Case histories and confidentiality

Dear Sir

I applaud Arnold Goldberg’s recent editorial on the writing of case histories in psychoanalytic journals. This issue has long been shrouded in secrecy and it is high time it was brought out into the light of day for open discussion. As Dr Goldberg points out, our need to advance the field by publishing case reports inevitably conflicts with our obligation to maintain patient confidentiality. I share his view that every solution to this problem is imperfect, and I also agree that the cessation of publishing case reports is not a viable alternative.

Beyond those areas of agreement, however, I view the dilemmas he describes somewhat differently. I think he overstates the problem with disguising case material. A welldisguised case can nevertheless be a highly factual report of what actually happened in the course of a psychoanalytic treatment. The disguise generally involves changing the identifying features of the patient to preserve confidentiality while leaving elements of the process intact. Indeed, the American Psychoanalytic Association Committee on Scientific Information developed a model of reporting clinical material that emphasized detailed process accounts of dialogue in analytic sessions while minimizing any biographical information about the patient.

Dr Goldberg also states that ‘It may come as a surprise to realize that most case histories, long and short, are written and/or presented with only a minimal or even no effort at disguise’. How does he reach this conclusion? I know of no data that would support this assertion. In my career as a writer and a reviewer of manuscripts for many editorial boards, my impression is quite the opposite.

In discussing the ever-present conflict of the obligation to protect our patients with our other obligation to advance our science, Goldberg suggests that we will run a risk of essentially writing fiction if we become firm protectors of confidentiality. I think his doomsday scenario is premature. By using the followi