Integrated Behavioral Health: Ethical Considerations Frederic G. Reamer, Ph.D. Professor School of Social Work Rhode Island College

Illustrative Scenarios 32-year-old patient presents with symptoms of bipolar disorder and anxiety. Psychiatrist prescribes psychotropic medication and refers to clinical social worker for counseling. Patient discloses to social worker that he is struggling with sexual orientation issues. Patient consents to disclosure of this information to psychiatrist but not to primary care physician. 15-year-old patient who struggles with clinical depression discloses to social worker at health clinic that he fears he is addicted to synthetic marijuana. The agency has a federal grant to provide state-of-the-art treatment to high-risk adolescents diagnosed with co-occurring disorders. The patient is willing to enroll in the program but refuses to consent to disclosure to his parents. 43-year-old patient who struggles with sickle cell disease served 2.5 years of prison sentence at ACI, where he was treated for chronic depression. Patient paroled and seeks medical care at neighborhood health clinic, where he had been a patient prior to incarceration.

Permitted and Required Disclosures Legal considerations Federal and state statutes (for example, HIPAA, FERPA, RI statutes 5-37.3, 14-5-3, and 23-6.3) Federal and state regulations (for example, 42 CFR Part 2, Veterans Administration, RI licensing regulations) Ethical considerations Medicine: file:///home/chronos/u- baee9c0517ff7c8a58f1762abfc69a13d1d74b60/Downloads/code-2016- ch3%20(1).pdf [Chapter 3]  Nursing: http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for- Nurses.html [section 3.1]  Social Work: https://www.socialworkers.org/pubs/code/code.asp [section 1.07]  Mental Health Counseling: https://www.counseling.org/resources/aca-code-of- ethics.pdf [section B]  Addictions: http://www.naadac.org/code-of-ethics#iii [section III] 

Key Ethical Issues Informed consent (considering evidence of voluntariness and capacity to consent based on age, cognitive status, literacy) Privacy (respecting patients' privacy rights and control over release of sensitive information) Confidentiality (managing protection and release of protected health information) Privileged communication (managing protected health information in conjunction with legal proceedings, e.g., custody, divorce, criminal, workers' compensation, termination of parental rights)

Key Ethics Concepts Regarding Disclosure Duty to disclose  Privilege to disclose  Varying state laws: http://www.ncsl.org/research/health/mental-health- professionals-duty-to-warn.aspx Need to know/disclose: The extent to which a colleague needs to know the information in order for the recipient to perform her/his professional duty, consistent with prevailing laws and ethical standards (adhering to standards of care regarding meeting patients' needs and protecting third parties from harm).

Sample Guidelines and Protocols Bazelon Center for Mental Health Law: http://www.bazelon.org/LinkClick.aspx?fileticket=R9fUUiBzuS4%3d&t abid=320 SAMHSA-HRSA Center for Integrated Health Solutions: http://www.integration.samhsa.gov/operations- administration/confidentiality Washtenaw Community Health Organization (Michigan): http://www.integration.samhsa.gov/operations- administration/Integrated_Behavioral_Health_and_Primary_Care_Co nfidentiality_Policy.pdf