CLINICAL WRITING OF A THERAPY IN PROGRESS:

ETHICAL QUESTIONS AND THERAPEUTIC

CHALLENGES
Susanne Bennett, Ph.D.
1
ABSTRACT: Clinical implications and ethical dilemmas of the use of
condential case material in clinical writing are examined, including a review
of the discourse among professionals who publish clinical work. This literature is
applied to a clinical illustration of psychotherapy with a client who gave consent
for publication and read the clinical write-up of her case material. It is suggested
that clinical writing may increase client self-reection if there is a secure base
of attachment between therapist/author and the client. The impact on the clients
treatment process is examined, in addition to a discussion of ethical questions
and professional recommendations.
KEY WORDS: Clinical writing; ethical dilemmas; attachment theory.
INTRODUCTION
The typical format for clinical writing includes an overview of theory
followed by an extended case illustration. Grounded in a theoretical con-
ceptualization of my therapeutic work with a current client, my recent
journal submission followed this format. I recognized that cases are
every bit as empirical as experiments (Westen, 2002, p. 882) and asked
the client under discussion to sign consent for publication of her case
material. I also asked her to read the presentation and collaborate with
1
Correspondence should be directed to Susanne Bennett, Ph.D., National School of
Social Service of the Catholic University of America, 620 Michigan Ave., NE, Washington,
DC 20064, USA; e-mail: bennetts@cua.edu.
Clinical Social Work Journal, Vol. 34, No. 2, Summer 2006 ( 2005)
DOI: 10.1007/s10615-005-0011-7
215 2005 Springer Science+Business Media, Inc.
the way her story was told. My initial submission for publication was re-
turned for revisions with one reviewers cogent observation that writing
a paper in collaboration with a client is a controversial one in the eld of
clinical writing and should be taken up more extensively by the author.
Further investigation into the literature on clinical writing supported
the reviewers critique.
The initial decision to include my client in the writing process
was not merely an attempt to respect her condentiality, though that
was of major concern. The decision emerged from my clinical
thoughts about this client and our long and complex relationship. We
are both aware of the intersubjective nature of our relationship, and
we regularly explore the transference (and countertransference) is-
sues that emerge. Yet the healing nature of the real interpersonal
relationship has shaped more recent interventions, and it was out of
this latter dimension of our clinical work that I asked for her permis-
sion to write about our work and invited her to read and comment on
the writing. The following paper is two-fold in purpose. It includes a
general review of the controversial and, indeed, ethical issues that
emerge from clinical writing, followed by a discussion of the client
and my perceptions of the writing process and its impact on the
ongoing treatment.
CURRENT DEBATES ABOUT CONFIDENTIALITY AND CLINICAL
WRITING
In the last decade, concerns have intensied within health care
about patient medical privacy and condentiality, especially with the
onset of managed care and the 1996 passage of the federal Health Insur-
ance Portability and Accountability Act (HIPAA). The National Associa-
tion of Social Workers (NASW, 2004) has acknowledged these
contemporary challenges through revisions in 1999 to the NASW Code of
Ethics and through provision of information and training about the
application of HIPAA for social workers. The Code of Ethics clearly
states that social workers may disclose condential information when
appropriate with valid consent from a client (NASW, 2004, p. 7), and
social workers engaged in evaluation or research should obtain volun-
tary and written informed consent from participants, when appropriate
(p. 19).
Further explicit directives regarding both research and practice
ethics cover concerns about client self-determination and the goal to
protect the client from harm. Nevertheless, there is no mention in the
Code regarding consent for the use of condential case material in
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clinical writing. Current literature on social work research ethics does
not address this issue or, apparently, equate the clinical case with
other forms of empirical data (Antle & Regehr, 2003; Congress, 2002;
Conrad, 1989; Gibelman & Gelman, 1999; Palmer & Kaufman, 2003;
Reamer, 1998). Consultation with both a senior editor for NASW publi-
cations (personal communication, August 17, 2004) and with Frederic
Reamer, who has written extensively on social work ethics (personal
communication, August 26, 2004), conrmed that the profession does
not have specic condentiality guidelines for the use of clinical case
material in publications. Decisions for publication of clinical material
are made on an individual basis under the direction of the various
journal editors.
By contrast, the current 2002 Code of Ethics of the American
Psychological Association (APA, 2004) does have a guideline on the
Use of Condential Information for Didactic or Other Purposes,
which states that psychologists must disguise the person under discus-
sion and the person must give consent for condential information to
be used. This more focused guideline has not silenced the debate
among those who both publish and present clinical case material. Aron
(2000) argues that disguising case material alone is insufcient
(p. 232). Gabbard (2000) agrees that disguise without consent is not
acceptable (p. 1072). Nevertheless, a qualitative study conducted by
Kantrowitz (2002) revealed there was not a uniform approach among
the 30 American psychoanalysts interviewed regarding their use of
patient material in published articles.
Ethical issues outlined by Gabbard (2000) include concerns that (1)
the writers ability to provide honest, thick disguise may be insufcient;
(2) the patients capacity to provide honest, informed consent may be
skewed due to the inuence of the transferences; and (3) the potential
harm a patient may experience remains despite informed consent and/
or termination. As Gabbard says, we can never know in advance when
it is appropriate to seek a patients permission or how that patient will
react (p. 1080). Further muddying the discussion, he points out that
consent may actually interfere with the patients candid disclosure of
certain transferential feelings and may taint the therapeutic process.
Despite this dilemma, Gabbard takes a convincing stand that disguise
and consent are not either/or alternatives (p. 1080).
Aron (2000) furthers this discussion by recognizing the legal
considerations in using clinical material even if the patient gives
informed consent. Conceivably, patients could accuse therapists of vio-
lating condentiality because consent was obtained when the patient
was vulnerable to undue inuence (p. 234). He suggests that most
patients would indeed have mixed feelings about being used in this
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SUSANNE BENNETT
way (p. 235). For this reason, some therapists choose to write about
clients after their termination, though this option minimizes recogni-
tion of the ongoing impact of the transference long after the analysis or
psychotherapy has ended. Aron, like Gabbard, argues that a patients
permission must be gained if extensive material is going to be used,
and he believes this request may open the possibility of mutuality and
symmetry in the therapeutic process. He recognizes that having a pa-
tient serve as a collaborator after consent has been given may meet
certain narcissistic gratications for the patient. While such gratica-
tion may make it relatively simple to obtain authorization, he proposes
that an important question remains: Do therapists have a professional
obligation to protect patients even if collaboration encourages thera-
pists to publish? In other words, the conicts of interest between pa-
tients and therapists may raise difcult ethical dilemmas.
Despite these concerns, Aron (2000) makes a persuasive case for
the potential value to the clinical process when written material is
shared with a patient. In a summary of his own collaborative process
with a patient, he says: Sharing the write-up with the patient and
encouraging his feedback served to clarify my own blind spot and
advance the analysis (p. 239). Kantrowitzs (2002) qualitative study of
psychoanalysts that publish clinical data reported a similar theme.
Some analysts she interviewed believed the patients reading of the
clinical account served to validate both the therapeutic work and the
relationship because it served as conrmation that the analyst shares
the patients understanding of his or her difculties and the process of
their work (p. 89). Consequently, it was believed by some analysts
that these patients experienced therapeutic benets, in addition to
gratication, in the collaborative writing process.
CLINICAL MATERIAL
Admittedly, I did not fully realize the depth of these ethical dilemmas,
including the potential benets and pitfalls, when I asked my client, MK, if she
would be willing to have me write about her life and our treatment relation-
ship. A prevalent theme in our work had always been her desire to feel under-
stood by me, while she continued to experience a subjective distance that
troubled her despite years of exploring our transferential and counter-transfer-
ential issues. Therefore, I believed she would be interested and felt condent
that our relationship could be enriched by the process. These convictions
shaped my assessment that the writing process should be part of the ongoing
therapy, rather than a hindsight analysis of a terminated treatment. I began to
consider that a written explanation of our work would enable us to move
beyond the subjective impasse. In addition, I had begun to conceptualize our
work through the lens of attachment theory and wondered if attachment
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concepts might facilitate a deeper, yet more real, understanding of our rela-
tional dynamics and her perceptions of them.
When I rst mentioned the prospect of writing about her, MK was
initially quite pleased, even thrilled. I always wanted to have someone write
about me, she said. The offer to write her story made her feel special and
that she had something to contribute to others. I explained that I would write
a theoretical piece and include a clinical illustration from our work together. I
assured her that I would disguise her identity substantially, that she could
read the paper, and that I would not publish anything that she did not
approve. We realized the paper might not be published, yet we saw this project
as a way to further the treatment process. MK also believed it would help her
better understand herself. In the year between the rst discussions of this col-
laboration and the time that I actually wrote the paper, she would bring up the
topic, as if to remind me in case I had forgotten.
After my rst draft of the paper was completed, I asked MK if she felt
ready to read it with me. I proposed that we meet at a time that did not inter-
fere with her regular appointments. I did not charge for her time since it
seemed unethical to bill for a session scheduled at my instigation. She was ini-
tially hesitant and anxious, a reaction that took her by surprise. After a week
of thinking about her understandable doubts, she decided she was ready. When
we met in an extended session, I read the clinical portion aloud to her, pausing
to assess her affective and cognitive responses, clarify her questions, and re-
spond to memories that the initial reading evoked. I then gave her a written
copy of the paper and encouraged her to contact me if she had reactions that
needed exploring before our next scheduled appointment. In contrast to our
regular alternate week therapeutic frame, we had weekly appointments for
four weeks about the paper. Each week MK offered reactions and revisions to
my version of the story. I continued to assure her that I would not submit
material for publication unless she felt comfortable with the write-up and until
she signed a written informed consent giving me permission. After much
review of our long and intensive therapeutic relationship, and ve revisions of
the clinical account, she decided she felt comfortable with the submission.
As discussed earlier, the original paper that MK read was returned for
revisions. An extended and separate summary of the theoretical portion of that
paper was revised and accepted (Bennett, in press). The clinical information
that follows is an abbreviated version of the original case write-up and is
designed to illustrate two concepts from attachment theory that I consider sali-
ent to MKs treatment: (1) the concept of the secure base (Bowlby, 1988) and
(2) the concepts of metacognitive functioning (Hesse, 1999; Main, Kaplan, &
Cassidy, 1985) and mentalization (Fonagy, 2001, 2003)). These concepts and
clinical illustrations suggest justications for involving MK in the collaborative
writing process. The clinical material that follows further suggests the poten-
tial risks involved in this decision. A discussion of the ethical issues of clinical
writing as they pertain to this case concludes the paper.
The Secure Base
The therapeutic process has often been compared with Bowlbys (1988)
well-known concept of the secure base of attachment in childhood and its role
in enabling the childs exploration of the world (Eagle, 2003; Holmes, 2001;
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SUSANNE BENNETT
Sable, 2000). Theoretically, clients who experience a secure base in treatment
are able to engage in self-exploration of their world of affects, memories, and
cognitions. The complexity of this seemingly simple idea is that clients with
personality disorders have internalized attachment patterns that preclude an
easy establishment of a secure base in treatment, especially when they have a
dismissing model of attachment and features of a narcissistic personality disor-
der (Hertz, 1996; Holmes, 2003; Imbessi, 1999; Slade, 1999). Blatt and Levys
research (2003) suggests correlations between narcissistic personality disorders
and dismissing avoidant attachment in adults. Both the disorder and the
attachment model are characterized by an avoidance of interpersonal contact
and by the individuals need for self-denition, autonomy, and self-sufciency.
These characteristics are prominent features of MKs personality. A dominant
theme of her therapy has been her desire to understand her life and to feel
understood by me and by others. Establishing and maintaining a secure base
of treatment also has marked our work together.
A middle-aged, white, divorced single parent, MK initially presented for
psychotherapy with severe and chronic depression. When she began treatment,
she was still grieving the loss of her marriage and had no friends or interests
outside of work and her children. It became apparent within the rst year of
treatment that in addition to her diagnosis of major depression, she had an
underlying personality disorder that was difcult to discern in terms of DSM
classication categories. At times she seemed schizoid and occasionally
schizotypal, but generally she had traits of narcissism. She was seen twice a
week for many years and received additional collateral medication management
from a psychiatrist. In time the treatment decreased to once a week, and then
eventually to every other week sessions.
The early period of treatment focused on creating a mutually trusting
working alliance that would keep MK functional and safe from suicidal
thoughts. She recalls feeling a debilitating insecurity at that time, which left
her virtually non-functional. She was anxious, frantic, and overwhelmed
when confronted by challenges that threatened [her] sense of competence. In
addition, she was emotionally fragile and dismissive of my efforts to hold her
clinically, but at the same time she demanded that I hold her physically. While
unable to tolerate any separation from me, she could not establish eye contact
when with me. It was a true challenge for me to hold on to the therapeutic alli-
ance. Often we were caught in a web of relating that exemplied the narcissis-
tic defense of projective identication. When I claried her experiences or
interpreted her defenses, she would lash out with a great deal of anger at my
perceived lack of empathy.
Her transference placed me in a position of being, in her eyes, a dismissive
and critical mother. I sometimes felt like an inadequate therapist, decient in
empathic capacities. When she pushed me away, I struggled with counter-trans-
ferential defensiveness about my professional abilities. She frequently
expressed disappointment with me because she thought that I, like her mother,
was disappointed in her. Ruptures in my efforts to be empathic inevitably trig-
gered her memories: I want [you] to understand my feelings the way I do, but
[you] interpret them differently and that makes me mad, just like my mother
got mad at me for not seeing things her way. In her eyes, I often missed the
mark. We did not have that consistent secure base of treatment so vital to the
therapeutic process.
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Difculty occurred when I took three consecutive summer leaves of
absence from my private practice in order to attend doctoral classes in another
state. For the three months prior to my departure, MK was enraged that I
would dare to leave her (though we planned to have weekly telephone sessions
and monthly in-person visits). She repeatedly voiced her anger, while exhibit-
ing disdain and supposed lack of curiosity or interest in the reason behind my
leave. When I returned after the rst summer, she was cold, withdrawn, and
dismissive. It took months to repair the misattunement activated by the break
in our in-person contacts. She related by distancing her emotional proximity to
me, a defensive covering and miscue of her attachment needs.
Although MK spent years trying to distance me through an open expression
of dismissive anger, she eventually internalized a realization that I was predict-
ably present. For this reason, as well as my improved capacity to read her cues
and mirror her longings and affective states, a generally secure base of attach-
ment was nally established and has been maintained. We now have a rhythm,
an ongoing, reciprocal circle of security (Marvin, Cooper, Hoffman, & Powell,
2002) that is holding her as our relationship matures. She lets me know when
she wants to explore the internal world of her feelings or her external world of
budding relationships and achievements. When her healthy grandiosity becomes
threatened, she comes to me with renewed need for support, with tears of
sadness, and with irritation and disappointment if I do not really understand her
pain. It is in these moments that she still needs comfort and help with regulating
her affects and organizing her feelings and thoughts. In a dyadic, intersubjective
process, we reestablish the proximity that helps regulate her self-esteem and
identity.
A primary component of MKs current stability is that she eventually
internalized a sense of our treatment process as a secure base and now
expresses felt security in our relationship (Holmes, 2001). Some characteristics
of her dismissive attachment model remain, but she has learned that she can
tell me her feelings and thoughts and we will together come to understand.
Consequently, I believed that our relationship could withstand the rupture
that might be stimulated by reading my written account of her treatment
(clearly, this undertaking would have been inappropriate, if not impossible, at
an earlier phase of our work). When we considered the potential impact of this
writing, she said, I gure it will be grist for the mill. As we move into the -
nal phase of our work together, I thought this collaboration would validate for
MK the importance of her therapeutic process.
Coherence, Metacognitive Monitoring, and Mentalization
In addition to Bowlbys concept of the secure base, more recent concepts
about self-reective functioning have emerged from attachment research. Rele-
vant for MKs treatment process, these ideas have inuenced my thinking
about the benets of collaborative clinical writing. In particular, the research
of Main and her colleagues on the Adult Attachment Inventory (AAI) (George,
Kaplan, & Main, 1996; Hesse, 1999; Main et al., 1985) and the work of Fonagy
(2001, 2003)) on the concept of mentalization, or the capacity for self-reection,
enrich the understanding of adult security and psychopathology.
Mains research on the AAI, a semi-structured qualitative interview that
empirically assesses adult attachment classications, has revealed that
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coherence in an individuals discourse regarding attachment is a hallmark of
a secure and autonomous adult attachment (Hesse, 1999). In other words, se-
cure attachment is marked by an individuals capacity to describe attachment
experiences in a consistent and coherent manner, one that is truthful, succinct,
relevant, clear, and orderly. Even when parental relationships are remembered
unfavorably due to negative childhood experiences, an individual is considered
to have a secure state of mind with respect to attachment (p. 421) when these
experiences are recalled with objectivity and when the individual continues to
value attachments. Additional ndings from AAI research suggest that secure
individuals exhibit metacognitive monitoring, or the ability to monitor per-
sonal thought processes actively, recognize contradictions and biases in ones
own speech, and acknowledge that reality may not be what it appears to be
(George et al., 1996). For example, strong metacognitive monitoring leads the
individual to realize that the way the world is viewed today may not be the
way it was viewed yesterday (a phenomenon that often occurs in a successful
psychotherapy).
Similarly, Fonagy has hypothesized that mentalization, or the capacity
to reect upon ones internal, mental states and realize the complexity of ones
thoughts, is a sign of attachment security. He argues that a child acquires this
mentalization or reective functioning only in the context of a secure parent-
child relationship. When the primary caregiver is able to read the childs state
of mind sensitively and respond in a patterned and predictable manner, this
enables the child to feel regulated and contained. The child in turn incorpo-
rates this reality and develops a personal capacity to reect, to understand,
and to give meaning to experiences in the world, even when distressed.
Since the beginning of her treatment, I have embraced the importance of
containing MKs affects through reecting her state of mind. However, enhanc-
ing her metacognitive monitoring and mentalization processes through actively
and directly discussing her own reective functioning has become a recent
focus. Using the language of attachment research, a primary goal of therapy at
this time is to increase her metacognitive capacities with the hope that this
will move the therapy forward and further develop her sense of self. It has
become vital for us to work together to facilitate a sense of reality that allows
her to see that her perceptions may be different than others and that her per-
sonal biases and interpersonal distortions have interfered with her relation-
ships. Enhancing this sense of reality has become key to the diminishment of
her grandiose illusions and, consequently, to the management of her depres-
sion. I hypothesized that reading my account of her treatment and collaborat-
ing on points of agreement and divergence could facilitate MKs mentalization
process. The following brief vignette illustrates how the collaboration may have
facilitated mentalization, as well as metacognitive monitoring.
MK has longed to feel like the special child of her memories, and a conict
early in our relationship was her sense that she did not feel special to me. In
comparison, benchmarks from her younger adult life were two short-lived expe-
riences she had with persons she idealized. She had memories of feeling
intensely understood, appreciated, and accepted by them. A common theme in
her therapy with me has been her drive to re-experience that feeling again.
She recently said, Everything I do is based on trying to feel that way. It made
me feel in love with myself. She admitted, I desperately need peoples atten-
tion and approval in order to feel goodI feel so good when something about me
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makes someone else happy. She longed to see the gleam in the eye of a deeply
admired and admiring other, someone who would make her feel special on a
continuing basis. As she said, Its hard for me to accept that Im ordinary. I got
the message that I could be so much more.
As MK and I reviewed her therapy history and her memories of these
idealized early relationships, she began to recognize the manner in which she
had distorted her impressions of these persons. She realized that her feelings
about them may have been different than their feelings about her and that she
had used these relational distortions to distance herself from our own thera-
peutic relationship. We have discussed this subject many times over the years,
but my willingness to return again to these early dynamics in our relationship
seemed validating to her in that she and I now view that reality in the same
manner. Discussion about this early period in our treatment conrmed to both
of us that we have moved a long way together. She is now able to think about
others with more clarity and understanding, and she thinks about herself with
more appreciation for who she is and how she has evolved.
DISCUSSION
My original intent in writing about the clinical work with MK was
to hit the mark in her eyes, to nally have her sense that I under-
stood her, at least for the moment. Together, we seemed to achieve this
goal, and the process served to deepen our therapeutic relationship.
Nevertheless, there were potential drawbacks to this writing project
and, therefore, ethical questions to consider.
For example, it is always important to evaluate whether the benets
of clinical writing outweigh potential harm. Initially, MK felt delighted
that I wanted to write about her, but this excitement (and narcissistic
gratication) mellowed when she read my initial thoughts about her
dynamics and saw herself described in such theoretical and clinical
terms. She did not feel my words matched her self-perception, particu-
larly since narcissism evokes a pejorative stereotype in popular culture
that does not describe her. Some of the clinical language was new to her
and served to conceptualize (and intellectualize) our relationship in a
manner that was emotionally distancing, perhaps triggering a dismiss-
ing attachment between us, thus enacting her parent-child history.
Further, inviting MK to read the write-up interrupted her ongoing treat-
ment process because the paper and discussion were directed by me,
rather than by following her cues. One legitimately could question if the
benets were more for my professional gain (i.e., publication) than for
MKs personal gain (i.e., self-reection and growth).
There also were serious questions to be raised about the
transference relationships and the theoretical frame of our treat-
ment. Given her history with a mother who was very controlling and
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authoritative (a know-it-all), it is not clear that MK was genuinely
free to say no to my request to write about her. Given the difculties
and intensity of our beginning relationship, there is the question of
whether my counter-transference from earlier years was continuing to
inuence my current conceptual view of her, foreclosing an unfolding
therapeutic process. Gabbards (2000) comments are pertinent to this
last question when he says that when we think about the patient in
terms of a particular theoretical or technical issue, [we are] at risk for
consciously or unconsciously skewing the patients material in the
direction of that issue (p. 1074).
Ultimately, these issues were considered in the process of
discussing the write-up with MK and in the weeks that followed the
initial submission of the rst paper. In addition to my private musings
and professional consultations with colleagues on this matter, MK and
I engaged in our own dialogue and exploration. To use her words, we
considered these concerns grist for the mill in our ongoing work. Due
to my research for this current paper, the ethical questions moved into
the forefront of my mind, and I listened carefully for any unspoken
lingering doubts. We explored her option to withdraw her consent prior
to publishing her clinical material, but she remained interested in
moving forward with the submission. She eventually acknowledged a
deeper understanding and appreciation of our therapeutic process and
came to value in a new way the personal changes that she could see
through our clinical review. We both agreed that at this stage in her
treatment (which could be described as a long termination), she is now
seeing the big picture. In other words, the benets of her participa-
tion in the writing process outweighed any potential harm through
disruption in her treatment. For MK, the process served to clarify and
validate her growth, afrming her sense that she is exploring the
world with more condence. For me, the process enabled a more
focused and comprehensible understanding of our long relationship,
which was additionally benecial to MK. At this point, our mutual
assessment is that the writing process did facilitate and advance the
treatment process.
Experiences writing about and with MK have led to an enriched
understanding of the complexities and subtleties of the use of clinical
material in both writing and professional presentations. I agree with
Gabbard (2000) who says that professional therapists and academics
need to obtain informed consent from our clients, in addition to heavily
disguising their identifying information, when we use their clinical
material in our professional undertakings. But, that is just the begin-
ning. Beyond consent and disguise, we need to consider, both privately
and in exploration with our clients, the benets and potential harm of
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such clinical disclosure (even when condentiality is maintained). We
need to evaluate whether the therapeutic relationship is secure enough
to honestly explore the transferential impact of the use of clinical
material and whether usage will enhance self-reection for the client,
as well as understanding for the professional community.
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Susanne Bennett, Ph.D.
National School of Social Service of
the Catholic University of America
620 Michigan Ave., NE
Washington, DC 20064, USA
bennetts@cua.edu
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