The historical foundation of psychotherapeutic confidentiality is usually assumed to be the Hippocratic oath, the oldest known statement of medical secrecy: "Whatsoever I see or hear in the course of my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets."(1) Hippocrates' belief in the obligation to protect patient information was based on ethical principles, not fear of lawsuits or the threat of licensure revocation. He and his followers advocated professional confidentiality at a time when "healers" freely disclosed patient information. However, the oath does not require absolute confidentiality, nor does it specify criteria for what should not be revealed.(2) Contemporary beliefs about the importance of confidentiality draw on the Hippocratic tradition of moral good but are also influenced by pragmatic concerns. Many psychotherapists emphasize that without the perception of confidentiality, patients will postpone treatment-perhaps making their problems more serious and expensive to treat-or will avoid sharing highly personal information because of fear of public exposure and social consequences.(3,4) The tradition of maintaining patient confidences has been seriously challenged by the legal, economic, and social conditions of modern society.(5,6) Factors leading to the erosion of confidentiality and privacy include third-party payers' and publicly funded service providers' insistence on patient information, as well as the creation of laws intended to enlist the assistance of psychotherapists in law enforcement.(7) In addition, billing clerks, waiting rooms, collection agencies, FAX machines for transferring patient information, access of trainees to patient records, and quality assurance committee audits also threaten confidentiality protection. Borenstein(6) points out that a particularly bothersome concern in managed care is "telephone review," in which the therapist is asked to provide sensitive clinical information to an individual who identifies himself or herself only as a reviewer for a specific managed care organization. Rarely does the caller state his or her credentials or provide the therapist with a signed release from the patient in advance. Unless the psychotherapist discloses the requested information, he or she is likely to have difficulty in obtaining continued treatment authorization and payment. Yet the therapist who makes such disclosures without the patient's written consent (oral consent is legally valid in some states) is breaching the clinician's obligation to the patient.
The level of protection for
patient disclosures in psychotherapy may be lower now than ever
before.(4) A significant role strain for psychotherapists stems
from the conflict between the belief that informing patients of
limits in confidentiality jeopardizes successful treatment
outcome(3) and the belief that not informing them violates their
ethical and legal rights to informed consent.(8)
Our primary
objective in this article is to examine empirical evidence relevant
to the effects of perceived confidentiality on the dyadic
therapeutic interaction. Our selection of studies to review was
governed by our judgment of 1) relevance to the topic
(confidentiality as a primary focus of the research) and 2)
soundness of the research protocol (clear definition of research
problem, information on how confidentiality was conceptualized and
measured, rigorous data analyses). In addition, we have reviewed
only studies of adult subjects; the special confidentiality
problems of therapy with minors are not addressed.
The review
includes studies published from 1970 through 1993. It is organized
into two primary sections on the basis of research methodology: 1)
clinical studies involving the actual psychotherapeutic context and
2) analogue studies with nonpatients (prospective patients). Brief
summary statements follow those sections that offer diverse studies
on a specific topic. An assessment of studies presented in this
review article should be of help in evaluating the credibility of
prevailing assumptions about psychotherapeutic confidentiality,
such as the belief that "Without the assurance of confidentiality
in treatment, patients won't come or won't talk." The next section
addresses such concerns by examining relevant empirical research.
Confidentiality: Patient Concerns
In Shuman and Weiner's study,(9) 31 psychiatrists distributed questionnaires to an unspecified number of their psychotherapy outpatients. Responses were received from 79 patients (primarily women in their mid-30s who had been in therapy for a median of 3 years). Although 40% of respondents admitted to withholding information from their therapists, much of that information dealt with sexual acts or sexual thoughts. Only 9% of the information withheld concerned thoughts of violence (that is, information covered under mandatory reporting laws). The investigators concluded that their results, rather than indicating patient concern over unauthorized disclosures of an illegal or endangering act, suggested that patients-at least female patients-may be most threatened by their perceptions of how the therapist might respond to their embarrassing social or emotional secrets. However, our rival interpretation is that women's acting out may tend to be more sexual than violent and that they are concerned about social and legal consequences if the therapist were to breach confidentiality. For example, if the patient's secret involved an extramarital affair, the consequence could be the loss of her children (through a divorce hearing), her social standing, or her role in her religious community.
Lindenthal and Thomas(10) studied attitudes toward confidentiality of 76 psychiatric outpatients and found that 45% of them reported concern that a psychiatrist might divulge confidential information; 22% said that such concerns had initially held them back from seeking treatment. However, Lindenthal and Thomas's results also suggest that patients frequently divulge the same confidences to friends, and to a lesser extent family members, that they disclose to their therapists. According to Smith and Meyer,(4) "secrets" revealed in therapy lose the protection of a privilege if also disclosed to third parties. Legal thinking appears to be, "If the world knows about it, why not the court?"(7)
McGuire et al.(11) surveyed 50 psychotherapy outpatients, 26 nonpsychotic psychiatry inpatients, and 50 hospital employees at a regional medical center. Although all respondents said that they considered confidentiality important, inpatients reportedly were more concerned about potential violations than outpatients and nonpatients. Perhaps this is because of the perceived stigma of psychiatric hospitalization or because their inpatient status heightened feelings of vulnerability and dependence. In addition, differing levels of pathology might be a factor influencing these findings. That is, inpatients tend to be sicker and thus have more to fear from word of their condition being made public.
Schmid et al.(12) used a brief semistructured interview to survey the attitudes of 30 adult inpatients regarding the importance of confidentiality and privilege in their own treatment. Most patients were concerned about the possibility of confidentiality violations, although their expressed levels of concern varied according to who would be receiving the information. For example, more than 80% of the sample said that they would be angry and upset if information were released to their employers, but only 40% felt this strongly about release to a family member, and none objected to disclosure by the therapist to another staff professional who might help them.
Using a slightly modified version of the same semistructured
interview, Appelbaum et al.(13) conducted a similar study with 58
outpatients. Sixty-two percent of the respondents (34 of 55) said
that they would dislike learning that their therapists had
disclosed information about them without their consent, regardless
of the circumstances. Fifty-seven percent said that a therapist's
breach of confidentiality would adversely affect the therapeutic
relationship, and 78% said that they might take some form of action
in the event of such a disclosure. Of the latter, 29% said they
would complain to higher authorities or get a new therapist, and 5%
said they might take legal action. Reactions varied according to
the recipient of the information. Only 24% of the outpatients said
that they would take action over disclosure to a family member, but
64% would take action over disclosure to an employer. That is,
patients were most upset when the breach of confidentiality could
cause them harm.
In sum, patient concerns about confidentiality
breaches are related to content of information, recipient of
information, and patient status (outpatient versus inpatient).
Mandatory Reporting: Therapist and Patient Concerns
It is mandatory in all 50 states to report suspected child physical and sexual abuse. Psychotherapists are more likely than other health care providers to receive information concerning abuse directly from the abusers.(4)
Berlin et al.(5) compared the number of self-referred sexual abusers, plus patients who revealed such behavior during treatment, seen at the Johns Hopkins Sexual Disorders Clinic during equal time periods before and after the implementation of Maryland's mandatory reporting statutes. The severe drop noted in self-reported child sexual abuse after the statutes took effect led Berlin and colleagues to conclude that mandatory reporting deterred many undetected adult abusers from entering treatment.
The research findings of Kalichman et al.(14) suggest that many mental health professionals report child abuse selectively despite the attendant legal risk.
Levine et al.(15) found that some clinicians' distress about making a report is based on their experience of its having a negative impact on the therapeutic alliance. Levine and colleagues found that 15% to 25% of patients terminated treatment immediately, and those who remained in therapy went through a period of resistance and mistrust that in some cases was never overcome. However, therapists in the Levine study also conveyed that if the relationship was good before the report, then a number of patients made additional progress in processing abuse and other family issues in therapy. This finding suggests a need to train clinicians on how to use the process of disclosure "therapeutically."
Wise(16) found that nearly one-quarter of responding psychotherapists experienced reluctance on the part of their patients to discuss violent tendencies after the patients were informed about reportable offenses. This finding indicates that patient fears of a breach of confidentiality altered the therapeutic dialogue, thus probably hindering treatment.
Conte et al.(17) surveyed 100 experienced psychotherapists from various mental health professions and found that the less experienced therapists believed more strongly than did the therapists with 14 years or more of clinical experience that it was important to warn potential victims, police, or family members in the event of possible suicide or homicide. This finding may reflect the more senior clinicians' greater confidence in their own ability to manage extreme situations, or it may reflect differences in professional acculturation-that is, the effects of receiving psychotherapy training and establishing a profession during the post-Tarasoff era.
Ignorance or confusion on the part of both patients and therapists regarding reporting requirements, confidentiality, and privilege statutes has also been identified in several studies in the psycholegal literature.(18-22) Many clinicians appear to have only a rudimentary understanding of relevant statutes in their own states that are directly relevant to their professional practices.
In sum, therapist concerns about
reporting decisions appear to be related to anticipated impact on
treatment, limited knowledge about reporting laws, and cohort
effects (that is, the time when people went through training).
Patient concerns involve the seriousness of the sociolegal
consequences if their confidence is breached.
Confidentiality Instructions
Cutler(3) provides a rare prospective investigation of
the effects of using various methods of informing patients about
the limits of confidentiality in a natural counseling setting.
Prior to the start of a typical intake interview, 36 patients at a
university counseling center were presented with one of the
following: 1) no information regarding confidentiality, 2) a
written document about confidentiality limitations to read and
sign, or 3) a written document plus an oral presentation of the
same information. Using patient ratings of self-disclosure and
therapist trustworthiness, the investigator found that knowledge of
confidentiality limits did not negatively affect patients'
subsequent self-disclosures in therapy or trust in the therapist. A general finding of this study, unrelated to the three varying
experimental conditions, was that therapists rated patients as
increasing their levels of self-disclosure over time. If the
therapists' perception is accurate, it suggests that once the
confidentiality ground rules have been laid out, the therapeutic
alliance will likely dictate the level of patient self-disclosure.
Confidentiality Violations
Forty-eight percent of the 84 therapists in the Shuman and Weiner study(9) reported that they had been approached on at least one occasion with a request to disclose in court patient information that had been revealed in therapy, but ultimately only 15% of those respondents had actually been required to disclose. In most cases, "some alternative" was devised. More often than not, when the therapist was required to testify in court, it was about a patient who was no longer in therapy. Forty-one percent of the therapists had warned a third party of potential harm by a patient on at least one occasion. These respondents described the patients' responses to these therapist disclosures as "variable- from anger to relief." Four therapists reported that the patients dropped out of treatment.
Pope et al.(23) found that about 74% of 456 responding psychologists (primarily in private practice) had discussed a patient with friends, and 8.1% blatantly breached the confidentiality of a patient by identifying the individual by name.
The studies presented in the next section are distinguished
from the previously cited clinical research in that they are
primarily of analogue design. A benefit of psychotherapy analogue
research is that it enables experimental manipulations that may not
be possible within the natural therapy context. The crucial
limitation of this research concerns the question of
generalizability of these findings to the actual psychotherapy
context.(24)
Confidentiality Instructions
Meyer and Willage(25) studied the amount and type of information that 63 undergraduate research subjects disclosed under three confidentiality conditions: a pledge of complete confidentiality, no mention of confidentiality, and clearly expressed nonconfidentiality. The subjects in the no-confidentiality condition provided the most socially desirable responses and reported being the least bothered by psychopathological symptoms. The subjects in the confidentiality condition reported more psychological symptoms than those in the other two groups and produced fewer socially desirable responses than did the subjects in the no-confidentiality condition. Subjects were most influenced by confidentiality concerns when they were asked to report very personal information. The more private the information sought, the stronger the effect of the degree of perceived confidentiality.
Nowell and Spruill(26) investigated 75 undergraduate research subjects' anticipated willingness to disclose information about several clinical concerns: depression/anxiety; substance use/abuse; physical/psychological aggression; suicidal thought/behavior; and psychotic thought/behavior. Subjects were randomly assigned to one of three experimental groups: absolute confidentiality group, short-form group (provided with general information about confidentiality limitations), and long-form group (provided with highly detailed information about specific exceptions to confidentiality). Results indicated that subjects in the condition of absolute confidentiality reported more willingness to disclose information than did subjects informed of confidentiality restrictions. However, greater detail about confidentiality limits did not result in greater inhibition between short-form and long-form groups.
Woods and McNamara(27) used an interview analogue to investigate self-disclosure in one-to-one interviews under different confidentiality conditions. The questions involved low-intimacy items (for example, "How do you like to spend your spare time?"), moderately intimate items ("How do you react to criticism and praise by others?"), and high-intimacy items ("How can you tell when you are getting sexually aroused?"). The instructions either 1) promised full confidentiality, 2) explained that confidentiality could not be guaranteed, or 3) did not mention the issue of confidentiality.
The results indicated that instructions regarding
confidentiality had a strong effect on the depth of
self-disclosure. When interviewees were told that their responses
might not be confidential, they were less open in their disclosures
than were interviewees who were either assured of confidentiality
or were not apprised of the issue.
Confidentiality Violations
Merluzzi and Brischetto(28) found that undergraduate
students' perceptions of therapists' trustworthiness were lower for
those clinicians who breached confidentiality, even under the
condition involving a patient with a highly serious problem (an
audiotaped interaction between two people represented to them as a
therapist and a very suicidal patient). Therapists who maintained
confidentiality were rated by the students as understanding the
patient well, being someone to whom the student would refer
friends, and being a clinician who would have a favorable outcome
with the patient.
Methodological Critique
Methodological inadequacies in confidentiality research have been
discussed by Cutler.(3) Perhaps the most important is whether or
not persons actually struggling with reportable issues self-select
out of such studies by avoiding treatment because of the risks
involved (such as incarceration or loss of a child). The issue of
whether or not the subject pool for confidentiality studies is
primarily those individuals with the least to hide should be
examined empirically.(29) Further, independent measures of patient
self-disclosure (e.g., therapist and independent judges) are seldom
employed. The generalizability of results from college counseling
center student-patients to mental health center patients, and vice
versa, can also be questioned. Longitudinal studies of the impact
of confidentiality instructions on the therapeutic process are
rare. Therapist and investigator biases are rarely addressed, and
subject recruitment methods and selection criteria are seldom
reported adequately. Until results from more rigorous
investigations are available, we need to consider the following
implications of the current wave of empirical studies as tentative.
Implications of Findings
Implications of Analogue Studies:
Analogue findings support
prevailing assumptions that most "potential patients" 1) assume
that information divulged in psychotherapy is confidential, 2)
report that they will not talk about unprotected topics, and 3) may
not enter treatment when apprised of limited
confidentiality.(27,30,31) Also, the strength of the effect of
confidentiality limitations depends on the type of information
requested-that is, the more personal the information, the greater
the effect.(25) However, although undergraduate college students
may be potential patients, they are not a well-matched patient
equivalent group; therapy analogues cannot approximate the
emotional and interpersonal conditions of a distressed individual
seeking help.
Implications of Therapy Studies:
Findings from studies with a clinical population of individual therapy patients generally indicate that, for some patients, knowledge of the limitations of confidentiality may delay entry into treatment. However, once a patient is in therapy, this knowledge does not appear to negatively affect trust in an attentive, skilled therapist. Patients do not want information about their cases to be disclosed to employers, fearing that mental health information might negatively affect current or future employment.(32)
In two studies,(5,16) those at risk for serious consequences (such as loss of a child, psychiatric hospitalization, or imprisonment) were deterred from treatment or chose not to make disclosures considered reportable offenses. That is, a patient's awareness that a therapist is likely to report certain behaviors may prevent the patient from revealing harmful intentions, leading to a lack of protection for the patient's innocent victims.(5,9,15,33)
On the other hand, Slovenko(34) believes that potentially violent patients may benefit from learning that the therapist will impose external controls when the patient's self-control is breaking down. This might account for therapists' reports(15) of an enhanced relationship with some patients whom they reported to social services after the patients admitted child abuse. One might also consider in some cases the possible psychodynamic importance of making reportable disclosures. The latter may well be worthy of examination in the therapy itself.
Until data from more methodologically refined studies are available, we can only conclude from available research findings that the empirical relationship between confidentiality protection and therapeutic effectiveness is highly complex. An appropriate goal for the next wave of studies is to characterize the subgroup of persons most likely to be deterred from seeking treatment, or to censure their therapy communications, because of confidentiality restrictions. The role of gender and socioeconomic status on confiding behavior and trust attitudes warrants further study as well. Research also suggests that the developing therapeutic alliance during the course of therapy is a strong influence on self-disclosure, regardless of initial patient attitudes. It will be important to determine how short-term therapy affects this process.
Lastly, data on the impact of the intrusive requirements of managed care on patient self-disclosure are clearly needed.
Implications for Education:
Psychotherapists' level of information regarding psycholegal issues and statutes is seriously inadequate; if clinicians are to be professionally responsible, more attention needs to be given to these matters both during training and through continued education. It has been recommended that, in addition to information about ethical and legal responsibilities, students in the mental health field receive training in how to handle clinical issues in mandatory reporting, such as what to expect from patients after making a report.(15) Educational research into the causes of clinicians' ambiguity and uncertainty about psycholegal issues is also warranted.(19,35)
Findings from one study(23) suggest that therapists may be "loose-lipped" in discussing patient matters with friends. Psychoanalysts such as Dr. Volney Gay (personal communication) and Langs(36) suggest that when a patient directly or indirectly expresses raw images of sexual or aggressive feelings, the therapist may experience the urge to "rid" himself or herself of attendant affects. Hence, it may be the normal experience of the young therapist to "tell all" about a "horrible borderline" patient or talk about patients indirectly with others and thereby share the feelings aroused by the patient's pathology. To keep "confidence" in this sense is to manifest the maturity to deal with affects and raw images privately, without actions and without discharge. It seems essential for therapists to be trained to deal constructively with strong affects. We should note that the foregoing comments are not meant to deter therapists from seeking peer consultation about patients.
Implications for Public Policy:
The studies reviewed in this article do not directly address public policymaking. However, several researchers have commented on directions that confidentiality research might take that would be relevant to public policy. These recommendations appear to be based on at least some systematic observations of research findings. For example, Taube and Elwork(29) advise policymakers and researchers to begin determining precisely when, how, and for whom limits to confidentiality affect therapy or prevent harm. They also advocate a cost-benefit analysis of current policies compared with other policies. As these recommendations imply, we do not know how much harm is caused or prevented by current laws, nor do we know whether another policy would be more beneficial.
An example of such an
alternative policy is the specific recommendations offered by Meyer
and co-workers(4,25) for modifying mandatory child abuse reporting.
Changes would include eliminating the reporting requirements when
the therapist receives information about the abuse from a patient
(the abuser) or the patient's spouse. That is, these authors
propose that the psychotherapist-patient privilege should not be
abrogated when the abuser reveals information intended to help stop
the abuse, unless there is a threat of serious, permanent physical
harm to a child or unless therapy is not continuing and the threat
of child abuse continues.(4,25) These reforms are meant to
encourage perpetrators to voluntarily seek professional help to
stop the abuse. Other areas of reform proposed by Smith and
Meyer(4) involve third-party disclosure. They propose that the law
define and limit information concerning therapy that third-party
payers may demand, and, further, that the law mandate that the
institution receiving information from therapy have the same
responsibility as the clinician to protect that information.In
considering the restructuring of confidentiality legislation to
keep current with rapid changes in the demands for information
about therapy, policymakers need recourse to an empirical
literature. Although it cannot help us place weightings on
competing values (individual privacy rights, availability of
accurate and complete information at judicial hearings, third-party
utilization and review committees' needs, society's needs), such
research can help clarify the stakes in these relative
weightings.(9)
1. Simon R: Clinical Psychiatry and the Law. Washington, DC, American Psychiatric Press, 1987
2. Appelbaum P: Confidentiality in psychiatric treatment, in Psychiatry 1982: The American Psychiatric Association Annual Review, edited by Grinspoon L. Washington, DC, American Psychiatric Press, 1982, pp 327-334
3. Cutler W: Informed consent to limited confidentiality. Doctoral dissertation, Southern Illinois University, Carbondale, IL, 1986
4. Smith S, Meyer R: Law, Behavior, and Mental Health. New York, New York University Press, 1987
5. Berlin F, Malin M, Dean S: Effects of statutes requiring psychiatrists to report suspected sexual abuse of children. Am J Psychiatry 1991; 4:449-453
6. Borenstein D: Managed care: a means of rationing psychiatric treatment. Hosp Community Psychiatry 1990; 41:1095-1098
7. Box S: Secrets. New York, Vintage Press, 1983
8. Everstine L, Everstine D, Heymann G, et al: Privacy and confidentiality in psychotherapy. Am Psychol 1980; 35:828-840
9. Shuman D, Weiner M: The privilege study: an empirical examination of the psychotherapist-patient privilege. North Carolina Law Review 1982; 60:894-942
10. Lindenthal J, Thomas C: Psychiatrists, the public and confidentiality. J Nerv Ment Dis 1982; 170:319-323
11. McGuire J, Toal P, Blau B: The adult client's conception of confidentiality in the therapeutic relationship. Professional Psychology 1985; 16:375-384
12. Schmid D, Appelbaum P, Roth L, et al: Confidentiality in psychiatry: a study of the patient's view. Hosp Community Psychiatry 1983; 34:353-355
13. Appelbaum P, Kapen G, Walters B, et al: Confidentiality: an empirical test of the utilitarian perspective. Bull Am Acad Psychiatry Law 1984; 12:109-116
14. Kalichman S, Craig M, Follingstad D: Professionals' adherence to mandatory child abuse reporting laws. Child Abuse Negl 1990; 14:69-77
15. Levine M, Anderson E, Ferretti L, et al: Mandated reporting and the therapeutic alliance in the context of the child protection system. Paper presented at annual meeting of American Psychological Association, San Francisco, August 1991
16. Wise T: Where the public peril begins: a survey of psychotherapists to determine the effects of Tarasoff. Stanford Law Review 1978; 31:165-190
17. Conte H, Plutchik R, Picard S, et al: Ethics in the practice of psychotherapy: a survey. Am J Psychother 1984; 43:33-42
18. Jagim R, Wittman W, Noll J: Mental health professionals' attitudes toward confidentiality, privilege, and third-party disclosure. Professional Psychology 1978; 9:458-466
19. Roback H, Ochoa E, Bloch F, et al: Guarding confidentiality in clinical groups: the therapist's dilemma. Int J Group Psychother 1992; 42:426-431
20. Roback H, Purdon S, Ochoa E, et al: Effects of professional affiliation on group therapists' confidentiality attitudes and behaviors. Bull Am Acad Psychiatry Law 1993; 21[?]:147-153
21. Smith S, Meyer R: Child abuse reporting laws and psychotherapy: a time for reconsideration. Int J Law Psychiatry 1984; 7:351-366
22. Swodoba J, Elwork A, Sales B, et al: Knowledge of and compliance with privileged communication and child-abuse-reporting laws. Professional Psychology 1978; 9:448-457
23. Pope K, Tabachnick B, Keith-Spiegel P: Ethics of practice. Am Psychol 1987; 42:993-1006
24. Kiesler D: Experimental designs in psychotherapy research, in Handbook of Psychotherapy and Behavior Change, edited by Bergin A, Garfield S. New York, Wiley, 1971, pp 36-74
25. Meyer R, Willage D: Confidentiality and privileged communication in psychotherapy, in New Directions in Psycholegal Research, edited by Lipsitt P, Sales B. New York, Van Nostrand Reinhold, 1980, pp 237-246
26. Nowell D, Spruill J: If it's not absolutely confidential, will information be disclosed? Professional Psychology 1993; 24:367-369
27. Woods K, McNamara J: Confidentiality: its effects on interviewee behavior. Professional Psychology 1980; 5:714-721
28. Merluzzi T, Brischetto C: Breach of confidentiality and perceived trustworthiness of counselors. Journal of Counseling Psychology 1983; 30:245-251
29. Taube D, Elwork A: Researching the effects of confidentiality on patients' self-disclosures. Professional Psychology 1990; 21:72-75
30. Miller D: Confidentiality in psychotherapy, in Encyclopedic Handbook of Private Practice, edited by Margenau E. New York, Gardner, 1990, 677-686
31. Muehleman T, Pickens B, Robinson F: Informing clients about the limits to confidentiality, risks, and their rights: is self-disclosure inhibited? Professional Psychology 1985; 16:385-397
32. Rosen C: Why clients relinquish their rights to privacy under sign-away pressures. Professional Psychology 1977; 8:17-24
33. Faustman W, Miller D: Considerations in prewarning clients of the limitations of confidentiality. Psychol Rep 1987; 60:195-198
34. Slovenko R: Group psychotherapy: privileged communication and confidentiality. J Psychiatry Law 1977; 5:405-466
35. Monahan J: Limiting therapist exposure to Tarasoff liability. Am Psychol 1993; 48:242-250
36. Langs R: Making interpretations and securing the frame:
sources of danger for psychotherapists. International Journal of
Psychoanalytic Psychotherapy 1985; 10:3-23
Received September 28, 1994; revised December 9, 1994; accepted December 28, 1994.
From the Division of Psychodynamic Psychiatry, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee. Address correspondence to Dr. Roback, Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN 37232.
Copyright © 1995 American Psychiatric Press, Inc.
Published electronically on this site courtesy of the authors and American Psychiatric Press, Inc.
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