Psychotherapy 2012, Vol. 49, No.

1, 2225

2012 American Psychological Association 0033-3204/12/$12.00 DOI: 10.1037/a0026965

COMMENTARY

Clinical Writing: Additional Ethical and Practical Issues

Susan S. Woodhouse
Pennsylvania State University
The recommendations by Sieck (2011, Obtaining clinical writing informed consent versus using client disguise and recommendations for practice, Psychotherapy, 49, pp. 311.) are a helpful starting point for considering the ethical issues involved in the decision to seek or not to seek informed consent from clients before writing about them. Sieck makes a compelling case for the idea that there are circumstances in which the most ethical choice would be to engage in clinical writing about a client without seeking informed consent, but instead disguising the clients identity. The present response raises a number of questions not considered in the article by Sieck. First, how should one disguise a case? Moreover, how should one assess whether the disguise is sufficient to preserve confidentiality while not distorting the clinical material to the point that the material is no longer useful to the field? Second, how can we estimate the likelihood of clients reading clinical writing, particularly in the age of the Internet? Given that psychologist-authored blogs that include reference to clinical material are beginning to emerge, it is crucial that we engage in a much deeper dialogue about the ethics of clinical writing. Third, how does the presentation of clinical material influence public perceptions of psychotherapy and confidentiality? If these public perceptions, in turn, could influence the likelihood of seeking psychotherapy, might these attitudes be important to consider in ethical thinking about clinical writing? Finally, where do we draw the line between clinical writing and single case study research (which requires informed consent)? Keywords: clinical writing, ethics, informed consent

Ethical considerations related to whether, under what conditions, and how to discuss client clinical material are relevant not only to those who write about clinical theory, but are also relevant to those who teach or are involved in teaching and clinical training. I found the article by Sieck (this issue, pp. 311) very stimulating. In particular, I appreciated the balanced discussion about the very controversial issues at stake and the effort to make clear recommendations regarding the decision-making process related to deciding whether to write about a particular client and whether to pursue an informed consent process with that client. Sieck made a compelling case that, at least in certain circumstances, it may be best to write about a well-disguised case without seeking informed consent. At the same time, I found myself pondering a number of lingering ethical and practical questions. I was struck by the poignancy of the fact that, despite Freuds clear efforts to disguise the identity of the woman he called Dora in Fragments of an Analysis of a Case of Hysteria (1953/1905), today everyone knows who Dora was (Ida Bauer, 18821945), the trauma that she went through, and the ways in which Freud construed her case. It was especially meaningful to me that Doras true identity is known despite the fact that Freud believed that she

Susan S. Woodhouse, Department of Educational Psychology, Counseling, and Special Education, Pennsylvania State University. Correspondence concerning this article should be addressed to Susan S. Woodhouse, 313 CEDAR, Department of Educational Psychology, Counseling, and Special Education, Pennsylvania State University, University Park, PA 16802-3110. E-mail: ssw10@psu.edu 22

would have refused to give consent to write about her case. For me, this raises the very important question of what it means to disguise a case. What would it take to write about a case in a way that the client could not be identified? I would have liked to see recommendations about how to disguise a case effectively, while preserving the crucial clinical aspects. In my view, this is an area that deserves much greater attention. A number of writers have taken on the issue of how to disguise case material. Kantrowitz (2004) summarized the current debates about the topic of hiding client identity. For example, some have argued that the material should be disguised to the point that no one, not even the client, would recognize the client. This is a very difficult standard to meetparticularly if one cannot check with the client to ensure the results are as intended. How can we know that the goal has been met? In addition, if the case were to be so well disguised, would the material even be relevant for advancing the field? Would the remaining description describe anything real? These questions reflect the problem of how we should balance the ethical obligations of preserving confidentiality (nonmalifasence) and moving the field forward so that others can be helped (beneficence). The issue of how to disguise a case without changing the clinical meaning of the case material strikes me as a thorny one, particularly if we are serious about the possibility that the intersecting, culturally based identities we have are meaningful. It could be very difficult to make sense of a case without reference to these important cultural factors. For example, can the case of Dora really be understood without reference to her status as a young, Jewish woman in a particular place at a particular point in history? Each

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author must decide (for better or for worse) which details are relevant to the interpretation of the case material, and which can be safely changed. Kantrowitz (2004) points out that some argue that what writers must do is change the identifying features and omit as many identifying details as possible. But at the same time, authors should maintain the psychological dynamics or the process of the treatment and avoid changes that distort the meaning of the case. The psychoanalysts in the study by Kantrowitz reported that they changed names and other identifying data (e.g., location, age, profession, family constellation, religion, and gender) and also added fictitious details that could potentially pull readers away from the true identity of the client. One example of such a red herring given by a psychoanalyst in the Kantrowitz study was to change the setting from a warm climate to a cold climate and then add a detail about how snow had delayed the client (when in actuality the client was delayed for a different reason). I suppose that such an approach could work as long as the known identity of the psychotherapist did not make it impossible for such changes to be believable. One key problem with disguising client material is the difficulty of knowing (or testing) whether the disguise actually hid the clients identity or not. One can imagine the horror a client might feel upon recognizing him or herself in a clinical vignette (or worse, an in-depth case study) if the client had not been expecting it. Stoller (1988) described the strange mix of feelings that might be felt upon recognizing oneself in a clinical vignette despite the fact that ones identity has been disguisedincluding horror, outrage, sadness, feelings of having been used, in addition to feelings of being honored and cared about. I find that list of feelings is a humbling reminder of the risks we take whenever we discuss or write about clinical material. I think that is why I was so gratified to see this complex issue beginning to be addressed in Psychotherapy. It could be very helpful to learn more about how the identity of individuals represented in clinical case descriptions end up being revealed. I was quite struck by Liptons (1990) data suggesting that several of the 15 psychoanalysts studied had been confronted by past clients who were unhappy about finding themselves in their analysts writings. It struck me that more research on this issue could be very important because if we know how identities are revealed, that could inform how to best protect confidentiality. Sieck (this issue) suggests that we should weigh the risk of clients finding themselves in therapists writing and implies that there is low risk, but I am not aware of what the data have to tell us about how frequently this happens (and thus how much risk there is). The brief mention of the Liptons data indicate that this unfortunate event is occurring, but more research on this question could be very beneficial in helping us understand the true risk to clients. Siecks recommendations suggest consideration of whether the client is likely to read the professional literature, and I would assume we must also consider the likelihood of people who might know the client reading professional writings. It is not clear to me, however, how such a determination of likelihood should be made. Given that these days anyone can Google the name of a therapist, it may be possible that the likelihood of clinical writing being seen by clients (and the people who know them) may be going up.

Concern about what is available on the Internet may shift the discussion about the ethics of clinical writing. For example, Vartabedian, Amos, and Baruch (2011) recently presented a hypothetical case discussion about the issue of physicians blogging anonymously about their patients in ways that could be problematic if the identity of either the blogger or the patient were discovered, yet how easily either or both identities could be revealed. As I read the article, I thought to myself with relief that psychotherapists do not blog about clients but then I realized that I actually did not know if this was the case. A simple search of the term psychotherapy blog revealed a number of psychotherapists blogs. Thus, I think that as a field, we need to be alert to the fact that the Internet and social media may require that we become more thoughtful about how client material is discussed. It is no longer the case that publicly available clinical material is only put into print after a careful peer review. Whatever flaws the traditional publication system may have can only be magnified by the ease of putting material into print on the Internet. Vartabedian et al. also raise the issue of minding ones digital footprint, that is, paying careful attention to the searchable materials we make available on the web. Materials placed on the web remain well into the future. Thus, we must be mindful of how we write about clinical information on-line, even if we believe the material to be anonymous. Pies and Kantrowitz (2011) discussed the issue of journal policies about the ethics of clinical writing in their analysis of a hypothetical case study. In their hypothetical case, a psychiatry resident contemplates whether to write a clinical case study on differential diagnosis of bipolar disorder and mood disorder associated with substance abuse in a complex case involving Teresa, the 15-year-old daughter of a university staff member. In the discussion of this ethical dilemma, in addition to considering issues related to writing about a minor and the complexities of gaining informed consent in such a case, Pies and Kantrowitz point out that medical journals may have differing editorial policies. Some journals require patient anonymity through avoidance of identifying information (including hospital names and dates) and use of patient disguise. Other journals require that consent be obtained from the client (or a legal representative) and that the client should read the report before submission. If consent cannot be obtained, then the author must disguise the patient so well that even the patient would not recognize him or herself. It struck me that perhaps we should be thinking as a field about these issues and considering whether policies such as these could be useful (or harmful). Moreover, it might be helpful to consider how such a policy could be enforced if we do not have clarity on what would allow a case to be sufficiently disguised. Pies and Kantrowitz (2011) argued that, on the basis of data collected by Kantrowitz (2006) through interviews with 141 psychotherapists about their clinical writing and 37 clients about their experiences of reading about themselves, there is no simple solution to the problem of establishing editorial policies given the wide variation in reactions possible. Nevertheless, given that psychotherapists can easily publish material via the Internet, it is crucial that as a field we engaged in discussions about the ethics of presenting case material. As I thought about the ethical issues relevant to clinical writing, I found myself thinking about a very similar issue: confidentiality

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for research participants. For example, Beck, Levinson, and Irons (2009) described their investigation into the true identity of Little Albert in the famous conditioning experiment by Watson and Raynor in the 1920s. The piece led me to thinking about when does science move into becoming history, such that the rules of our science (e.g., confidentiality for research participants or clients) fall away and we shift into the apparent rules of history, which seems to favor the uncovering of identity over protection of confidentiality. As I read the piece by Beck et al., I admitted to myself that enquiring minds want to know yet at the same time feeling revulsion at my own interest. I felt some satisfaction in the fact that the identity of Little Albert could not be known conclusively, as I wondered what it might have been like to be the mother of the little boy who became known as Little Albert, wondering if she might posthumously wish for anonymity given everything she and her son might have experienced. In fact, I wondered whether the ethics of our science and practice should ever be thrown over so as to practice history instead. In terms of the ethics of revelations about clinical material, another famous example that comes to mind is psychiatrist Martin Ornes release of the poet Anne Sextons therapy tapes. Werth, Burke, and Bardash (2002) provide an analysis of the ethical issues related to postdeath confidentiality, pointing out that Orne did not violate the ethical guidelines or laws about confidentiality because Sexton had given her permission for the therapy tapes to be given to her legal executor. The legal executor, Linda Gray Sexton, in turn, gave the tapes to author Diane Middlebrook, who quoted from the tapes verbatim in the biography she wrote. Werth et al. point out that Orne clearly complied with the letter of the law, but raise the question of whether Orne complied with the spirit of the law. Werth et al. note that in addition to thinking about the potential violation of confidentiality for the client, we must also think about the potential harm to society if others see clinical case details released and subsequently avoid treatment due to a perception that despite claims of confidentiality, clinical information is actually released. In the case of the Anne Sexton tapes, perhaps one could argue that the recordings had clearly been released by the client. Nevertheless, psychotherapists who write (or speak) about case material must also face the same question about how the general public could be affected by these actions. Fisher (2008) frames the question about protection of confidentiality in terms of understanding the ethical floor and reaching for the ethical ceiling. The question is what does it mean to reach for the ethical ceiling in trying to balance potential clinical harm to the client, protection of client autonomy, as well as potential benefit to others if treatment is advanced with potential harm to others and people have the perception that confidentiality can be violated without the clients consent in clinical writing. In other words, perhaps the decision tree about whether to write about client material or gain client consent must include consideration of wider effects on others who may seek psychotherapy in the future, in addition to considering the client. It could be very helpful to conduct research on how different kinds of presentations of case material affect peoples perceptions about confidentiality in psychotherapy and attitudes about seeking psychotherapy. Such research could help the field to design more nuanced recommendations that take into account relevant client, therapist, contextual, and relational factors.

I agree with Sieck (this issue) that it may be very important to think very carefully about whether different kinds of decision rules should be used for different kinds of clinical writing. For example, perhaps the bar for deciding to forgo client informed consent must be set much higher for writing an in-depth clinical case study that reveals a great deal of material about the clients inner process than for a brief clinical vignette that simply illustrates a single principle. In the case of the in-depth clinical case study, it could be that even if the identity of the case is highly disguised, the public may perceive the in-depth description of the dynamics of the case as a violation of privacy and so tend to avoid psychotherapy in the future, fearing that their innermost stories could be revealed even if their identity were to be protected. I think it might even be meaningful to ask ourselves how to decide whether clinical writing should be considered single case study research, which would require informed consent, and when clinical writing can be considered clinical examples (rather than research). In my response, I have touched on only a few of the questions stimulated by Siecks interesting article. There are many other ethical questions that must be addressed in the future. For example, what about if a therapist seeks informed consent and is deniedis the therapist then to avoid writing about the client? Or can the therapist move forward with a disguised case? Do we need to focus on proper destruction of records so that later on no one can use our records to track down client identities? If we do pursue more stringent requirements to seek informed consent, either early in treatment or at any point later on, how can we help clients fully appreciate the meaning of the consent they are giving and anticipate its effects. I appreciate the effort made to clarify the process through which psychotherapists might decide whether or not to write about clients, and whether or not to seek informed consent, given the potential clinical issue that may be encountered. Discussion of these issues is a difficult endeavor that perhaps raises as many questions as it answers. Nevertheless, it behooves us, as a field, to strive for answers through a combination of empirical research on the relevant issues and ethical consideration of the potential harms and potential benefits.

References
Beck, H. P., Levinson, S., & Irons, G. (2009). Finding Little Albert: A journey to John B. Watsons infant laboratory. American Psychologist, 64, 605 614. doi:10.1037/a0017234 Fisher, M. A. (2008). Protecting confidentiality rights: The need for an ethical practice model. American Psychologist, 63, 113. doi:10.1037/ 0003-066X.63.1.1 Freud, S. (1953). Fragment of an analysis of a case of hysteria. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 7, pp. 3112). London: Hogarth Press. (Original work published 1905) Kantrowitz, J. L. (2004). Writing about patients: Ways of protecting confidentiality and analysts conflicts over choice of method. Journal of the American Psychoanalytic Association, 52, 69 99. doi:10.1177/ 00030651040520011101 Kantrowitz, J. L. (2006). Writing about patients: Responsibilities, risks, and ramifications. New York: Other Press. Lipton, E. L. (1990). The analysts use of clinical data, and other issues of confidentiality. Journal of the American Psychoanalytic Association, 39, 967985. Retrieved from http://apa.sagepub.com/

COMMENTARY Pies, R., & Kantrowitz, J. L. (2011). Case studies and the therapeutic relationship. Virtual Mentor, 13, 425 434. Retrieved from http:// virtualmentor.ama-assn.org/2011/07/toc-1107.html Sieck, B. C. (2011). Obtaining clinical writing informed consent versus using client disguise and recommendations for practice. Psychotherapy, 49, 311. Stoller, R. J. (1988). Patients responses to their own case reports. Journal of the American Psychoanalytic Association, 36, 371391. doi:10.1177/ 000306518803600205

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Vartabedian, B. S., Amos, E., & Baruch, J. (2011). Anonymous physician blogging. Virtual Mentor, 13, 440 447. Retrieved from http:// virtualmentor.ama-assn.org/2011/07/toc-1107.html Werth, J. L., Burke, C., & Bardash, R. J. (2002). Confidentiality in end-of-life and after-death situations. Ethics and Behavior, 12, 205322. doi:10.1207/S15327019EB1203_1

Received October 3, 2011 Accepted October 4, 2011