Ethical and legal dilemmas of Jerusalem treatment model for drug addiction

IntemationelJownalof Lmv and PsychMy, Vol. 13. 155-161, 1990 Printed in the U.S.A. All rights reserved.

01~2527/90$3.00 + .w Copyright Q 1990 Pergamon Press plc

Ethical and Legal Dilemmas of Jerusalem Treatment Model for Drug Addiction

Naftali Fish*, Emi Shufman**, and Yair Barel***

A crucial dimension of the Jerusalem Drug Clinic (J.D.C.) treatment model for detoxification and rehabilitation is creating conditions that facilitate develop- ment and maintenance of a positive therapeutic working relationship between therapist and drug abuser.

It has been clinically observed that the sense of being understood, accepted and valued as a person by a therapist is often a new and powerful emotional experience, that many times contributes to increased motivation by the clients to make difficult changes, such as detoxification, as well as increasing their self- confidence about their ability to accomplish such a challenging goal.

Yet, there is always an on-going tension for therapists concerning the parallel need for setting appropriate limitations, and when, why and how to apply them fairly and effectively.

A real difficulty in developing and maintaining realistic trust in the other, which is a basic element of a positive therapeutic relationship, is that both sides naturally harbor much suspicion. Therapists fear being manipulated, with their empathy being misunderstood as a sign of naivete or weakness. Drug abusers fear that the clinic is somehow “really” connected to the “other side” (police, the establishment) and that they may be risking their own freedom by publicly acknowledging use of illegal drugs, as well as other activities.

In this context confidentiality can be viewed as being an important and sensitive issue that often raises difficult legal, ethical and treatment dilemmas. This paper will discuss several areas from practice that are related to confidentiality and drug treatment, within the context of a government sponsored outpatient clinic in Israel. Issues to be explored include:

1. General overview of confidentiality in clinical practice; 2. Confidentiality and drug treatment; 3. Evaluation research and confidentiality;

*Jerusalem Center for Drug Treatment and Rehabilitation, 14 Bet-Lehem Road, Jerusalem, Israel. **Jerusalem Center for Drug Treatment and Rehabilitation, 14 Bet-Lehem Road, Jerusalem, Israel. ***Kfar Shaul Psychiatric Hospital and Chief Psychiatrist Jerusalem Catchment Area. Address Correspondence to: Dr. N. Fish, Jerusalem Center for Drug Treatment and Rehabilitation, 14 Bet-

Lehem Road, Jerusalem, Israel.

155

156 N. FISH, E. SHUFMAN, and Y. BAREL

4. Clinic and public security and confidentiality; 5. Family therapy and confidentiality

Issues Related to Confidentiality

General Overview of Confidentiality in Clinical Practice and Human Services

This section will begin with a brief overview of the concept of confidentiality in the human services in the United States and Israel, while outlining some general practice implications.

In its “Ethical Principles of Psychologists”, adopted by the American Psy- chological Association in 1981 it is stated in principle five that “Psychologists have a primary obligation to respect the confidentiality of information obtained from patients in the course of their work as psychologists. They reveal such information to others only with the consent of the person, or the person’s legal representative, except in those unusual circumstances in which not to do so would result in clear danger to the person or others. Where appropriate psychologists inform their clients of the legal limits of confidentiality.“’ Confiden- tiality has also been defined to mean that “disclosure by the patient or client to the professional will not be revealed to others except under certain circumstances and then only for the purpose of helping him.“2

Several major pieces of federal legislation have been passed in the U.S. in recent years which regulate the handling of record materials and confidential information in federally funded and administered programs. The Federal Priva- cy Act of 1974, for example, clearly requires that the consumer have access to his records, and establishes exact procedures as to how this must be done. For purposes of this paper the most important principles of these regulations are:

1.

2.

3.

the individual on whom a record is maintained has the right to find out what records are being maintained on him, and how they are used and disseminated by the agency; prohibit those records which are being used for a particular purpose in agency from being used for any other purposes without the individual’s written consent; the Agency must secure the individual’s written consent before it can release information from that person’s record to another person or agency. However there are some exceptions and situations where this written or informed consent is not required: (a) when information is being released or exchanged among employees in

the agency who must use the record to carry out their duties; (b) when information is released to another governmental agency for law

enforcement activities; (c) in emergency situations where this release is necessary to protect

health or safety of an individual; (d) where there is an appropriate court order, or when information from

“‘Ethical and Legal Issues in Counseling and Psychotherapy.” p. 179. 2“Confidentiality in Social Work.” p. 2.

DRUG ADDICTION DILEMMA 157

the record is conveyed to researchers in disguised form (emphasis author’s) so that no particular individual is identifiable.3

In Israel issues of confidentiality can be analyzed from legal and ethical dimensions.

1955 national law on treatment of Mentally Ill stipulates that physician can reveal information concerning patients only if given permission by a Court, but a physician is not exempt from answering questions from authorized personnel who are investigating a possible criminal action.4

A 1976 physician regulation from Israeli national law states that physicians and psychiatrists cannot reveal any information they have concerning illness of patient that has come to their attention.5

Ethically, Israeli standards of confidentiality stress that physicians must keep secret any information concerning a patient in their treatment, except if requested to divulge material by patient or court system.

Medical doctors also have formal responsibility for ensuring that other workers under their authority will also preserve confidentiality of patients.

It should be noted that J.D.C. is administered by a licensed psychiatrist and confidentiality within clinic falls within the category of above mentioned medical regulations.

Confidentiality and Drug Treatment

Until this point, our paper has dealt with confidentiality in general medical and human services. It will now describe some legal aspects of substance abuse treatment in U.S. and Israel.

In 1975 the United States Department of Health, Education and Welfare (H.E.W.) issued an exhaustive set of regulations under the heading “Confiden- tiality of Alcohol and Drug Abuse Records.” These regulations filled many gaps in the authorizing legislation and superseded any state or local law less protective of the confidentiality of patient records. For all practical purposes these regulations constitute the universe of legal requirements in this area. This paper will now highlight those dimensions of H.E.W. regulations most relevant to its goals. Most important is the “general rule” that prohibits the disclosure of the records of any patient that are maintained in connection with the performance of any alcohol or drug abuse treatment function supported or licensed by the federal government. Regulations also include some situations where disclosure of information is permitted with patient’s consent, and several situations where disclosure can be made without patient consent. These situations are: (1) in event of medical emergency; (2) for purposes of research or governmental audit; (3) response to court order; (4) in situations of threatened crime.‘j

It is relevant for the paper’s goals that while disclosure without consent as possible for research purposes, there are certain safeguards. Most importantly,

xlbid, p. 2. 4lsraeli National Law on Treatment on Mentally 111, 1955, Paragraph 28 slsraeli National Physician Regulations, 1976, Paragraph 36. 6Federal Register, Part II.


the regulations restrict the conduct of researchers who receive such disclosures. They are “strictly forbidden from redisclosing any patient identifying information.“’ It does seem paradoxical however that researchers can gain access to patient’s identity, when most regulations seek to protect patient’s identity, a goal that is a generally “not” protected by physician-patient privileges, where focus is on protected information that physicians must acquire in order to obtain treatment for patients.

In Israel there are no specific regulations concerning drug treatment beyond general confidentiality guidelines briefly enumerated previously. This may be due in part that only in past decade has drug usage become recognized in Israel as a social phenomenon and problem.

Evaluation Research and Confidentiality

This section will delineate some of the presumed “benefits” against possible “risks” of drug treatment agency participating in evaluation research projects.

It is clearly of crucial importance that drug treatment clinics develop some scientifically based methodology for assessing treatment process and outcomes. In Israel, as in other countries, this is particularly relevant because of lack of reliable data measuring effectiveness of existing treatment, and where competi- tion and professional conflicts concerning preferred approaches are often basi- cally battled out on an ideological, political level, rather than on basis of empirical findings.

One such area, for example, is ongoing heated debate over the desirability of Methadone versus drug free clinic models, such as the Jerusalem Drug Clinic, which is an outpatient unit associated with Kfar Shaul Psychiatric Hospital, a governmental institution connected to the Ministry of Health. In the J.D.C. model method of detoxication is a combination of psychosocial therapy plus limited administration of medication such as clonidines*9~10~1’ during physical detoxification stage, and as antidepressant for the next month or so. However, the J.D.C. model views physical detoxification as being just the first stage of broader psychosocial goals such as crime prevention, family and social functioning and work. Thus, it is important to be able to judge client functioning on these dimensions. Ideally this involves some baseline or even “before treatment” data or picture which then allows for comparison of during as well as after treatment functioning.

As crime is often an almost integral part of a drug addict’s “life style” (if not character) it would be relevant to document empirically any changes, hopefully positive in direction, in this area, that can be shown to be correlated to treatment experience. In order to meet this goal it was recommended to the J.D.C. by an outside recognized evaluation researcher that the agency seek to gain access to official police records concerning crimes committed by J.D.C. clients

‘Federal Register, Part II. s”Clonidine Blocks Acute Opiate Withdrawal Symptoms.“, p. 599. Y‘Clonidine in Acute Opiate Withdrawal.“, p. 1421. lo“Tolerance of Locus Coeruleus Neurons to Morphine and Suppression of Withdrawal Response by

Clonidine.“, p. 186. II”Clonidine in Outpatient Detoxification from Methadone Maintenance.“, p. 392.


before they began treatment. Heated staff debate ensued concerning the confidentiality that has also been promised to clients during the intake stage of treatment. Especially sensitive was the possibility of identifying information about the patient being sent to the police, and acknowledging that he was using drugs, without patient’s consent. This was despite the evaluation researcher’s affirmation that a procedure could be devised that would minimize the possibility of police using this information. While such a procedure does seem possible legally according to H.E.W. regulations it seems to present possible negative implications upon the clinical dimensions of treatment, where as mentioned, earlier fragile trust between client and therapist/agents can be damaged so easily. In the author’s viewpoint there is a clear danger of “throwing out the baby with the bath water”. That is, while evaluation research under certain conditions is important, it is not a greater priority than creating and maintaining those treatment conditions where a target population will feel maximally able to utilize service that is supposed to be for their, as well as ultimately the public’s benefit. The meaning a client attributes to policy should be taken into account to prevent self defeating reactions.

A more complicated, as yet unresolved issue which also involves confidentiality has arisen recently concerning whether the clinic which is part of and funded by the National Ministry of Health is obligated if requested by appropriate Ministry officials to supply identifying data concerning clients currently in clinic treatment. It is still not clear concerning the purpose of obtaining such information from a new computerized system. Fears that such data could be passed on to other governmental agencies, to clients possible detriment, again raise dilemmas of confidentiality.

Dilemma between Need for Security and Confidentiality

A recommendation was made to enlist policemen to work at the clinic as a deterrent to client acting out and violence, after several such incidents had occurred. This creates a dilemma between real need for security (for clients as well as workers) and fears of those clients who are not delinquent or violent that coming to clinic might lead to police harassment, arrest, or at the very least awareness of their use of drugs, an illegal activity.

Historically there has been informal agreement between local police and clinic that the latter is a “refuge” for drug users (i.e. police do not keep record of who is in treatment in any way), partly because police also recognize the need for the community to offer an official framework for addicts to detox and begin rehabilitation. In the end it was decided by the J.D.C. that the symbolic meaning for most clients of policemen being in the clinic would destroy the “sanctu- ary” like boundary that had been established and would discourage clients from seeking treatment. Staff did discuss other strategies of preventing or reacting to threatened or actual violence, and decided to accept the “risk” of working in a situation without police.

Another dilemma arose after an actual violent incident in clinic where one angry client caused damage to property. The dilemma here was whether the clinic should bring charges to police, and if so, whose responsibility it was to do so, i.e. the client’s therapist who witnessed act, or the clinic administration?


It should also be pointed out that in Israel there is no legal precedent currently such as the Tarasoff decision12vL3 of the California Supreme Court concerning clients in treatment who threaten violence against others while in session, and the legal responsibility of a therapist to report such material. The Tarasoff decision, which had ramifications on other states vividly raises tension concerning the limits of confidentiality, and the dilemma of uncertainty of predicting seriousness of a client’s threats. The psychiatrist’s role as social control agent is also affirmed. In Israel such situations are sometimes handled quietly through offices of a psychiatrist who has mandated authority in some specific geo- graphical area. Sound clinical judgment must be used, which involves the need for supervision or consultation, especially in dealing with the drug population in Israel who often respond with verbal threats when angry or frustrated.

Confidentiality and Family Therapy

In this section the paper will finally raise the dilemmas related to confidentiality within an actual treatment context. Professional literature as well as experience show that it is often constructive to have a drug user’s family involved actively in the treatment contract and process. It is necessary, for example, to attempt to understand the patient’s role in the family, and how this may have contributed to his/her drug problem. Dilemmas arise when during course of treatment it becomes known to a therapist by results of urine exam that the client is still using drugs, usually after he had stopped for some period. In cases where family is involved (parents, wife, etc.), should a therapist reveal this information, and for what rationale? How does a therapist react to pressure from family to know results of urine examination, when he has decided not to reveal actual results? What are treatment and ethical justifications for “protecting” drug client in this situation?

Conclusion

This paper has raised and analyzed some of the dilemmas relating to confidentiality that arise in drug treatment. Specific cases derived from actual practice at the Jerusalem Drug Clinic Model, Jerusalem, Israel were used as illustra- tions. At the core of dilemma is the conflict between a clinic in its role of providing treatment to drug addicts versus its concurrent responsibility to respond to the larger society’s needs and rights. It is indeed a challenge that almost requires the wisdom of a proverbial King Solomon to achieve a proper and fair balance of interests.

References

Aghajanian, G. K. (1978). Tolerance of Locus Coeruleus neurons to morphine and suppression of withdrawal

response by clonidine. Nature, 276, 186.

Applebaum, P. (1981). Tarasoff: An update on duty to warn. Hospital and Community Psychiatry, 32, 14- 15.

12“Tarasoff: Protective Privilege versus Public Peril.” p. 289.

I3“Tarasoff: An Update on the Duty to Warn.” p. 14.


Federal Register, 27802, July, 1975. Gold, M. S. (1978). Clonidine blocks acute opiate withdrawal symptoms. Lancer, II, 599-601. Gold, M. S., Pottash, A., Extein, I., Kleber, H. D. (1980). Clonidine in acute opiate withdrawal. New

England Journal of Medicine, 302, 1421-1422. Gurevitz, H. (1977). Tarasoff: Protective privilege versus public peril. American Journal of Psychiatry, 134,

289-292. Gurman, A. (1981). Handbook ofFamily Therapy. New York, BrunnerIMazel. Hofling, C. (1981). Law and Ethics in Practice ofPsychiatry. New York, Bruner. Israeli National Law of Treatment of Mentally III. (1955). Paragraph 28. Israeli Regulation for Physicians. (1976). Paragraph 36. Kleber, H. D. (1985). Clonidine in outpatient detoxification from methadone maintenance. Archive Genera/

Psychiatry, 42, 391-394. Lidz, C. (1984). Informed consent: A study of decision making in psychiatry. New York, Guildford Press. Mills, M. J. (1987). Protecting third parties: A decade after Tarasoff. American Journal of Psychiatry, 144,

68-74. Rosenbaum, M. (1982). Ethics and values in psychotherapy. New York, Free Press. Reamer, F. (1982). Ethical dilemmas in social work practice. New York, Columbia University Press. Schuerman, J. (1983). Research and evaluation in human services. New York, Free Press. Seba, L. (1988). Rehabilitation aspunishment: The treatment of drug addict offenders. Jerusalem, Hamacabi

Press.

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Ethical and legal dilemmas of Jerusalem treatment model for drug addiction