2025 Confidentiality Guide (English)

The IPA’s Confidentiality Committee has published a series of new guidance documents that aim to promote collective sensitivity to the issue of confidentiality, consistent with their report published in 2018.

Thoughts on Confidentiality for Conference Planners

Created by the IPA Confidentiality Committee

2025

Complexity of Clinical Presentations at Conferences

Analysts are likely to agree that clinical presentations at conferences are essential to the work of furthering and deepening our shared understanding of psychoanalytic process. However, open and unscripted conversations about clinical work at conferences carry the risk that the identity of a patient could be revealed, or even that a patient could be harmed by hearing an account that she recognizes as her own treatment. Even when a clinical presentation has been carefully vetted, we cannot ensure that in group discussion, attention to confidentiality will not slip. Analysts are especially attuned to the presence of unconscious mental life and its intense mobilization during treatment in both analyst and patient in a mutually activating and intertwined spiral. No clinical presentation can be exempt from unknown unconscious strivings on the part of the author. Further, clinical material selected as the subject of a presentation is always to some extent a construction created by the analyst. These observations highlight that while presenting clinical material may be a professional necessity, it is also a constant call to scientific modesty. We simply cannot know everything that we may be unconsciously communicating in our presentations. We are also not able to reliably predict the impact on patients, either immediately or long afterwards, of discovering that their analyst has presented them, whether their permission has been obtained or not.

Difficulties of Disguise; Difficulties of Informed Consent

Across analytic cultures, there is no clear consensus about how best to deal with the violation of confidentiality that clinical presentations enact. There are clear limitations to disguising a patient’s identity, but significant conflicts in asking for patients’ consent such that many analysts consider this option unethical. 1 Because of these limitations in our capacity to be confident about specific ethical choices, along with conflicting views on how to handle clinical publications, we do not feel able to provide a clear-cut, universal solution to how to publish clinical material. Rather, we aim to highlight the risks and concerns and offer broad guidelines that will support an ongoing concern with protecting patient confidentiality. We aim to foster a “community-of-concern” approach to confidentiality 2 in which protection of the patient’s privacy and dignity becomes a paramount concern at every point in the development, sharing, and presentation of clinical material. With this in mind, we offer guidance in the overarching planning of conferences, along with specific guidelines for vetting presenters’ work.

1 This is more fully elaborated in “Thoughts on Confidentiality in Journal Publication " 2 Glaser J.W. (2002). The community of concern: an ethical discernment process should include and empower all people relevant to the decision. Health Prog. Mar-Apr 83 (2) 17-20, cited in IPA Report on Confidentiality, 2018, p. 12.

BROAD RECOMMENDATIONS FOR CONFERENCE PLANNERS

● Prepare a statement about confidentiality in calls for papers.

This statement should alert presenters to the documented negative consequences of lapses in confidentiality for both patients and analysts and spell out expectations surrounding presentation of clinical material. Presenters should be advised to consult their peers early on about their wish to share clinical material in a meeting. Circulating material in written or digital form should be avoided.

● Review submitted papers carefully.

The scientific committee should vet particularly carefully each submission containing clinical material. It may be prudent to delegate a specific member with the responsibility for vetting confidentiality risks in clinical presentations. Since this committee may not know the author and his or her milieu, consultation at the local level may be an alternative form of protection. Once accepted, a direct conversation between the planning team and the author should ensure that the clinical material has been thoughtfully presented. Planners might opt to include a form that asks presenters to disclose how they have addressed concerns with patient confidentiality. Appendix A provides the vetting process used for clinical publications by the International Journal of Psychoanalysis that might be adopted for use by conference planners .

● Include a statement on confidentiality in the printed programme if there is one.

● Have chairs read a statement aloud before every panel or workshop.

Chairs of events in which clinical material will be shared could be asked to read aloud a statement. We recommend that these statements be re-worded regularly, so that they continue to command the audience’s attention. This statement should remind attendees of the risks of inadvertent disclosures that can occur in group discussion after formal presentations.

● Raise the risks on informed consent with presenters

Although informed consent is always complicated by transferential implications, in some jurisdictions, the presentation of clinical material may be legally safe only with the written consent of the patient. Legal safety might not, however, fully discharge our ethical responsibility towards the patient and the treatment. When informed consent is proposed as an option, the presenting analyst should consider, if possible in consultation with colleagues, the possible impact of such consent upon an ongoing or completed treatment. ● Ask each presenting analyst for a brief statement justifying the strategy chosen for protecting confidentiality within his or her ethical framework. (See Appendix A for a possible form that presenters could complete.) ● Have chairs announce that non-authorized audio or audio-visual recording of presentations containing clinical material is not allowed . Audience members should also be urged to turn off their cell phones, to minimize the risk of this occurring inadvertently.

● Presenting clinical material about candidates or professional colleagues should not be permitted.

Candidates are especially vulnerable when their personal analyses are spoken or written about by their analysts, given the risk of recognition by the candidate or by someone in the candidate’s professional and social circles. Possible consequences include undermining a candidate's identification with psychoanalysis as a future career and even adversely affecting a candidate's opportunity to pursue analysis as a career if, for example, those hearing the material take it to indicate a serious problem with the treatment. Presenting clinical material about a candidate could thus border on becoming a reporting analysis by another name. Similar considerations apply to the analysis of professional colleagues.

SPECIFIC RECOMMENDATIONS FOR PRESENTERS

● Announce that some details of the material have been omitted and/or changed to preserve patient confidentiality.

● Minimize the biographical details of the patient.

Presenters should be encouraged to reveal only what is necessary to illustrate the ideas of the author. In smaller gatherings where everyone knows each other, this by itself may be adequate, and is certainly advisable. There should be an evaluation, preferably with colleagues, in cases in which the aspects of interest could even conceivably identify the patient.

● Disguise clinical material.

This should be done so thoroughly in all clinical presentations that the likelihood of the patient being identified is remote. • Use of the form provided in Appendix A might assist presenters in appraising all of the confidentiality concerns to be considered.

For a comprehensive discussion of confidentiality in psychoanalytic practice as a whole, please see the 2018 IPA Report on Confidentiality. https://www.ipa.world/IPA_DOCS/Report%20of%20the%20IPA%20Confidentiality%20Co mmittee%20(English).pdf

Appendix A: Patient Anonymisation Checklist

(used with permission from The International Journal of Psychoanalysis)

Publication of clinical material by psychoanalysts and psychotherapists is essential to the development of knowledge in psychoanalysis and the broader mental health field and the growth and maintenance of high standards of patient care. Patient privacy should be protected such that patients can speak and act freely with full confidence . Ethical and legal considerations require theprotection of patients’ anonymity in case reports and elsewhere. Authors whose papers include accounts of clinical work are required to take all necessary measures to ensure that none of the individuals written about can be identified by any third party and to fully minimise the likelihood that patients will recognise themselves. To meet these objectives, this publication has adopted guidelines to be followed by all authors, which are required in the online submission and throughout the review process. Special care should be takenin cases including children and adolescents. There will be no exceptions. Fill out the below checklist using Adobe PDF Fill & Sign and submit this document with yourmanuscript in the Submission Portal.

Submitting Your Anonymised Article

The form below contains a check list whose purpose is to create the space to think about what might be being disclosed (even unconsciously), which could identify a patient. The anonymisation policy and check-list below are not intended to discourage papers addressing intersectional or other issues where background matters. Rather, what authors are required to dois to verify that they have reflected on the details they have given and how far they are suitable for their particular argument. Therefore, on reflection, they must be confident that they are not disclosing their patients’ identity, and they must indicate which method(s) of anonymisation hasbeen used.

1. Confirm by Checking the Box

☐ I verify that I have reflected on potential identifiers that might make the patients described in thispaper identifiable to third parties and following that process I am confident that my patient's identityis now unrecognisable to others and as unrecognizable to him/her/themself as possible.

2. Have you Protected the Patient from Identification (explain using more than one, if so)?

☐ Thorough Disguise of Individual Patients ☐ When presented, details of patient-therapist interactions have been described so as to precludeidentification of the patient.

☐ Use of Composites ☐ Other (please describe below):

3. Anonymisation Details

Category 1: The following must be changed or omitted (Please confirm all.) ☐ Patient name ☐ All other names ☐ Patient place of birth ☐ Patient occupation

☐ Dates and exact length of treatment ☐ Organisational or other affiliations ☐ Exact location

Category 2: The following to be omitted or disguised if there is any possibility inclusioncould lead to identification. (Please consider each category separately.) ☐ Medical conditions ☐ Age ☐ Family and family history ☐ Details of specific traumata and other key historical events Category 3: To be omitted unless essential to the case report, but disguised if so. (Please confirm or explain why and what you have retained to protect patient from identification.) ☐ Religion ☐ Historical and cultural details ☐ Photographs and all other images from the treatment ☐ Other (please elaborate):

Article Disclaimer of Anonymisation

☐ I verify that I have included the following disclaimer in my manuscript, placed directly before thereference list: “Potentially personally identifying information presented in this article that relates directly or indirectly to an individual, or individuals, has been changed to disguise and safeguard the confidentiality, privacy and data protection rights of those concerned, in accordance with the journal’s anonymisation policy.”

Thoughts on Confidentiality for Directors of Psychoanalytic Institutes

Created by the IPA Confidentiality Committee

2025

Directors of Psychoanalytic Institutes confront an array of issues relating to confidentiality including a) protecting the confidentiality of candidates; b) protecting the confidentiality of the patients of candidates; c) teaching candidates about the necessity of confidentiality for the psychoanalytic process; d) creating an atmosphere within the Institute and Society where confidentiality of members and patients is valued; and e) addressing broader confidentiality concerns at scientific meetings. This document will describe some of the threats to confidentiality inherent in psychoanalytic institutes and suggest practices to mitigate these risks.

A: Confidentiality for Candidates:

Admissions : Before they are even accepted to a psychoanalytic institute, candidates are encouraged to explore their personal histories and unconscious motivations in the process of interviewing for candidacy. During the application process, candidates reveal much about themselves to multiple member analysts, both in written personal statements and during the interviews, and these interviewers then discuss the case with other members of the institute. This, then, while necessary in evaluating aspirants for psychoanalytic training, becomes problematic with respect to maintaining a sense of privacy for applicants who will soon be our students and colleagues. Therefore, institutes should minimize the number of people, including administrators, who have access to the applications. Conversations about applicants should be confined to what is truly necessary to discuss after the interview process in making the decision about whether a candidate is suitable for admission. For instance, the fact that the candidate is self-reflective is useful to share; the facts of their early childhood are not. Psychoanalytic Training: Once admitted, candidates present their clinical work in seminars and with supervisors, where they are often encouraged to include their countertransference experience. There will inevitably be an asymmetry of vulnerability between those who are applicants and candidates at any particular time and those who are in faculty roles, and yet, ultimately, we are all colleagues. We must balance our need to understand the psyches of those in training with candidates’ needs to trust that whatever they reveal in supervisions and classrooms will be treated with the utmost respect. This requires a “community-of-concern” 1 approach, in which safeguards (such as those described below, e.g. limiting the number of readers of case reports) are instituted to protect our candidates’ privacy. Supervisory reports : Like the recommendations for the admissions process, reports from supervisors about candidates should refer to the candidate’s work and not personal process. It may be that a candidate is having difficulty working with a narcissistic patient and the supervisor knows the candidate had a narcissistic father so that the countertransference is distorted by this. Ideally, the report would mention the difficulty but minimize to the bare necessity the details about why. The number of people reading candidate analytic case reports should be restricted—it is useful to have several readers in order to get

1 Glaser, JW (2002) The community of concern: An ethical discernment process should include and empower all people relevant to the decision Health Prog . Mar-Apr 83 (2) 17-20 cited in IPA Report on Confidentiality, 2018, p. 12.

different perspectives on a candidate’s work, but that utility needs to be balanced with maintaining the privacy of both the patient and the candidate. It is incumbent upon the institute to remind supervisors to be mindful of confidentiality concerns in their reports. Supervisors writing about their supervisees and candidates writing about their patients should use password protection when sending documents by email.

B: Protecting the confidentiality of candidates’ analysands:

Candidates may also struggle to maintain the confidentiality of their patients in the process of presenting clinical material in class. It can be difficult to discern, especially early in training, which of the multitude of details in a session are relevant and what should be disguised or omitted. New analysts may be overwhelmed by the clinical material they are engaged with and unconsciously seek relief by telling more than is warranted. Candidates hearing their classmates’ clinical material may also struggle to contain their affective responses and need to find a confidential place in which to discuss these. Certain strategies for maintaining confidentiality can be taught, but there are the also “unconscious strivings in ourselves,” 2 which are harder to manage procedurally, and which may lead to breaches of confidentiality unless those strivings can be satisfied in other ways. Supervisors should be encouraged to play a role here in helping their supervisees think about how to present their cases in a way that reveals the truth of the clinical situation without exposing identifying details of the patient.

C: Teaching on Confidentiality :

The importance of confidentiality in psychoanalytic treatment requires that candidates be made aware of this issue early in their training, by identifying it as a key point in our practice.

1. Include a seminar about confidentiality as part of the training which would have the following goals: (a) to make candidates aware of this issue early in their training; (b) to keep the issue alive in our minds whenever we talk about analysands; (c) to facilitate discussion of the advantages and disadvantages of different ways in which confidentiality might be protected in the sharing of clinical material (disguise, informed consent from a psychoanalytic point of view, amalgamated case material, multiple or anonymous authorship, etc.); (d) to facilitate discussion of the local legal and professional regulatory environment with scenarios about how to proceed when there is or could be a conflict with psychoanalytic confidentiality. 3

2. Sample articles from institute syllabi include:

Furlong, A. (1998). Should we or shouldn’t we? Some aspects of confidentiality of clinical reporting and dossier access. International Journal of Psychoanalysis, (79): 727-739.

2 2018 IPA Report on Confidentiality 2018 p. 7. 3 2018 IPA Report on Confidentiality p. 13

Lear, J. (2003). Confidentiality as a virtue. In C. Levin, A. Furlong & M. K. O’Neil (Eds.), Confidentiality: Ethical perspectives and clinical dilemmas (pp. 4-17). The Analytic Press.

Stimmel, B. (2013) The Conundrum of Confidentiality, Canadian Journal of Psychoanalysis , 21(1):84-106

Ackerman, S. (2018). (How) can we write about our patients? Journal of the American Psychoanalytic Association , 66(1): 59-81.

Schechter, S. (2024) Ethics Education in Psychoanalytic Institutes, Psychoanalytic Inquiry , 44:(2): 178-193.

3. Using case-based learning with dilemmas about confidentiality should be preferred to rule-based teaching. Discussions of fictional vignettes may be very useful in helping candidates think through the dilemmas around patient confidentiality in an experience near way. [See Appendix for an example of a such a vignette]

D: Institute Culture :

Make the protection of confidentiality an issue of regular and collective concern each time members or candidates present clinical material in society meetings, seminars, working groups, supervisions, etc. Often, the greatest risk of breaching patient confidentiality occurs during spontaneous discussions after a planned presentation. It would be a virtue if an Institute’s culture encouraged (kindly) reminding members to omit or disguise identifying data. Training/Personal Analysts should be mindful of the possibility that candidates might meet each other in the waiting room of their offices. The privacy of the Candidate-Personal Analyst relationship should be preserved institutionally, and Candidate cohorts should be encouraged to discuss how they want to handle privacy around the identities of their analysts. Some groups might feel it helps to know who each person is in treatment with so that that analyst is not discussed. Others feel that the information is private and better not shared. Candidates should feel free to not reveal the identity of their analyst if they do not want to.

E: Scientific Meetings at Psychoanalytic institutes:

1. Presenters should read a statement about confidentiality. 2. Meeting organizers should ascertain from the presenters their method of maintaining patient confidentiality in clinical portions of presentations. 3. The audience should be reminded that the most frequent breaches in confidentiality occur during the unprepared and spontaneous discussion with the audience. 4. For further information, see the IPA Confidentiality Committee’s “Thoughts on Confidentiality in Conference Planning.”

Conclusion:

Directors of psychoanalytic training institutes face dilemmas around maintaining confidentiality in many domains. The confidentiality of candidates must be maintained, and yet we must learn about their minds in order to help them become better analysts. Candidates must present their clinical work, and yet we must protect their patients’ confidentiality. Principles of confidentiality can be taught, and yet breaches of confidentiality often arise from unconscious forces. This document attempts to address ways to protect the confidentiality of candidates and their patients at the various stages of psychoanalytic training. We would argue that these practices require an attitude of mindfulness, an awareness of competing needs, institutional structures designed to minimize exposure of applicants and members’ personal information, and a humility toward our unconscious drives to reveal secrets. For a comprehensive discussion of confidentiality in psychoanalytic practice as a whole, please see the 2018 IPA Report on Confidentiality. https://www.ipa.world/IPA_DOCS/Report%20of%20the%20IPA%20Confidentiality%20Committee%20(En glish).pdf

Appendix: The Crux of the Matter

stephschechter@aol.com

(Reprinted in Stephanie Schechter (2024) Ethics Education in Psychoanalytic Institutes, Psychoanalytic Inquiry, 44:2, 178-193.)

Dr. Jablonski teaches a clinical section of a fellowship class at BPSI. She knows some of her students have limited experience and is not surprised when no one volunteers to be the first to present clinical material. She decides to present her own work for the first class. She chooses to present her work with Ms. Duarte, a patient whom she finds fascinating. Ms. Duarte is a 30-year-old single woman, an attorney who is extremely bright, successful and attractive; she is on track to become a partner at a well-known Boston law firm. Ms. Duarte was raised in a wealthy Venezuelan family which was very religious; her parents insisted she and her sisters attend church and go to confession several times a week. Her father was a judge on the Venezuelan Supreme Court and had numerous adulterous affairs throughout his marriage. Ms. Duarte came to the US to attend Barnard College in New York. She enrolled in a pre-law curriculum and performed well academically. Having had no sexual experience, she began to experiment with numerous partners. Her second year of college, she learned of several women at Barnard who worked for an on-line prostitution service and was surprised to find herself intensely curious. Eventually, she joined the on-line service and had several “dates” with men which involved being paid for sex. She found these experiences exciting and terrifying. After several months, she worried about the negative impact this behavior could have on her life and career and decided to stop. After college and law school, she moved to Boston to accept an associate position at a prestigious firm. Professionally, she performed extremely well and became known as a “rising star” at her firm. However, after a meeting where she thought she recognized an opposing attorney as one of her former “dates,” she had her first panic-attack. She developed intense fear of this episode of her life being revealed, and the panic attacks became severe and frequent. Eventually, she decided to seek psychotherapy. Dr. Jablonski is intrigued with Ms. Duarte and her story and thinks that the class could learn a great deal about the unconscious, internalization, and intrapsychic conflict – much of which they are learning about in the fellowship curriculum. She is also aware of many of her countertransference reactions to Ms. Duarte and feels that she would like to model openness to these dynamics by discussing some of her feelings which have arisen in the treatment. To disguise Ms. Duarte’s identity, Dr. Jablonski gives her a pseudonym and says she is an “immigrant” but does not specify from where. She does not mention Barnard, and merely says she attended a “prestigious university.” She omits that her father is on the Supreme Court but does mention that he was a “powerful judge” because she feels this is relevant to the patient’s intrapsychic conflict. She feels the patient’s career choice is also clinically relevant and says the patient is a lawyer, but nothing more about her work.

She decides to present a session in which Ms. Duarte is talking about a large silver crucifix she wears around her neck. She had recently been approached by the firm’s senior partner, who asked her to remove the cross, stating it was inappropriate for their work environment. Ms. Duarte spends an entire session speaking about the cross, which was given to her by her father, its meaning to her, and her conflict around being asked to remove it. Dr. Jablonski feels that process notes from this session would be a tremendous learning opportunity for her class. She tells them the cross was one of the first things she noticed about Ms. Duarte the first time she met her in the waiting room. Most notable was the way the cross dangled seductively in her cleavage, accentuating both the cross as well as her breasts. In this session, as they work to understand the numerous nuanced meanings of the cross, Dr. Jablonski struggles with her own feelings about how to talk with Ms. Duarte about the way it hangs between her breasts, and interpretations of the sexual meanings attached to the cross her father gave her. She is open with the class about her own thought process and internal struggle to raise these issues with Ms. Duarte, including her anxieties of appearing to Ms. Duarte as if she is “judging” her. The class goes extremely well. The group is active and engaged and, as she predicted, extremely interested in the case. They are appreciative that Dr. Jablonski chose a case which represents many of the concepts they are reading about in the fellowship. The discussion of her countertransference is especially engaging. The trainees leave feeling intrigued and positive about the course. Dr. Heller, fourth year psychiatry resident, is especially excited. Having struggled through her residency to feel inspired, she goes home after the class and tells her husband that she is optimistic about her training at BPSI. She tells him about the case Dr. Jablonski presented, the way she looked at the material and how profoundly the analytic approach resonated with her own views about human nature. She tells her husband that she thinks she may have found an intellectual home at BPSI. Six months later, Dr. Heller and her husband are at a party hosted by her husband’s law firm. At the party, they are introduced to a young female attorney. Dr. Heller immediately notices that she wears a large silver cross which dangles between her breasts.

Questions to consider:

Did any ethical breaches occur in this situation? Was anyone harmed? Whose responsibility was confidentiality in this situation?

Is some risk that a patient’s identity be revealed acceptable in case presentations? How frequently do you think those risks occur? How forthright are we with our patients about the risks?

How do you measure the need to present clinically relevant details about the patient with the wish to protect their confidentiality?

Thoughts on Confidentiality for IPA Members

Created by the IPA Confidentiality Committee

2025

GENERAL PRINCIPLES

Psychoanalytic approaches to confidentiality

For psychoanalysts, confidentiality is not merely a requirement for the safe or ethical conduct of work, 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 compromised. How can an analysand say everything that comes to mind if she feels that her analyst will disclose her most private thoughts? The IPA states explicitly in the Ethics Code that confidentiality is “one of the foundations of psychoanalytic practice” (IPA, 2015, Part III, paragraph 3a). The issue of confidentiality takes on specific implications, which deserve a separate discussion, when psychoanalysts use telecommunications, including for remote analysis and supervision, for communication with patients and with colleagues 1 .

Confidentiality as an ethical and technical foundation of psychoanalysis

The challenge for analysts is that the object of our study, the unconscious, is as much a part of our being as it is of our patients’ and as likely to emerge in unexpected ways. Our wish to protect our patients may be undermined by unconscious strivings in ourselves.

The analyst’s responsibility for the frame/setting

Although unconscious impulses and emotions are stirred up in both partners to the analytic encounter, there remains an important ethical asymmetry: the analyst has the responsibility to respect the autonomy and separateness of the patient. The full impact of the person of the analyst, and of the setting, on the treatment and on the patient’s reaction to it, may never be fully known to the analyst, and yet the analyst must always work with the patient’s experiences in mind.

The possibility of unresolvable conflict between competing needs or views

The need for the analysand to be able to trust the analyst to protect confidentiality is liable to come into conflict with the analyst’s ethical and scientific need to share anonymized material with colleagues in supervision, teaching, and publication. This is a conflict that rests with the analyst, and with which analysts must eternally grapple.

1 See “Thoughts on Confidentiality for Remote Treatment”

PROTECTION OF PATIENTS IN THE USE OF CLINICAL MATERIAL FOR TEACHING, ORAL PRESENTATIONS, PUBLICATIONS AND RESEARCH 2

Reducing potential and experienced harm to patients induced by the profession's scientific, technical, and ethical needs to share clinical experience

Candidates routinely present their analytic patients in classes, in supervision, and in written write-ups for graduation. Analysts often feel drawn to present clinical material when teaching or in talks at conferences, in consultation groups or in papers for publication. Research frequently draws on specific clinical material from analytic work. But in all of these cases, and many more, there is an inevitable compromise of the patient’s confidentiality. Analysts need to be aware that clinical material, whether written or oral, once presented has a potentially unlimited audience, especially when it can be accessed over the web. Although the risks of recognition may be judged to be low, any such risk raises the crucial issue that it is not only the reality of a consequent breach that is of concern, but also any perception that there has been or could be a breach.

The problem of “informed consent”

Neither the analysand nor the analyst can be immediately aware of all the unconscious motives that underlie the request and granting of permission for the sharing of clinical material and neither of them can predict the future après-coup impacts of such a decision. There is therefore an inherent ethical uncertainty about informed consent in psychoanalysis, given the always-only-partial knowability of transference and countertransference. We know that patients can give consent to share clinical material and still feel that the analyst has breached their trust, with potentially serious consequences for their treatment.

The disguise of clinical material

A classic alternative to informed consent is the disguise of clinical material. Problems also arise here, however, because it is not easy to find the right balance between disguise and respect for clinical reality.

Moreover, even when patients’ anonymity is respected so that they are not recognizable to others, their self-recognition may have distressing repercussions on their views of their analysts, of themselves, and of the treatments, whether ongoing or concluded.

THIRD-PARTY REQUESTS FOR A BREACH OF CONFIDENTIALITY

Requests from outside the profession for breaches in confidentiality by psychoanalysts usually take one of three forms: requests that material from a treatment be shared with another party who has a stake in the treatment (insurance companies, government agencies, parents); orders from a legal body (a court or the equivalent) that an analyst testify or produce clinical notes; and, where there is no specific legislation to that effect, requirements to report to authorities suspicions about crimes or harm or risk of harm to self or third parties, such as minors.

2 See also “Thoughts on Confidentiality in Journal Publication” , as well as “Thoughts on Confidentiality in Conference Presentations” and “Thoughts on Confidentiality for Directors of Psychoanalytic Institutes”

Current recommendations from the Ethics Committee make a case for what is called “discretionary privilege”, meaning that the who, how, and why of any demand for a breach in confidentiality is considered first and foremost a matter for clinical decision and ethical judgment by the individual analyst, a decision that can be based on what best protects the integrity of treatment and the patient. With regard to the treatment of minors, jurisdictions with mandatory reporting obligations must be honored. Additional factors may also have to be considered: when there is a concern of a credible threat of serious injury to self or others or of imminent suicide, a breach of confidentiality may be required.

PATIENTS’ ACCESS TO FILES, INCLUDING PROCESS NOTES

In relation to a patient’s right of access to any information held about them by a psychoanalyst, there appear to be noticeable variations internationally in the approach taken in different jurisdictions. The overall trend seems to be moving toward collapsing the distinction between formal, medical-type files (which must be accessible to the patient on request), and "process notes" taken by the analysts to aid their thinking about a case (which may remain private to the analyst).

Some useful suggestions for psychoanalysts to keep in mind include:

● Maintaining acceptable standards of record- and file-keeping; ● When requested, give the patient a summary of their information based on process notes; ● Ensuring that process notes do not contain any personal identifying information such as name, address, birthdate, and the like; ● Maintaining secure storage for the time that records must be kept and then ensuring the secure destruction of records once that time has passed. For a comprehensive discussion of confidentiality in psychoanalytic practice as a whole, please see the 2018 Report on Confidentiality. https://www.ipa.world/IPA_DOCS/Report%20of%20the%20IPA%20Confidentiality%20Committee%20(En glish).pdf

Thoughts on Confidentiality In Journal Publication

Prepared by the IPA Confidentiality Committee

2025

Publishing Clinical Material is Essential

It is a widely shared conviction that analysts need to be able to present and to publish clinical material. Trainees learn from presenting their work in case seminars, and they benefit from hearing others’ responses. Members of institutes need to come together to reflect on clinical presentations that highlight emerging insights in the practice of psychoanalysis. Further, all analysts rely on clinical accounts in books and journal articles to widen their perspective on analytic work. Psychoanalytic writing allows authors to engage one another and a broader audience, in order to gain greater insight into analytic work. And of course, every individual analysis profits from the analyst’s ability, in a considered way, to gain perspective by sharing her experiences with a trusted colleague.

Publishing Clinical Material is Also a Complex Undertaking

Analysts are especially attuned to the presence of unconscious mental life and its intense mobilization during treatment in both analyst and patient in a mutually activating and intertwined spiral. No clinical presentation can be either exhaustive or exempt from unknown unconscious strivings on the part of the author. Further, clinical material selected as the subject of a presentation is always to some extent a construction created by the analyst. These observations highlight that while sharing clinical material with peers or supervisors may be a professional necessity, it is also a constant call to scientific modesty. We simply cannot know everything that we may be unconsciously communicating when we write about or orally present our analysands to others. We cannot rely on our scientific accuracy, and we cannot anticipate how our patients might respond to our writing. We are also not able to reliably predict the impact on patients, either immediately or long afterwards, of discovering that their analyst has written about them, whether their permission has been obtained or not. There are a variety of theoretical schools represented within the IPA, each with its own understanding of this complexity, with its own techniques and associated ethics. This means that there are many lenses through which to view the complexity of the unconscious transference and countertransference dynamics in any analytic treatment. Based on these complex, divergent models of unconscious processes, we conclude that there is no universal, fail-safe procedure in line with all of the theoretical models of psychoanalysis which can be recommended as the best way to protect the analysand when sharing clinical material with colleagues. Our ethical responsibility to protect our patients and their treatment goes beyond strict legal liabilities. Even when patients’ anonymity is respected so that they are not recognizable to others, their self- recognition may have distressful repercussions on their views of their analysts, of themselves, and of the treatments, whether ongoing or concluded.

We are forced to conclude that our ethical responsibility is a paradoxical one: we are responsible for the impact on our patients of our sharing their clinical material with others, despite the fact that we cannot

fully predict or control this impact, or even know what aspects of it may have eluded our perception. Our ethical commitments are divided between acknowledging that we need to share clinical material as part of training and advancement in our work, but that this very sharing is a threat to the sacred commitment to our patients’ confidentiality.

The Issue of Digital Capture

The complexity of publishing clinical accounts is magnified by the ubiquity of digital capture of much that is written. Patients can find our articles, even when they are written for obscure journals. Any writer publishing clinical material in the present day should assume that their patients will read their words, given that any patient could indeed do this. The presence of clinical material on psychoanalytic e-journal sites is a particular cause for concern. Increasingly, e-versions of articles become available at the same time as the print edition or may be republished electronically at a later date. Protection and control of this material is often seriously inadequate, while its readership is global and unlimited. Additionally, some journals post submitted articles online, before there is any opportunity to secure the protection of patient confidentiality. This is again concerning in that readership of these articles is global and unlimited.

Conferences frequently advertise online, increasing the risk of patients identifying themselves in the case description.

E-journal and website administrators need to be vigilant to their ethical commitment to protect patients’ confidentiality.

Problems with Disguise; Problems with Informed Consent

In a survey of journal editors, respondents were divided on how to handle publication of clinical material. Some respondents saw consent as a thorny issue with irresolvable and unknown consequences for the patient that should be avoided. They viewed informed consent as unethical due to our inability to fully detect or correctly predict a patient’s reactions when information is shared, along with the risk of après- coup understandings that were unanticipated at the time when consent was requested. They questioned whether informed consent is truly possible, taking account of the unknown influences of transference dynamics. Can a patient truly feel free to say “no” to her analyst? Whereas in most other professions the ethical requirement of informed consent is relatively straightforward, in psychoanalysis it is anything but. The object of analytic inquiry, the unconscious, complicates any notion of informed consent within the transferential field. Neither the analysand nor the analyst can be immediately aware of all the unconscious motives that impel permission for the sharing of clinical material and neither of them can predict the future après-coup impacts of such a decision. There are documented cases in which a patient has given consent to share clinical material and still felt that the analyst breached their trust. These analysts concluded that there is an inherent ethical uncertainty about informed consent in psychoanalysis, given the always-only-partial knowability of transference and countertransference.

These respondents who rejected patient consent promote disguise as the best way to protect publication of clinical material. Some have managed this by narrowing the clinical material to a short vignette, or grouping a few patients to present a broader picture of a clinical dilemma. Of course, disguise threatens the scientific validity of clinical reports, as we might wonder how well a case presentation mirrors the analytic experience if important aspects of a patient’s history, major life events, and cultural background have been distorted. Other respondents supported the necessity of obtaining consent and working through a patient’s feelings about being presented. Some additionally recommended having the patient read and authorize clinical material that is included in a publication. These analysts believe that the interactive engagement instigated by the request for consent is in fact the optimal ethical action to take. They claim that therapeutic benefits and enhanced scientific accuracy are obtained as a result of adding the patient’s point of view. Many of these analysts point to the losses of nuance in a clinical encounter when elaborate disguises are introduced. Of course, there are also potential losses in involving the patient in the description of the clinical material. Parties from the first camp would challenge the utility of including a patient in the process of writing and would argue that such behavior is ultimately unethical. To write about a treatment with one’s patient in mind as audience would constrain the analyst’s ability to speak into the unconscious dimensions of the treatment—there is no way to do this that would not risk disturbing a patient, and as a result, what gets written about a treatment would inevitably be profoundly diminished. For these analysts, the goal is to write as fully about a treatment as possible, but in a way that anonymizes the material so that even the patient would not recognize herself.

Ways Forward

The irresolvable conflict within our survey of journal editors in how to best present clinical material for publication indicates the range of perspectives on this issue and makes it clear that each journal, and possibly each author, will need to assess a situation-specific solution. Because of these limitations in our capacity to be confident about specific ethical choices, along with conflicting views on how to handle clinical publications, we do not feel able to provide a clear-cut, universal solution to how to publish clinical material. Rather, we aim to highlight the risks and concerns and offer broad guidelines that will support an ongoing concern with protecting patient confidentiality. We aim to foster a “community-of-concern” approach to confidentiality 1 in which protection of the patient’s privacy and dignity becomes a paramount concern at every point in the development, sharing, and presentation of clinical material. Recommendations 1. Journals may opt to prioritize a particular approach, such as disguise or anonymization, or consent with disguise. In these cases, the process of submitting a paper for publication should include a clear statement about how this journal treats clinical papers, and how authors can satisfy the

1 Glaser J.W. (2002). The community of concern: an ethical discernment process should include and empower all people relevant to the decision. Health Prog. Mar-Apr 83 (2) 17-20, cited in IPA Report on Confidentiality, 2018, p. 12.

journal’s expectations. Readers might want to peruse editorials by Frances Grier of the International Journal of Psychoanalysis ( https://pep- web.org/search?preview=IJP.104.0981A&q=editorial%20%20grier) and Lucy Lafarge of The Psychoanalytic Quarterly ( https://www.tandfonline.com/doi/full/10.1080/00332828.2024.2316219). These editorials outline two contrasting perspectives on how to best address the publication of clinical material. We hope they will serve as models for how journals might wish to create a stance on how to handle confidential clinical material. 2. The responsibility for vetting clinical material should be clearly delegated to a particular member of the editorial team, who understands that it is her obligation to consider risks that might be present in clinical vignettes and follow each paper through its submission process, ensuring that adequate care has been taken. 3. Once accepted, a direct conversation between the editorial team and the author should ensure that the clinical material has been thoughtfully presented. One rule of thumb is to suggest that everything an author says about her patient would ideally have already been said to her patient. Another is to do the thought experiment of reading the paper through one’s patient’s eyes, trying to imagine how a patient might feel should she recognize herself in the author’s account. 4. There should be a system of checks in place, to ensure that clinical material has been appropriately handled. It is helpful to ask the author to complete a form that discloses how they have addressed concerns with patient confidentiality and requires that authors consider a range of choices that they might make. Appendix A provides the vetting process used by the International Journal of Psychoanalysis. Again, we hope this questionnaire might serve as a model for other journals. 5. At the end of every clinical paper, it is recommended that the journal attach a disclosure about the clinical material presented. Appendix B presents a carefully worded example used by both the International Journal of Psychoanalysis and The Psychoanalytic Quarterly. 6. Journals might choose to publish in every volume a statement about confidentiality. Appendix C presents the statement published by The Psychoanalytic Quarterly.

For a comprehensive discussion of confidentiality in psychoanalytic practice as a whole, please see the 2018 Report on Confidentiality. https://www.ipa.world/IPA_DOCS/Report%20of%20the%20IPA%20Confidentiality%20Committee%20(En glish).pdf

Appendix A: Patient Anonymisation Checklist

(used with permission from The International Journal of Psychoanalysis)

Submitting Your Anonymised Article

1. Confirm by Checking the Box

2. Have you Protected the Patient from Identification (explain using more than one, if so)?

☐ Thorough Disguise of Individual Patients ☐ When presented, details of patient-therapist interactions have been described so as to

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