Case studies in confidentiality.

Although a fundamental principle of psychiatric practice in general and psychotherapy in particular is that interactions and communications between clinician and patient are private, there are certain instances in which there is an affirmative obligation to break confidentiality, or in which such a breach is at least legally (if not ethically) permitted. The author examines the various situations in which a psychiatrist's obligation to maintain confidentiality is modified or even completely overridden by some other competing clinical, legal, or ethical principle or obligation. He reviews the duty to protect third parties (Tarasoff warnings), situations in which a psychiatrist's loyalties are divided between the patient and some other entity, person, or principle (dual agency issues), the release of information in emergencies, and the reporting of abuse. He also discusses the circle of confidentiality and which individuals are deemed to be inside and outside that circle. Guidelines for the use of clinical material in presentations and publications are reviewed. The author also considers how psychiatrists should deal with knowledge of past criminal behavior that they may obtain during the course of treatment. Finally, the author discusses the need to carefully document the rationale for whatever course of action is taken.