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Confidentiality in Clinical Writing:
Ethical Dilemmas in Publishing Case Material from Clinical Social Work Practice
Susanne Bennett
The Catholic University of America
Author Note
Susanne Bennett, PhD, LICSW, is an Associate Professor at National Catholic School of Social
Service of The Catholic University of America in Washington, DC.
Correspondence regarding
this article should be addressed to Dr. Bennett at NCSSS-CUA, 100 Shahan Hall, 620 Michigan
Avenue, NE, Washington, DC, 20064; email: bennetts@cua.edu.
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Abstract
This article summarizes perceptions of experienced social work clinicians and journal editors
regarding the ethical dilemmas of publishing confidential case material in writing about clinical
practice. Based on a qualitative study of 8 professionals, participants explore the benefits and
limitations of clinical writing, informed consent and disguise of case information, and personal and
editorial policies regarding publishing confidential material. While embracing ethical obligations,
participants express confusion and ambivalence about preferred means of protecting client privacy.
This article reviews literature on the ethics of clinical writing and makes recommendations for
social work educators and practitioners who publish their work.
Keywords: ethical dilemmas, clinical writing, confidentiality, informed consent
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Confidentiality in Clinical Writing:
Ethical Dilemmas in Publishing Case Material from Clinical Social Work Practice
Although many social work journals publish empirical studies about clinical practice, others
give context to practice through illustrations of clinical cases. This difference in focus mirrors the
discourse within the profession regarding empirically based versus theoretically based practice
(Gambrill, 1999, 2006; Goldstein, 2007; McNeill, 2004; Simpson, Williams, & Segall, 2007; Rosen,
2003; Thyer, 2007). Despite contrasting approaches, all authors face the same challenge of
describing empirical methods or clinical interventions in an ethical manner. As Gambrill (2006)
has emphasized in her review of the current landscape of evidence-based practice, social workers
must first follow “ethical obligations described in professional codes of ethics: beneficence,
avoiding harm, informed consent, and maximizing autonomy and self-determination” (p. 339).
Application of a code, however, does not erase the confusion that exists about the ethics of
writing and presenting examples of clinical practice. The latest National Association of Social Work
Code of Ethics (2008) does not address specific guidelines for the use of confidential case material
in published clinical writing. Although the NASW code mandates that professionals obtain
informed consent from research participants, it does not equate clinical case writing with empirical
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research. Nevertheless, some scholars say that clinical cases could be considered single case design
studies (Cooper, 2006), and Weston (2002) has proposed that “cases are every bit as empirical as
experiments – that is, they involve observation of events in the world, which is what empirical
means – and they can yield a great deal of insight” (p. 882). The American Psychological
Association (2010) is more explicit than NASW in its ethical guidelines for the “Use of Confidential
Information for Didactic or Other Purposes” (No. 4.07). It specifically instructs psychologists to
disguise confidential material and obtain informed consent from any client being discussed in
written or oral presentations.
With these mandates in mind, questions emerge about the ethics that undergird case
presentations in social work journals and academic texts on clinical practice. Were informed
consents obtained from the clients under discussion, and were the details of their lives well
disguised? Or, were the case presentations fictionalized to illustrate a particular point about social
work practice? Such ethical questions regarding the use of confidential material are particularly
relevant for journals that publish clinical case content, but with few exceptions, there has been little
discussion about these questions among social work educators or clinical authors. In order to
explore these questions and address the paucity of research about them, a qualitative study of
clinical writers and journal editors was conducted to examine the ethical issues regarding the
publication of confidential clinical case material. This study was designed to investigate the
practice of clinical writing among social workers and explore the ethical dilemmas thought to exist.
The following is a brief review of the literature on this topic, an overview of the methodology of the
study, and a discussion of the qualitative findings that emerged from the narratives.
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Literature Review
Ethics in Social Work Practice and Research
Historically, attention to ethical issues has been central to social work and is considered
“the lifeblood of the profession” (Reamer, 1998, p. 497). According to Reamer (1998), guidelines
for ethical practice have evolved as the social work profession has developed, with a current
emphasis on ethical standards and risk management. Reamer (2005) further notes, “Difficult
ethical choices in social work, or ethical dilemmas, emerge when social workers encounter
competing values, duties, and obligations,” and these dilemmas “occur in every social work domain”
(p. 165).
Managing confidentiality in clinical writing can lead to such dilemmas. In general,
confidentiality has been defined as the legal and ethical regulations that protect either the research
participant or the client in terms of their rights to privacy (Millstein, 2000). Ethical dilemmas
center on conflicts between the rights of the individual to privacy versus the rights of the larger
community to have access to the client’s private information. In direct practice, such conflicts are
evident in the dilemmas about writing and protecting case records, in sharing confidential
information for purposes of referral or consultation, in following mandates regarding duty-to-warn
or duty-to-protect, and when there is court involvement such as in child welfare cases and adoption
(Millstein, 2000; Palmer & Kaufman, 2003; Reamer & Siegel, 2007; Saxon, Jacinto, & Dziegielewski,
2006). Yet Millstein’s (2000) study of 372 direct practice MSWs suggested “there is a gap” (p. 278)
between what clinicians understand to be their ethical obligations and what they actually do in
practice, particularly regarding confidentiality. Over half the respondents in Millstein’s study
reported they did not have clients sign consent forms prior to the release of confidential clinical
information to other professionals.
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In research, the concept of confidentiality holds a different meaning. Empirical studies are
designed to gather and disseminate data in a manner that protects the participant’s anonymity or
right to privacy, but data collected is not considered confidential because aggregate findings are
released. Although all research must be approved through Institutional Review Boards to assure
the protection of human research subjects (U.S. Health and Human Services, 2009), that process
does not remove the ethical dilemmas about protecting anonymity. According to Delva (2007), the
process of “protecting the rights and welfare of human research subjects recruited to participate in
research activities is fraught with complexities and dilemmas” (p. 101). For example, assuring that
a participant’s consent is truly “informed” can be challenging (Palmer & Kaufman, 2003).
Social work journals generally do not require authors to present evidence of signed consent
forms prior to the publication of research studies. Likewise, journals do not require evidence that
authors have protected clients discussed in clinical articles that include confidential case
information. In fact, clinical information does not fall under the same HHS guidelines as research
data unless the interventions that produced the information were deemed part of a single case
design study.
Ethical Dilemmas in Clinical Writing
Though little has been written in social work, a growing body of commentary and research
regarding confidentiality and the ethical issues in clinical writing can be found in the psychoanalytic
literature (Aron, 2000; Gabbard, 2000; Galatzer-Levy, 2003; Goldberg, 2004; Kantrowitz, 2002,
2006; Levine & Stagno, 2001; Wharton, 2005).1 Historically, psychiatrists and psychoanalysts have
included detailed case summaries in their professional literature as a means of developing theory
and illustrating new technique. This form of writing is considered to be a scientific and valued
avenue for professional pedagogy (Levine & Stagno, 2001). However, with the advent of computer
1
For expanded reviews of this literature, see Kantrowitz (2006) and Levin, Furlong, & O’Neill (2003)
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technology and ready access to the content of professional journals, some patients reportedly have
discovered their private stories published without consent and without sufficient disguise (Levin,
Furlong, & O’Neill, 2003). Such breaches in trust, combined with a professional shift toward more
relational collaboration, triggered an increased debate about clinical writing. One of the ethical
dilemmas to emerge was how to publish new scientific ideas in practice and theory development
without damaging the therapeutic relationship or violating patient privacy.
Among the analysts who have voiced opinions, two have summarized these complex issues
with clarity and conviction. Aron (2000) and Gabbard (2000) both argue that informed consent
from the patient and heavy disguise of the patient’s identity should be essential requirements for
publishing any clinical work. In addition, they both suggest that consent and disguise do not alone
preclude the emergence of ethical, clinical, and even legal dilemmas. Gabbard notes that the
patient’s capacity to give honest consent may be skewed by transference, and “we can never know
in advance…how that patient will react” (p. 1080). Aron agrees and points out that transferences
are continually changing. Over time, the patient could exact legal charges against the analyst for
seeking consent at a time the patient was most vulnerable. Both Aron and Gabbard recognize the
potential risks and benefits for the therapeutic relationship when analysts collaborate with patients
regarding clinical writing. They also believe that ethical dilemmas exist due to conflicts of interest
between the analyst, who may wish to publish, and the patient, who generally wants privacy
maintained.
Over the course of several years, Kantrowitz (2002, 2006) conducted extensive qualitative
research focusing on these issues. A psychoanalyst and clinical professor of psychology at Harvard’s
Medical School, she interviewed 141 of her colleagues regarding the ethics and complexities of
clinical writing. Her sample included a wide range of American and European psychoanalysts who
published in three different journals, and she explored their experiences with clinical writing and
their views about the impact of this on their patients, who sometimes were interviewed. In her
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book summarizing this body of work, she states: “There are no easy answers about how to write,
when to write, or who and what to write about. Simple rules will not work” (2006, p. 308).
Despite this rich discussion in allied professions about the ethical challenges of clinical
writing, only three studies or commentaries have emerged from the social work literature on this
topic (Bennett, 2006; Bridges, 2007; Naiburg, 2003). In a qualitative study of 12 social work
journal editors, Naiburg (2003) examined the peer review process of reviewing clinical
manuscripts for journal publication. Though confidentiality was not the specific focus of her study,
she reported, “many of the editors identified it as one of the biggest challenges for clinical writing”
(p. 102). One editor told her he looks for “finely discriminated details” when determining clinical
manuscripts suitable for publishing; but as Naiburg noted, such “vivid, thick description often
requires more details than the limits of confidentiality allow” (p. 101).
Bridges’ (2007) study directly addressed the focus of ethical dilemmas in publishing
confidential case material. She described her experience of seeking the consent of 16 clients for
publishing their confidential clinical vignettes in a book she authored on social work practice
(Bridges, 2005). In the consent-seeking process, she encountered a wide range of emotions from
her clients, some positive and others not, but she found she was able to use their reactions as
“valuable therapeutic material and movement” (2007, p. 40) in the therapeutic process. Bridges
(2007) cautioned: “the process of seeking consent forever changes the therapeutic endeavor in
ways that may enhance or derail exploration and patients’ development” (p. 39).
In her role as a clinician, the investigator of this study also collaborated with a client on a
published writing project about their therapeutic relationship (Bennett, 2006). Since only one
client was involved in this process, in contrast to 16 clients in Bridge’s work, the conclusions were
limited in scope. However, both client and clinician found the writing process changed the therapy
trajectory, and they agreed that their collaboration was not harmful to the client; instead, it
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facilitated the client’s emotional development and interpersonal functioning. Moreover, the ethical
and therapeutic ramifications of this clinical experience enriched the clinician’s awareness of the
opportunities and complexities of clinical writing.
In addition to this particular collaboration, this investigator has had a variety of experiences
publishing clinical work and has used a range of approaches to disguise confidential clinical
material. In her role as a social work educator, the investigator is interested in the ethical dilemmas
that emerge when the client’s right to privacy and the clinician’s responsibility to respect that right
compete with the societal good of educating other professionals about the process of social work
practice. These ethical issues served as the impetus and foundation for the following qualitative
research.
Methodology
This qualitative study was designed as an exploration of the experiences and opinions of
veteran social work practitioners who publish clinical case material in social work journals. Based
on a realist epistemology, the study’s goal was to examine potential ethical dilemmas evoked by
clinical writing. Areas of inquiry for the interviews were developed after reviewing literature from
other disciplines regarding clinical writing, particularly the initial qualitative study conducted by
Kantrowitz (2002). Through open-ended questions, the investigator examined the participants’
education and training, experiences with clinical writing, ethical and therapeutic challenges evoked
by undertaking such writing, and recommendations for the social work profession regarding
publishing clinical case material.
Sample
The investigator selected a purposeful sample of senior-level social workers who were well
published and had written clinical articles including case material. Two previous editors of social
work journals that publish summaries and discussions of clinical intervention recommended names
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of potential participants. Of the persons suggested by these editors and contacted by the
investigator, eight persons agreed to participate in the study. All participants were clinical social
workers, and seven of the eight were either full or part-time clinicians in social work private
practice. Three had published professional and academic books on social work practice. All had
taught in graduate level social work programs either as adjunct instructors (n=3) or full-time
professors (n=5). At the time of these interviews, four were Editors-in-Chief of social work journals
that published articles with clinical case material. In terms of education and training, all
participants had MSWs and four had PhDs in social work. All were trained in psychodynamic theory
and practice, but their approaches varied from practice based on ego psychology to contemporary
relational models of practice. All participants were white; four were women, and four were men.
Data Collection
Audio taped interviews were conducted by telephone (n=7) and in-person (n=1), and length
of interviews ranged from 1-2 hours. Interviews were transcribed verbatim and then reviewed by
the participants. To more closely reflect his views, one participant edited his interview. Prior to
submission for publication, the manuscript was given to all participants to read and confirm that
the quotations of each participant were presented accurately.
Data Analysis
In analyzing the data, the investigator used a grounded theory approach of “constant
comparative analysis” (Charmaz, 2006; Corbin & Strauss, 2008). The investigator first
deconstructed the data into conceptual categories of the phenomenon discussed in the narratives
(open coding), and then collapsed and reformulated these categories into larger categories (axial
coding). Through the method of constantly comparing the data with the open and axial codes, as
well as reviewing field notes and code memos, themes began to emerge from the data to address
the focus of this study. In line with a grounded theory approach, particular attention was given to
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the context of the phenomenon, the processes under discussion, and the action-interaction
strategies explored by the participants. Analysis of the data was reviewed and discussed with a
professional colleague to increase trustworthiness. Atlas.ti qualitative data analysis software was
used to facilitate the coding process.
Study Findings
The following summary of findings is organized according to the primary areas of inquiry.
First, participants were asked about their familiarity with the historical context, the literature, and
the professional debates regarding ethical and clinical dilemmas inherent in clinical writing.
Second, they were asked to discuss their perceptions of the benefits and limitations of clinical
writing. Third, participants were asked to explore their thoughts about ethical dilemmas in clinical
writing and to share dilemmas they have experienced in writing about their clinical work. Finally,
participants were asked to describe their personal policies about managing ethical dilemmas in
clinical writing, and in the case of journal editors, to describe the professional policies of their
journals at the time of the interview. The following discussion summarizes responses from these
four areas of investigation.
Familiarity with Historical Context
These eight participants were unequally familiar with the debates regarding the ethical and
clinical dilemmas inherent in clinical writing. At the time of their interviews, three of the four
editors were not aware of this topic being discussed “very much” among social work journal editors
or educators. However, one editor and two non-editors were knowledgeable regarding the broader
discourse and gave historical context to these concerns. They noted that discussions about clinical
writing and debates about client involvement in that process began to emerge in the 1990s in the
psychoanalytic community. The discussion became of special concern when “non-psychiatric folks
would find their way to psychiatric literature” and would discover their own stories in journal
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articles or books written by their therapists. Prior to that time, one participant said, “There was a
kind of doctor-knows-best mentality. We didn’t think of including our patients” in the decisions
about publishing clinical work because it was common to use clinical case material to illustrate
theoretical or professional views. Instead, she said, in her presentations and published writings, “I
disguised. I used fictionalized composites...and I think I couldn’t bear the exposure of what I had
actually said to people or had done.”
Both this participant and two others noted that a cultural shift toward a “consumer-rights
approach,” plus the advent of the Internet, jump-started the sophistication and interest of clients.
One participant thought that social work clients might “Google” their clinicians, and he assumed
that “private patients, particularly analytic patients, do so with some regularity, especially when
transference issues are intense.” He recognized that clients sometimes find citations for
manuscripts published by the therapist and then discover that the client’s own therapeutic session
had been discussed without permission. He observed:
In the old, old days when a client became curious about a therapist, s/he might look up the
therapist in the telephone directory or look for information by asking people in the
community. Now, when clients or patients become curious, they go to the Internet. Voila!
And there the therapist is, along with references to much, if not all, of what s/he has written.
Another historical influence that increased sensitivity regarding clinical writing was
attention to compliance with the U.S. Health and Human Services (1996) Insurance Portability and
Accountability Act (HIPAA) regarding confidentiality and case records. One person said, “With the
advent of HIPAA, I’m a lot more gun-shy about using patient’s material.” Another participant stated
emphatically, “If a therapist is going to write up a case report that attempts to describe a patient’s
life experience and treatment, both the life and the treatment are the patient’s property.” He
believed HIPAA applies to more than case records and should include clinical writing in the
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professional literature. To that end, “People should say, first, if they want their lives presented in
the professional literature, and, second, in what form they want it presented.”
Benefits and Limitations of Clinical Writing
Though the debates about clinical writing and client involvement were new to some
participants, all had opinions about the benefits and limitations of the undertaking. Everyone
agreed it is “helpful to people to hear what other clinicians have actually said and done,” and they
were convinced of the educational value of “explicating a clinical moment” for social work students
and seasoned clinicians alike. One editor stated, “The main point of publishing treatment process is
that it has value in informing other clinicians,” because “readers have opportunities to see clinical
process unfold with particular patients.”
Three of the participants saw therapeutic benefits to having clients informed and, possibly,
involved in the writing process. One editor pointed out that clinicians who ask permission of
clients to publish learn from the process, and it may facilitate the treatment. “I can imagine some
pay-off in that I can be educated by clients about how it affects them, so it’s another opportunity to
have clients teach me about themselves and about treatment.” Another clinician agreed and added,
“The overwhelming pro in asking permission is that it may make it possible for the presentation of
important clinical material, the absence of which would be a real loss to the profession.” In other
words, publishing clinical material may be indirectly beneficial to the client in the sense that all
therapists are then better educated and prepared.
Although some participants saw advantages of client involvement in clinical writing, all
noted limitations and were mixed about how to undertake the process of writing about clinical
practice. One editor proposed that clinical writing has value but could not “be really accurate in a
scientific sense. It’s just not possible.” She realized “there are going to be distortions in any case
material that you publish…there’s no way to remove the distortion. It’s simply there, and there’s
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nothing you can do about it.” For this reason, she and several other participants published
composite clinical work as “illustration, rather than fact.” Another participant echoed her views but
did not support the use of composites. He said: “To a limited degree, all case write-ups are, in some
sense, fictional because they reflect the therapist’s perception of the patient’s narrative; i.e., the
patient as seen through the therapist’s eyes.” He believed composites are too distorting, and he
preferred disguising his patient’s clinical material, rather than “mixing and matching patients.”
With fictionalized composites, “you seriously distort the treatment process and the uniqueness of
the relationship between patient and therapist.” In contrast, the previous participant made the
following argument for composite clinical writing:
Some people could say, “Well, why do it if it’s not real, how can it be used?” And the issue
becomes for me, “How can you judge what is a good illustration?” I think that people who
are good clinicians notice details, notice possibilities, and so they are included within the
case material. Even if in fact this is not exactly the literal case from that material, you do get
from that case material a real sense of what it is the person is talking about and what that
might look like in practice.
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Ethical Dilemmas in Clinical Writing
Whether case material is the disguise of one case or a composite of several, and whether a
client’s permission has been granted or the clinician has published without asking, ethical
dilemmas still exist. All participants were clear about that fact. Several shared the view of one who
said, “What is good in a general sense for society,” such as benefiting the professional community,
“is not necessarily the best thing for an individual.” Three ethical concerns relevant to this
comment emerged from the data: (a) concerns about writing’s influence on the treatment process;
(b) concerns about the risks to and protection of the client; and (c) concerns about the
ramifications of the clinician’s self-disclosure.
Writing’s influence on treatment. The first ethical challenge emerges when the client
learns that the clinician writes for publication. “It shapes the treatment,” said one, because such
information may trigger feelings within the client that could affect the work. In explaining this
point, another participant observed, “many patients have fantasies about wanting therapists to
write about them. It’s part of wanting to be important to your therapist.” However, one person
thought that clients who want to feel special may begin to wonder, “All right, is this exchange going
to appear in the next article?” Yet another participant said that one of his own clients “knows that I
write a lot of clinical stuff…. She’s intrigued with the prospect of being written about, but it’s also
disturbing her.” This participant was quite clear that he would never write about a client who was
currently in treatment because “it feels like it’s introducing a parameter that I would prefer to
avoid.”
If the clinician wishes to publish clinical writing with the inclusion of a client’s confidential
case material, simply asking the client’s permission does not lessen the ethical dilemmas. This is
particularly the case if consent is requested at intake or in the midst of the clinical work. “Even to
be asked to consent may be very off-putting,” one person said. Some clients may feel “that in order
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to be seen, they would have to agree” with the clinician’s request to write about them. “I don’t
know if there are people who say it is okay but really didn’t wish it and thought they didn’t have a
choice.” In other words, the power dynamics in clinical relationships, combined with transference
issues, may complicate and thereby limit the freedom of clients to know what they feel and decide
what they want in terms of granting consent.
Client risks and protection. Despite concerns that arise when asking a client for consent
to publish material, there was general agreement that, “from an ethical perspective, therapists
should consult with and discuss case reports with patients while they are writing them.” The
participants realized that “potential harm” could be done to a client if he or she discovered a
clinician had published details of the client’s life without permission. To minimize that risk, one
person thought it could be useful for the treatment process if the writing actually took take place
“during the course of treatment, as well as at the end.” However, there are potential risks with that
as well, depending on the type of treatment and the personality characteristics of the client.
One participant, who is herself an ethicist, thought that “the ultimate question” should be
whether “the protection of the client would outweigh the risk or the danger” to the client. She
suggested that asking patients for their permission to publish, or having them involved in the
writing process itself, “might expose certain clients to a kind of danger.” Clinicians should “make
some good clinical judgments about who can handle” involvement in the writing process and
“which clients might be basically too vulnerable or too paranoid or too just non-resilient.” For
example, if a clinician asks permission to write about the life of a person with a borderline or
narcissistic pathology, “the danger is that we’re complicating their pathology” by having this type of
involvement. If such clients are involved in the actual writing process, this participant feared that
such involvement could further set-back the treatment and wound the client’s sense of self if the
article were refused by reviewers or had to be revised.
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Due to such concerns, seven of the eight participants had never asked clients for
permission to write about them. Instead, they either wrote case composites or they heavily
disguised the case material and hoped the client would never read it. It was pointed out that many
social work clients may not be privileged enough to know how to access the Internet for
publications written by their clinicians. Yet, that phenomenon in itself presents an ethical dilemma.
The ethicist again asked: “Do we not have an obligation, an ethical obligation, if not a legal one, to
give such clients just as much protection as we would the more sophisticated client?” This
participant thought that “if writing is attempting to illustrate a process,” then it “probably is
stereotypical to think that even the simplest client, who would not read a journal, wouldn’t be
capable of understanding the contribution they could be making.” She believed informed consent
should be asked of such clients, but she noted, “Very often, the poorest clients have also been so
disadvantaged by systems that they have no good reason to trust the system.”
In other words, as another participant summarized, asking clients for consent or involving
them in the writing process, is “enormously complicated.” She based this statement on her view
that “there is intrusiveness about this, no matter how benign we think it is. It is something of our
doing, rather than their doing.” At least two others agreed with her and, as a result, expressed
strong personal ambivalence about collaboration with clients, though they could see some value.
One person, who is a journal editor, said:
I can understand why one would decide to do that with a patient or wish to do that. You
know, one wants to be fair, and one wants to not do something harmful to somebody, and
one wants to respect the person’s rights, and I think all of those motives can be there, but—
and again, I think some of this is a personal preference—it’s not something I feel
comfortable doing. At least, not as yet.
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Another participant, also a journal editor, shared similar sentiments about informing or involving
clients in the writing process. He said: “That’s something I feel intensely conflicted about. The
conflict arises because I think doing so is a good idea, at least ethically and theoretically. I simply
have not, yet, been able to bring myself to do so.”
Clinician’s self-disclosure risks. In addition to concerns about risks to clients, clinicians
who write often consider professional risks due to their self-disclosure. Three of these participants
discussed the vulnerability they face when they write about their clinical work, thereby exposing
themselves to the wider professional community. One person said: “For me, there’s a fair amount
of anxiety involved in sharing the written work, both the wish that it be useful, that others might
like it, and a worry about my own vulnerability and the exposure.”
One possibility is that others will look at the work and interpret meanings not necessarily
intended. Clarifying this point, one person said, “I do believe there is a dynamic unconscious. I
believe there are things that patients tell us that they are not consciously aware of.” He further
added, “I think there are things therapists experience that they (we) are not consciously aware of.”
In other words, there is the risk that clinicians who write about their work are disclosing their own
unconscious processes to a wider professional community. In reaction, there is the possibility that
the writer’s self-disclosure may evoke criticism, contempt, or perhaps envy from his or her
professional colleagues. Or, as one participant stated, some may think the clinician has
“exhibitionistic needs,” rather than a priority on “what’s really in the interest of the patient.”
There also remains the risk of disclosing the clinician’s unconscious processes to the actual
client. If the clinician involves the client in the writing process—either by asking for permission to
publish the work or by actually co-constructing the case for publication—the client is likely to see
the clinician in a new way. One participant, who reportedly practices from a more traditional
psychodynamic framework, expressed concern that the client would become aware of “the
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therapist’s self-serving motivations,” and he thought this could disrupt “the patient’s illusion that
the therapist is only interested in ‘serving,’ in treating him/her.” He proposed: “Disrupting that
illusion significantly changes the patient’s transference; current, retrospective, and prospective. It
probably also changes the therapist’s countertransference.”
Participants who practiced from a relational or constructivist framework took a different
stance on the issue of therapist self-disclosure. One author, who intentionally involved her clients
in the writing process, found that her “collaborative approach” to writing was similar to the “more
mutual, open approach” she takes as a therapist. However, she discovered that when she
collaborated with clients about writing, this sharing “was very mixed and very painful” for some of
them. She admitted that part of her “anguish” as a therapist has been the “guilt and shame” she has
felt for stirring up “toxic” feelings in her clients when they read her writing about their therapy. She
said she worried about using her clients for her own purposes “and harming them.”
Other participants also expressed concern about having clients read the clinician’s selfdisclosure regarding the clinical work. One person acknowledged he has “ambivalence about
relational concepts,” particularly about self-disclosure. He said, “Even in writing up material about
therapy that has ended, I imagine it would be very disconcerting to patients to hear more than what
I’ve said in actual therapeutic conversations, to hear my hypotheses about what’s going on in their
unconscious minds.” Along similar lines, a different participant discussed an experience that
seemed to validate this view. He described how a former client returned to see him and then
abruptly quit treatment and “fell off the face of the earth. Nothing unusual happened in our
meeting, so I had this eerie feeling that perhaps he had found this article that I had in fact written
about him” regarding their earlier work. “I ended up picking over words and phrases and
wondered if he could have reacted to that. And so now I feel much more hesitant about writing
about patients.”
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Personal and Professional Policies
Personal policies. Professional experiences, as well as cultural, legal, and theoretical
paradigm shifts, have influenced these participants in terms of their current personal policies on
clinical writing. A couple of persons said that over their years of experience, they have become
more open to client involvement in the writing process and would never again write without asking
for a client’s signed consent. Several participants believed it was ethical to request both client
permission and involvement, but they remained personally uncomfortable engaging in that process.
Consequently, they have stopped including clinical case material in their writing, albeit disguised,
and they only use fictionalized composites to illustrate their practice ideas. Two of the participants
have stopped writing articles with case illustrations altogether.
In other words, there was no consensus about the best way to address the ethical and
therapeutic questions about clinical writing for publication. Three personal policies and
approaches were proposed. Participants who did not ask permission, but still published actual
clinical work, took a great deal of care to disguise all identifying information so that the client’s
privacy could be maintained. One person said that as a beginning professional in the 1950s, he was
taught that all writers of case material should “go through a series of steps to make it difficult, even
for readers who know the client fairly well, to recognize who the client is.” That process included
changing the client’s name, age, profession/occupation, and the location and description of the
agency, as well as the dates of treatment and service. In other words, he changed all details that
were not important to the case discussion, including those about family structure. However, this
participant said he now feels that those “standards probably were adequate for the times they were
designed in and for. They are, I think, not adequate for today.”
Due to her awareness of the changes in today’s standards regarding confidentiality, one
participant had developed a personal policy to both disguise and request consent from her clients.
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21
This approach included exploring with clients their range of feelings about publishing confidential
clinical information and examining with them the risks and benefits for the client and the clinical
process. For clients who have terminated treatment, she has invited them to return for free
sessions to discuss possible writing. In all cases, she has had clients sign informed consents and
does not publish case material if the client prefers privacy for any reason.
Finally, many of the participants preferred to write a fictionalized composite as a practice
illustration. One person described this process as taking “a kernel of something that actually
happened with a patient that I think is important,” and then changing “a whole bunch of things.” She
feels “that’s enough of a reworking so that I don’t have to share that with that patient.” Another
participant said she would write “a story based on reality, a story based on clinical experience, but
not necessarily the literal story of what happened with this particular client.” She was concerned
that “there would be lots of people who would be horrified with what I’m saying,” but she felt that
composite writing was the most ethical and legally sound way to write a case illustration.
Journal policies. When each of the four editors were asked if there were formal written
policies for their social work journals regarding clinical writing and client confidentiality, they all
admitted no policies existed at the time of these interviews. The first editor interviewed stated that
her journal “doesn’t have policies about that that I’m aware of. Essentially, as editor there was not
need for it – not because it’s not an important topic – but the author takes responsibility for that
and the journal doesn’t or would not.” She added: “Most journals would not.” However, she said
the journal had no disclaimer, in the event a client should ever decide to take legal action against
the author or the journal.
The other three editors appeared to assume a more personal role for issues regarding client
confidentiality, in contrast to saying it was totally the author’s responsibility. One said, “I have not
formally articulated a policy that I inform the writer about, although I have standards that I use
CONFIDENTIALITY IN CLINICAL WRITING
22
myself and apply to manuscripts that are submitted.” Another said, “There are certain assumptions
I make that the venues are not described in detail, and the agency name is never published. We
would catch something like that.” He added, “There’s a level of detail with which I’m not
comfortable because I read all these things on numerous occasions before I commit them to
publication, and then my inclination is simply not to include it.” Finally, the third editor noted that
his publisher has a statement that requires the author to receive “any necessary permission to
quote from another source.” Although he acknowledged this statement actually was referencing
plagiarism, he thought it could apply to case writing. He admitted, however, that his journal’s
unwritten policy is “very informal. It’s a taken-on-faith kind of thing. I certainly don’t do any
checking-back with the person” who wrote the clinical case material.
These editors concurred that there might be some value in having policies regarding
written and oral clinical presentations specifically stated in the NASW Code of Ethics. They realized
that these issues are not addressed directly in the NASW Code, while The American Psychological
Association Code of Conduct “gives much more emphasis on the importance of disguising.” One
person recalled that when he published in an APA journal, he had to “procure informed consent or I
had to reassure them, basically, that the informed consent was therapeutically inadvisable or not
possible.”
In closing, these participants noted that informed consent is required for qualitative
research studies, and they could see the argument for requiring informed consent for scholarly
clinical writing as well. One said that clinical writing published in a journal is like reporting on a
single case design study. Another agreed that he too sees clinical writing “as a form of qualitative
research.” But, he said, “That’s not all it is. It’s the story of someone’s life…That’s part of what
makes this issue so complicated.”
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Discussion
The findings from this study suggested there are similarities in the perspectives of these
social workers compared to other allied professionals who have explored the ethics of clinical
writing. Like non-MSW psychoanalysts, these social work clinicians and editors shared strong
commitments to their clients’ rights to privacy and expressed concern about how best to maintain
confidentiality. The participants recognized the inevitable influences writing can have on the
treatment process, varying from positive growth to potential harm for the client. In general, they
shared the views of Aron (2000) and Gabbard (2000) that using heavy disguise and informed
consent is the best path to follow if authors wish to use detailed case material of actual clients in
writing about practice. Yet, like others, they expressed ambivalence about seeking informed
consent from their own clients, though they agreed it is the ethical action to take.
Another similarity between these social workers and the psychoanalysts studied by
Kantrowitz (2006) is that their theoretical leanings seemed to influence their opinions about how
to deal with the challenges presented by clinical writing. As with the analysts, the social workers
who embraced a more relational form of practice – valuing mutuality and co-construction in the
treatment process – expressed the most comfort with the concept of asking clients to sign consent
forms and offering clients the opportunity to read the writing. The social workers that practiced
from a traditional psychodynamic frame and used less self-disclosure were more ambivalent about
informing or involving clients in the writing process. It is interesting to note that the social worker
that seemed most oriented toward a constructivist postmodern frame was the strongest proponent
of using case composites or fictionalized illustrations in clinical writing. This author seemed
convinced that whatever form writing takes – be it case summery, composite, or pure fiction – it
remains subjective, shaped by the clinician’s construction of the clinical process, rather than some
objective reality.
CONFIDENTIALITY IN CLINICAL WRITING
24
In contrast to Kantrowitz’ cohort of psychoanalysts, this group of social workers generally
highlighted values that are central to the ethical perspectives and focus of the social work
profession. Unlike the psychoanalysts interviewed by Kantrowitz – primarily psychiatrists and
psychologists – these participants embraced social work’s commitment to working with diverse,
oppressed, and marginalized populations. Their views supported Naiburg’s (2003) observation
that social workers have a unique vantage point in terms of a bio-psychosocial perspective, the
diversity of the populations served, and the values that underpin the profession. Like Naiburg, they
agreed that workers are adept at capturing the context of clinical work. Consequently, social work
writers potentially could influence allied professionals by enhancing their sensitivities to the
diverse lives of social work clients.
In closing, clinicians who are authors have ethical obligations to all clients and not just the
ones who may read the clinician’s writings by searching the Internet. Though the economic or
educational levels of many social work clients might lessen the likelihood they will scour the
Internet, these clients are no less deserving of ethical treatment. Yet questions remain: Is it more
ethical, and thus preferable, to present detailed examples of practice by way of fictionalized case
composites? Or is it ultimately most useful and ethical to write disguised case discussions of real
clients who have permitted clinicians to write in detail about their lives?
Clearly, there are no simple answers to these questions. Generalizations cannot be made
from such a small qualitative study, and additional research with a larger, diverse sample would be
needed to explore these issues in more depth. Nevertheless, these findings suggest that ethical and
therapeutic dilemmas exist when clinicians chose to include confidential case material in their
writings. The findings further point out the need for educators to critically examine these issues in
their classes and for journal and book editors to consider guidelines for assuring confidentiality in
their publications. Most importantly, the findings underscore the need for clinicians who write –
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25
and who present at conferences and in educational settings – to consider the dilemmas inherent in
this undertaking and to remember their ethical obligations.
The solution to these dilemmas is not to dismiss clinical writing as unscientific or to suggest
that “best” practices can only be validated through empirical research. In reality, a majority of
social work practitioners and students are clinicians who likely prefer reading practice process in
clinical writings, rather than practice outcomes in empirical research. They are hungry for good
examples of the actual art of social work practice. In addition, more seasoned clinicians are
interested in sharing what they have come to understand. As one senior clinician has written:
“There comes a time in the life of every clinician when writing about therapeutic work is a natural
next step in professional development” (Shechter, 2003, p. 65). The challenge for clinicians taking
this next step is to remain true to the values and ethics of social work, while capturing the
intimacies of the therapeutic process and the complexities of the human condition.
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26
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