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Freedman, A.M. (1979). Threats to Confidentiality. J. Amer. Acad. Psychoanal., 7(1):1-5.

(1979). Journal of American Academy of Psychoanalysis, 7(1):1-5

Threats to Confidentiality

Alfred M. Freedman, M.D.*

If there is a fixity in medicine in the flux of our times, it is the conviction of the sanctity of the doctor-patient relationship. While all physicians are concerned about confidentiality, the sensibilities of psychoanalysts and psychotherapists are heightened in regard to this issue. The patient must be assured beyond peradventure that his or her communications to the therapist will be held inviolate. Otherwise treatment cannot proceed satisfactorily and the whole effort will come to naught, since a prerequisite for successful therapy is freedom to reveal the most intimate, the most embarrassing or humiliating experiences, thoughts, dreams, and fantasies. The patient discloses not only his or her own private life, but also the secret and intimate life of others with whom the patient is involved. Thus, in the course of therapy, the patient must surrender his or her privacy to the psychiatrist. The psychiatrist, therefore, is under the strictest obligation to protect the patient and, in the words of the Hippocratic Oath hold communications “to be holy secrets.”

However, such absolute secrecy is no longer feasible in numerous situations. At the present time, in the U.S.A., there are innumerable intrusions into the psychiatrist-patient relationship, some necessary, others unavoidable, and some totally unwarranted. For the most part, however, we are dealing with the conflict of two rights—on the one hand, the right of the individual to privacy, deeply cherished since the founding of this nation, versus the right of the people, the government, the insurance companies, health providers, and many others to know. It is the struggle of right versus right that makes for the complex issues in confidentiality and compels the necessity for development of guidelines in all health practice that, above all, protect the privacy of the individual, yet permit access where indicated and appropriate.

what are some of the areas where this conflict between two rights appears most acute? Foremost, particularly for practicing psychiatrists, are the problems of confidentiality engendered through third party payments, whether the reimbursement is from the government or from private insurance companies. One must

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