Confidentiality
Under the tutelage of managed care, psychotherapists and other health care
providers find themselves ushered into the new era of the information
society, where the currency of wealth is no longer capital but information.
Probably the most debated issue about the future of this new society has to
do with the loss versus the protection of privacy. The conflict between
psychotherapy and managed care should be interpreted against the background
of this larger issue. To understand managed care simply in terms of its
negative power to say "no", as when benefits are terminated, is to miss the
larger picture, which encompasses the more subtle forms of power at work
here. We need to see beyond our usual view of power as an overbearing force
(perhaps rooted in our image of the dictator), in order to appreciate the
more modest forms of power constituted by disciplinary technologies, which
operate by producing knowledge and information. "Modern" power aims at
cultivating and controlling life, but without being dependent upon the
threat of the executioner. Instead, through the techniques of discipline,
it builds up aggregates of individuals that are both useful and docile.
Unfortunately, for psychologists, it is not clear which side of this issue
they fall on, because the practice of psychology is also constituted by
information gathering and knowledge producing techniques. We, as human
scientists, traffic in the same objectifying methods that managed care
companies use in their operations. They are equally powerful in either
case, so how are we to judge whether their effects are beneficial in one
case and harmful in another?
My suggestion is that we always remain suspicious of knowledge and
information producing techniques, as these are applied to people, because
objectification and normalization, for example, are inherent dangers. In
addition, we need to safeguard individual rights, since these provide a
degree of protection against the excesses of disciplinary power. For
example, although the psychotherapist is in the same position to judge and
document clients (thereby objectifying them and turning them into cases) as
is the managed care case worker, the client holds the privilege of
determining what becomes of this information. The psychotherapist may not
release this information without the client's consent and understanding as
to the consequences of such a decision. It is the client's ultimate control
over what is to be done with his or her "case" that provides some
counter-balance to the inequity in the therapist (as expert, as scientist,
as psychologist)-client relationship. At least this is the theory. I'm not
sure how well we as a profession fully appreciate the dangers created when
allowing so many exceptions to confidentiality, which in turn begs the
question of how well we are able to counsel others about the risks that they
face if they sign a release of information.
Beyond Managed Care
Finally, we need to bear in mind that these issues are much more general
than having to do with managed care alone. For instance, Foucault has an
interesting discussion of delinquency in his book. He notes how by
identifying and labeling delinquents they are split off and constituted as
an underclass to be monitored by the police. They are identified as a
potentially dangerous element in society that needs to be watched over and
corrected. Yet, at the same time, they constitute a further reach and
penetration of this element of surveillance into society, since they provide
the police with their informers. I find the parallel fascinating if one
thinks of managed care as labeling providers as dangerous to our society
(since they run up unjustifiable costs and therefore are in need of being
policed) while at the same time legislation is passed and court precedents
are established that constitute psychotherapists as the new social
informants who are to identify dangerous elements in our midst, such as
child molesters and murderous individuals.
We need to be more cognizant and wary of all instances in which we are
called upon to turn over our professional judgements and reports to others.
Bearing this in mind, I hope this essay can contribute to a renewed
appreciation for how much hinges upon what becomes of confidentiality in the
practice of psychotherapy.
Under the tutelage of managed care, psychotherapists and other health care
providers find themselves ushered into the new era of the information
society, where the currency of wealth is no longer capital but information.
Probably the most debated issue about the future of this new society has to
do with the loss versus the protection of privacy. The conflict between
psychotherapy and managed care should be interpreted against the background
of this larger issue. To understand managed care simply in terms of its
negative power to say "no", as when benefits are terminated, is to miss the
larger picture, which encompasses the more subtle forms of power at work
here. We need to see beyond our usual view of power as an overbearing force
(perhaps rooted in our image of the dictator), in order to appreciate the
more modest forms of power constituted by disciplinary technologies, which
operate by producing knowledge and information. "Modern" power aims at
cultivating and controlling life, but without being dependent upon the
threat of the executioner. Instead, through the techniques of discipline,
it builds up aggregates of individuals that are both useful and docile.
Unfortunately, for psychologists, it is not clear which side of this issue
they fall on, because the practice of psychology is also constituted by
information gathering and knowledge producing techniques. We, as human
scientists, traffic in the same objectifying methods that managed care
companies use in their operations. They are equally powerful in either
case, so how are we to judge whether their effects are beneficial in one
case and harmful in another?
My suggestion is that we always remain suspicious of knowledge and
information producing techniques, as these are applied to people, because
objectification and normalization, for example, are inherent dangers. In
addition, we need to safeguard individual rights, since these provide a
degree of protection against the excesses of disciplinary power. For
example, although the psychotherapist is in the same position to judge and
document clients (thereby objectifying them and turning them into cases) as
is the managed care case worker, the client holds the privilege of
determining what becomes of this information. The psychotherapist may not
release this information without the client's consent and understanding as
to the consequences of such a decision. It is the client's ultimate control
over what is to be done with his or her "case" that provides some
counter-balance to the inequity in the therapist (as expert, as scientist,
as psychologist)-client relationship. At least this is the theory. I'm not
sure how well we as a profession fully appreciate the dangers created when
allowing so many exceptions to confidentiality, which in turn begs the
question of how well we are able to counsel others about the risks that they
face if they sign a release of information.
Beyond Managed Care
Finally, we need to bear in mind that these issues are much more general
than having to do with managed care alone. For instance, Foucault has an
interesting discussion of delinquency in his book. He notes how by
identifying and labeling delinquents they are split off and constituted as
an underclass to be monitored by the police. They are identified as a
potentially dangerous element in society that needs to be watched over and
corrected. Yet, at the same time, they constitute a further reach and
penetration of this element of surveillance into society, since they provide
the police with their informers. I find the parallel fascinating if one
thinks of managed care as labeling providers as dangerous to our society
(since they run up unjustifiable costs and therefore are in need of being
policed) while at the same time legislation is passed and court precedents
are established that constitute psychotherapists as the new social
informants who are to identify dangerous elements in our midst, such as
child molesters and murderous individuals.
We need to be more cognizant and wary of all instances in which we are
called upon to turn over our professional judgements and reports to others.
Bearing this in mind, I hope this essay can contribute to a renewed
appreciation for how much hinges upon what becomes of confidentiality in the
practice of psychotherapy.