CHALLENGES Susanne Bennett, Ph.D. 1 ABSTRACT: Clinical implications and ethical dilemmas of the use of condential case material in clinical writing are examined, including a review of the discourse among professionals who publish clinical work. This literature is applied to a clinical illustration of psychotherapy with a client who gave consent for publication and read the clinical write-up of her case material. It is suggested that clinical writing may increase client self-reection if there is a secure base of attachment between therapist/author and the client. The impact on the clients treatment process is examined, in addition to a discussion of ethical questions and professional recommendations. KEY WORDS: Clinical writing; ethical dilemmas; attachment theory. INTRODUCTION The typical format for clinical writing includes an overview of theory followed by an extended case illustration. Grounded in a theoretical con- ceptualization of my therapeutic work with a current client, my recent journal submission followed this format. I recognized that cases are every bit as empirical as experiments (Westen, 2002, p. 882) and asked the client under discussion to sign consent for publication of her case material. I also asked her to read the presentation and collaborate with 1 Correspondence should be directed to Susanne Bennett, Ph.D., National School of Social Service of the Catholic University of America, 620 Michigan Ave., NE, Washington, DC 20064, USA; e-mail: bennetts@cua.edu. Clinical Social Work Journal, Vol. 34, No. 2, Summer 2006 ( 2005) DOI: 10.1007/s10615-005-0011-7 215 2005 Springer Science+Business Media, Inc. the way her story was told. My initial submission for publication was re- turned for revisions with one reviewers cogent observation that writing a paper in collaboration with a client is a controversial one in the eld of clinical writing and should be taken up more extensively by the author. Further investigation into the literature on clinical writing supported the reviewers critique. The initial decision to include my client in the writing process was not merely an attempt to respect her condentiality, though that was of major concern. The decision emerged from my clinical thoughts about this client and our long and complex relationship. We are both aware of the intersubjective nature of our relationship, and we regularly explore the transference (and countertransference) is- sues that emerge. Yet the healing nature of the real interpersonal relationship has shaped more recent interventions, and it was out of this latter dimension of our clinical work that I asked for her permis- sion to write about our work and invited her to read and comment on the writing. The following paper is two-fold in purpose. It includes a general review of the controversial and, indeed, ethical issues that emerge from clinical writing, followed by a discussion of the client and my perceptions of the writing process and its impact on the ongoing treatment. CURRENT DEBATES ABOUT CONFIDENTIALITY AND CLINICAL WRITING In the last decade, concerns have intensied within health care about patient medical privacy and condentiality, especially with the onset of managed care and the 1996 passage of the federal Health Insur- ance Portability and Accountability Act (HIPAA). The National Associa- tion of Social Workers (NASW, 2004) has acknowledged these contemporary challenges through revisions in 1999 to the NASW Code of Ethics and through provision of information and training about the application of HIPAA for social workers. The Code of Ethics clearly states that social workers may disclose condential information when appropriate with valid consent from a client (NASW, 2004, p. 7), and social workers engaged in evaluation or research should obtain volun- tary and written informed consent from participants, when appropriate (p. 19). Further explicit directives regarding both research and practice ethics cover concerns about client self-determination and the goal to protect the client from harm. Nevertheless, there is no mention in the Code regarding consent for the use of condential case material in 216 CLINICAL SOCIAL WORK JOURNAL clinical writing. Current literature on social work research ethics does not address this issue or, apparently, equate the clinical case with other forms of empirical data (Antle & Regehr, 2003; Congress, 2002; Conrad, 1989; Gibelman & Gelman, 1999; Palmer & Kaufman, 2003; Reamer, 1998). Consultation with both a senior editor for NASW publi- cations (personal communication, August 17, 2004) and with Frederic Reamer, who has written extensively on social work ethics (personal communication, August 26, 2004), conrmed that the profession does not have specic condentiality guidelines for the use of clinical case material in publications. Decisions for publication of clinical material are made on an individual basis under the direction of the various journal editors. By contrast, the current 2002 Code of Ethics of the American Psychological Association (APA, 2004) does have a guideline on the Use of Condential Information for Didactic or Other Purposes, which states that psychologists must disguise the person under discus- sion and the person must give consent for condential information to be used. This more focused guideline has not silenced the debate among those who both publish and present clinical case material. Aron (2000) argues that disguising case material alone is insufcient (p. 232). Gabbard (2000) agrees that disguise without consent is not acceptable (p. 1072). Nevertheless, a qualitative study conducted by Kantrowitz (2002) revealed there was not a uniform approach among the 30 American psychoanalysts interviewed regarding their use of patient material in published articles. Ethical issues outlined by Gabbard (2000) include concerns that (1) the writers ability to provide honest, thick disguise may be insufcient; (2) the patients capacity to provide honest, informed consent may be skewed due to the inuence of the transferences; and (3) the potential harm a patient may experience remains despite informed consent and/ or termination. As Gabbard says, we can never know in advance when it is appropriate to seek a patients permission or how that patient will react (p. 1080). Further muddying the discussion, he points out that consent may actually interfere with the patients candid disclosure of certain transferential feelings and may taint the therapeutic process. Despite this dilemma, Gabbard takes a convincing stand that disguise and consent are not either/or alternatives (p. 1080). Aron (2000) furthers this discussion by recognizing the legal considerations in using clinical material even if the patient gives informed consent. Conceivably, patients could accuse therapists of vio- lating condentiality because consent was obtained when the patient was vulnerable to undue inuence (p. 234). He suggests that most patients would indeed have mixed feelings about being used in this 217 SUSANNE BENNETT way (p. 235). For this reason, some therapists choose to write about clients after their termination, though this option minimizes recogni- tion of the ongoing impact of the transference long after the analysis or psychotherapy has ended. Aron, like Gabbard, argues that a patients permission must be gained if extensive material is going to be used, and he believes this request may open the possibility of mutuality and symmetry in the therapeutic process. He recognizes that having a pa- tient serve as a collaborator after consent has been given may meet certain narcissistic gratications for the patient. While such gratica- tion may make it relatively simple to obtain authorization, he proposes that an important question remains: Do therapists have a professional obligation to protect patients even if collaboration encourages thera- pists to publish? In other words, the conicts of interest between pa- tients and therapists may raise difcult ethical dilemmas. Despite these concerns, Aron (2000) makes a persuasive case for the potential value to the clinical process when written material is shared with a patient. In a summary of his own collaborative process with a patient, he says: Sharing the write-up with the patient and encouraging his feedback served to clarify my own blind spot and advance the analysis (p. 239). Kantrowitzs (2002) qualitative study of psychoanalysts that publish clinical data reported a similar theme. Some analysts she interviewed believed the patients reading of the clinical account served to validate both the therapeutic work and the relationship because it served as conrmation that the analyst shares the patients understanding of his or her difculties and the process of their work (p. 89). Consequently, it was believed by some analysts that these patients experienced therapeutic benets, in addition to gratication, in the collaborative writing process. CLINICAL MATERIAL Admittedly, I did not fully realize the depth of these ethical dilemmas, including the potential benets and pitfalls, when I asked my client, MK, if she would be willing to have me write about her life and our treatment relation- ship. A prevalent theme in our work had always been her desire to feel under- stood by me, while she continued to experience a subjective distance that troubled her despite years of exploring our transferential and counter-transfer- ential issues. Therefore, I believed she would be interested and felt condent that our relationship could be enriched by the process. These convictions shaped my assessment that the writing process should be part of the ongoing therapy, rather than a hindsight analysis of a terminated treatment. I began to consider that a written explanation of our work would enable us to move beyond the subjective impasse. In addition, I had begun to conceptualize our work through the lens of attachment theory and wondered if attachment 218 CLINICAL SOCIAL WORK JOURNAL concepts might facilitate a deeper, yet more real, understanding of our rela- tional dynamics and her perceptions of them. When I rst mentioned the prospect of writing about her, MK was initially quite pleased, even thrilled. I always wanted to have someone write about me, she said. The offer to write her story made her feel special and that she had something to contribute to others. I explained that I would write a theoretical piece and include a clinical illustration from our work together. I assured her that I would disguise her identity substantially, that she could read the paper, and that I would not publish anything that she did not approve. We realized the paper might not be published, yet we saw this project as a way to further the treatment process. MK also believed it would help her better understand herself. In the year between the rst discussions of this col- laboration and the time that I actually wrote the paper, she would bring up the topic, as if to remind me in case I had forgotten. After my rst draft of the paper was completed, I asked MK if she felt ready to read it with me. I proposed that we meet at a time that did not inter- fere with her regular appointments. I did not charge for her time since it seemed unethical to bill for a session scheduled at my instigation. She was ini- tially hesitant and anxious, a reaction that took her by surprise. After a week of thinking about her understandable doubts, she decided she was ready. When we met in an extended session, I read the clinical portion aloud to her, pausing to assess her affective and cognitive responses, clarify her questions, and re- spond to memories that the initial reading evoked. I then gave her a written copy of the paper and encouraged her to contact me if she had reactions that needed exploring before our next scheduled appointment. In contrast to our regular alternate week therapeutic frame, we had weekly appointments for four weeks about the paper. Each week MK offered reactions and revisions to my version of the story. I continued to assure her that I would not submit material for publication unless she felt comfortable with the write-up and until she signed a written informed consent giving me permission. After much review of our long and intensive therapeutic relationship, and ve revisions of the clinical account, she decided she felt comfortable with the submission. As discussed earlier, the original paper that MK read was returned for revisions. An extended and separate summary of the theoretical portion of that paper was revised and accepted (Bennett, in press). The clinical information that follows is an abbreviated version of the original case write-up and is designed to illustrate two concepts from attachment theory that I consider sali- ent to MKs treatment: (1) the concept of the secure base (Bowlby, 1988) and (2) the concepts of metacognitive functioning (Hesse, 1999; Main, Kaplan, & Cassidy, 1985) and mentalization (Fonagy, 2001, 2003)). These concepts and clinical illustrations suggest justications for involving MK in the collaborative writing process. The clinical material that follows further suggests the poten- tial risks involved in this decision. A discussion of the ethical issues of clinical writing as they pertain to this case concludes the paper. The Secure Base The therapeutic process has often been compared with Bowlbys (1988) well-known concept of the secure base of attachment in childhood and its role in enabling the childs exploration of the world (Eagle, 2003; Holmes, 2001; 219 SUSANNE BENNETT Sable, 2000). Theoretically, clients who experience a secure base in treatment are able to engage in self-exploration of their world of affects, memories, and cognitions. The complexity of this seemingly simple idea is that clients with personality disorders have internalized attachment patterns that preclude an easy establishment of a secure base in treatment, especially when they have a dismissing model of attachment and features of a narcissistic personality disor- der (Hertz, 1996; Holmes, 2003; Imbessi, 1999; Slade, 1999). Blatt and Levys research (2003) suggests correlations between narcissistic personality disorders and dismissing avoidant attachment in adults. Both the disorder and the attachment model are characterized by an avoidance of interpersonal contact and by the individuals need for self-denition, autonomy, and self-sufciency. These characteristics are prominent features of MKs personality. A dominant theme of her therapy has been her desire to understand her life and to feel understood by me and by others. Establishing and maintaining a secure base of treatment also has marked our work together. A middle-aged, white, divorced single parent, MK initially presented for psychotherapy with severe and chronic depression. When she began treatment, she was still grieving the loss of her marriage and had no friends or interests outside of work and her children. It became apparent within the rst year of treatment that in addition to her diagnosis of major depression, she had an underlying personality disorder that was difcult to discern in terms of DSM classication categories. At times she seemed schizoid and occasionally schizotypal, but generally she had traits of narcissism. She was seen twice a week for many years and received additional collateral medication management from a psychiatrist. In time the treatment decreased to once a week, and then eventually to every other week sessions. The early period of treatment focused on creating a mutually trusting working alliance that would keep MK functional and safe from suicidal thoughts. She recalls feeling a debilitating insecurity at that time, which left her virtually non-functional. She was anxious, frantic, and overwhelmed when confronted by challenges that threatened [her] sense of competence. In addition, she was emotionally fragile and dismissive of my efforts to hold her clinically, but at the same time she demanded that I hold her physically. While unable to tolerate any separation from me, she could not establish eye contact when with me. It was a true challenge for me to hold on to the therapeutic alli- ance. Often we were caught in a web of relating that exemplied the narcissis- tic defense of projective identication. When I claried her experiences or interpreted her defenses, she would lash out with a great deal of anger at my perceived lack of empathy. Her transference placed me in a position of being, in her eyes, a dismissive and critical mother. I sometimes felt like an inadequate therapist, decient in empathic capacities. When she pushed me away, I struggled with counter-trans- ferential defensiveness about my professional abilities. She frequently expressed disappointment with me because she thought that I, like her mother, was disappointed in her. Ruptures in my efforts to be empathic inevitably trig- gered her memories: I want [you] to understand my feelings the way I do, but [you] interpret them differently and that makes me mad, just like my mother got mad at me for not seeing things her way. In her eyes, I often missed the mark. We did not have that consistent secure base of treatment so vital to the therapeutic process. 220 CLINICAL SOCIAL WORK JOURNAL Difculty occurred when I took three consecutive summer leaves of absence from my private practice in order to attend doctoral classes in another state. For the three months prior to my departure, MK was enraged that I would dare to leave her (though we planned to have weekly telephone sessions and monthly in-person visits). She repeatedly voiced her anger, while exhibit- ing disdain and supposed lack of curiosity or interest in the reason behind my leave. When I returned after the rst summer, she was cold, withdrawn, and dismissive. It took months to repair the misattunement activated by the break in our in-person contacts. She related by distancing her emotional proximity to me, a defensive covering and miscue of her attachment needs. Although MK spent years trying to distance me through an open expression of dismissive anger, she eventually internalized a realization that I was predict- ably present. For this reason, as well as my improved capacity to read her cues and mirror her longings and affective states, a generally secure base of attach- ment was nally established and has been maintained. We now have a rhythm, an ongoing, reciprocal circle of security (Marvin, Cooper, Hoffman, & Powell, 2002) that is holding her as our relationship matures. She lets me know when she wants to explore the internal world of her feelings or her external world of budding relationships and achievements. When her healthy grandiosity becomes threatened, she comes to me with renewed need for support, with tears of sadness, and with irritation and disappointment if I do not really understand her pain. It is in these moments that she still needs comfort and help with regulating her affects and organizing her feelings and thoughts. In a dyadic, intersubjective process, we reestablish the proximity that helps regulate her self-esteem and identity. A primary component of MKs current stability is that she eventually internalized a sense of our treatment process as a secure base and now expresses felt security in our relationship (Holmes, 2001). Some characteristics of her dismissive attachment model remain, but she has learned that she can tell me her feelings and thoughts and we will together come to understand. Consequently, I believed that our relationship could withstand the rupture that might be stimulated by reading my written account of her treatment (clearly, this undertaking would have been inappropriate, if not impossible, at an earlier phase of our work). When we considered the potential impact of this writing, she said, I gure it will be grist for the mill. As we move into the - nal phase of our work together, I thought this collaboration would validate for MK the importance of her therapeutic process. Coherence, Metacognitive Monitoring, and Mentalization In addition to Bowlbys concept of the secure base, more recent concepts about self-reective functioning have emerged from attachment research. Rele- vant for MKs treatment process, these ideas have inuenced my thinking about the benets of collaborative clinical writing. In particular, the research of Main and her colleagues on the Adult Attachment Inventory (AAI) (George, Kaplan, & Main, 1996; Hesse, 1999; Main et al., 1985) and the work of Fonagy (2001, 2003)) on the concept of mentalization, or the capacity for self-reection, enrich the understanding of adult security and psychopathology. Mains research on the AAI, a semi-structured qualitative interview that empirically assesses adult attachment classications, has revealed that 221 SUSANNE BENNETT coherence in an individuals discourse regarding attachment is a hallmark of a secure and autonomous adult attachment (Hesse, 1999). In other words, se- cure attachment is marked by an individuals capacity to describe attachment experiences in a consistent and coherent manner, one that is truthful, succinct, relevant, clear, and orderly. Even when parental relationships are remembered unfavorably due to negative childhood experiences, an individual is considered to have a secure state of mind with respect to attachment (p. 421) when these experiences are recalled with objectivity and when the individual continues to value attachments. Additional ndings from AAI research suggest that secure individuals exhibit metacognitive monitoring, or the ability to monitor per- sonal thought processes actively, recognize contradictions and biases in ones own speech, and acknowledge that reality may not be what it appears to be (George et al., 1996). For example, strong metacognitive monitoring leads the individual to realize that the way the world is viewed today may not be the way it was viewed yesterday (a phenomenon that often occurs in a successful psychotherapy). Similarly, Fonagy has hypothesized that mentalization, or the capacity to reect upon ones internal, mental states and realize the complexity of ones thoughts, is a sign of attachment security. He argues that a child acquires this mentalization or reective functioning only in the context of a secure parent- child relationship. When the primary caregiver is able to read the childs state of mind sensitively and respond in a patterned and predictable manner, this enables the child to feel regulated and contained. The child in turn incorpo- rates this reality and develops a personal capacity to reect, to understand, and to give meaning to experiences in the world, even when distressed. Since the beginning of her treatment, I have embraced the importance of containing MKs affects through reecting her state of mind. However, enhanc- ing her metacognitive monitoring and mentalization processes through actively and directly discussing her own reective functioning has become a recent focus. Using the language of attachment research, a primary goal of therapy at this time is to increase her metacognitive capacities with the hope that this will move the therapy forward and further develop her sense of self. It has become vital for us to work together to facilitate a sense of reality that allows her to see that her perceptions may be different than others and that her per- sonal biases and interpersonal distortions have interfered with her relation- ships. Enhancing this sense of reality has become key to the diminishment of her grandiose illusions and, consequently, to the management of her depres- sion. I hypothesized that reading my account of her treatment and collaborat- ing on points of agreement and divergence could facilitate MKs mentalization process. The following brief vignette illustrates how the collaboration may have facilitated mentalization, as well as metacognitive monitoring. MK has longed to feel like the special child of her memories, and a conict early in our relationship was her sense that she did not feel special to me. In comparison, benchmarks from her younger adult life were two short-lived expe- riences she had with persons she idealized. She had memories of feeling intensely understood, appreciated, and accepted by them. A common theme in her therapy with me has been her drive to re-experience that feeling again. She recently said, Everything I do is based on trying to feel that way. It made me feel in love with myself. She admitted, I desperately need peoples atten- tion and approval in order to feel goodI feel so good when something about me 222 CLINICAL SOCIAL WORK JOURNAL makes someone else happy. She longed to see the gleam in the eye of a deeply admired and admiring other, someone who would make her feel special on a continuing basis. As she said, Its hard for me to accept that Im ordinary. I got the message that I could be so much more. As MK and I reviewed her therapy history and her memories of these idealized early relationships, she began to recognize the manner in which she had distorted her impressions of these persons. She realized that her feelings about them may have been different than their feelings about her and that she had used these relational distortions to distance herself from our own thera- peutic relationship. We have discussed this subject many times over the years, but my willingness to return again to these early dynamics in our relationship seemed validating to her in that she and I now view that reality in the same manner. Discussion about this early period in our treatment conrmed to both of us that we have moved a long way together. She is now able to think about others with more clarity and understanding, and she thinks about herself with more appreciation for who she is and how she has evolved. DISCUSSION My original intent in writing about the clinical work with MK was to hit the mark in her eyes, to nally have her sense that I under- stood her, at least for the moment. Together, we seemed to achieve this goal, and the process served to deepen our therapeutic relationship. Nevertheless, there were potential drawbacks to this writing project and, therefore, ethical questions to consider. For example, it is always important to evaluate whether the benets of clinical writing outweigh potential harm. Initially, MK felt delighted that I wanted to write about her, but this excitement (and narcissistic gratication) mellowed when she read my initial thoughts about her dynamics and saw herself described in such theoretical and clinical terms. She did not feel my words matched her self-perception, particu- larly since narcissism evokes a pejorative stereotype in popular culture that does not describe her. Some of the clinical language was new to her and served to conceptualize (and intellectualize) our relationship in a manner that was emotionally distancing, perhaps triggering a dismiss- ing attachment between us, thus enacting her parent-child history. Further, inviting MK to read the write-up interrupted her ongoing treat- ment process because the paper and discussion were directed by me, rather than by following her cues. One legitimately could question if the benets were more for my professional gain (i.e., publication) than for MKs personal gain (i.e., self-reection and growth). There also were serious questions to be raised about the transference relationships and the theoretical frame of our treat- ment. Given her history with a mother who was very controlling and 223 SUSANNE BENNETT authoritative (a know-it-all), it is not clear that MK was genuinely free to say no to my request to write about her. Given the difculties and intensity of our beginning relationship, there is the question of whether my counter-transference from earlier years was continuing to inuence my current conceptual view of her, foreclosing an unfolding therapeutic process. Gabbards (2000) comments are pertinent to this last question when he says that when we think about the patient in terms of a particular theoretical or technical issue, [we are] at risk for consciously or unconsciously skewing the patients material in the direction of that issue (p. 1074). Ultimately, these issues were considered in the process of discussing the write-up with MK and in the weeks that followed the initial submission of the rst paper. In addition to my private musings and professional consultations with colleagues on this matter, MK and I engaged in our own dialogue and exploration. To use her words, we considered these concerns grist for the mill in our ongoing work. Due to my research for this current paper, the ethical questions moved into the forefront of my mind, and I listened carefully for any unspoken lingering doubts. We explored her option to withdraw her consent prior to publishing her clinical material, but she remained interested in moving forward with the submission. She eventually acknowledged a deeper understanding and appreciation of our therapeutic process and came to value in a new way the personal changes that she could see through our clinical review. We both agreed that at this stage in her treatment (which could be described as a long termination), she is now seeing the big picture. In other words, the benets of her participa- tion in the writing process outweighed any potential harm through disruption in her treatment. For MK, the process served to clarify and validate her growth, afrming her sense that she is exploring the world with more condence. For me, the process enabled a more focused and comprehensible understanding of our long relationship, which was additionally benecial to MK. At this point, our mutual assessment is that the writing process did facilitate and advance the treatment process. Experiences writing about and with MK have led to an enriched understanding of the complexities and subtleties of the use of clinical material in both writing and professional presentations. I agree with Gabbard (2000) who says that professional therapists and academics need to obtain informed consent from our clients, in addition to heavily disguising their identifying information, when we use their clinical material in our professional undertakings. But, that is just the begin- ning. Beyond consent and disguise, we need to consider, both privately and in exploration with our clients, the benets and potential harm of 224 CLINICAL SOCIAL WORK JOURNAL such clinical disclosure (even when condentiality is maintained). 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