In his first Gawker column on Wednesday, an anonymous therapist discussed the challenges of dealing with physically deformed patients, described counseling a confessed rapist, and revealed some clients’ troubling confessions. (One patient tried to sodomize his dog.) Although the patients weren’t named, some commenters wondered whether such disclosures are ethical. Can your shrink spill your secrets?
Yes, if your identity is concealed. Standard 4.07 of the American Psychological Association’s Code of Ethics prohibits publication of patient information in “writings, lectures, or other public media” unless the therapist obtains the patient’s consent or takes “reasonable steps to disguise the person.” Most of the Gawker writer’s stories are vague enough to satisfy this rule. The closest call is the female patient who “took 50 Ambiens at one time as a teen and is now one of the heads of a large marketing firm.” There may be enough information there to at least raise confidentiality concerns. Obscuring identity often comes down to statistics, and the number of women leading large marketing firms is relatively small. If a nosey investigative reporter discovered the identity of Gawker’s anonymous therapist, he might be able to uncover the identity of the patient.
It’s impossible to know for sure whether Gawker’s therapist has violated any ethics rules, however, without additional information. The article describes the writer as a therapist, not as a psychologist. A different set of rules apply to social workers and counselors (although they are broadly similar). It’s also possible that the writer altered details of the patients’ stories to protect their identities. For example, maybe the Ambien patient actually heads up an accounting firm rather than a marketing firm. In addition, some of the patients may have given the therapist their consent, in which case there’s no confidentiality issue.
Psychologists have been struggling with the tension between confidentiality and the need to publish their findings for more than 100 years. Sigmund Freud expounded on the duty to publish in his 1905 book about “Dora,” a patient who had lost her voice due to hysteria. Freud argued that the interests of society sometimes outweigh the confidentiality concerns of an individual patient. He revealed several clues to his young patient’s identity—her brother’s age, her father’s job and medical history, that her mother was a compulsive house cleaner—along with some lurid sexual details. Yet, while people close to Freud and a few others in the field knew “Dora” to be a woman named Ida Bauer, her identity didn’t become public until the 1970s, a quarter century after her death.
Patient confidentiality rules have become somewhat stricter since Freud’s heyday. In 1995, a coalition of medical journals published guidelines requiring doctors to obtain patient consent “if there is any doubt” that the published details conceal the subject’s identity. (Freud’s account of Dora would not have satisfied these requirements.) The rules also prohibited authors from altering any details to mask the patient’s identity, although medical journal guidelines do not apply to Gawker columns. The rules upset some psychiatrists, who argued that their field presented special complications: A patient’s occupation, family situation, and sexual history might not always be relevant to a case report in a cardiology or endocrinology journal, but such details can be crucial in psychiatry and psychology.
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Explainer thanks Stephen Behnke of the American Psychological Association.
