Ethical quandary: Work with patients, family members presents many conflicts

Working more closely with the patient's family in addiction treatment can uncover a number of ethical dilemmas that were discussed Aug. 18 at the opening day of the National Conference on Addiction Disorders (NCAD) in Denver. Michael Barnes, PhD, LPC, clinical program manager at the Center for Dependency, Addiction and Rehabilitation (CeDAR) at the University of Colorado Hospital, cited factors in both law and clinicians' own value systems that can complicate the effort to gain helpful buy-in and collateral information from a patient's loved ones.

Barnes told the audience in an ethics breakout session that as a marriage and family therapist, he tends to see the family as the client. Yet he added that many clinicians will quickly write family members off as soon as they start to perceive that the family has contributed greatly to the patient's problems in the past.

Moreover, the federal confidentiality law that governs what information may be released about a substance use treatment patient without consent attests that the patient, not the family, is the client. The 42 CFR Part 2 mandates often create a duality for programs and clinicians seeking more family involvement, said Barnes.

His session was among the opening-day presentations at NCAD, produced by the publishers of Addiction Professional and Behavioral Healthcare.

Counselors' values

Barnes discussed how counselors' personal values shape their professional behavior. At one extreme, those with an “absolute” value system will seek to influence the patient to the highest degree; Barnes said this often occurs with counselors in recovery who believe all patients should get well in the same way they did.

At the other end of the spectrum, those espousing a “hidden” value system believe they must be objective at all times and can never reveal any point of view to their patients, Barnes said. “It is impossible,” he said of maintaining this stance.

He sees several examples of such absolutist views in the field, relating a recent encounter he had with a clinician who essentially shut down after Barnes mentioned the encouraging experience CeDAR has had with buprenorphine treatment. “The conversation couldn't end fast enough,” Barnes said.

He emphasizes the importance of a detailed and honest first clinical session with a patient in addiction treatment—a session that he said should include a recounting of the purpose of any of the disclosure forms or other paperwork that the patient signed at intake. He added that CeDAR is developing a formal disclosure statement for family members of patients entering treatment as well.

“At CeDAR, we allow no 'drive-by' first visits to the patient,” Barnes said. He urges, “If you don't have the 45 minutes to spend, don't introduce yourself.”

This is critical, he believes, because patients in that first visit are sizing up the clinician as much as the professional is evaluating the patient.

Legal complications

One of the most telling examples of conflicting views on how to work with patients and families, Barnes suggested, lies in the vast difference between the 42 CFR Part 2 confidentiality protections and what is being proposed in the Helping Families in Mental Health Crisis Act now being considered in the U.S. Senate.

The proposed legislation, which passed the House as HR 2646, would open the door to wider disclosure of patient information to families and others without the patient's consent. This would include circumstances in which it was determined, for example, that a patient's ability to make rational healthcare decisions is diminished because of his/her behavioral health condition.

Barnes warned that components of the proposed bill would infringe on patients' constitutional rights. He added that already in the field, friction is created when a clinician approaches family members on a matter, such as to gain leverage on a goal in treatment, and the patient protests the possible breach of confidentiality.