Confidentiality Issues with Illegal Substance Abuse Patients

The mental health profession has been intertwined with ethical issues from its inception. The ability to help people resolve or overcome their mental trials and tribulations has placed great responsibility on the mental health professional; a responsibility that should never be taken lightly or too cavalierly. Like many other professions the mental health professional can stand to do more harm than good if they do not follow closely to a guide of ethics. The leading governing body for psychologists is the American Psychological Association or APA. Around the time of World War II the APA decided that having a set framework of ethical guidelines was necessary (Hobbs, 1984, as cited by Fisher, 2003). For the past 50 years, the APA has been using sound scientific techniques to develop and revise the code (Fisher, 2003). This development and revision practice is conducted by surveying practicing psychologists in the field, getting their concerns about the ethical climate, researching those claims, and finally developing a set of rules that pertain to the most pressing of those issues (Fisher, 2003). Critical portions of the APA ethics code are the sections that deal with confidentiality and privacy.

Confidentiality composes the cornerstone of every client/professional's relationship. Professionals of all walks of life protect this bond even when threatened with jail time and hefty fines. The governing document that is to be followed by all psychologists and therapist is the Ethical Principles of Psychologists and Code of Conduct (2002 version). This is a guidelines developed and revised over the years as to how psychologists should conduct themselves professionally. Section 4 of this document outlines the psychologist's responsibilities with respect to confidentiality. Section 4 states that "psychologists have a primary obligation...to protect confidential information..." (as cited by Fisher, 2003, p.254, ¶ 7). The ethics code goes on to instruct psychologists as to the procedures for protecting the confidential information, who is privy to said information, how confidential information may be recorded and stored, the disclosure process, consultations, and using confidential information for other purposes (as cited by Fisher, 2003). These guidelines are in accordance with federal and state laws and do not in any way supersede those laws (Fischer, 2003). The issue then arises as to how a psychologist would handle the confidentiality of a patient that may or may not be at risk of harming themselves or the general public.

According to section 1.02 of the Ethical Principles for Psychologists and Code of Contact (2002), a psychologist may reveal confidential information if it is required by law, regulations, or other governing body without violating the code (as cited by Fisher, 2003). Is this the same, however, under state regulations? The researcher of this paper currently lives in Texas and subsequently he investigated those regulations for his current place of residence.

Texas has many different governing bodies that regulate the various psychological and health services available. The most likely code that would handle the regulation and supervision of steroid abuse would be the Texas Health and Safety Code. With respect to confidentiality, the Health and Safety code states:

"CONFIDENTIALITY REQUIREMENTS.

(a) All records, reports, and testimony relating to the medical condition

of an applicant or license holder:

(1) are for the confidential use of the medical

advisory board, a panel, or the Department of Public Safety of the

State of Texas;

(2) are privileged information; and

(3) may not be disclosed to any person or used as

evidence in a trial except as provided by Subsection (b).

(b) In a subsequent proceeding under Subchapter N, Chapter

521, Transportation Code, the medical standards division may

provide a copy of the report of the medical advisory board or panel

and a medical record or report relating to an applicant or license

holder to:

(1) the Department of Public Safety of the State of

Texas;

(2) the applicant or license holder; and

(3) the officer who presides at the hearing.

Added by Acts 1995, 74th Leg., ch. 165, § 9, eff. Sept. 1, 1995. " (Section 12.097, Texas Health & Safety Code). It is apparent that the state statues are in line with the guidelines set forth by the American Psychological Association's code of conduct. This demonstrates that Texas agrees with the policies set forth by the APA and those psychologists in that state shall be held accountable to the code as well. The use of anabolic steroids can be seen in a wide variety of subsets of the general population including but not exclusive to athletes, young adults, bodybuilders, and even adolescents (Trenton & Currier, 2005). The excessive use of steroids has been linked to a variety of physical and psychological issues. Some maladaptive psychological issues include violence, aggression, mania, and in some cases suicide (Trenton & Currier, 2005). Unfortunately, the wide spread use of illegal steroids goes mostly underreported (Gonzalez, McLachlan, & Keaney, 2001).

What are anabolic steroids? Anabolic steroids are a broad group of chemicals that are variations of testosterone (Gonzalez, McLachlan, & Keaney, 2001). These chemicals are used by athletes to push the body beyond its normal physical limitations. How do anabolic steroids accomplish this function? Simply stated, the use of anabolic steroids allows an athlete to increase muscle mass and at the same time reduce energy expenditure by increasing protein production and reducing the catabolic effect (2001). It has been reported as early as the 1950's that steroids have been employed by athletes trying to gain that extra physical advantage (2001). Subsequently many international athletic governing bodies have banned the used of performance enhancing drugs like anabolic steroids (2001). So how perverse is the problem of anabolic steroid use?

One study conducted in the United States concluded that the use of anabolic steroids had steadily increased between 1992 and 2002 in adolescents (Johnston, O'Malley, Bachman, & Schulenberg, 2004). The study looked at self-reported steroid use by high school seniors and found that 6.2% of those that participated in the study acknowledged that they used anabolic steroids (2004). Another study cited that over one million people living in the United States claimed to be current or former users of steroids in 1991 (Trenton & Currier, 2005). Three major surveys conducted in the 1990's concluded that steroid use among high school aged individuals ranged from 1.9% to 2.2% (2005). Unfortunately these numbers have failed to change as of late.

Data from reports conducted in 2002 and 2004 still showed high school steroid use at 1.8% to 3.8% for males and 1.2% to 1.3% for females (2005). The data depicts a slow but steady increase in steroid use among high school students living in the United States of America (2005). The use of steroids is not only an American problem but a worldwide issue as well. One particular study in Sweden also reported anabolic steroid use among 16 and 17 years old as well, 3.6% and 2.8% respectively (Nilsson, Baigi, Marklund, & Frindlund, 2001). Similar results to the American and Sweden studies have been found all over the globe including in South Africa, England, France, Canada, and Australia (Maycock & Howat, 2005).

Steroid use and abuse comes at a high price to the individual taking a heavy toll both physically and psychologically. Steroid use prolonged and even short term can result in a variety of physical concerns including an enlargement of the breasts in men, transient infertility, testicular atrophy, tendon damage, skin irritations, acne, excessive facial and body hair growth, edema, jaundice, a change in sexual urge, and the potential for contracting diseases, like HIV or Hepatitis, due to the sharing of needles (Maycock and Howat, 2005). The prolonged use of anabolic steroids has also been linked to various chronic health issues such as liver disease, cerebral hemorrhages, cardiovascular disease, and in some cases sterility (2005). Psychological issues may include depression, mood swings and disorders, thoughts of suicide, violence and aggression, mania, and dependency (2005).

Unfortunately even with the knowledge of the destructive nature that anabolic steroids have on the human body, many users disregard and devalue the negative effects and continue long term use (Hildebrandt, Langenbucher, Carr, Sanjuan, & Park, 2006). The Hildebrandt studied recruited 500 male self-reported steroid users over the age 18 via the Internet with a mean age of 29.3 years, and whom described themselves as bodybuilders or recreational weigh lifters mainly (2006). The study concluded that long term use of anabolic steroids is a distinct possibility do the devaluation of the negative side effects and the use of additional drugs to control many of those side effects (2006).

This paper has outlined several of the physical and psychological risk components for individuals that engage in the use of anabolic steroids. It has also demonstrated that even when faced with the serious health concerns linked to steroid use, many individuals still continue to use and abuse the drug (Hildebrandt, Langerbucher, Carr, Sanjuan, & Park, 2006). Research findings have demonstrated that anabolic steroid use has been linked to a variety of health concerns such as water retention (mild to severe), breast development in men, tendon damage, chronic liver disease, excessive body and facial hair growth, bouts of infertility, sterility, depression, suicidal thoughts, and even burst of violence and aggression (more commonly known as "roid rage") (Maycock & Howat, 2005). This paper also revealed that the use of anabolic steroids was not solely a bodybuilder problem or even an adult problem.

The Trenton and Currier (2005) study concluded that steroid use has been slowly increasing since the 1990's and that usage rates among high school students had increased as well to as high as 3.8% in 2004. In conclusion this paper has clearly demonstrated that the problem of anabolic steroid use is a cross gender and cross societal issue. The problem is common among men and women, adults and adolescents, and serious and recreational athletes (2005). The issue natural begs to ask the question as to what is the ethical consideration of a professional or therapist that is treating a client for substance abuse. The Ethics Principles of Psychologists and Code of Conduct specifies that specifies that the professional or psychologist must take all reasonable steps to protect and maintain the confidentiality of the information discussed during the therapeutic process (Fisher, 2003). The question then becomes how far should a psychologist go to adhere to these principles if they sense risk to the individual or the general public? All of the research and debate leads to ultimately one great question, where do we go from here?

Unfortunately there is not much in the way of research on the ethical dilemmas that psychologists face with regards to impressions that get from patients. The leading guidelines developed and supported by the American Psychological Association do not instruct psychologists how to act when they have inklings as to potential trouble with a client. The limits of confidentiality prohibit a psychologist from bringing a complaint or even raising concerns without concrete proof. So how does a psychologist prove that an individual is a likely candidate of "roid rage"? Until this question can be answered, psychologist can do nothing more than monitor the situation and hope their treatment modalities prevent and serious harm from occurring to either the patient and/or the general public.

It is clear that additional revisions and supplementations need to be made to the APA's Ethics Code for Psychologists and Code of Conduct. This paper has exposed a grey area with regards to what to do with the potential of harm to patients and the general public. Better test measures need to be developed along with a better understanding of the behaviors and potential behaviors associated with substance abuse. It would appear that steroid use among athletes of all levels is not going away any time soon. It would be prudent for psychologist to focus more attention on this issue so as to better help and prepare the next generation from the pitfalls of this all too readily available drug.

Fisher, C.B., (2003). Decoding the ethics code: A practical guide for psychologists. Sage Publications, Inc. Thousand Oaks, California.

Gonzalez, A., McLachlan, S., & Keaney, F. (2001). Anabolic steroid misuses: How much should we know? International Journal of Psychiatry in Clinical Practice, 5(3), 159-167. Retrieved on July 4, 2007 from Academic Search Premier.

Hildebrandt, T., Langenbucher, J., Carr, S., Sanjaun, P., & Park, S. (2006). Predicting intentions for long term anabolic-androgenic steroid use among men: A covariance structure model. Psychology of Addictive Behaviors, 20(3), 234-240. Retrieved on July 6, 2007 from PsycARTICLES.

Johnston, L.D., O'Malley, P.M., Bachman, J.G., & Schulenberg, J.E. (2004). Monitoring the future: National survey results on drug use, 1975-2003. Volume I: Secondary school students (NIH Publication No. 04-5507). Bethesda, MD: National Institute on Drug Abuse.

Maycock, B. and Howat, P. (2005). The barriers to illegal anabolic steroid use. Drugs: education, prevention, and policy, 12(4), 317-325. Retrieved on July 4, 2007 from Academic Search Premier.

Nilsson, S., Baigi, A., Marklund, B., & Fridlund, B. (2001). The prevalence of the use of androgenic anabolic steroids by adolescents in a county of Sweden. European Journal of Public Health, 11, 195-197. Retrieved on July 4, 2007 from Academic Search Premier.

Texas Health and Safety Code (1995). Retrieved on July 10^th from http://tlo2.tlc.state.tx.us/statutes/hs.toc.htm.

Trenton, A.J. & Currier, G.W. (2005). Behavioural manifestations of anabolic steroid use. CNS Drugs, 19(7), 571-595. Retrieved on July 4, 2007 from Academic Search Premier.