Confidentiality and boundaries are stringent when working with chemical-dependency clients and especially when working with HIV, AIDS and hepatitis patients. All the regular confidentiality issues exist (turning over charts and program cards to hide names, obscuring anything with a client's name, locking file cabinets when not in the clinic, not talking about clients/patients in hallways or other areas where you can be overheard, etc).
The hardest rule to follow is when you run into a client/patient outside the hospital. Confidentiality regulations require you to ignore that person unless they acknowledge you first. They may not want their status known or to have to explain how it is we know each other. This applies not only to patients/clients you are presently working with but any past patients/clients as well. This can get a little tricky at times.
We once had a new chemical-dependency client, "Bonnie" who opted for acupuncture. Bonnie made no apologies for her past but knew she had to change it. To support her habit, she did strong-arm robberies. As she calmly explained to me, she would walk up to people on the street, shove a gun in their face and demand money, wallets, purses, watches or drugs (if they had them). She also did burglaries. She did jail time too. There were two ways to get enough money to keep using: prostitution or "boosting," according to Bonnie. As she so succinctly put it, she wasn't "nobody's bitch."
Bonnie started acupuncture her first day. She had a good experience and reported she would definitely be back for more tomorrow, maybe even the rest of her stay with the program. She wasn't the first macha (means about the same as macho) woman I had met in the program, but she was one of the most impressive.
After work that same day, I had to do some errands and grocery shopping, so it was late in the day when I stopped to wait for traffic to make the left turn onto our street. Out of the corner of my eye, while watching traffic, I saw a woman sitting on the city garbage can by the bus stop at our corner. As I made the turn, I recognized Bonnie. She and I made eye contact but you could not say she acknowledged my existence. I thought, "I do not want Bonnie knowing where my family and I live." When people slip, they fall back on old skills. I considered driving up the street out of sight and waiting for her to catch the bus but, reconsidered, thinking she probably lived somewhere in the neighborhood and would again be at the bus stop. I pulled into my driveway, three houses up. When I got out of my truck, we made eye contact again. I walked down to the corner, hoping she would acknowledge me so we could talk, when she smiled and said, "You live in this neighborhood?"
Clients/patients are always surprised to see me outside the hospital in their environment. They think because I have letters after my name that I must live in a big house. I make less money than a registered nurse but much more than I ever made in any of the unskilled working-class jobs I had before the "letters after my name." Once in a crowded movie theater, a former client saw me and yelled out, "Hey, Needle Man, what are you doing here?" He always called me that; it was sort of a joke between us. Given that the theater was in his neighborhood, we got some interesting stares.
The gist of the conversation with Bonnie was that until she could get her own place, she was staying one block over with her cousin who did not abuse drugs or alcohol. She had no money, no job, no place else to live and, she assured me, without my asking, no gun. I had to laugh at that, I didn't know if I believed her or not but it is easy to get a gun when you know the right people. We exchanged a few more pleasantries, I said I would see her tomorrow for treatment and went home to start dinner. Bonnie made it about two months in the program and then moved to another part of the country to be with another part of her family and away from the many temptations here in Oakland. I never saw her again at the bus stop after our encounter and do not know what happened to her after she left the program.
"Jerome" offered a different challenge to confidentiality. Jerome has attempted the program six times over the last 10 years, the most recent and shortest experience just a few months ago. Before the end of the first week, he was "missing in action" (a euphemism for returning to drug usage). He is a polysubstance user, but his drug of choice is heroin. He tries but usually gets himself involved with an abusive lover who is not interested in getting clean and Jerome just gives in. This last time, he needed to prove to a judge that he was in a program. Once that was done, he knew he had a few weeks or even months before paperwork caught up with him and a warrant was issued. A period of getting high before the inevitable: jail or, if lucky, another chance at a program.
The confidentiality issue with Jerome is that he panhandles in a business district of Oakland that my family and I frequent. When we see each other, he barely makes eye contact and with a completely impassive expression, politely asks, "Excuse me mister, do you have any spare change." I politely try to make eye contact and usually give him a dollar in hopes that he might actually buy himself some food.
One of the times he was actually trying; going to a methadone clinic early in the morning before coming to the program for groups, counseling and acupuncture, he left me a little "gift" after a treatment. As he was leaving the acupuncture clinic to go to a group I noticed a paper bag in the chair. "Jerome, you forgot something," I said. He stammered a bit and said, "Maybe you could throw that away for me." I don't consider it my job to clean up after clients and I told him so. He stammered some more and just said, "Please" in such a way that I went to get the bag, as he darted out the door. Opening the bag, I saw a few syringes and a lighter. It was his "works." I put it in the "sharps" container. It is tough for an IV drug user to get rid of their works. About a week later, he was gone from the program. A few months later, he once again politely asked for spare change and I politely gave him a dollar. As much as I wanted to engage him and try to get him back into the program, unless he acknowledged me first, all I could do was, well, nothing.
As hard as the stuff with Jerome was, "Steve" was the worst. He was bipolar, HIV-positive and addicted to crack. He was a difficult person to work with; emotionally labile and had thought patterns that often would lead to fits of irrational anger. He was a little paranoid as well. The biggest problem with Steve was that he viewed the program as his personal dating service and was always trying to "find a girlfriend." Sexual relationships between clients while in the program are against the rules. However, if our clients followed the "rules," they would do better in the program, and I would be out of a job.
He didn't like using a condom and didn't see any reason why he had to tell a sexual partner who didn't ask about being HIV positive. His rational was that he didn't ask them their status. The laws mandated that his status was confidential, under penalty of loss of job and possible lawsuit. After his second "girlfriend," someone we didn't know who leaked his info to one woman client, of course it spread like wild fire. Steve threatened to come back with a gun and "fix" us all, and then we didn't see him for about 18 months.
He didn't make it through the program that time either. His reputation had preceded him, so the "girlfriend" issue was moot. He lasted about a month and dropped out again. About a year later, I heard he had died. Another year after that, he walked in and laughed at the rumor that he had died. He gave getting clean a half-hearted try, but we have not heard from him since. It has been many years now, but I asked one of his old counselors before writing this piece. He is still alive.
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