Ethics Rounds

Recently I had conversations with two colleagues that touched upon the same topic: gossip about patients. In these separate conversations, which coincidentally occurred within the same week, each colleague described a distinct feeling of discomfort from being in a social context and hearing a treating psychologist talk about a patient.

In one instance the patient is a mental health professional whose personal and professional life intersects in more than peripheral ways with those of my colleague--a fact known to the psychologist who disclosed the information over dinner. In the second instance the setting is a small university town and the gossip concerned distinctive features of the patient's life, which left my other colleague wondering whether she might encounter and recognize this patient at some point in the community. Both colleagues found the incidents unsettling yet were unsure of how best to respond.

Psychologists share information about patients for many reasons and in many contexts. We disclose information about our patients in supervision, in consultations and in case presentations. When done properly these disclosures benefit our patients and improve our clinical skills. They can be an essential part of our growth as clinicians. The APA Ethics Code provides a process for how to disclose information in these contexts:

4.05 Disclosures

(a) Psychologists may disclose confidential information with the appropriate consent of the organizational client, the individual client/patient, or another legally authorized person on behalf of the client/patient unless prohibited by law.

(b) Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to (1) provide needed professional services; (2) obtain appropriate professional consultations; (3) protect the client/patient, psychologist, or others from harm...

4.06 Consultations

When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation.

4.07 Use of Confidential Information for Didactic or Other Purposes

Psychologists do not disclose in their writings, lectures, or other public media, confidential, personally identifiable information concerning their clients/patients, students, research participants, organizational clients, or other recipients of their services that they obtained during the course of their work, unless (1) they take reasonable steps to disguise the person or organization, (2) the person or organization has consented in writing, or (3) there is legal authorization for doing so.

As clinicians, there are circumstances outside of formal relationships and contexts when we disclose information about patients for a useful purpose. Every clinician, at some point in his or her career, will struggle with managing intense feelings toward a patient or client, sometimes referred to as the countertransference. A colleague who understands the nature of the work can be enormously helpful; it's the person whom we encounter with a smile (or wince), roll our eyes and say, "You'll not believe what my four o'clock told me today." That communication can strike an outsider as disrespectful. But between colleagues who are trained in this work it can elicit an empathic response and may serve as an invitation for a clinical observation or suggestion. The laughter, anger, sadness, frustration and sense of poignancy our patients evoke in us are part of our lived experience as clinicians. Sharing these feelings, and the incidents that go with them, can help us synthesize and integrate our experiences and grow into more mature and skilled psychologists.

There is an important distinction between these kinds of communications and gossip. First, in these sorts of communications the identity of the patient is almost always irrelevant--the communication is about a dynamic or about the clinician's experience rather than any person's identity. It isn't important who the patient is. With gossip, identity is very often central. Communications shared with individuals who know the patient's identity often veer more toward gossip and risk exposing the patient without any reasonable expectation of benefit.

Second, communications with a legitimate purpose are made professional to professional--that's the point. The communication is to another trained clinician who has a context and an expertise that allows the recipient to hear the material and respond in a particular way. Gossip often happens in the presence of non-clinicians or, even when made to a clinician, the identity of the recipient as a clinician is not particularly relevant to the communication.

Third, communications with a clinical or professional purpose or utility generate one set of feelings in the recipient. Gossip generates another. The recipient of gossip may be titillated, feel special or may simply wish the author of the gossip to stop talking about the patient in this manner or altogether. In the other instance, the recipient will hear the communication as primarily about the treatment or the clinician's experience, not about the person of the patient, which allows for and promotes a different kind of response, ideally one that will benefit the treatment.

Fourth, space and time can be revealing. Social gatherings and public places, such as restaurants, provide relaxed atmospheres where work is set aside, especially in the evening hours. These settings invite gossip, which is a quintessential human social activity. The likelihood that mention of a patient will quickly devolve into gossip rises dramatically when we move away from work-related contexts and working hours.

Fifth, gossip is impossible to defend. If a patient learns that we have gossiped, there is no explanation, only an apology. If a patient inadvertently overhears us sharing an intense reaction--"blowing off steam"--an apology may be in order, but the apology will have a different tenor, and may be placed in the context of an explanation or even discussion of the clinician's experience of the treatment at that moment in time. ("Yes, I was very frustrated at the end of our last session...")

The distinction between the two categories of communication is not always entirely clear. When uncertain, it can be helpful to ask, "Why am I sharing this particular information, about this patient, with this person?" Hesitation over whether we would be willing to share our response to these questions with our patient, or a colleague whom we respect were the need to arise, can be a sign that we are closer to gossip than we'd likely prefer.

Gossip about patients is destructive because it exploits. It exploits the willingness of patients to share intimate aspects of their lives and their psyches with us, which is why gossip is troubling from an ethical perspective. Only by accident will a patient ever benefit from being gossiped about; almost by definition the purpose of gossip about patients is entertainment or prurient interest. My friends described a feeling of discomfort upon hearing a colleague gossip about a patient. Such a feeling can be a cue that all is not ethically well.

I was describing this column to a colleague who replied, "You'll not be much fun at cocktail parties." That comment captures something important: We can be so focused on ethics that we lose our humanity. We must also be mindful, though, that we have fiduciary relationships with our patients, relationships of trust. Trust is based on respect--if not of the person, then at least of the relationship. Treating patient communications with care is a way of showing respect. Gossip is care-less.

Our Ethics Code is relational. Our principles and our standards describe how we relate to other persons in the very special role we have as psychologists. Having information revealed carelessly violates a basic tenet of the relationship--in the same way we would feel violated were a close friend to take something private and intimate we had shared in the context of the friendship and tell it at a social gathering. I don't think keeping such intimate confidences will make us any less fun at cocktail parties. I am certain, though, that respecting intimate confidences will make us much better friends.

Further Reading

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Previous "Ethics Rounds" columns can be found at APA Ethics Office in the "From the Director" section.