Confidentiality and Mental Health

In Confidentiality and Mental Health, Christopher Cordess has assembled 13 papers written by specialists in different segments of the mental health field. Community psychiatry, psychoanalysis, child protection, social work, and confidentiality themes in clinical practice are some of the subjects explored in these papers. Many of the themes are of general interest, and others target problems that are specific to the legal system in Great Britain.

The introduction by Bill Fulford, entitled "The Paradoxes of Confidentiality: A Philosophical Introduction," provides an excellent description of the double bind faced by those of us who are involved in health care. "To expose and to keep secret, to expose and to hide" is the phrase he uses to identify the paradox involved in our encouraging patients to reveal and then our struggling to conceal.

He sees this contradiction as being driven by the change from closed institutions to open facilities. Community health centers and multiagency teams are forced to provide services beyond health care to meet the needs of a seriously disturbed patient population that is now living in the community. This necessitates their working with social-service and nonclinical agencies that have a practical need to know the details of a patient's mental health information to provide appropriate care.

Added to this are the negative forces related to issues such as dangerousness and child abuse. It is a thoughtful treatise. It appears that Great Britain is only now beginning to consider some of the laws breaching confidentiality that we in the United States have already been dealing with. For example, the Tarasoff duty to warn and laws requiring the reporting of child abuse and elder abuse have been in effect in the United States for several years. Still, it is thought provoking to reflect once again on the meaning this paradox has for society and to consider how it hampers our clinical work.

Throughout the book, references are made about the degree to which we have lost true confidentiality. In a paper entitled "Confidentiality and Contemporary Practice," Christopher Cordess raises the question of whether it is "time to abandon the pretense of the confidential patient-doctor relationship altogether." He then retreats from this thesis with the hopeful query, "Or is there time to rescue some important aspects of it?"

Similarly, Christopher Bollas, who is a psychoanalyst, states that matters would be less complex if we abandoned the pretense of confidentiality. He also chides psychoanalysts for what he sees as bringing to the consultation room a form of denial because they have difficulty acknowledging what he calls "their own complicity in abandoning their patients to the state" when they respond to legal demands for medical information.

The papers in Confidentiality and Mental Health are well written and easily readable. Although the described legal problems are not exactly the same for our two countries, there are many parallels. We in the United States also must look openly and honestly at the issues raised in this book. These papers remind us that hidden behind the rhetoric of the Department of Health and Human Services privacy regulations are many avenues for disclosure of health care information. Yes, there is a continuous erosion of the concepts of confidentiality and privacy. We must still continue to fight to preserve what we can, but we must not fool ourselves about the reality of the current situation.