Response to Dr Slade

Dear Sirs,

Laurie Slade expresses a concern shared by many clinicians: when analysts and therapists write about patients, there is a conflict of loyalty between the needs of the patient and the need to share clinical material with the professional community. Her solution is to ask patients' permission and explain this dilemma in the initial meeting. This approach has been employed by many clinicians, especially those in academic settings. Most analysts report that they have not found it problematic. However, Aron (2000), who tried this method, abandoned it because he realized that patients did not really understand the meaning of the request nor did they have a reason to trust him on first meeting. I would add a caution from a slightly different vantage point; that is, the analyst does not yet know the patient. There are some patients whose treatments are detrimentally affected by the intrusion of such a request. Defining which patients fall into this category is difficult and complex; it is very unlikely to be clear in a first meeting. Aron addresses part of the issue when he states that there needs to be trust. For some patients, trust may take a long time to develop and may be fragile at best. For others, issues of shame make privacy essential; it may take a long time for their potential to feel humiliated to lessen. For still others, the exposure of guilt and feared punishment makes privacy essential. I refer to only a few of the possible reasons why patients might resist the idea of being written about. It is not only, and often not primarily, because they fear they would be identified; often, it is that they want what is said to remain just with the analyst. The meaning of this, of course, is worthy of analysis, but, nonetheless, patients are entitled to have such wishes respected. Many analysts who argue that it is best to carefully conceal patients' identity and not ask permission believe most patients have some of these concerns.

From the reports of the 141 a