by Judy Leopold Kantrowitz. New York, Other Press, 2006, 256 pp., $26.00.
I scan the article before putting it aside for later, and my eye catches a vignette. Which I then read. I felt a kind of panic. I felt my blood turn cold. For there I was, the patient, displayed (circumspectly) on the printed page. Here I was being written about without knowledge of the fact. Confidentiality was not an issue. But I was stunned.…
My feelings ranged from horror to outrage…even sadness welled up. I felt used. I felt particularly honored. But why such varied emotions? …How could you know that by not informing, or warning me, or whatever, that you were transgressing that sacred boundary, the infinite trust I placed in you. Why did it matter so?
Stoller, 1988 (pp. 268–269)
Author of The Patient’s Impact on the Analyst, training and supervising analyst at Boston Psychoanalytic Institute, and Associate Clinical Professor at Harvard, Judy Leopold Kantrowitz continues her work on the patient-analyst relationship in her new book Writing About Patients. In this compelling and intriguing text, Kantrowitz takes on the subject of publishing psychoanalytic case material. It is an excellent book—well-structured and elegantly written—but its exceptional quality derives from the array of resources used by the author to explore the many tensions inherent in this complex topic. Illustrative clinical case material, data from empirical studies, conceptual literature from diverse disciplines, publication policy documents, and narrative perspectives of therapists and patients alike are brought together to create a substantive and valuable examination of the issues associated with writing about patients’ distinct, intimate psychological experiences.
In the first section of her book, Kantrowitz presents the responses of 141 national and international psychoanalysts interviewed about their reasons for writing, their approach to ensuring patient confidentiality, and their internal conflicts about writing and publishing case material. Most psychoanalysts report that their reason for writing clinical material is to make a contribution to the scientific literature by illustrating a conceptual, theoretical, or technical point. Fewer analysts write for more personal reasons. These reasons include attaining greater clarity in their clinical work, working through countertransference feelings, or simply satisfying professional ambition.
In the second section, Kantrowitz presents psychoanalysts’ perceptions of patients’ reactions to reading about themselves. Analysts differentiate between situations where patients discover, on their own, materials about themselves written by their analysts and situations where analysts explicitly request permission from patients to publish their stories, sometimes even showing their patients the manuscripts. Patients who read about themselves report a variety of reactions, from feelings of anger and hurt based on perceived misunderstanding or betrayal, to feelings of special importance based on being singled out for written report, to feelings of gratitude based on being deeply understood.
In the third section, Kantrowitz reports the interview results of 37 patients, 11 of whom are not themselves psychoanalysts and 26 who are, on the effect of reading what their analysts wrote about them. In general, nonanalyst and analyst patients express the same types and ranges of reactions and concerns when reading about themselves in case material.
Finally in the fourth section, Kantrowitz concludes her book by exploring psychoanalysts’ use of themselves in clinical examples. She also articulates the main ethical issues in writing clinical case material. The central ethical dilemma for analysts writing about patients is dual agency or divided loyalties. On the one hand, analysts have a duty to advance the knowledge that serves as the basis of their profession. On the other, they have a duty to protect their patients’ privacy. Thus, analysts who write must make decisions regarding whether they will disguise their written case material, secure informed consent from the patient, or both.
Disguising case material poses several interesting ethical issues. It is one of the few times in which a profession affirms the use of deception. As with placebo use and research on deception itself, there must be very careful, special, and rigorous safeguards (1). For instance, disguise most frequently takes the form, or some combination, of concealing or deleting superficial details, using composite case material drawn from more than one patient, omitting background biographical information, or having a colleague who is not involved in the patient’s treatment author the case material.
Informed consent involves requesting explicit permission of patients to publish their case material. In some cases, it may also entail allowing the patient to view prepublication drafts and even modifying the drafts after discussion with the patient. Some analysts believe that securing permission from patients to publish their case material dilutes scientific integrity. Other analysts believe that transference makes true voluntarism impossible and that many patients are unable to refuse their analysts’ requests. Yet others believe that the consent “conversation” may have therapeutic value and may be folded ethically into the therapeutic process. An analyst’s decision whether to obtain the patient’s consent for publication as opposed to merely disguising the material depends on how the analyst views ownership of the clinical material. Some analysts view the history and the narrative as being the property of the patient and clinical formulations, interpretations, and countertransference reactions as being the property of the analyst. Other analysts maintain that all the clinical material is joint property of both the patient and the analyst. These analysts argue that there would be no conceptualization, interpretation, or countertransference without the patient’s history and narrative.
The modern trend, one which gives more weight to patient autonomy, is the practice of securing informed consent, showing patients the written manuscript, and enlisting the patients’ input in changing the written manuscript, while discussing the entire process of creating the written case material in the course of treatment. Ultimately, Kantrowitz suggests that ethical tensions cannot be easily resolved. Instead, careful consideration must be given to individual patient characteristics and the nature of the treatment relationship prior to undertaking any clinical writing for publication. The scrupulous case-by-case approach advocated by Kantrowitz will lead to the occasional conclusion that there are some patients who should not be written about and that there is some material too private for publication.
1.Roberts LW, Lauriello J, Geppert C, Keith SJ: Placebos and paradoxes in psychiatric research: an ethics perspective. Biol Psychiatry 2001; 49:887–893