Commentary: Peeling the Layers of Confidentiality in Addiction Treatment

As addiction treatment providers become integrated into the larger health care system as part of health care reform, it will become especially important for addiction professionals to understand issues of patient confidentiality in this new environment.

The Patient Protection and Affordable Care Act (the health care legislation signed into law in March 2010, known as ACA) is centered on the idea that the client/patient controls his or her own health care. So the question becomes, what does the client/patient want to follow them in their records that move from substance abuse treatment to primary care and potentially to mental health care?

The foundational piece of the client/patient record is their diagnosis or diagnostic impression. The client/patient will want to be assured that the “least restrictive” diagnosis is applied to their specific condition. This has not always been the practice in some treatment centers that use a “one size fits all” diagnosis and treatment planning. In some treatment centers, the intake, screening and evaluation process is performed by new or inexperienced interns and addiction professionals due to the economics of the facility and treatment budgets. With more complex clients/patients (co-occurring and co-morbid disorders), it is even more important that the professional performing the screening and evaluation process is seasoned and trained in addictive and co-occurring disorders and is knowledgeable in performing a mental health status.

To measure the performance of individual clinicians in following confidentiality procedures, clinical supervision will need to be enhanced and more available. Currently, there is little to no reimbursement for clinical supervision and therefore, it is a low priority for many treatment programs. Ongoing supervision through case studies, multi-disciplinary team reviews, documentation reviews and training will need to be expanded in most treatment systems in order to meet this need and reduce the risk of malpractice lawsuits.

The ACA expands treatment to family members. For years, addiction providers emphasized how important family treatment is to the whole family system. However, few programs have been able to implement consistent and integrated family programs. While integrating families will improve outcomes, the expected growth of family treatment will push up against confidentiality boundaries. Issues of how and what to share of the primary client/patient’s progress, along with how much to share from the family members to the primary client/patient, need to be resolved. Training in ethics and confidentiality will become a higher priority to reduce perceived trust issues and potential malpractice claims.

Due to integration of primary care with addictive disorders and mental health, more use of QSOAs, or Qualified Service Organizational Agreements, will be helpful. A qualified service organization (QSO)  is a person or organization that works with an addiction service provider, either in providing services or in storing records. Clear examples of different types of QSOAs and individual/family releases of confidentiality will be helpful to all systems of providers. Cross training of records management will also be necessary for the addiction professional who has not worked in a primary care setting that includes documentation in that particular system. Understanding what should go into a medical chart and what should not will be important for the addiction professional to know.

Preventing relapse is another issue that will present challenges in the new health care environment. Addiction professionals know that a relapse can be used to promote the recovery process and not used in a punitive fashion by sending the patient/client to jail or removal of children from the home or other such penalties. We will have to figure out the best way to mitigate relapse with appropriate documentation, releases of information and treatment plan review in the child welfare and legal systems.

In the professional worlds of the primary care, mental health and addictive disorder, I believe that “no malice intended” is one part of a code we all live. However, as we transition to this new environment, there will be some trial and error that will result in negative experiences. We must work together to discuss how to protect the people who have been entrusted to our care, and their families. Building trust through communication and release of information systems will enhance client/patient protection and build stronger relationships among the health care and helping professionals.

For more information, visit the NAADAC website. Also posted on our website are the Substance Abuse and Mental Health Services Administration’s (SAMHSA) FAQs regarding confidentiality.

Cynthia Moreno Tuohy serves as the Executive Director of NAADAC, the Association of Addiction Professionals. To contact her directly on this or any other issue, email her at

8 Responses to Commentary: Peeling the Layers of Confidentiality in Addiction Treatment

  1. Jennifer Bolen, JD | November 29, 2011 at 2:23 pm

    I would like to complement Ms. Tuohy on her excellent article! There is a disconnect between diagnosis coding for reimbursement and coding based on the realities of the patient presenting with multiple clinical disorders, including addiction and mental health challenges. As a compliance professional in the pain management community, I see this a great deal and it’s the labeling of the patient without a thought toward the privacy and other consequences that contribute to licensing board and other legal challenges for doctors and employment and other consequences for patients. Thank you again! Jen Bolen, JD

  2. perryrants | November 29, 2011 at 4:18 pm

    least restrictive” diagnosis? huh?

    bipolar would be: clown like – happy and sad at the same time.

  3. James Sorensen, Ph.D. | November 29, 2011 at 7:09 pm

    This is an excellent and useful article. I think that substance abuse providers need help with understanding when their records fall within the substance abuse confidentiality regulations and when they are considered simply medical records, with fewer “layers of confidentiality. Thanks for drawing attention to these important issues.

  4. meltee | November 30, 2011 at 1:58 pm

    I hope I am misinterpreting her meaning, but it seems “The client/patient will want to be assured that the “least restrictive” diagnosis is applied to their specific condition.” means she is encouraging diagnosticians to factor in the social stigma that might possibly be attached to a diagnosis rather than its utility to other health care providers who may need to deal with the patient’s condition. How does putting a happy face on a diagnosis advance therapy?

  5. notwhatyouthink | December 2, 2011 at 1:40 pm

    I believe in confidentiality, and my wish is we find a reasonable manner in which we protect our client rights and confidentiality. My fear is this will end up meaning more regulation, another five forms to fill out, another auditing agency, more hoops to jump through, and less time to actually spend with the clients because of paperwork, procedures, policies, and regulation that just become mindless obligations. These types’ conditions have become so prevalent and so burdening on mental heath worker that it interferes and interrupts our ability to work with the very clients it is intended to help.

  6. MJB | December 2, 2011 at 8:36 pm

    This article encapsulates almost all of the problems that I am experiencing at the outpatient substance clinic where I work. From major breaches in confidentiality by front office staff to clinicians feeling that it is not necessary to have clients sign certain consent forms, as well as doing sloppy, haphazard and possibly illegal charting to not having a clincial supervisor or director for months to a choking amount of paperwork that has caused us to reduce the amount of time spent with clients to the minimal standards according to the OASAS regs to losing charts due to disorganization as a result of lack of staff and time to having an electronic charting system that has so many glitches that we can barely use it to…my goodness! It’s no wonder I am wiped out come Friday night!
    We need help and fast. Thank you, Ms. Tuohy for pointing out what is the tip of the iceberg when it comes to the major problems we are facing in the upcoming months before substance and mental health treatment merge.

  7. Kevin Murphy | December 3, 2011 at 11:09 am

    Excellent article. You captured some of the major challenges facing addictions treatment. Public perception of need for treatment is so high, but so many do not realize the important issues facing the field. Effective treatment cost money and resources and so many think it can be free. Professionalism has costs that many refuse to pay or don’t understand the need for a professional in the first place.
    The need for a muti focused family approach and the changing structure of confidentiality are huge challenges.

  8. Cynthia Moreno Tuohy | December 6, 2011 at 9:58 am

    The term “least restrictive” is applied to the diagnosis that we label a client/patient after completing a full intake/screening assessment and evaluation. There are times in a diagnostic assessment that even with evidenced based screening tools and comprehensive screening, the final diagnosis may not be clear, there are situations where the line between addiction and abuse, especially with adolsecents or co- occurring patients/clients. In these situations, it is more efficious to the patient/client to use the lesser diagnosis – that is to say, abuse rather than addiction. Labeling a person an “addict” or “dependent” without full confidence in the diagnosis adds distrust by the individual and the general public to our competence of the clinician. In the situations in the addictions profession there was a thought that “any treatment was better than no treatment and 28 days was the ticket to any degree of alcohol / drug issues.” Today, we know this is not so. It is actually harmful. The patient/client receives this impression only to later learn it is false.

    If we under diagnose, it is likely the patient/client will be back to us or another professional realizing that they most likely did not give all the information to make a clear diagnosis of “dependence,” not a negative reflection of the professional or the system. May be more of an indication of pre-complation of the symptoms that evidence the diagnosis of “dependence.”

    Again, this points to competent and consistent clinical supervision, especially in cases that are more complex with multilevels of needs and possible diagnosis. Multi-disciplinary team case consultations are especially revelent and helpful to fully review the case history, screening tools, client responses to screening questions and the history of the client and his or her family system.

    Therefore – when in doubt; time will tell the story as more information is collected.

    I appreciate all the comments and feedback on this article. It is clear there is more need for awareness, conversation and education as we grow through the new world of integrated care. Thank you. Cynthia

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