Lost Confidentiality

Lost Confidence and Confidentiality in Psychotherapy
Richard Shulman, Ph.D.

Originally published at MentalHelpNet

We don’t know what psychotherapy is anymore: It is not the screaming, finger pointing and denuding to the crowd of TV’s Sally, Jenny or Jerry, nor is it the moralistic pronouncements of radio shrinks to submissive callers. Therapy is not casting people to the lions in the coliseum, even if some do crave the limelight and temporary glory. We’ve lost confidence and confidentiality in psychotherapy.

Therapy is quieter, more private analysis of personal problems. It’s the girl labeled psychotic who describes visions of snakes coming into her room at night, and the careful exploration that unveils a family secret — incest that’s driving her crazy. It’s the little boy who tantrums while his parents unwittingly cower. When they’re helped back in charge of the family, the boy draws a picture of a monster who’s been tamed, and who says “thanks.” It’s the woman who talks a mile a minute. She’s been told she is “manic” and must take medication throughout her life. Gradual conversation reveals that she was raised to never commit “the sin of anger.” Her internal pressure fades as you both acknowledge her hints when she’s angry at you. Then she more directly faces the stockpile of unacknowledged transgressions that have fueled her fire since childhood.

These sorts of personal conversations don’t happen in public arenas. They reveal foibles, misunderstandings and family conflicts that make people nervous or ashamed and could easily propel them into fight or flight. To defuse the tension and permit rational exploration, you need privacy.

It is ironic. The Supreme Court (Jaffee v. Redmond) recently reaffirmed the right to ironclad confidentiality in order to promote honest and helpful discussion in psychotherapy. Managed care requires the breaking of confidences.

Every three, six or ten sessions, your managed care psychotherapist sends a required report to the insurance company, detailing your private discussions.

We shrinks are ultimately responsible for this. Years ago we fought for health insurance coverage to include the problems for which people sought psychotherapy. Now we are caught in our own lie. Many therapists and clients were happy at the prospect of a “free lunch”, of therapy sessions paid for by someone else. But those “third party payers” (employers, governments and insurance companies), eventually realized that “he who pays the piper calls the tune”. Great fortunes have been amassed for third-party payers by managed care executives and reviewers as access to therapy has been denied and rationed. The denied services are often labeled “not medically necessary”.

And in fact, therapy is not medically necessary. Emotional and personal problems may affect people’s lives powerfully, but they are not diseases of the body. (Look in Medical Pathology textbooks. Despite the parottings of some in the popular press, no biological causes for emotional problems have ever been verified. That’s why there are no medical tests for these mislabeled “mental illnesses”.) Psychotherapy is not a medical procedure. It is a discussion that explores subtleties of what a person says and does in order to understand complicated underlying human problems. Honest exploration of sensitive personal matters requires privacy and patience.

In order to be paid, therapists sign contracts with insurers requiring that they divulge information about clients to managed care reviewers. A steady flow of referrals at inflated fees comes at the cost of client privacy.

I’m not just spreading paranoia about peoples’ therapy reports becoming available on the Internet (though there are documented cases where health care information was sold for commercial purposes). Privacy is spoiled more insidiously.

An example: A young woman volunteered to have me publicly present her previously confidential therapy for a Psychiatric Hospital case conference. That’s what she said directly.Listen to how she then contradicted her offer, but indirectly:

She began to talk about all the “gossips” where she lived. They talked behind people’s backs, inhibiting what you could say openly and honestly. You might be sad or angry on the inside, but around such gossips you learned to just “talk the talk but not say much.”

Why did she let others take advantage of her, she wondered? She described her sacrifices to help others in exchange for the smallest crumbs of appreciation. She remembered a physician she consulted who angered her relatives by only discussing her condition with her, not them. She thought he was right though.

She embellished these themes — but I thought I understood. Indirectly but convincingly, she was saying that I would be wrong to violate her privacy by presenting our personal discussions to other staff. I would be gossiping and taking advantage of her, unlike a trustworthy doctor who would only talk directly to her. In the face of such gossip she would just “talk the talk but not say much”. She would be “smiling on the outside” as she later said, but she would be sad and angry inside.

She was starved for love and appreciation, for sensitive reasons she eventually divulged. She didn’t realize that her overt offer to sacrifice her privacy was contradicted by her indirect, camouflaged hints.

Modern psychoanalysts demonstrate that we best understand our clients by listening for a constant flow of indirect reactions they offer us — if we will only listen for it. My clients taught me to translate their talk, seemingly about others, but ultimately about how my actions and statements fit with their own submerged personalized views of themselves and others. That, in plain language, is what the concepts of “transference” and “the unconscious” are basically about. This may be the most valuable perspective that psychotherapists have to offer to people who are trying to understand themselves and their characteristic ingrained difficulties. Yet we therapists now collude in an economic system that obscures these insights and destroys the best of what we can offer people.

The most profound and consistent way in which our relationship to our clients will be undermined may be subtle. We therapists should be trained to hear it, but perhaps our financial self interest will deafen us to it. We will hear stories like my client told me: about gossiping, corruption and betrayal, and about how people learn to censor what they say outside of trustworthy sanctuaries for exploring sensitive personal matters.

This is why some of us now work completely independently, with no insurance payments. My clients have told me — indirectly but repeatedly and convincingly — to do this. Fees must be lower, but my clients have less need to conceal what they’re saying in sessions. No reports about therapy are sent to others.

And we are developing new ways to preserve confidential psychotherapy outside of managed care. Volunteers In Psychotherapy (VIP) is a new nonprofit organization that allows clients to receive truly private psychotherapy for no fee, in exchange for volunteer work they independently provide to the community charity of their choice. Clients’ “payment” in this way guarantees their privacy and control of their therapy. No reports go to insurers, and no managed care reviewer can dictate that only three therapy sessions are authorized before pills are recommended. Clients benefit both from volunteering in the community, and from being active therapy consumers rather than passive recipients. As a nonprofit, VIP is eligible for donations and grants that modestly reimburse therapists who preserve their clients’ privacy and trust. No third party will profit from the enterprise. But confidence and confidentiality in psychotherapy should be preserved all around.