The following is the second case originally presented in this blog several weeks ago for comments. Included are two invited comments and any further comments from the readers are welcome
A senior psychoanalyst is supervising a junior colleague who is treating the following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.
The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she rode up in the elevator with a young man a few years younger than her who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.” He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the supervisory session.
Does the supervisor have any obligation to either to suggest or urge his supervisee to try to influence the patient to report this information to the authorities and is the therapist or the supervisor obligated to do so.? What are clinical and therapeutic implications for the therapist to spontaneously bring up this incident if the patient is not talking about it ?
Response from invited discussant Sheldon Frank. M.D. Dr. Frank is a child and adult psychiatrist practicing in South Florida.
The implications from this patient’s statement about her neighbor are not clear. Legally, there doesn’t appear to be enough factual information to warrant any kind of report by the therapist. Therapeutically, it is warranted that the anxiety around the interchange be brought up to the patient for examination / reaction on her part. The result could be, for instance more (or less) of a hint by the neighbor as to possible criminal activities and/or plans; and perhaps even a conflict within the patient as to whether she needs to contact the authorities.
Response from invited discussant Myron L. Glucksman, M.D. Dr. Glucksman is a psychiatrist and psychoanalyst practicing in Redding Connecticut and New York City. He is a Clinical Professor at N. Y. Medical College and a training analyst at the Psychoanalytic Institute at N. Y. Medical College.The patient’s recounting of her male neighbor’s comment is basically heresay, and therefore does not warrant her or the supervisor’s obligation to report it to the police. However, the issue may connect with her distrust and fear of men. It certainly invites further exploration in regard to her father’s insensitivity and untrustworthy behavior. One might wonder whether her father was ever physically abusive toward her or her mother. If so, possible fantasies of being injured or killed by a man should be explored. I would also pay attention to dream material involving aggression by men. If the therapist is male, one would expect manifestations of a negative transference at this stage of treatment.
Other comments received about this case :
It seems quite clear that the patient has been told about a murder. If the therapist is denying this, he or she will not be able to understand any conflicts that the patient has in dealing with this information. Learning about a serious crime by a person who is likely to commit other such crimes does ethically obligate the therapist and the patient to notify the authorities. If you hesitate in doing this, is it because of the nature of the murder.? If it were immediately after 9/11 and the neighbor indicated that he was involved in the planning of that crime, would that push the therapist and the patient to action ? Does the ethical rule apply only to multiple murders? Of course, notifying the authorities could endanger the life of the patient and the therapist (and maybe even the supervisor) . Even if the information was given anonymously to the police, once they started investigating the neighbor, the hit man and his boss could soon figure out the only person who was told about the “putting to sleep” was the therapist. He or she could be eliminated or “made to talk ” and tell that the the other person that was told was the supervisor . Then they both could be put to sleep. So maybe it is best to just deal with the therapeutic implications of this interchange between the neighbor and the patient as well as the interchange between the patient and the therapist. It must be significant that the patient and her father shared a big secret (that of the father’s affairs). Now circumstances have occurred where the patient and the therapist are sharing a special secret . Understanding this may move the therapy forward in a productive manner. Dr. A (name withheld by request )
Comments are welcome in the comment section below and will be added to this blog.