Listen to the audio version of this article:
In medical practice, we often discuss the core ethical principles we encounter each day. Principles of Autonomy, Beneficence, and Justice are common ingredients as we try to cook up quality addiction care. One of the most coveted principles is that of Confidentiality – the right for someone’s healthcare to remain private and disclosed to others only at the discretion of the individual.
This principle is more than just ethical, it is the law according to the Health Insurance Portability and Accountability Act (HIPAA) and the Confidentiality of Substance Use Disorder Patient Records regulation (42 CFR). These entities require all communication regarding substance treatment to be with the express written consent of the identified party, the patient. In our country, special regulation is added to substance abuse treatment because of the inherent stigma attached to such a medical condition as alcoholism or drug addiction.
When patients enter treatment at CeDAR, their clinical team will discuss with them to whom (if anyone) they would like communication to occur during and after treatment. When our physicians or counselors communicate with a family member, either by writing, a phone call, or in person, it is understood that the patient has signed what we call a Release of Information document, or “ROI.” This document provides the necessary consent for us to comply with legal requirements.
The ROI documents we use through CeDAR allow the patient to partition what they would like discussed. This may include such topics as treatment planning, care recommendations, progress reports around treatment, or financial data. It is possible for the patient to allow disclosure of information surrounding any or all of these topics.
It is important to acknowledge that we can actually step over the ROI limits in certain cases. If a person presents with a perceived imminent danger to him or herself, danger to others, or is severely impaired to the point of medical danger, we can break the person’s confidentiality. For all patients entering treatment at CeDAR, they are informed of these regulations. We also can break confidentiality in the interest of child welfare. All healthcare providers are required to report to local agencies any suspicion of harm or neglect to children. This will open a case in the local county, warranting further evaluation regarding those issues.
It is also within a patient’s rights for them to revoke the release of information document at any time. Simply by verbalizing an intent to “revoke my ROI,” our treatment center must honor that request, and effectively cease communication to outside sources. This can be highly confusing and difficult for families; hence we need to elaborate on what processes may be occurring if this were to happen.
The ethical issues for behavioral healthcare around the United States are not unique to our approach through CeDAR. The issues of ROI agreement and revocation are so common, in fact, that many health centers use standard phrases to indicate the lack of an ROI. How do you know if an ROI has been revoked? Legally, we cannot communicate to you that the ROI has been revoked, as this would entail some further communication about healthcare.
Overall, if you, as a family member or outside party, were to hear the phrase “We can neither confirm nor deny the presence of ‘said person’ at our treatment center,” it is highly likely that your family member has chosen to revoke the ability for us to communicate with you about his or her healthcare progress. There are, of course, other possible scenarios with this, such as the CeDAR counselor very abruptly ceasing any communication for an extended period of time. Either way, you will have good reason to suspect that the ROI has been revoked.
This situation can be extremely frustrating to families, as we may have been openly communicating with you even one hour before such a drastic change. It is common for families to feel frustrated at the hospital, fearful, or outright confused about what is happening. Hopefully, in reading this article, you are representing yourself as an engaged support for your family member. We need to talk about what can be done to help if problems are building.
The most common reason we see patients revoke an ROI agreement is around issues of control and anger. Because we are often recommending significant changes in a person’s life, including the possibility of extended treatment, we have many patients who are quite fearful of that feedback. For instance, if a young adult, who is highly financially dependent on his or her parents, hears that they should enter a sober living environment after treatment, a strategic way to block that pathway would be to halt any communication to the parents. In this way, the rationale and guidance from the clinician cannot actually be received.
We have many patients who enter treatment more due to the expectations of their family than through an internal desire to fully change. Those patients are also the most likely to manipulate the ROIs at opportune times, effectively tying our hands as clinicians.
There are some instances in which an outside force is abusive or hurtful to one of our patients. In these scenarios, we are actually very supportive of the person revoking the ROI to the abusive person. This happens in the case of domestic violence, unstable external family, or excessively controlling family members.
If you sense that there has been a significant change in your family member’s attitude towards treatment or that an ROI has been eliminated, simply start by asking your family member. Our entire family program focuses on honest and direct communication, and this is a way to practice those behaviors with your loved one.
If the issues of treatment recommendations are part of the picture, it is definitely in your best interest, as a family, to know the reasoning behind CeDAR’s recommendations for your loved one. Even if those plans aren’t likely to be followed, it is very much worth your while to hear what we have to say. When we are working with people to guide their next steps in treatment, we really pay attention to their ability to have an open conversation about the topic. Any perception that the patient is trying to lock down or inhibit the conversation is always a negative prognostic sign.
Much of this connects back to some of our other articles about the continuum of care and treatment planning. Treatment centers such as CeDAR do not ‘cure’ your family member from alcoholism or addiction. We simply help to identify the problems, reach some basic stabilization, and work to arrange a recovery path over the upcoming year. Any blockage in those three things needs to be addressed.
Of note, if you have a family member who has revoked ROIs, you are still welcome to attend and engage in our CeDAR family program. We will not be discussing with you direct components of your family member’s care, but the messages of our curriculum will still be very useful to you. If you are interested in learning more, talk to our family program coordinators.
The addictive disease often involves severe distortions in a person’s thinking. Navigating these issues is one of the most challenging parts of our careers in behavioral healthcare. We both respect the legal boundaries around confidentiality, while also acknowledging that the addicted brain can be quite sick on insidious levels.
A patient’s ability to revoke releases of information may simply be that person’s futile attempt to control something in his or her life that is clearly out of control. We see the impairment through an external lens – the person struggling may not see the extent of distorted thinking. As a supportive family member, you can make some progress with these issues and your awareness if your family member is either moving towards health or stuck in further sickness.
Such controlling and stifling efforts by a patient almost always represent sickness. By acknowledging this, you can be more prepared as a family for what comes next.