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Paul Mosher and Jeffrey Berman's Confidentiality and Its Discontents: Dilemmas of Privacy in Psychotherapy is a wonderful account of these dilemmas. The title is telling: playing on Freud's “Discontents” title, it
highlights that therapists are faced with unwelcome and painful demands that may pull against the patient's therapeutic interests.
Mosher and Berman rightly point out how vital confidentiality would seem to be to psychoanalysis and psychoanalytic therapy. Patients will be loath to follow the “fundamental rule” to “say everything that comes to mind” unless they are confident that what they say will never leave the room. A condition of full disclosure is confidentiality. If this cannot be promised—or if the patient is actually warned of the limits of confidentiality—he or she will not be fully forthcoming.
A couple of things can be said here. First, it is just an article of faith that confidentiality is necessary. Logically it would seem to be. But often things that seem likely theoretically don't pan out that way empirically. Consider that it is a reality that confidentiality is not absolute, and yet treatments, good treatments, happen anyway. The idea that confidentiality is not absolute may not affect many people, though there is good evidence, seen in some of Mosher and Berman's case studies, that actual breaches of confidentiality do.
Does lack of confidentiality introduce complications? Maybe. Perhaps it would be well to study this empirically: one group of patients, say, could be told about the limits of confidentiality, while another group would not be. Do the former free associate about this? Does concern manifest in unconscious phenomena? Do patients given such warnings disclose less potentially damning information and, for example, stay away from revealing angry thoughts? Of course studying the effects when warnings to potential victims are given would be useful.
The second thing is that the psychodynamic manifestations of learning that confidentia