Confidentiality in psychotherapy - a further discussion
The problems of confidentiality in analytic psychotherapy are much more complex than they first appear. I will try to put a personal point of view, substantially based on a discussion by Gray (2006).
In offering you (the client) analytic psychotherapy, I am inviting you to talk freely about anything which comes to your mind. It is my job to make a private, safe space for you to do this. However, many people have "in the back of their minds" disturbing fantasies about actions which if likely to be realised would cause me considerable anxiety: illegal sexual behaviour, or acts of terrorism, for example. If you choose to tell me about such dark thoughts, you must rely on me not to take you literally: i.e. that you would consider doing these things. However, this places me in the role of "thought police" - how am I to decide whether it is safe not to report you to the authorities? If you should go on to commit one of these offences, would I have been wrong to remain silent?
Bollas and Sundelson (1995) make a distinction between psychoanalysis (where confidentiality is paramount) and "managed care", where the therapist is a sort of middleman between the needs of society and the reality of the client's existence. If you present me with thoughts that make me anxious, these two domains come seriously into conflict.
Ultimately, if my profession as an analytic psychotherapist is compelled by its ethical codes and the wishes of society to become a form of managed care, and to comply with the law at all times, the concept of a safe and private space for you to discuss unacceptable fantasies and desires becomes impossible. Gray argues, and I agree, that the "certainty" achieved by such restrictions would destroy the very essence of our profession. The uncertainties that you may feel about the safety of disclosing such matters to me, and the anxieties I would feel if you do, must remain. Otherwise, I cannot offer the you the full benefit of my art. In short, we have to trust each other.
Gray, A. (2006) Further thoughts on confidentiality. British Journal of Psychotherapy, 22(3), 363-372.
Bollas, C & Sundelson, D. (1995) The New Informants. Northvale, NJ, and London: Jason Aronson.