‘QUIS CUSTODIET?’: WHO HAS ULTIMATE RESPONSIBILITY FOR CONFIDENTIALITY IN MENTAL HEALTH SERVICES?

Abstract

Confidentiality is a complex and engaging subject. One of the questions I would ask the reader to consider is whether ‘absolute’ confidentiality can truly exist within the analytic relationship and whether it is worth asking the same question in relation to psychotherapy as it is practised within the NHS. Is the position of absolute confidence a noble aspiration or could it be regarded as a rather inflexible stance whose advocates occupy an arrogant and even omnipotent position? This last question deliberately invokes a false dichotomy and I would argue that the clinical reality of working with patients continually dispels the myth that ‘absolute’ confidentiality can exist within the analytic relationship. If we can accept this position, then the stage is set for a potentially more fruitful, if complex, debate about where the line of disclosure lies for individual cases. It would seem timely, in view of the recent publication of the Royal College of Psychiatrists' report Good Psychiatric Practice: Confidentiality & Information Sharing (2006), to reflect upon how the ‘contract’ of confidentiality is drawn up in the apparently dyadic relationship of analytic therapy as practised in the private sector and to consider the particular conflicts and threats to patient confidence posed by the multidisciplinary and highly transparent ways of working that have evolved within modern NHS mental health services.

ACKNOWLEDGEMENTS

An earlier version of this paper was selected for the Royal College of Psychiatrists' annual Psychotherapy Prize (2006). The author would like to acknowledge Mr Jeremy Clarke, Chair of the Primary Care Counsellors' group at the Maudsley Hospital, who provided the inspiration for the topic, and to the group as a whole for their thoughtful comments.