pleased when the President and the Department of Defense adopted a policy of viewing the drug abuser as a medical problem, while still maintaining its efforts to eradicate the traffic in drugs. A treatment program written by the military establishment must be seen as positive action directed toward furthering the primary mission of the armed forces. The role of confidentiality in successful psychiatric treatment has been well established. The development of a positive treatment atmosphere for a voluntary rehabilitation program for drug abusers is partially contingent upon the degree to which a psychiatrist can assure the patient of the confidentiality of his disclosures. The real or threatened adverse consequences of disclosure may cause personnel to avoid seeking treatment altogether or not to cooperate fully in the treatment regime. As civilian psychiatrists, we can only recommend those things concerning confidentiality which we feel will help lead to an effective voluntary military drug abuse treatment program. In any program offering confidentiality, the limits of confidentiality must be defined. Any promise of nonpunitive action must truly be nonpunitive; otherwise, subsequent disillusionment of the treated person will create destructive reaction to both his treatment and the program in general. There have been examples of previous unsuccessful treatment programs where the limits of confidentiality were not well defined and, indeed, did not prevent secondary punitive action from taking place. This protection for those honestly seeking help will provide a more effective program and increase motivation for help. The act of volunteering should only grant protection for a confidential evaluation prior to acceptance into the drug abuse treatment program, and for ongoing participation and cooperation in the program. In recommending this amnesty, we do not imply that personnel in treatment are immune from consequences of unacceptable behavior secondary to or not related to the fact of treatment. Being labeled a drug abuser is punitive in itself. For that reason, as far as possible, all medical records of treatment should be held inviolate in the medical treatment sector. In military programs, as in civilian programs, both the patient and psychiatrist recognize that, at times, for various reasons, this confidentiality cannot be absolute. The medical unit and command unit must be aware of each other's needs and responsibilities, and adequately keep each other informed of factors that would represent a hazard to the treatment of the individual or to the command's mission. (Army regulation AR-40-42 is an existing example of these safeguards.) There are three special considerations brought to our attention that could also seriously and adversely affect the viability of drug abuse treatment programs: First, compromising conditions for entering the treatment program should be avoided. For example, making amnesty or treatment conditional on the individual becoming an informer will seriously affect the credibility of the program. (The Army has taken note of this in Army regulation AR-40-42, paragraph 6G, which specifically deals with this point.) Secondly, there have been reports of damaging breaches of the patient's confidentiality by critical information being released to civilian sources after discharge from military duty. One way of exposing individuals in drug treatment programs after separation from service has been the SPN number on discharge papers. We would urge re-examination of the policy of using these SPN numbers on discharge records that are not kept in confidential military medical files. The third consideration is the intermingling of general personnel records and medical records at the National Personnel Record Center after separation from service. These medical records have been made available for other than military uses after personnel have returned to civilian life. For protection of confidential information, we would recommend an exploration of methods to separate from personnel records the medical records and references to medical diagnoses. We are pleased that the Department of Defense is already considering the problem of confidentiality and we hope these comments will be of use in the implementation of its programs. Proposed by the APA Task Force on Confidentiality as Related to Third Parties Maurice Grossman, M.D. Alan L. Krueger, M.D. Appendix E: Recommendations Of The Task Force On Confidentiality As It Relates To Third Parties To The Council On Professions And Associations, October 1971 1. That APA adopt a position recommending its members limit information to insurance companies for health care reimbursement to the following: a. Recognition that an unspecified psychiatric condition does exist (in place of diagnosis). b. Approximate date that patient recognized symptoms and need for treatment (or onset). c. Nature of treatment in general terms. d. Billing which shows frequency and cost of treatment. e. Billing which shows whether office, home, or hospital treatment to justify fees. If any of the above proves discriminatory in special situations and information is withheld, peer review should be offered. (The IBM system demonstrates it can work.) 2. That APA adopt a position recommending its members refuse to channel any sensitive reports through employer agencies; and that reports to medical directors of insurance companies be noted, "any divulgence to other party or for other purposes will constitute a breach of the release waiver and of medical ethics." 3. That APA adopt a position that the reports for life insurance applications be obtained from examinations for that purpose and not from psychotherapists. 4. That APA adopt a position approving forms only if waiver to release information is limited for specific agent, specific purpose and time, (in place of current blanket release) with notation given in #2. 5. That APA pursue these proposals with the AMA to get their support for similar position. 6. That APA encourage Congress to write in safeguards for confidentiality as an integral part of the plan in whatever bill for national health care finally evolves. a. Some forms of coverage automatically obviate any need of information to support treatment availability. b. Confidentiality of research data will depend on the mechanism and persons controlling the information "machinery." c. "There is need to demonstrate and explain graphically the difference between its general medical model of treatment and the current model of psychiatric care in our present day status of the art." (Minutes of July 10-11 meeting). 7. That APA issue a statement supporting Senator Hughes' position on the impact of lack of confidentiality on the drug abuse program of the military (and eventually of the general civilian program). 8. That APA commend the Commission of the Federal Judiciary for retaining Code 504-Psychotherapist-Patient Privilege-BUTa. Request them to strengthen it by adding to definition of psychotherapist, "or any licensed physician treating an illness with emotional components as cause." b. Request them to consider statement of psychiatrists' needs for protecting patients while defenses are down during therapy, to include version of Illinois law that extends the privilege to the psychotherapist as well; and that law's liberalization by deleting exceptions to the privilege. 9. That APA consider the suggestions from Louisiana, and notify its District Branches that the proposed Federal Code will be acted on in November; and that they enlist support of their congessmen to enact the above changes. 10. That APA consider, in any section of its code of ethics on maintaining confidentiality, NOT to include any exception, such as in AMA Section 9, "unless required by law," since being law abiding is a major ethic in itself. Further, that the AFA discuss with the AMA the deletion of this phrase from Section 9, for reasons already given. 11. That APA undertake a sampling survey of its members to determine their attitudes on confidentiality and incidence of impairment in patients' welfare occasioned by released information or threat of such release. 12. That APA subsidize a sampling survey of the general public about their beliefs, how protected they are from physician disclosures, and whether it would affect them in any way. 13. That APA bring this problem to the attention of training centers, with the following goals in mind: a. To emphasize to medical students and psychiatric residents their responsibility for confidentiality. b. To teach them that record keeping must vary with purpose in mind, and awareness of ultimate fate of the records. 14. That APA elaborate its previously issued discussion of response to subpoenas, and issue it as a brochure with a description of the subpoena-issuance process and its implications, with specific steps to be taken at specific times. 15. That APA consider the need for "consumer" demand for such protection and explore ways of publicizing the problems. The current growing general unease about invasion of privacy of information could facilitate this. 16. That the APA trustees secure legal counsel's opinion for the Task Force about: a. Patient's blanket authority for release of information, especially in light of doctrine of enlightened consent, and substitution of limited consent form. b. Some members' use of form to be signed by patients waiving their right to permit release of, or demand for, records. c. Some members keeping no records, as way of defeating any demand for records. 17. That the trustees emphasize to all councils, committees, and task forces that some of their actions and recommendations might adversely affect the climate of confidentiality, and their recommendations should include safeguards to protect it. a. Much of our discussion relates to the province of the Committee on Psychiatry and the Law, and our minutes have been made available to them. b. Much of our discussion relates to the province of the Committee on Financing of Mental Health Care, and our minutes have been made available to them. c. Reference has been made to problems that might concern Committee on Children and Adolescents. It is recommended that relevant sections of our minutes, especially of the July 10-11, 1971 meeting be brought to their attention. d. The question of research records and confidentiality has been explored by another Task Force. Our Task Force is uncertain that reliance can be placed in ordinary governmental safeguarding of privacy. e. The impact of lack of confidentiality on treatment programs should be considered by the Committees on Alcohol and Drug Abuse. 18. And, most importantly, that the APA seek funding for a project to explore systems of safeguarding data, while accumulating the valuable detailed information that will be available in a national health care program. Further, the APA should seek ways of using this data to better understand psychiatric illness, its nature, its sources, its response to treatment. One limited goal would be to seek a system of classification that would be meaningful for etiology, prognosis, and treatment. The recognition that this will require intimate individual identifiable data makes more pressing the consideration of safeguarding this data in the initial planning stages. |