and child psychoanalyst in New York city where she has practiced for the past several decades. She teaches and supervises widely and has contributed to psychoanalytic journals as well as editing and contributing chapters in several books. She has also presented papers, discussion groups and workshops in the wide world of psychoanalysis. She has held offices in psychoanalytic institutions on the local, national, and international level. Barbara is involved at Mt. Sinai Medical Center in New York, where she sits on committees, has taught residents, and serves on the Palliative Care team. She is on the President’s Council of Sanctuary for Families, an organization devoted to women and families surviving domestic violence and trafficking. She also sits on the Shakespeare Council of The Public Theatre in New York. This diversity of interests is reflected in the variety of topics within psychoanalysis and psychotherapy about which she has written, presented, and taught. In some sense, confidentiality is part and parcel of any clinical topic, regardless of theory and patient population.
Recommended Readings:
Crastnopol, M. (1999). The analyst’s professional self as a third influence on the dyad: When the analyst writes about the treatment. Psychoanalytic Dialogues, 9, 445-470.
Gabbard, G. O. (1997). Case histories and ««confidentiality»». International Journal of Psycho-Analysis, 78, 820-821.
Gabbard, G. O. (2000). Disguise or consent? Problems and recommendations concerning the publication and presentation of clinical material. International Journal of Psychoanalysis, 81, 1071-1086.
Kantrowitz, J. L. (2004a). Writing about patients: I. Ways of protecting ««confidentiality»» and analysts’ conflicts over choice of method. Journal of the American Psychoanalytic Association, 52, 69-99.
Kanwal, G. (2024) To Reveal or not to Reveal, That is the Wrong Question: Thoughts about Clinical Writing in Psychoanalysis. Psychoanalytic Quarterly 93:135-156.
Stein, M. H. (1988b). Writing about psychoanalysis: II. Analysts who write, patients who read. Journal of the American Psychoanalytic Association, 36, 393-408.
Stimmel, B. (2013). The Conundrum of Confidentiality. Canadian Journal of Psychoanalysis,21(1):84-106
What a vibrant and deeply thought-provoking (an in many ways, reassuring) interview – – I could feel the energy between Dr. Stimmel and Dr. Schwartz in probing the complexities of “confidentiality” and its many, perhaps underappreiated, challenges. I appreciate Dr. Stimmel’s thoughts about how she traverses the dilemma of protecting the patient’s privacy, integrity, and the relationship in treatment but also conveying, as best as possible through teaching, presenting/teaching the essence of the analytic process etc., the heart of the work. With the increasingly easy access to technology and social media, analysts are faced with how to manage their array of feelings that accompany their clinical and pedagogical work that is used outside the consulting room . I appreciate and resonate to Dr. Stimmel’s ongoing challenging self-examination. I was drawn into this spontaneous yet at the same time Dr. Stimmel’s honest and deep ongoing thoughts about this conundrum. This engaging interview illustrates – at least for me – the struggles, challenges, and ways of thinking about one’s own reactions (or “descent ” to quote Dr. Stimmel ) in constant awareness of how to convey clinical challenges as teaching principles. Thank you!!
Julie Jaffee Nagel
I enjoyed listening to this podcast episode and found it to be thought-provoking and informative. In particular, Dr. Stimmel and Sr. Schwartz highlighted the numerous dilemmas and constant considerations that analysts face in protecting patients and the analytic process in terms of confidentiality. In the Confucian culture of Korea, where I live, analysts are naturally placed in the position of idealized benevolent authority figures or fathers. Patients tend to passively conform to the idealized analyst, which can put patient confidentiality and clear boundary at risk. When publicly using patient cases, what should be considered to avoid exploiting the patient? Dr. Stimmel suggests focusing on conveying the principles of analytic concepts rather than exposing specific patients through case studies. This was a wise recommendation. Later, Dr. Schwartz mentions the need for a delicate approach to protect colleagues within the analytic society. This was something we all needed to reflect on once again. I deeply appreciate the efforts of Drs. Schwartz and Stimmel.
Thank you, John Churcher, my paper clearly needs an update!
The profound positives of teletherapy are diminished, potentially and seriously, by its vulnerability to the compromises of confidentiality.
The more we pay attention to these complex interactions, the less we are subject to serious errors.
This beautifully clear and thoughtful discussion between Barbara Stimmel and Harvey Schwartz about confidentiality is very much in harmony with the 2018 Report of the IPA committee to which Sarah Ackerman refers. The proposition that confidentiality is ‘constitutive’ of psychoanalysis is paralleled in the IPA Report by the statement that: “For psychoanalysts, confidentiality is not merely a requirement for the safe or ethical conduct of work that might otherwise be carried out unsafely or unethically. It is fundamental to the psychoanalytic method in a more radical sense: without the expectation of confidentiality, psychoanalysis would be impossible because both free association by the analysand and free listening by the analyst would be vitiated.” Stimmel’s 2013 paper, which they refer to frequently in the discussion, as well as her 1997 review of the landmark text by Christopher Bollas and David Sundelson, are both included in the list of Further Reading for Section 3 of the Report, which deals with the protection of patients in the use of clinical material for teaching, oral presentations, publications, and research.
One topic that they do not mention is the loss of confidentiality when using telecommunications, whether for remote analysis (‘teleanalysis’), or for supervision, clinical seminars, etc. The IPA Report addresses in detail the problem that in psychoanalytic work undertaken using telecommunications the patient’s confidentiality cannot be guaranteed. With the massive expansion in remote working since the pandemic, and its current rapid normalisation as a practice, we are at risk of what Stimmel in her paper calls ‘corrosive complacency’ about this fact. As psychoanalysts, we need to ask ourselves: what habitual psychic defences underlie this complacency?
I am glad Sarah Ackerman alerted our listeners to the existence of an IPA committee focused on confidentiality. Harvey Schwartz and I discussed briefly the philosophical proposition put forth by Lear (referenced above and in my paper) that confidentiality is “constitutive” of psychoanalysis, Simply put, along with all health care and helping professions, including law, psychoanalysis is wounded when trust is warped. Hence the term conundrum in my title given that case material is constitutive of psychoanalytic education. I encourage those interested in comprehensively thinking on these vexing contradictions to look at the list of more than 30 authors appended to my paper, especially those of Gabbard and Kantrowitz.
The IPA Confidentiality Committee is a resource on the challenging dilemmas facing clinicians surrounding confidentiality. We see confidentiality as an essential ingredient in psychoanalysis, crucial to our patients ability to say everything that comes to mind. But we are also mindful of the need to talk about our work as part of the learning and teaching process, and as a way of making sense of our emotional responses to our patients. In 2018, members of this committee wrote this comprehensive report on confidentiality in all aspects of analytic training and work. This report is translated into five language and can be found at:
https://www.ipa.world/IPA/en/IPA1/Confidentiality_Report_public_.aspx
Additionally, many authors have pushed into the particularly dicey issues surrounding publishing clinical material, especially in this era where nearly everything can be found on the world wide web. A few helpful articles on this subject include:
Lear, J. (2003). Confidentiality as a virtue. In Confidentiality: Ethical Perspectives and Clinical Dilemmas, ed. C. Levin, A. Furlong, & M.K. O’Neil. New York: Routledge, pp. 3-18.
Furlong, A. (2006). Further reflections on the impact of clinical writing on patients. International Journal of Psychoanalysis 87: 747-768.
Ackerman, S. (2018) (How) Can We Write about Our Patients?. Journal of the American Psychoanalytic Association 66:59-81
With kind regards,
Sarah Ackerman, Ph.D.
Chair, IPA Confidentiality Committee