Writing Case Histories

There seems to be little doubt that one must exercise extreme caution in writing case histories for presentation or publication in order to protect a patient's confidentiality. However, beyond that point, there is much in doubt, especially just how that is to be accomplished. Somewhere between the poles of presenting the clear and undisguised case report and that of composing completely fictionalised accounts, there are a number of possible alternatives, all of which carry some potentially undesirable features. There is a need both to safeguard the privileged communications of patients and to allow psychoanalytic science to progress by way of a free exchange of information. It is all too easy to take a firm stand at one or another of these extreme positions and so to dismiss the consequences of what may turn out to be a simple but possibly deleterious position.

In the present-day climate of justifiable concern about confidentiality (Bollas & Sundelson, 1995) there is a heightened alertness to issues relating to protection of privacy, especially in psychoanalysis and psychotherapy. Although one may feel free to publish a patient's x-rays or laboratory findings without explicit permission, there is no such freedom in disclosing a personal history. The Principles of Medical Ethics for psychiatry from the American Psychiatric Association (1995) states: ‘Clinical and other materials used in teaching and writing must be adequately disguised in order to preserve the anonymity of the individuals involved’. No clear guidelines as to how this is to be accomplished are offered. The American Psychological Association's Ethical Principles (1992) reads: ‘Ordinarily, in such scientific and professional presentations, psychologists disguise confidential information concerning such persons or organizations so that they are not individually identifiable to others and so that discussions do not cause harm to subjects who might identify themselves’. These seem fairly representative of t