Understanding 42 CFR Part 2: Substance Abuse Confidentiality

Posted on Aug 19, 2024 in Psychology and Sociology

Substance Abuse and Confidentiality: 42 CFR Part 2

Applicability: Any information (including referral and intake) about alcohol and drug abuse patients obtained by a program

Includes (but not limited to):

• Treatment or rehab programs
• EAP
• Programs within a general hospital
• School-based programs
• Private practitioners who provide alcohol or drug abuse diagnosis, treatment, or referral

Intent of 42 CFR Part 2 insure that an alcohol or drug abuse patient is not made more vulnerable by reason of the availability of his or her patient record than an individual who has an alcohol or drug problem and who does not seek treatment

What Information Is Protected? 42 CFR Part 2 applies to all records relating to the identity, diagnosis, prognosis, or treatment of any patient in a substance abuse program that is conducted, regulated, or directly or indirectly assisted by any department or agency of the United States.

42 CFR Part 2 Allowable Disclosures

• Written authorization • Internal communication (“need to know”) • No patient-identifying information • Medical emergency • Qualified Service Organization • Audit and evaluation • Crimes (or threats of) on program premises or against program personnel • Initial reports of suspected child abuse or neglect • Court order meeting specifications of 42 • Research

When used in the criminal-justice setting, expiration of the consent may be conditioned upon the completion of,

or termination from, a program instead of a date.

Federal Drug and Alcohol Confidentiality Regulations

Title 42 of the CFR Part 2

Title 42 of the CFR part 2 was first published in 1975 and last substantially updated in 1987

Two laws enacted in the early 1970’s (one for alcohol, one for drugs)

Guarantee strict confidentiality of information about persons receiving alcohol and drug prevention and treatment services

Regulations implementing the statues were issued in 1975

Amended in 1987: Mandated abuse reporting

Consolidated the statutes in 1992 (42 U.S.C 290-2) the regulations were not changed (42 CFR Part 2)

Many HIPAA provisions PERMIT something but don’t mandate it.

42 CFR Part 2 PROHIBITS all disclosures unless specifically allowed by the regulation.

Professional Ethics

Ethics Main Objectives

1. To educate professionals about sound ethical conduct.
2. Ethical standards provide a mechanism for professional accountability.
3. Code of ethics serve as a catalyst for improving practice.

Ethics: beliefs we hold about what constitutes right conduct represents aspirational goals, or the maximum or ideal standards set by the profession, and they are enforced by professionals associations, national certification boards, and government boards that regulate professions.

1. aid in provides a competent, terminally ill patient with a prescription for a lethal dose of medication, upon the patient’s request, which the patient intends to use to end his or her own life.
2. Aspirational Ethics The highest standard of thinking and conduct professional counselors seek. It entails an understanding of the spirit behind the code and principles on which the code rests.
3. Boundary violation versus Boundary crossing Boundary crossing may be beneficial for the client (e.g., attending their wedding) Boundary violation is NEVER healthy for the client (e.g., engaging in sexual relations with client).
4. Bracketing The ability of counselors to manage their personal values so that they do not contaminate the counseling process.
5. Burnout State of physical, emotional, intellectual and spiritual depletion characterized by feelings of helplessness and hopelessness.
6. Counter-Transference Any projections by therapists that distort the way they perceive and react to a client.
7. Covered Entity Jenson (2003b) explains there are three types : health plans, health care clearing houses, and health care providers
8. Culturally encapsulated counselor Defines reality per cultural assumptions; Shows insensitivity to cultural variations; Fails to evaluate other viewpoints.
9. Direct Liability Actions of the supervisors are the CAUSE OF HARM (e.g., Give tasks to trainees that exceed their competence).
10. Duty to protect Applies to situations in which the mental health professional has a legal obligation to protect an identified third party who is being threatened; in these cases, the therapist generally has other options in addition to warning the person of harm.
11. Duty to Protect versus Confidentiality (AIDS-related cases) All limits of confidentiality should be discussed at onset. Keep current about relevant medical information. Speak directly and openly with clients about their concerns regarding the danger of certain behaviors and the risk to third parties.
12. Duty to warn Applies to those circumstances where case law or statute requires the mental health professional to make a reasonable effort to contact the identified victim of a client’s serious threats of harm, or to notify law enforcement of the threat. THIS DOES NOT APPLY IN ALL STATES; CALL MALPRACTICE INSURANCE OTHERWISE.
13. Ethical and Legal Considerations in AIDS-related cases Courts have not applied the duty to protect to mental health professionals in cases involving HIV infection. Thus, legal responsibilities for protecting sexual partners of HIV-positive clients remain unclear.
14. Ethical issues in couples &family therapy Who is the client, one member of the family or the whole family?
15. Ethics The standards that govern the conduct of its professional members.
16. Giving or receiving gifts Monetary value? Clinical implications? When is it being given? Own motivations for accepting/rejecting? Cultural implications?
17. Guidelines for Assessing Suicidal Behavior Identify client risk factors, warning signs, and protective factors that can work to mitigate the risk. In an assessment interview, it is important to focus on evaluating depression, suicide ideation, suicide intention, suicide plans, and the presence of any risk factors associated with suicide.
18. Hastened death Ending one’s life earlier than would have happened without intervention.”Speeding up the dying process”
19. Health Insurance Portability and Accountability Act of 1996 (HIPAA) Promote standardization and efficiency in the health care industry and to give patients more rights and control over their health information. Federal law that contains detailed provisions regarding client privacy, informed consent, and transfer of records.
20. If counseling a minor in family therapy, you must. . . Inform the minor about his/her right to assent to treatment plan and objectives of therapy (A.2.d.)
21. Impairment Presence of chronic illness or severe psychological depletion that is likely to prevent a professional from being able to deliver effective services and results in consistently functioning below acceptable practice standards.
22. Informed Consent Therapeutic Process, Assessment of Client’s background, Therapist’s background, Fees/costs, Length/termination, Consultation with colleagues, Interruptions in therapy, Benefits/risks, Alternatives to traditional therapy, recording sessions, Client’s right to access their files, Diagnoses, Nature and purpose of confidentiality
23. Informed Consent Process with Minors“When counseling minors or persons unable to give voluntary consent, counselors seek the assent of clients to services, and include them in decision-making as appropriate . . ” (A.2.d.)
24. Issues in Theory & Practice Your techniques need to FIT your therapeutic style, your level of training, & the specific needs of your client.
25. Key Concepts of End-of-Life matters Rational suicide, Aid-in-dying, Hastened death
26. Law The body of rules that govern the affairs of people within a community, state, or country.
27. Legal considerations in the supervisory relationship (1) Informed Consent (2) Confidentiality and its limits (3) Liability
28. Levels of Ethical Practice Mandatory Ethics and Aspirational Ethics
29. Limitations of Codes of Ethics Lack clarity and precision; Will not necessarily make for ethical practice; Personal values may conflict with a specific standard.
30. Managing multiple relationships in a small community (1) Obtain an Informed Consent (2) Document thoroughly (3) Set clear boundaries & expectations (4) Pay attention to matters of confidentiality (5) Get involved in ongoing consultation
31. Mandatory Ethics Describes a level of ethical functioning wherein counselors act in compliance with minimal standards, acknowledging the basic”must” and”must not”
32. Morality Concerned with perspectives of right and proper conduct and involves an evaluation of actions based on some broader cultural context or religious standard.
33. Multicultural competencies Set of knowledge and skills that are essential to the culturally skilled practitioner
34. Non-erotic touching May be appropriate and have significant value. Evaluate the context of client’s factors (e.g., gender, age, culture, class, personal history with touch, presenting problem, diagnosis, & personality) the professional setting, the therapist’s theoretical orientation, and the quality of the therapeutic relationship
35. Palliative care Specialized approach to medical care for people with serious illness.
36. Principles to Guide Decision-Making Autonomy (promotion of self-determination),
37. Privacy Constitutional right of individuals to be left alone and to control their personal information.
38. Privileged communication Legal concept that generally bars the disclosure of confidential communication made to a psychotherapist from any judicial proceedings or court of law.
39. Process Notes Or psychotherapy notes, are not synonymous with progress notes; Deal with client’s reactions such as, transference and therapist’s subjective impressions of client.
40. Progress Notes Means of documenting aspects of a client’s treatment and are kept in a client’s clinical record.
41. Rational suicide The person has decided-after going through a decision-making process and without coercion from others-to end his/her life because of extreme suffering involved with a terminal illness.
42. Reasons for Malpractice suits Failure to obtain or document informed consent, Refusal to counsel clients due to value differences, Client abandonment, Sexual misconduct with a client, practicing beyond the scope of competency, Misdiagnosis, Unhealthy transference relationships, Failure to assess/manage dangerous client.
43. Record keeping Mental health practitioners bear the responsibility for what they write, how they store, and access records, what they do with these records, and when/how they destroy them.
44. Risk management The practice of focusing on the identification, evaluation, and treatment of problems that may injure clients and lead to filing an ethics complaint or malpractice suit.
45. Self-Awareness and the influence of therapist’s personality and needs Professionals who work intimately with others have a responsibility to be committed to awareness of their own life issues.
46. Self-care Searching for positive life experiences that lead to zest, peace, excitement, and happiness.
47. Self-compassion Involves developing attitudes of caring, being nonjudgmental, being accepting, and being kind to ourselves.
48. Sexual attractions in the client-therapist relationship There is a distinction between finding a client sexually attractive & being preoccupied with this attraction. Consider asking self how UNRESOLVED family-of-origin or current issues can lead to blind spots.
49. Slippery Slope Phenomenon Once a practitioner CROSSES a boundary, the tendency to engage in series of interestingly serious boundary VIOLATIONS can lead to a progressive deterioration of ethical behavior.
50. Some Guidelines for Dealing with Dangerous Clients Examine informed consent document. Know how to contact legal counsel. Review code of ethics. Familiarize self with others who are experienced dealing with violence. Hint of violence in the client’s history?
51. Steps in Making Ethical Decisions (1) Identify the problem. (2) Identify the potential issues. (3) Review the relevant ethics codes. (4) Know applicable laws and regulations. (5) Obtain consultation. (6) Consider courses of action. (7) Enumerate consequences. (8) Choose best course of action.
52. Stress in the Counseling Profession Feeling overly responsible for the client’s lack of progress; Empathy fatigue (themes of grief, loss may mirror therapist’s own personal struggles too closely).
53. The Tarasoff Case (1969) Prosenjit Poddar was a voluntary outpatient at the student health service at the University of California, and in counseling with a psychologist named Moore. Poddar disclosed to Moore his intentions of killing a woman named Tatiana Tarasoff when she returned from a trip to Brazil. Tarasoff and her family were never made aware of this potential threat. He was never confined to a treatment facility. The lower court cited a duty to warn.
54. Transference The process whereby clients project onto their therapists past feelings or attitudes they had toward their caregivers or significant people in their lives.
55. Two types of liability Direct liability and Vicarious liability
56. Unethical behavior of colleagues Professionals have an obligation to deal with colleagues when suspect unethical conduct. Depending on the nature of the complaint and the outcome of the discussion, reporting a colleague to a professional board is one of several options.
57. Value imposition Counselors directly attempting to influence a client to adopt their values, attitudes, beliefs, and behaviors.
58. Values Beliefs and attitudes that provide direction to everyday living.
59. Vicarious Liability Responsibilities supervisors must oversee the actions of their supervisees. Trainees are NOT expected to assume final responsibility for clients; rather their supervisors are legally expected to carry the decision-making responsibility & liability.
60. Working with children and adolescents Informed consent of parents/guardians may not be legally required when a minor is seeking counseling for addictions, STDs, pregnancy/birth control, or for an examination following an alleged sexual assault of a minor over 12 years of age.