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?
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