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Snyder, Gerald; And OthersPreventing Alcohol Problems Through a StudentAssistance Program: A Manual for Implementation Basedon the Westchester County, New York Model.National Inst. on Alcohol Abuse and Alcoholism(DHHS), Rockville, Md.DHHS-ADM-84-13448498p.; Portions contain small print.Superintendent of Documents, U.S. Government PrintingOffice, Washington, DC 20402.Guides - Non-Classroom Use (055)

MF01/PC04 Plus Postage.*Adolescents; *Alcoholism; *Drug Abuse; FamilyPrograms; Guidance Programs; Intervention; NeedsAssessment; Prevention; *School CommunityRelationship; *School Counseling; SecondaryEducation; Student Needs

ABSTRACTThis manual was designed to provide school

administrators, counselors, teachers, parent groups, and communitymembers with a comprehensive school-based program for preventingalcohol problems. Detection and intervention before the onset ofalcohol and drug problems is stressed. Modeled after employees'assistance programs used to identify and aid employees with negativework performance, the Student Assistance Program described in thismanual uses professional counselors who are accountable to thecommunity health agency and school in which they work. The manualdescribes the counseling program in five chapters, using a questionand answer format. The chapters include: 1) The Program in Action:Six Kinds of Groups; 2) Getting Started: Involving Schools, Students,and Parents; 3) Student Assistance Counselors: Qualifications andDuties; 4) Referral to the Program: Getting the Student in the Door;and 5) Community Support: Involving Parent Groups, Faculty, and theCommunity. A checklist for implementation and a bibliography areprovided. The appendices consist of the student assistance programpolicy for handling student alcohol and drug use, the Code of FederalRegulations regarding the confidentiality of alcohol and drug abusepatient records, a list of state and territorial alcoholism programdirectors, a counselor evaluation form, an evaluation summary, asample student questionnaire and a summary reporting form. (ABB)

************************************************************************ Reproductions supplied by EDRS are the best that can be made ** from the original document. *

***********************************************************************

US. DEPARTMENT OF EDUCATIONNATIONAL INSTITUTE OF EDUCATION

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC

This document has been reproduced asreceived from the person or organizationoriginating It

0 Minor changes have been made to improvereproduction quality

POMP of view or opinions stated in this docu-

ment do not necessarily represent WheelNIE

position or policy

PON

CD

OCDC.)

The Westchester County. New York. Student Assistance Program (SAP) was developedin 1979 under demonstration grants from the New York State Division of Alcoholism andAlcohol Abuse and the New York State Division of Substance Abuse Services, and in 1980from the National Institute on Alcohol Abuse and Alcoholism.

Student assistance programs have proven to be effective in reducing absenteeism andalcohol and other drug use, and in preventing alcohol problems. However, student assistanceprograms should be considered as only one avenue for prevention. Research strongly supportscomprehensive and integrated approaches for maximum effectiveness. To find out moreabout additional community resources and strategies, you may wish to obtain a copy ofPrevention Plus: Involving Parents, Schools, and the Community in Alcohol and DrugEducation. Single copies of this guidebook may be obtained free from the National Clear-inghouse for Alcohol Information, P.O. Box 2345. Rockville, Maryland 20852; (301) 468-2600.Refer to Order No. BK113. Multiple copies may be purchased at a cost of $9 each from theSuperintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402.Refer to Stock No. 017-024-01155-0. (Price is subject to change.)

For more information about the Westchester County Student Assistance Program,contact:

Ellen R. Morehouse, ACSWDirectorStudent Assistance ProgramWestchester County Department of Community Mental Health112 E. Post Road (2nd Floor)White Plains, N.Y. 10601Tel: (914) 285-5260

This publication is produced as partof NIAAA's Prevention Pipeline.

National Institute on Alcohol Abuse and Alcoholism

PreventingAlcohol ProblemsThrough a A Manual for

Student Bma

Implementation

WestchesterAssistance county.

plAeovgliork,

fr;C014-,-,

l000mmert

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health Service

Alcohol, Drug Abuse, and Mental Health Administration5600 Fishers Lane

Rockville, MD 20857

For sale by the Superintendent of Documents, U.S. Government Printing OfficeWashington, D.C. 20402

4

CG-

Acknowledgments

This manual is based primarily on discussions with Ellen R. Morehouse, ACSW, Directorof the Westchester County Student Assistance Program, as mentioned in the Introduction.The text was written by Gerald Snyder (BPA Order Number 85083-84), and staff of thePrevention Branch, Division of Prevention and Research Dissemination, NIAAA. Sandy Katzserved as the NIAAA project officer.

NIAAA expresses its sincere appreciation to the reviewers listed below whose com-ments and criticisms helped to make this manual as comprehensive as possible:

Beatrice Cameron, Assistant SuperintendentStudent Services and Special EducationFairfax County Public SchoolsFairfax, Virginia

Tirrunen L. Cermak, M.D.President, The National Association for Children of AlcoholicsChief, The Alcohol Inpatient UnitSan Francisco Veterans Administration Medical CenterSan Francisco, California

Craig Cummings, Special EducatorHoward County Public School SystemEllicott City, Maryland

Jim Neal, DirectorDivision of Prevention, Education, and InterventionSouth Carolina Commission on Alcohol and Drug AbuseColumbia, South Carolina

Dennis Nelson, CoordinatorSubstance Abuse PreventionFairfax County Public SchoolsFalls Church, Virginia

The National Institute on Alcohol Abuse and Alcoholism has obtained permission fromthe copyright holder to reproduce certain material as noted in the appendixes. Furtherreproduction of this material is permitted only as part of a reprinting of the entire manual;author's permission is required for any other use. All other material in the manual is in thepublic domain and may be used and reprinted without permission. Citation of the source isappreciated.

DHHS Publication No. (ADM) 84-1344

Printed 1984

Contents

Page

FOREWORD: Margaret M. Heckler, Secretary of Health and HumanServices

INTRODUCTION: Robert G. Niven, M.D., Director, National Instituteon Alcohol Abuse and Alcoholism vii

OVERVIEW: The Student Assistance Program ix

I. THE PROGRAM IN ACTION: Six Kinds of Groups 1.

II. GETTING STARTED: Involving Schools, Students, and Parents 9

III. STUDENT ASSISTANCE COUNSELORS: Qualifications and Duties 17

IV. REFERRAL TO THE PROGRAM: Getting the Student in the Door 25

V. COMMUNITY SUPPORT: Involving Parent Groups, Faculty,and the Community 2

CHECKLIST: Initiation to Implementation 33

BIBLIOGRAPHY: Suggested Readings 34

APPENDIXES

A. Sample Letter to Parents and Policy Statement

B. Federal Register: Confidentiality of Alcohol and Drug Abuse PatientRecords

C. List of State Alcohol Authorities and National PreventionNetwork Representatives

D. Counselor Evaluation Form

E. Evaluation Summary

iii

6

Foreword

This manual adds a factual, eloquent dimension to our Nation's drive againstthe tragedy of teenage alcohol and other drug abuse.

Family problems, poor grades, trouble with the law, feelings of distress andinadequacy--the pangs and pull of adolescence itself--often plague young people.By emphasizing prevention and early intervention, student assistance programsoffer a way to head off the severe physiological, psychological, and social problemsthat lead to and foster adolescent alcohol and other drug use. Such programs areespecially important, because alcohol-related traffic fatalities--the leading causeof death among our young people - - -can be prevented.

Student assistance programs, modeled after the successful employee assist-ance programs, give needed attention to young people where they spend a greatdeal of their timeat school. Teachers, parents, and other community leaders lookupon this type of program as one that has perhaps the most promise of helpingstudents reduce their use of alcohol and other drugs or avoid the use of thesesubstances entirely. The model program described in this manual was developed bythe New York State Division of Alcoholism and Alcohol Abuse in WestchesterCounty, New York, and is often referred to as "The Westchester County StudentAssistance Program." It was supported, in part, through a research demonstrationproject funded by the National Institute on Alcohol Abuse and Alcoholism, De-partment of Health and Human Services. Several evaluations of the program haveshown it to be effective and useful. I am proud to give my support to thisachievement of the combined efforts of Federal, State, county, and school, theoutgrowth of years of work.

I hope this manual will inform and inspire as we work together to preventteenage alcohol and drug abuse.

Margaret M. HecklerSecretary of Health andHuman Services

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Introduction

In the struggle to combat alcohol and other drug problems, prevention andintervention efforts stand in the forefront. One such effort--in WestchesterCounty, New York--has led to the development of a comprehensive school-basedprogram aimed at those students who are the most vulnerable: pupils new to theschool, seniors facing life after graduation, children of alcoholics, and others whomay need special guidance in dealing with alcohol and other drug problems.

As they grow to adulthood, many youths face a particularly high risk fordeveloping alcoholism and related problems. Research clearly indicates thatchildren of alcoholics may be predisposed to alcoholism and may be twice as likelyas children from nonalcoholic families to develop alcoholism and related problems.The sons and daughters of alcoholics often go undetected and therefore may beignored or inappropriately treated. Some say that only 5 percent of the 12 to 25million children of alcoholics are being helped. As they mature, high-risk youthmay experience difficulties with personal relationships or develop mental and/oremotional problems. Alcohol and other drug use may be a form of self-medicationto allay anxiety and ward off feelings of low self-esteem. The Westchester CountyStudent Assistance Program is located in the schools, where adolescents have easyaccess to highly trained counselors and where other alcohol- and drug-use-relatedfactors such as drinking at an early age, poor academic performance, deviantschool behavior, and poor parent-child relationships are more likely to be detectedthan at home. Parents, school administrators, teachers, and others in the com-munity find the school an effective place to provide services to children in need.

Based on the highly successful employee assistance program model found inindustry, the Westchester County Student Assistance Program uses professionalcounselors to provide a wide range of primary prevention and early interventionservices. The student assistance counselors are trained to detect and reachtroubled children. They are able to devote full, quality time to help students par-ticipating in the program. Looked upon as a model for school administratorsthroughout the United States, the program stresses behavior and performance,combines intervention with prevention, uses a referral process in addition toworking with self-referred persons, and screens participants for alcohol and otherdrug involvement when school attendance or performance has decreased.

A valuable characteristic of the program is its ability to identify and helpyouth, especially those at high risk, before the onset of alcohol and other drugdisturbances. This early detection and intervention has proven effective in reducingabsenteeism, in decreasing the consumption of alcohol and/or other drugs, and inlessening the problems caused by alcohol and other drug abuse.

Since its inception in 6 diverse schools during the 1979-80 school year, theWestchester County Student Assistance Program has been adopted by 24 other highschools and 4 junior high schools in Westchester County and by many high schools inother parts of New York, Virginia, Massachusetts, New Jersey, New Mexico, NewHampshire, and Oregon, as well as by the Seneca Indian Nation.

This manual is designed for the wide audience of people concerned with

vii

changing the attitudes and habits of young people threatened by the abuse ofalcohol and other drugs. These individuals might include school administrators andteachers, alcoholism counselors, community task force members, parent actiongroups, parent support groups, town or city officials, members of parent and schooldrug and alcohol education programs, and any other citizens interested in launchinga prevention program aimed at teenage alcohol use and abuse. As an aid in thiseffort, this manual is designed to supplement the National Institute on AlcoholAbuse and Alcoholism's comprehensive guidebook, Prevention Plus: InvolvingSchools, Parents, and the Community in Alcohol and Drug Education, which des-cribes in detail the operation of five model programs that have proved successfulat the local level.

I would like to acknowledge the tremendous contribution of Ellen R.Morehouse, ACSW, director and creator of the Westchester County Student As-sistance Program, who had the courage of her convictions to begin such a programand who contributed significantly to the development of this manual.

viii

Robert G. Niven, M.D.DirectorNational Institute on Alcohol Abuseand Alcoholism

9

Overview: The Student Assistance Program

The Student Assistance Program developed in Westchester County, New York,is modeled after the employee assistance programs (EAPs) used successfully byindustry to identify and aid employees whose work performance has been nega-tively affected by alcohol, other drugs, or personal and family problems. Theprogram uses professional counselors to provide alcohol and other drug abuseintervention and prevention services for high school students who have alcoholic ordrug-abusing parents, have themselves been abusing alcohol or other drugs, orexhibit behavioral and academic problems or signs of stress that could be related totheir own or their parents' abuse of alcohol or other drugs.

The schools and program staff must have a mutually cooperative relationshipto ensure success. Counselors are accountable to both the community mentalhealth agency that employs them and the school where they are based, and theproject director and principal have equal voices in evaluating, hiring, and firingthem.

These same individuals, along with the superintendent of the school district,meet early on to review program objectives and to agree on procedures. Eachparticipating school must agree to provide office equipment; explain the programto students, parents, and faculty; furnish counselors with attendance and gradeinformation, and give students the time they need, to conduct the program; ensureconfidentiality; and maintain pupil personnel service at a level corresponding withstudent enrollment.

Counselors. Explicit criteria require that each student assistance counselor beknowledgeable about adolescent development, counseling methods, and availablecommunity resources; be able to work effectively with others in a counselingrelationship and to relate well to school staff; and have a master's degree in coun-seling, psychology, or social work and the equivalent of 2 years of full-time post-graduate experience that has included work with adolescents. Each counselorundergoes a series of interviews that involves answering clinical questions, par-ticipating in role-playing situations, and being screened by school staff. Prior toplacement, each counselor receives 4 weeks of intensive training.

Training is conducted by the Westchester County project director and outsideconsultants from community agencies. Student assistance counselors visit com-munity treatment programs as part of their training and develop a working rela-tionship with agency staff to facilitate later referral of students.

Counselors meet frequently with faculty and other school staff to increasereferrals. Counselors make presentations about the program at faculty and de-partmental meetings, provide consultation on specific students or student activi-ties, such as how to make sure there is no drinking at the prom, and meetindividually with new staff members. Attending faculty social activities and meet-ing with staff in faculty lounges or over lunch results in counselor visibility and apositive relationship with school staff.

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Counselors try to increase their credibility with students as well. They makebrief, 20-minute presentations to classes explaining the program and how con-fidentiality is protected. These presentations emphasize that the counselors areavailable to discuss any personal crises or questions. Counselors go out of their wayto be seen in the halls with all types of students and staff and frequent teen hang-outs and student activities such as sports events, plays, and student council meet-ings. They also make the program visible within the community by makingpresentations to the PTA, youth service agencies, local clergy, and other groups.

Services to students. Students enter the program through confidential, self-,or mandatory referral. Students and school staff who think a student has a problemare urged to make confidential referrals with the understanding that the sourcewill not be revealed if they do not want it to be.

Students are required to enter the program if they are found under the influ-ence of alcohol or other drugs on the school grounds. The first two times thisoccurs, in-school counseling is mandated. A third incident results in automaticsuspension and a required meeting among student, parents, and counselor.

Counseling groups, typically consisting of six to eight students, are the pri-mary method used to provide assistance to students. All the groups strive to helpstudents reduce their alcohol or other drug use, increase their self-esteem, andimprove their ability to function in school and with peers and family members.Generally groups meet for 8 to 10 weeks, and students can recontract for anothergroup series. In addition to groups for students abusing alcohol or other drugs,preventive groups focusing on children of alcoholics, seniors, newcomers, short-term crises, and parental conflict exist in most schools.

All students are seen individually before their first group session so that thecounselor can determine their needs and assess their chances for successful groupparticipation. Individual counseling also is available for students who are not readyfor group interaction or whose problem is not shared by enough other students tojustify forming a group.

Parents are always informed if the student is mandated to the program forbeing drunk or high on school grounds. Counselors also conduct family sessions forany family when requested and help the family locate community resources forongoing help when needed. Referrals to community treatment agencies or privatepractitioners are made for both students and parents when intensive treatment iswarranted.

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I. The Program Sixof

in Action: Groups

The Student Assistance Program is geared toward short-term school counselingof students to prevent alcohol- and/or other drug-related problems. Through avariety of time-limited groups, the program strives to provide educational andmotivational counseling resulting in decreased use of alcohol and other drugs.

Q. What is the main aim of the program?

A. The goals of the program are to prevent students from using alcohol and otherdrugs to increase school and community awareness about alcohol and drug use,and to eliminate alcohol and other drug use among those students who areabusing by educating them about the negative consequences of their use.

Q. How are the participants divided into groups?

A. There are six kinds of groups--three focusing on primary prevention and threeon secondary prevention or early intervention.

1. Groups for students new to the school districtThese groups meet for three or four sessions in October and are organizedby grade. The emphasis is on helping students adapt to being in a new schooland thus lessening the chance that they will start using alcohol or otherdrugs to deal with the stress of being new or to gain acceptance. Manystudents are new to a school because of business or military transfers orbecause of separations or divorces. These students often have problems

1.

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resulting from the stress of change and can too easily join groups that areusing alcohol and other drugs. Sessions are aimed at preventing the de v el-opment of alcohol or other drug problems.

2. Groups for seniorsThese groups usually start around January and are for senior students whoreport fears about leaving the security of school and home or having todecide whether to work, go to college, or enter the Armed Forces. The focusis on preventing students from starting to use or increasing their use ofalcohol or other drugs to deal with these stresses.

3. Supportive education groups for students with alcoholic parents who do notuse alcohol or other drugsThese groups attempt to help students better understand alcoholism, how itaffects the family, and how to cope with their drinking parents and theresulting stresses on their own lives. In order to lessen the chance that thestudent will turn to alcohol or other drugs, emphasis is put on increasedself-esteem and improved academic, behavioral, social, and emotionalfunctioning.

4. Groups for students who are using alcohol or other drugs and have alcoholicor drug-abusing parentsThese groups direct attention to parents' and students' use of alcohol andother drugs and the resulting relationship between them. Some of the issuesinclude comparing student and parent drinking patterns, discussing parents'attitudes toward student drinking, dealing with the students' guilt abouttheir behaviors, and becoming alcohol- and drug-free.

5. Motivational counseling groups for students who are abusing alcohol or otherdrugs at schoolThese groups are for students who know they have a problem with alcohol orother drugs and want to deal with the problem and improve their function-ing. The focus is on being alcohol- and drug-free. Students who have been intreatment, have returned to school, and want support in remaining alcohol-and drug-free also are included in these groups if there are not enough ofthem to form their own group.

6. Groups for students who acknowledge having problems with parents or peersbut don't see their alcohol or other drug abuse as a problemThese students see their main problem as their relationship with theirparents or peers, and this is what they want to work on. The focus of thegroups is to help students see the connection between their alcohol andother drug use and their problems with parents or peers.

Q. Can a student who doesn't fit the category Jan one of the six groups?

A. No. It is best to have students together who share the same problems andconcerns. The students who participate in a group must be willing to acknowl-edge that they want to work on the focus of that particular group. The cohe-siveness is lost when someone in a group is there just to "check out" the

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program and doesn't share the concern of other members.

Q. What percentage of participants falls into the various program categories?

A. It varies among schools and depends on the stigma that may keep students outof the program. The Westchester County program strives to have 20 to 25percent of the participants be students who do not have alcoholic parents andwho themselves do not use alcohol or other drugs. The other 75 to 80 percentare target-group students, meaning students who abuse alcohol or other drugs,who are children of alcoholics, or who fit into both categories. The reason forwanting a significant number of non-target-group students is to prevent theprogram from being stigmatized.

Q. How does the program control this percentage?

A. The counselors are continually monitored and reminded by the program's cen-tral office that it is important to reach target-group students and also toattract non-target-group students.

Q. 'Whtzh of the groups is the most educational?

A. The children of alcoholics group is the most topic-oriented and the group mostrun like a class. In a typical session, for example, the counselor may explainwhat a blackout is or why students should not feel guilty or responsible for theirparents' drinking.

Q. How does the program go about increasing self-esteem and improving aca-demic, behavioral, social, and emotional functioning of a student with alcoholicparents?

A. The program uses a five-step approach:First, the student assistance counselors try to demonstrate to children of

alcoholics that the counselors understand what it is like to live with the prob-lem of alcoholism.

Second, the students are urged to express their fellings and perceptions aboutwhat is going on in their home--what hurts and upsets them the most and howtheir parents' alcoholism interferes with their functioning.

Third, the program aims to provide specific education around the individuals'greatest concerns and needs. This immediately lessens some of the anxiety andlow self-esteem they feel by making them realize that the problem is not withthem and not caused by them, but is related to the use of alcohol.

Fourth, the program strives to give the students concrete solutions for copingwith problems. For example, if they cannot do their homework at night, alter-natives such as becoming involved in afterschool activities or going to a friend'shouse are considered. Once they see that they can solve their own problems,they start to feel better about themselves and realize that the situation is nothopeless.

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Fifth, the program tries to get the students to look closely at themselves andto understand how their parents' behavior may affect them, so that they cantake more responsibility for their own attitudes and actions.

Q. What are some of the other issues that are dealt with in groups of children withalcoholic parents?

A. Session discussions maycover such topics as thefollowing:

The fear that parents willget hurt or sick, or willdie, as a result of beingintoxicated

The willingness to takecriticism from friends orteachers rather than ex-pose parents' problems

The upset and angryfeelings caused by the unpredictable and inconsistent behavior of an alcoholicparent or the lack of support and protection from the nonalcoholic parent

The pain caused by worrying about fights and arguments between parents

The scared and upset feelings caused by violence or the possibility of violencein the family

The anxiety caused by parents' behavior that might include criminal orinappropriate sexual behavior

The feelings of disappointment caused by broken promises

Q. Why are these sessions valuable to the children of alcoholics?

A. They give the children--many of them for the first time--an opportunity toexpress their feelings and concerns about what is going on at home, to realizethat there are other students in the same situation, and to see that there aresolutions to some of the problems. If the student assistance counselor candemonstrate an understanding of what is being experienced in the home, thestudent will realize that what is occurring is not unique and will be able tounderstand much of the parents' behavior, how the student is affected, and howthe student can function better.

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Q. What factors are considered in deciding if the children of alcoholics should bereferred elsewhere for treatment or evaluation?

A. Certain questions are answered:Are the children unhappy with their own behavior?Do they exhibit poor peer relationships?Are they involved in self-destructive behavior?Do they contribute to poor relationships with their parents?Are serious mental or emotional problems present?Do students have difficulties that cannot be adequately addressed in thegroup?

Q. How is it determined that a student needs to become involved in an earlyintervention group?

A. The decision is made if a student is abusing alcohol or other drugs and it isdetermined that the student is experiencing some negative consequences.

Q. Are problems or stresses unrelated to alcohol and other drugs ever dealt with?

A. Yes.If a student comes in with a problem, the student assistance counselor will

try to deal with it. Three counseling sessions are provided to determine whetherthe problem is alcohol- or other-drug-related. If it is not, the student may bereferred to the school's psychologist, social worker, guidance counselor, orschool nurse for counseling, or may be referred to an outside counselor in thecommunity. If, however, the school has no one else who can help with thespecific problem, or if the student is unable to obtain help elsewhere, and if thestudent is under a great deal of stress, the student assistance counselor mayprovide additional individual sessions.

Q. Is there a problem releasing students from class?

A. It is often controversial--for both teachers and parents. But the program di-minishes the negative impact by rotating the time of group meetings so thateach week the student misses a different class. Individual counseling sessionsare scheduled for students' free periods--unless a teacher believes it would bemore beneficial for a student to miss a class to see the counselor or if a studentis in extreme crisis and cannot wait. If, despite this system, a teacher continuesto complain about a student's missing class, the student assistance counselortries to meet with the teacher to resolve the problem.

Q- When does a family member become involved fn the program?

A. The counselors attempt to involve parents whenever possible. In some cases--inmandated referrals when a student has been caught drunk or high on the schoolgrounds, or at school functions, or has been making suicidal gestures--parentinvolvement is essential. Parents also are encouraged to become involved in

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family sessions in which problems are identified and community resources forongoing help are dis'.:ussed. Occasionally, counselor-led groups meet in theevenings for parents of alcohol- and other-drug-abusing students. Parents areencouraged to participate in parent-peer support groups or Al-Anon whenappropriate.

Q. Is the program ever modified for different ethnic and cultural groups?

A. In some cases, the program must be modified. Working class, blue collar com-munities, for example, may show more negative feelings about discussingproblems outside the family than upper class communities do. Students fromworking class communities often are reluctant to attend treatment programs,and families generally are not enthusiastic about such participation. In thesecases, the program tries to recruit personnel to provide treatment services onthe school grounds, where the program is not apt to be stigmatized. Someonefrom an outside alcoholism, drug treatment, or mental health program mightcome to the school once a week, for instance.

One Westchester County community with a large low-income, minoritymakeup--primarily black, Hispanic, and Italian--showed poor acceptance of anexcellent psychiatric clinic right in the community, even though there wereminorities on the clinic staff. The Student Assistance Program arranged forstaff members of the clinic to use an office in the school 2 days a week toprovide in-house services.

For other cultural groups with the attitude that drinking is "macho" for men,the program tries to concentrate on the personal harmful effects of alcohol.For students who still show reluctance to participate in community programsbut indicate that they would see a private therapist, use is made of an extensiveprivate practitioner list developed and monitored by the program.

Q. When can a student be ordered to attend the program?

A. If the student is identified as being under the influence of alcohol or otherdrugs, he or she can be mandated to see a student assistance counselor for arequired number of sessions. Eight percent of all students seen are referred inthis manner.

Q. How are students prepared for outside treatment?

A. Counselors work with all students individually to prepare them for referral.Limited contact is maintained after treatment has begun to increase thechances of successful referral. Periodic followup also ensures that the studentis still attending treatment.

Q. Who determines the membership of a group?

A. Usually the student assistance counselors make the determination. Many timesthe students themselves will come in groups to the counselor, and sometimesthe students do their own recruiting to form a group.

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Q. Do students usually tell their parents of their involvement in a group?

A. Once they feel confortable in a group, most students inform their parents.

Q. How long does each session last?

A. Each group meeting takes about 40 minutes or one class period.

Q. How large are the groups?

A. Each group includes between 5 and 10 students, with the size of the groupdetermined by the student assistance counselor in each school. After the thirdsession, membership remains closed for the duration of the group.

Q. How many sessions are held for each group?

A. Except for newcomers, groups meet for a minimum of 8 weekly sessions and amaximum of 20, with the average group meeting for about 8 to 10 weeks.Should more time be necessary, the students have the option of meeting againfor another group series.

Q. Haw might it be determined that group interaction is inappropriate for aparticular student?

A. Some students might be so disturbed that they cannot function in a groupenvironment. For example, they might be too impulsive, which prevents themfrom participating in an orderly fashion with others or their problem may be toosensitive to share with others. If it involves incest, for example, the studentmight best be seen individually, prior to a recommendation for outsidetreatment.

Q. How is the composition of a group determined?

A. Counselors strive to get the right mix in every group. It would not be right, forinstance, to have one girl in a group of boys or one boy in a group of girls.Similarly, it would be inappropriate to have one very quiet student in a group ofespecially verbal students, or vice versa. Intellectual level is also important--itwould not be beneficial to put an intellectually limited student in a group withexceptionally bright students.

Q. Which works better for helping adolescent children of alcoholic parentsindividual or group counseling?

A. Although individual counseling is beneficial, research and experience indicatethat group sessions are best for most students. A group reduces isolation andoffers the students support and confrontation when needed.

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Q. Are students ever seen individually?

A. Upon completion of the group sessions, students who need more intensivecounseling are seen individually by the student assistance counselor in prepa-ration for referral to appropriate treatment agencies.

Q. How is the focus of a particular group determined?

A. The students are asked at the first group session to verbally agree to make acommitment to work toward a specific goal--e.g., to eliminate alcohol andother drug use or to try to improve relationships with parents or peers, schoolperformance, and/or attendance. If a group strays too far off base, the coun-selor reminds the student of the group's focus and this helps to get the discus-sions back on course.

Q. Is any disciplinary action taken against students who refuse to participate in theprogram?

A. No. However, if a student is mandated to see the counselor and doesn't, theparents are contacted.

Q. Is there way followup after a group has concluded?

A. No formal followup involving a set of procedures takes place. Their continuedpresence in the school building, however, maintains informal contact betweenthe students and the counselor and encourages feedback from teacher andfriends regarding students' progress. At the end of each group, certain studentsmay be encouraged to participate in support groups such as Alateen ov Alco-holics Anonymous or to go for outside treatment. In all cases, students areencouraged to remain in touch with the student assistancecounselor.

Q. Does followup take place aftergraduation?

A. There is no formal followup. Somestudents write letters or visit the coun-selors during the Christmas or Thanks-giving breaks from college. Graduateswith extremly important or urgentmatters to discuss are encouraged tocall or drop in on the counselors at anytime during the year.

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l';.*30C .Aot

H. Getting Involving Schools,Students, and

Started: Parents

Before implementing a student assistance program, both the school and thecommunity must be ready to discuss openly the issues of alcohol and other drugabuse. In other words, the groundwork for acceptance of such a program must belaid. Only when all participants feel that the program is responding to a real needcan the program achieve success.

Q. Why would a school want a student assistance program?

A. As the Secretary's Initiative on Teenage Alcohol Abuse points out, prevention isthe best "plus" for combatting alcohol and other drug abuse among youth. Byconcentrating on prevention--and early intervention--a student assistanceprogram helps students understand the negative consequences of alcohol andother drug abuse. Most important, such a program can help students who arenew to the school, seniors facing the work world, college, or Armed Forcesservice, children of alcoholics, and others who may need help during theiradolescence.

Q. Who makes the initial contact with the program?

A. Usually the school principal or other school administrator does, often in re-sponse to information from a parent or other community member or teacherabout the program.

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Q. What must a school do to start a student assistance program?

A. In Westchester County, the school must send a letter to the office of the proj-ect director to indicate a need and interest in participating. Generally thedirector will then meet at the school with the principal, other administrators,and staff designated by the principal. Questions about the cost and procedurefor setting up the program are answered, and the project director explainsdetails of the services to be offered.

The project director provides literature about the program, answers otherrelevant questions, and encourages the interested parties to get in touch withprincipals of other schools that have the program and their counselors to getfurther, independent perspectives. If the principal and other staff are inter-ested, the superintendent is then involved and may bring the idea to the boardof education for approval.

Q. How does a school outside of Westchester County start a program?

A. A school or alcohol or drug abuse agency located outside of Westchester Countywanting to start a student assistance program should follow a similar procedure.First, officials should contact the county department that has responsibility foralcohol or drug programing or the person with responsibility for alcohol or drugabuse prevention within their State government to determine if funding isavailable to contribute to the cost of the student assistance counselor andclinical supervisor. If county or State funding is not a possibility, the school orinterested agency might consider paying for the program out of its own budgetor trying to raise money locally.

Next, the interested parties should contact the Westchester County programdirector about how to proceed. If only one school wants to implement theprogram, replication materials such as forms, bibliographies, and resourcematerials can be purchased by the school for a nominal fee. The new program'sstudent assistance counselor can be sent to Westchester County for the 1-weekorientation given for all new counselors. If several schools in one area want tostart the program, it is suggested that a meeting of principals, superintendents,teachers, and representatives of parent groups and alcohol and other drugagencies be arranged, at which the Westchester County project director and oneof the Westchester County principals will give a 3- to 4-hour presentation. Atthis time, material will be distributed for replication, and a principal fromWestchester County will explain the effectiveness of the program and some ofthe issues that typically arise among school administrators.

Q. What is the next step?

A. In Westchester County, once a decision is made by the board of education toenter the program, the school sends a letter to the project director stating anintent to participate and the amount to be spent for the period of July 1 to June30. The Westchester County Department of Community Mental Health(WCDCMH) recruits and interviews applicants, with the school making the finalselection. The counselor is hired by the WCDCMH, participates in a 4-weektraining program, and then begins in the school.

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Q. How much does the program cost?

A. The cost will depend to a large degree on the existing community salary scalefor hiring skilled counselors, as well as the number of hours the counselors areinvolved in the schools. In Westchester County, each of the 24 counselors costsan average of $32,000 a year for salary and fringe benefits (25.2 percent ofsalary costs). In 1983, for 22 schools, the total program budget was approxi-mately $950,000. For a new program outside of Westchester County, costswould involve salary plus fringe benefits for a counselor, supervisory services,and materials and supplies.

Q. Can an individual implement a student assistance program by just reading thismanual?

A. This manual is not intended to provide all of the answers and techniques.Rather, it is meant to familiarize readers with the concept of student assist-ance programs and to offer basic information on establishing one. Anyone isfree to start up a program in his or her own school district. Obtaining materialsand training from Westchester County will ease the process, however.

Q. Can school administrators vary the program to suit themselves?

A. Local variations in the program are strongly discouraged. NIAAA demonstratedthis program for replication. The manual was developed because the programwas successful in decreasing or ceasing alcohol and other drug use and de-creasing absenteeism among those participating in the program. Therefore, onecan assume that, if replicated as described, the program will reduce absentee-ism and alcohol and other drug problems.

Q. How is the program in Westchester County funded?

A. The program is funded by the New York State Division of Alcoholism andAlcohol Abuse, the New York State Division of Substance Abuse Services, theWestchester County Department of Community Mental Health, and each of theparticipating school districts. The WCDCMH applies every year to the Stateagencies for the money that comes to the WCDCMH. The WCDCMH combinesthis State money with some of its own local money and the money from theschool districts to pay for the program. The counselors are county employeesplaced at the school. Technically, the school district is purchasing a servicefrom the WCDCMH. The time it takes to apply for and receive funding will varyfrom State to State. Procedures also may vary from State to State and countyto county.

Q. How much of the cost is borne by the school?

A. Although policies can vary, a participating school generally provides 50 percentof the cost of a student assistance counselor's salary plus fringe benefits. The

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school also pays indirect costs for office space, office furniture, and supplies,which usually are minimal.

The other 50 percent is paid by State funding. The 50/50 breakdown is in-tended to make the program a partnership and provide a degree of independencefrom the school. In this way, the central purpose of the program is kept infocus, and the student assistance counselors are kept from becomingall-purpose school counselors. In some school districts that employ individualsserving as alcohol and drug abuse prevention counselors, such individuals havebeen asked to fill in for other school staff in conducting psychological testing,coaching, cheerleading, etc.

Q. Who determines the objectives and procedures of the program?

A. The project director formulates the objectives and then consults with theprincipal or designated school administrators on the procedures that should beimplemented to accomplish those objectives. All principals meet with theproject director and other administrative staff every 6 weeks in the beginningto consider changes and discuss any needs that are not being met. For example:Are counselors and students getting along? How can drinking before the prombe reduced? Do teachers object to the program? Is the program accepted by thestudents? How will questions from reporters be handled? What communitygroups should counselors address?

Q. Now is the program presented to school staff?

A. Student assistance counselors describe the program to school staff, listing thebehavioral signs of alcohol and other drug abuse or other problems to be lookedfor and suggesting ways to determine the appropriateness of a referral to theprogram.

Staff members are coached in the different ways to make a referral (seesection IV: Referral to the Program) and told how to initiate immediate referralof students under the influence of alcohol or other drugs at school.

Q. Now are the parents and students notified?

A. At the beginning of the school year, a letter describing the program is sent bythe principal to every student and his or her parents. A written policy state-ment describing the handling of students using alcohol or other drugs is includedin the student handbook (see appendix A).

Q. What are the ages of the students involved?

A. In Westchester County, most of the students range in age from 14 to 18--theaverage age of students attending high school.

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Q. What grade levels does the program cover?

A. In some schools, the program covers grades 9 through 12, in others--10 through12 or whatever the ages are of students attending high school. In some schooldistricts, the program is being modified on an experimental basis for junior highschools to reach students at a younger age and to get their parents involvedearlier. The program ends in the 12th grade.

Q. Is the program geared toward a specific cultural or socioeconomic group?

A. The program is intended for all racial, ethnic, and socioeconomic groups of allurban, suburban, and rural backgrounds.

Q. Is parental consent required?

A. The important issue of parentalconsent must be individually ad-dressed at the State and locallevels, since State laws andschool policies vary. In somecases, parental consent for astudent to participate in theprogram may be required.Regardless of whether parentalconsent is mandatory, the schoolshould always notify parentsabout the existence and policiesof the program, and counselorsshould encourage as muchparental involvement as possiblein solving students' problems.

Q. If a parent absolutely forbids his or her child to participate, what is the pro-gram's policy?

A. If this is made clear to the school administration and the program, the studentassistance counselor will not see the child.

Q. What general confidentiality issues apply?

A. Since the counselor's interactions with students are not for the purpose ofmaking educational plans, no official school records are kept. The counselormay, however, write personal notes on students in the program. Because thesenotes are the counselor's personal property and are not accessible or revealedto anyone, the Fs.deral Family Educational Rights Privacy Act does not apply tothese notes.

Federal statutes and regulations protecting the confidentiality of alcohol and

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other drug abuse records may apply. These laws protect the confidentiality ofthose individuals receiving treatment for alcohol or other drug abuse in pro-grams that are federally conducted, regulated, or directly or indirectly assisted.These confidentiality protections normally apply to any information, whetheroral or written, in the possession of the counselor about those students who arereceiving treatment for alcohol or other drug abuse problems. Whether theprogram is self-described as prevention-oriented or educational is a questionthat must be answered individually for each prozram. If the counselor is pro-viding services to a student who is considered to have an alcohol or other drugabuse problem, the information discussed about the student is covered by theconfidentiality protections. It has been the policy and practice of the StudentAssistance Program to apply these protections to all students seen in the pro-gram. For additional information, see appendix B, Federal Register: Confi-dentiality of Alcohol and Drug Abuse Patient Records. Questions on the Federallaws may be directed to Chief, Technical Assistance Branch, Division of Ex-tramural Research, NIAAA at (301) 443-1273. State confidentiality laws mayprotect information about students in the program. Questions about Stateconfidentiality laws may be directed to the pertinent State Alcohol Authorityor National Prevention Network representative (see appendix C for listings).

Q. If a student participating in the program is not covered under the Federal orState confidentiality laws, how is confidentiality treated?

A. Confidentiality is especially vital to early intervention, and therefore it isprotected and given enormous respect in all aspects of the program. In thesecircumstances, it is a matter of program policy and professional ethics and notFederal or State laws.

Q. Does anyone outside the program know who is being seen?

A. The principal of each school is the only person outside the program who knowsofficially who is being seen. This is for attendance purposes only, so studentsreported to have missed class will not be penalized if they are seeing a coun-selor during that time. Each day, the principal is provided with the names ofstudents in the program and the times they are attending the various groupsessions. No reason for attendance is given. This policy is made clear to allstudents.

Q. What are the responsibilities of the school district in relation to the studentassistance program?

A. The school agrees to:

Maintain existing pupil personnel services without a corresponding decreasein student enrollment while the school is participating in the program. Thismeasure guarantees that pupil personnel staff will not view the studentassistance counselor as someone who can take over their jobs and that ade-quate support services will be maintained while the program is in existence.

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Provide an office with a telephone, a locked desk, and a file cabinet for thecounselor.

Send a letter to parents and students before or during the first 2 weeks ofschool.

Hold a faculty meeting in the first month of school so that the counselor willhave the opportunity to explain the program and methods for referral.

Provide attendance and academic records of students for program evaluation.

Allow students to participate in rotating group sessions and permit them tomiss academic classes except when tests have been scheduled.

Comply with applicable confidentiality protections, whether State or Federal.

Q. What is the size of the program's central office staff in Westchester County?

A. In Westchester County, besides the project director, the staff consists of threesupervisor-administrators, one research assistant, one administrative assistant,and two secretaries. This size staff is not required to set up a program, al-though in time it may grow to that size. Westchester County started with oneproject director, one secretary, and one part-time research assistant (to serve 6schools).

Q. How does the Westchester County program differ from other student assist-ance programs?

A. Many programs, using a core team approach, train guidance counselors, healthteachers, physical education teachers, English teachers, vice-principals, nurses,and others to intervene with students having alcohol and other drug problems.The groups, usually called support groups, may be led by nonprofessional coun-selors or non-student-assistance counselors.

Q. What percentage of schools in Westchester County participate in the StudentAssistance Program?

A. Of the 43 high schools in the county's 40 school districts, 30 are currentlyparticipating.

Q. What is the best advice for getting started?

A. If questions remain after reading this manual, interested parties should write tothe project director in Westchester County. At the same time, prospectiveparticipants should seek out information about the strengths and weaknesses ofthe program from administrators familiar with the Westchester model.

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The program should be viewed not as a panacea, but as an approach that hasachieved positive results. Other types of student assistance programs do exist,e.g., the South Carolina Intervention Program (SCIP), and may serve your needs.If you decide to implement the student assistance program, parent support thenshould be solicited and a local agency contacted that can provide a studentassistance counselor. Most important, it is advisable not to try to grow too fast.Programs should start small to preserve the highest quality possible.

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Ill. Student Assistance Qualificationsand

Counselors: Duties

The people most responsible for making the student assistance program work ineach school are the student assistance counselors. Among their most importantqualifications, they must have a master's degree, past experience with adolescents,good assessment skills, and proven aptitude for organizing and leading groups. Thekey intangible ingredient for all counselors is the ability to communicateto workeffectively with others. Even though they are not a part of the faculty, they mustearn faculty members' respect, as well as respect from students, parents, and allothers with whom they come in contact.

Q. What are the basic qualifications for all student assistance counselors?

A. In Westchester County, all counselors in a student assistance program musthave a master's degree in social work or psychology from a recognized collegeor university and 2 years of postmaster's full-time clinical experience workingwith adolescents. The kinds of experience deemed most useful are work as asocial worker or psychologist in a school, mental health clinic, family agency,or psychiatric hospital, or work with other alcohol- and drug-related programswith adolescents. However, other qualifications and experience may be ap-propriate in other locations.

Q. How are the counselors recruited?

A. When a position is open, the Westchester County Department of CommunityMental Health posts a notification at convenient locations throughout the

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county. After 10 days, advertisements are placed in local newspapers and one ortwo large metropolitan dailies. Once resumes and application forms have beenscreened, qualified applicants are called in for a two-part interview. The firstinterview is performed by one of the program's supervisors, who judges thecandidates' clinical skills. For example: How would they assess an adolescentwho is depressed? How do they react in role play situations? Do they know thedifferent approaches needed for different groups?

Those who qualify are seen next by the project director, who continues theinterview. Five qualified candidates are then sent to be interviewed by theschool principal. If the principal does not like any of the five, five more candi-dates are sent, until the principal feels comfortable with one particular person.

In this process, a candidate who might be wrong for one school might beconsidered right for another, or vice versa. For example, a candidate who hasnever worked in an urban area might not understand the needs of students in alarge city high school, or a candidate who has never worked with affluentadolescents may not understand the problems of that particular group.

Ideally, the counselors should not live in the school districts where theywork--in order to maintain a professonal and not too familiar relationship withthe students or parents they are trying to help.

Q. Who pa,ys the counselors?

A. In Westchester County, counselors are paidby the Department of Community MentalHealth. Each school, however, reimbursesthe department for 50 percent of the cost ofa counselor's salary and fringe benefits.

Q. How much are the counselors paid?

A. The starting salary for counselors in West-chester County for 1984 is $21,000 per year,plus fringe benefits, with the salary scalegoing up as high as $28,000. The programrecommends that counselors be paid a salary equivalent to thatmaster's level social worker or psychologist in such nonschooluniversity hospitals or outpatient mental health clinics. To obtaincounselors, salary level should be kept as high as possible.

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Q. How is it determined that a school needs a full- or a part-timesistance counselor?

earned by asettings as

high-quality

student as-

A. It depends on the size of the school and the amount of money the school thinksit can afford. In Westchester County, generally schools of 500 students or lesshave counselors available for at least 2-% days a week; between 500 and 1,000students, 3 or 4 days a week; and 1,000 or more, the full 5 days. Of course, evena school with fewer than 500 students may wish to have a counselor on hand 5days a week.

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Q. What schedule do the counselors work?

A. With the exception of ocassional evening hours to see parents or to make pres-entations to community groups, counselors follow a regular school schedule.After school hours, the counselors receive compensatory time, which can beused on days when the school is closed, such as snow days, school vacations, etc.The counselors work a 12-month year and save most of their vacation time forJuly. If they have not accumulated enough time, they can take leave withoutpay or be assigned to a summer 'school or alcohol, drug, or mental healthtreatment agency while students are on vacation.

Q. Why not assign the Job of student assistance counselor to a school guidancecounselor?

A. There are several reasons. First, the guidance counselor has numerous respon-sibilities, including course scheduling, college planning, vocational assessment,and advising students with academic difficulties. These duties often becomemore intensive at certain times of the year, limiting the counselor's ability todevote time to the program. If the program is to be optimally effective, it mustconsistently be a full-time responsibility. The student assistance counselorshave full time to devote to counseling and to crisis response. Their caseloadbecomes high very quickly leaving little time for other responsibilities.

In schools where students are motivated to go to college, the guidance coun-selor coordinates college planning and makes personal recommendations. Moststudents would not want to turn for help with alcohol or other drug problems tothe person who will have to write their recommendation for college acceptance.Other similar conflicts of interest may occur.

Finally, the guidance counselor does not have the same training as a studentassistance counselor. A guidance counselor does not get an intensive 4-weektraining program on alcohol, other drug, and adolescent issues or the weeklyhour-and-a-half of individual clinical supervision that a student assistancecounselor receives in the student assistance program.

Q. Do the student assistance counselors cooperate with the guidance counselors?

A. Yes, they are viewed as part of the pupil personnel team. Guidance counselorsare encouraged to become involved with students in the student assistanceprogram. If, for example, the child of an alcoholic complains that chaos athome is a detriment to study during final exam week, the student assistancecounselor may suggest that the guidance counselor also see the student and helpdeal with this particular problem. In this case and others, both counselors maymeet to discuss the best way to help the student.

At the same time, the student assistance counselor may involve the schoolpsychologist, school social worker, vocational counselor, or any other personwho can contribute to handling a particular problem. The student assistancecounselor routinely asks each student if his or her guidance counselor can betold he or she is being seen. Most students agree. Some may just ask that cer-tain information not be shared, such as a student's alcohol use or a parent's

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alcoholism. Meeting with the guidance counselor is important, because manytimes he or she can give the student assistance counselor background informa-tion and support that will lead to the student's being helped most effectively.

Q. How are the student assistance counselors trained?

A. In an intensive 3- or 4-week summer program, the counselors are trained towork with students experiencing a wide variety of concerns. Topics discussedmay include the following:

Eating disordersDepressionMarital breakupAdoptionPeer violenceChild abuseSuicideChildren of alcoholic parentsWorking with adolescentsConfidentialityStatistical records keepingGenerating referralsPublic speaking skillsStrategies for implementing the program in the schoolMotivating students to join a groupReferring to outside resourcesTraining for new counselors during the first week focuses on how to start the

program, how to handle crises, and how to work closely with students experi-encing various alcohol- and other drug-related problems. During the remaining2 to 3 weeks, counselors learn about a variety of other topics, such as how toevaluate a student who cannot function due to anorexia.

While the counselors are expected to know basically how to form and conducta group, specific training is given to cover a broad range of topics. Inservicetraining, staff meetings, and weekly supervision are conducted throughout theyear.

Q. Does any of the training take place outside the schools?

A. Yes, the training is held every August when the schools are empty. As part oftheir training, the counselors visit community programs and develop a workingrelationship with hospital and treatment agency staff to facilitate later referralof students needing outside assistance.

Q. Is the training mandatory for counselors?

A. Annual training is part of the program's requirements. Returning counselorsskip the first 2 weeks of training. All new counselors must attend the entire 4weeks unless they are hired to fill a vacancy that occurs once school has begun.

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Q. Who conducts the training?

A. Instruction is given by the project director, the program supervisors, experi-enced counselors, and outside consultants from community agencies with ex-pertise ill different subject areas.

Q. Can anyone send counselors for training?

A. Counselors or program administrators from any county or State can attend thefirst week of training. For a nominal feeapproximately $200they receive thefull range of training and special training materials. This sum does not includetravel, lodging, or meals, however.

Q. Can out-of-State administrators and counselors receive training in any otherway?

A. They can receive assistance in setting up a program by calling the WestchesterCounty project director's office. Also, different parts of the training sessionscan be purchased and sent anywhere on cassette tapes. Program staff areavailable to conduct training in other counties and States if all expenses arepaid.

Q. Is the counseling limited only to students?

A. No. Parents may be seen for no more than 3 sessions. In addition to helpingstudents, the student assistance counselors provide consultation on alcohol andother drug issues to school staff, parents, and local community groups.

Q. Specifically, how do the counselors introduce the program?

A. At the beginning of every school year, the counselors make brief presentationsto each English classthe only class (in New York State) that every student isrequired to take every year--thus making sure that all students are familiarwith the program. The class presentation includes a description of the range ofconcerns that students can discuss with the counselor, parent involvement, howto set up a time to talk to the counselor or refer a friend, mandatory referrals,and activities of the counselor. At the same time, as indicated earlier, theprincipals send letters to each home to explain the purpose and objectives ofthe program and to provide assurance that parents can talk to the counselors inconfidence, if they are worried about their child's behavior. Counselors alsomeet with students in informal groups to discuss the program.

Q. Do the counselors train school personnel?

A. After orienting school personnel to the program, the counselors teach them howto identify a student who is intoxicated or high in class and how to encourage

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the student to enter the program. Faculty members are not taught how to makean assessment, but rather how to notice the signs and symptoms that warrant areferral to the student assistance counselor. Falling grades might be one in-dicator, for example, or continual tardiness, moodiness, change in behavior orappearance, and, of course, the smell of alcohol on a student's breath. Schoolpersonnel also are advised on different ways of referring students.

Q. How do the counselors go aboutgaining the students' confidence?

A. They try to become as visible aspossible and go out of their wayto mix with all types of stu-dents--"freaks," "brains," "jocks,"and others--in the halls, lunch-rooms, and student hangouts bothinside and outside the building.They also attend plays, sportsevents, and student council meet-ings. They go anywhere, in otherwords, where it is possible tomeet the students and show aninterest in them. As studentsmeet the counselor, positivefeedback should start to spreadthroughout the student grapevine.

Q. Do the counselors also try to mix with faculty?

A. Besides holding frequent meetings with key administrative staff, the counselorshold informal meetings with faculty members. They also eat lunch with thefaculty and use faculty lounges, attend faculty and departmental meetings, andmeet individually with new teachers to explain the purposes of the program andto solicit their participation.

Q. What are the counselors' main responsibilities?

A. The counselors must provide individual, family, and group counseling sessions asrequired, be available to the school staff for consultation and training, beknowledgeable about community resources and refer students to them whenappropriate, and meet with parent groups. Experienced counselors supervisegraduate student interns from psychology, or social work, or counseling pro-grams and attend supervisory training at the graduate school.

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Q. How are the counselors supervised?

A. Every week, the project director and supervisors from the county mental healthdepartment visit each school for an hour and a half to provide both clinical andadministrative supervision to counselors and to ensure that correct policies andprocedures are being followed. In addition, school principals meet with coun-selors regularly throughout the school year. During the first month, counselorsare urged to meet with their principal for an hour each week to discuss detailsabout getting the program started. Twice a month, the counselors all come tothe project director's office for a 2-hour staff meeting. The first hour of themeeting is for peer supervision, the second hour for general business. Duringpeer supervision, the counselors meet in small groups of six to eight with asupervisor and share administrative, clinical, or personal concerns with theirpeers.

Q. Who has the main responsibility for supervising the program?

A. Because the school has, in effect, bought a packaged program, the main re-sponsibility comes from within the program. Supervisory cooperation is es-sential, however. As employees of the Department of Community MentalHealth, the counselors are supervised by the department and the school prin-cipal throughout the school year.

Q. How is the counselor's work evaluated?

A. Using a counselor evaluation form (see appendix D), each principal assesses thecounselor's work in four general areas: work performance, professional orien-tation, supervision, and personal conduct. On the form, the principal specifiesthe counselor's strengths and limitations and makes suggestions for improve-ment. The principal's evaluation, which is shared with the counselor, is com-bined with the program supervisor's evaluation for a final appraisal.

Q. What is the nature of the meetings held between the counselors and schooladministrators?

A. In weekly administrative meetings, the subject matter may vary widely. Forexample, the student assistance counselor may be concerned because manyparents are serving alcohol at parties attended by students, or a school mayrequest the student assistance counselor's advice in planning a superintendent'sconference on "Alcoholism and the Family."

In other child study or pupil personnel service meetings, general problemsmay be discussed among a social worker, school psychologist, guidance coun-selor, nurse, student assistance counselor, and possibly a teacher. These meet-ings usually proceed according to an agenda. If it is known that one of thestudents in the program is going to be discussed, the student assistance coun-selor will ask the student for permission to share information.

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Q. During department meetings, do the counselors make official decisions orrecommendations?

A. Advice is frequently sought from the student assistance counselors, but infor-mation on a student can be given only with the student's permission. If, forinstance, a school psychologist wishes to send a student to a neurologist fortesting, and the counselor knows that the student is heavily involved withalcohol and other drugs, the counselor may feel it necessary to urge that thestudent be referred to an alcohol treatment program for detoxification beforetesting by a neurologist.

Q. What safeguards are built into the program to alleviate the fears of pupilpersonnel staff as well as community agency members that the counselors willnot take over their jobs?

A. The project director, the student assistance counselors, the principals, and theDepartment of Community Mental Health all are sensitive to this issue. As aresult, the student assistance counselors are told to try to refer students withproblems that are not alcohol- or other-drug-related to the appropriate pupilpersonnel staff members and community agencies as soon as possible. Also,students who have alcohol or other drug problems and need treatment arereferred to appropriate treatment programs or private practitioners. A studentwith both an alcohol problem and academic problems will be seen by both thestudent assistance counselor and the guidance counselor. Individual supervisionwith the project director and supervisors is used to discuss students and makesure they are being referred appropriately. A second check is provided by aresearch assistant who tabulates information on referrals made by thecounselors.

One of the nonnegotiable conditions of participation for a school district isthat it agree not to reduce pupil personnel staff unless a corresponding decreasein enrollment warrants it.

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IV. Referral to Gettingthe Student

the Program: in the Door

Referrals can come from parents, administrators, faculty, or any other con-cerned party. If a program is to operate with real effectiveness, however, themain source of referral must be the students themselves. The number of studentsreferred by even the most vigilant administrators can never approach the realnumber of students in need of counseling.

Q. Are students required to enter the program?

A. Participation is voluntary, except for students referred for three mandatorysessions because they are caught using alcohol or other drugs in school.

Q. How are students referred to the program?

A. Students come to the program from three sources: (1) self-referral, (2) referralby school personnel, peers, or parents, or (3) compulsory referral.

In self-referral, the main source of referrals, a student learns of the programthrough a class presentation by the student assistance counselor, or meets acounselor and decides to come in voluntarily, or comes in contact with otherstudents in the group and wants to join.

In the second type of referral, also voluntary, someone refers the student tothe program in one of several ways. For instance, the person making the re-ferral may tell the counselor about a suspected alcohol or other drug problemand provide the counselor with the student's name but choose to remain anony-mous, thus leaving the counselor to get in touch with the student. Or a slip of

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paper may be put under the counselor's door with the simple message: "SeeJohnny . He drinks a lot." On the other hand, the person making the re-ferral, who may be a teacher, a parent, a worried girlfriend or boyfriend, or anyother concerned individual, may permit his or her name to be used.

Under mandatory referral, the referring party actually introduces the studentto the counselor. This usually occurs when a student is identified as being underthe influence of alcohol or other drugs and the principal orders the student tosee the counselor. In such cases, the parents are always automatically notifiedwhen the referral has been made.

Q. What happens if a student appears under the influence of alcohol or other drugsin class or on school grounds in one of the participating schools?

A. Procedures vary in each school, but usually the student is sent to the nurse'soffice for examination. The nurse notifies the parent and principal, then sendsthe student home for the remainder of the day on medical grounds. Upon re --turning the next day, the student reports to the student assistance counselor forone to three required sessions to determine if problems led to the alcohol orother drug use. If an alcohol or other drug problem is identified, the counselortries to motivate the adolescent to participate in the program or in an outsideprogram to stop drinking or using drugs.

If a student appears under the influence a second time, essentially the sameprocedure is followed. This time, however, the student is required to see thestudent assistance counselor in order to determine the number, frequency, andkinds of contacts to be had with the student, including meetings with parents orreferral of the student to other services.

A third incident results innotifying the school principaland suspension of the student.When a student returns to

IIP e fit school, he or she is required tobe accompanied by a parent.They in turn are required tomeet with the student assist-ance counselor. If the parents

1

fail to comply, the schoolprincipal takes further appro-priate action, such as contact-ing Child Protective Services.The parent is told that, treat-ment is needed, and an outside

referral is made. Sometimes it is necessary for the parents and principal to doan intervention with a student to get him or her to accept a referral totreatment.

Q. Are referrals to an outside agency for treatment usually mandatory?

A. They generally are not mandatory. The counselor may try to make it easier forthe student by offering to go along to the first appointment or by asking the

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practitioner to come to the school to meet the student.

Q. Are all students who exhibit school performance problems referred to thestudent assistance counselor?

A. It depends on the school. In some schools, the student assistance program is theonly show in town, and everyone with any kind of problem takes it to the, stu-dent assistance counselor. In other schools with adequate pupil personnel staff,students with school performance problems might first be sent to a guidancecounselor or to the school psychologist or social worker.

Q. Who does the screening for the program?

A. Screening usually is done by the person who identifies the problem. A teacherwho identifies a student as routinely absent, for example, may decide not tomake a referral to the program but seek help instead frcm a guidance counselorwho, in turn, may expose an alcohol or other drug problem and make the re-ferral. If the problem is clearly identified at the start as possible alcohol- orother-drug-related, the student assistance counselor almost always does thescreening.

Q. Now many of the referrals to the program come directly from students, byreferring either themselves or their friends?

A. 60 percent.

Q. Who else, besides parents, students, counselors, and school administrators,might refer students to the program?

A. Among numerous other referral sources are school bus drivers, school aides, hallmonitors, youth officers, police officers, doctors, therapists, and school nurses.

Q. Now many of the students are referred to outside agencies or privatepractitioners?

A. Approximately 20 to 25 percent.

Q. What other groups are the students urged to Join?

A. If appropriate, some are encouraged to join groups offering drug- and alcohol-related services, such as Narcotics Anonymous, Alcoholics Anonymous, orAlateen--a nationwide self-help organization for teenagers with alcoholicfamily members or friends. The Student Assistance Program is responsible forstimulating the formation of two of the five Alateen groups in WestchesterCounty.

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Q. How many of the students are seen as a result of mandatory referrals?

A. About 10 percent.

Q. Of the mandatory referrals, haw many students return on their awn for at leasta fourth session?

A. Approximately 60 percent.

Q. Does this figure have any significance?

A. It indicates that students who are initially coerced into joining the program canbe engaged and then stay on their own free will.

Q. Is a lack of referrals significant?

A. A lack of referrals from any group, such as faculty or administrators, canindicate a problem in the ,celationship between the counselor and the referralsource, or the referral source's resistance to the program.

Q. How is the student assistance program kept from being perceived as punitive?

A. Care is taken to separate the disciplinary action taken by school administratorswhen a student is caught using alcohol or other drugs and the referral forcounseling based on a health problem. In fact, efforts are made to convincethose who are referred to the program that cooperation with the student assistance counselor is the way to avoid a future disciplinary action. Behaviorrequiring disciplinary action, such as fighting, selling drugs, cutting class, orbeing under the influence, is handled in the usual way by the school with theappropriate disciplinary consequences.

Q. What happens to students who are already involved in the program and get intotrouble even though they are receiving counseling?

A. They are still subject to the school's regular disciplinary action. As a result, thestudents do not see counseling as being equal to punishment or as a way ofgetting out of punishment.

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V. Community Involving Parent Groups,Faculty, and

Support: the Community

14110...

01711.1'

If the student assistance program is to work in a school, it must have the sup-port of parents, faculty, and the community at large. The program's aim of pre-venting and reducing alcohol and drug abuse must become a common goal.

Q. Now do staff members work with parent groups?

A. Staff of the program believe in the value of parent peer support groups andparent peer task forces in the county. At one end of the spectrum are parentpeer support groups that resemble true self-help therapy groups. The parentsmeet in small groups of no more than 10, according to the ages of their off-spring, and talk about the paths and problems of raising children. At the otherend of the spectrum are large task forces with 100 or 200 parents and specificgoalsfor example, getting the local delicatessen not to sell beer to minors orworking to close headshops or to keep drinking from occurring at teenageparties. A variety of groups fall in the middle, and some communities have botha task force and a support group.

With parent peer support groups, the student assistance counselor tries to actas a resource, believing that these groups should not rely on professionals but beself-help entities in the truest sense, offering support to each other and notfeeling the need for an expert to tell them what to do.

The counselor is a resource, for example, in that if a group were to complainof having a hard time making decisions on appropriate activities for 12-year-olds, the program might suggest that the group contact a child psychiatrist whoknows the developmental needs of 12-year-olds and bring that person in as aresource at one of the meetings. The counselor would not try to analyze such

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needs itself. On the other hand, if the task force desires a program for educat-ing parents on, say, legal consequences of using marijuana, it would likely ask alocal police officer to provide a perspective on the situation. Another examplewould be if a group wants to talk about why adolescents use alcohol or otherdrugs, the counselor is available to lead discussion on that subject.

Q. How do the counselors work with community members?

A. At the request of parent and community groups, and with the permission of theprincipal, student assistance counselors help not only parents but such com-munity members as clergy, police, and recreation personnel to develop a uni-form attitude toward the handling of problems related to adolescent alcohol andother drug abuse. Counselors also provide training when requested.

Q. For what other reasons might parents see the counselor?

A. Parents can be seen alone, in parents' groups, or for up to three family sessionsfor the purpose at gaining or giving information about a student or for making areferral to an outside agency.

Occasionally, a parent is seen before a child ever participates in the program.This generally happens when a parent gets in touch with a student assistancecounselor and requests an interview before the child is seen. Sometimes theparent is seen alone and at other times with other parents of children of thesame age. These meetings are short-term group sessions dealing with a specificproblem, usually one that is alcohol- or drug-related.

Q. In family sessions, might persons other than parents be involved?

A. Any concerned relative or person close to the family may become involved.

Q. When do these meetings take place?

A. They can take place any time butare usually either early in themorning, before work hours, or inthe late afternoon or early eveningafter work.

Q. Is publicity about the programwelcomed or frowned upon?

A. The program welcomes publicity.Generally when a school takes onthe program for the first time, localnewspapers, radio, and TV seek todo interviews and stories. As a way

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41

of disseminating news about the program and thus reaching more people, theprogram encourages counselors to cooperate with media representatives. Publicawareness also is increased when media do followup stories year after year.Publicity often results in additional referrals to the program.

Q. Are students involved in this public awareness effort?

A. Students may participate in a group session attended by a reporter, but thepermission of all students must be granted. No student's name may be used.None of the students are permitted to go on TV fullface. In order to avoid anychance of identification, students must be viewed from the back of the head.Also, students write stories or provide information for student newspapers.

Q. Are special publicity efforts made during certain times of the year?

A. Special opportunities for increased community awareness present themselvesduring Alcoholism Awareness Month or similar periods focusing on youth andalcohol or other drugs. Program staff may seek to publicize their efforts innumerous ways--for example, by putting displays about alcoholism on bulletinboards, by encouraging English teachers to have their classes read plays thathighlight the effects of alcohol, by having French teachers give lessons inFrench about alcoholism, or by bringing a drinking-and-driving awarenessprogram into the school

Q. How is confidentiality protected from inquiring reporters?

A. An attempt is made to answer media questions as honestly and forthrightly aspossible. It is, however, made clear before any interviews are given that nonames are to be used. If a particular case is cited, the identity of the partici-pants must be altered to eliminate any chance of exposing real persons.

Q. What other attempts are made to reach the community?

A. The student assistance counselor is encouraged, if invited, to speak beforemeetings of the PTA, civic, fraternal organizations, religious groups, neigh-borhood associations, and any other groups expressing interest in the program.

Q. Can anyone come and see the program in action?

A. The groups themselves are closed to outsiders. Once a year, however, a meetingis held for anyone serious about starting a program. This is a kind of show-and-tell gathering of all counselors, as well as some principals, students, and par-ents, at which different aspects of the program are discussed.

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Q. What reports does the program provide to the schools?

A. Monthly statistical summaries providing information on referral patterns,number of groups, individual sessions, class presentations, speaking engage-ments, and consultation to faculty are given to each principal. Evaluations oftraining programs also are provided, as well as supplementary training programsfor pupil personnel staff.

Q. What impact has the program had on modifying the handling of problemsinvolving adolescent alcohol and other drug abuse?

A. The evaluation data indicate that the program had a significant positive impacton reducing and preventing use of alcohol and marijuana (see appendix E forevaluation results). The schools now have specific procedures for helping stu-dents with alcohol and other drug problems. Principals report more consistencyand greater school staff involvement in identifying students who may be usingalcohol or other drugs. At the same time, parents are increasingly willing torefer children when alcohol or other drug use is suspected, because they knowreferrals will be kept confidential.

Q. Can improved academic performance be demonstrated?

A. No. Comparison of the grade point average for students during the 1980-81 and1981-82 school years suggested very little difference from one school year tothe next. Possibly due to the subjective nature of this measure, no significantimprovement occurred in academic performance. It therefore appears in-appropriate even to tiy to measure academic performance for the program,since it has as its main objective the impact on alcohol and other drug abuse,not on student grades.

Q. Has the program been evaluated?

A. Yes. Evaluation results show that school attendance has improved, and the useof alcohol and other drugs has declined among students participating in theprogram. These results, plus the observations of school administrators, faculty,parents, and students, have generated a great deal of enthusiasm for the pro-gram and optimism that further positive results can be expected anddocumented.

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t 4 3

Checklist: Initiation to Implementation

This list is in si:'nplified form. Fuller descriptions of each step must be read inthe manual for infovmation needed to start a student assistance program.

Community determines a need for a student assistance program.

School sends a letter to the Westchester County project director indicating aneed for and interest in the program.

Project director meets with principal (or designated person) to discuss cost,procedure for setting up the program, and other details.

Principal obtains approval from board of education.

Principal sends a letter to the project director stating intent to participate inprogram and proposed budget approval.

Project director and principal meet to discuss policies and procedures neededfor school or school district.

Qualified student assistance counselor is recruited.

Counselor attends 4 weeks of mandatory training.

Counselor introduces program to school staff and provides training to facultyto recognize signs and symptoms warranting student referral to the program.

Principal sends letter describing program to every student and his or herparents.

Counselor is introduced to parents and community groups.

Counselor makes brief presentation about program to each student in theschool.

Referrals are made.

Groups are formed.

All systems are go!

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44

Bibliography: Suggested Readings

Black, C. Children of Alcoholics. Holmes Beach, Fla.: Learning Publications,1978.

Black, C. It Will Never Happen To Me! Denver, Colo.: MAC Printing and Publica-tions Division, 1982.

Deutsch, C. Broker, Bottles, Broken Dreams. New York: Teachers College Press,1982.

DiCicco, L.; Davis, R. B.; Hogan, J.; MacLean, A.; and Orenstein, A. Group ex-periences for children of alcoholics. Alcohol Health and Research WorldSummer: 20-24,1984.

Filstead, W. 3: Adolescents and alcohol. In: Pattison and Kaufman, eds. Encyclo-pedic Handbook of Alcoholism. New York: Gardner Press, 1982. pp. 769-778.

Fischer, J. Psychotherapy of adolescent alcohol abusers. In: Zimberg, Wallace, andBlume, eds. Practical Approaches to Alcoholism Psychotherapy. New York:Plenum Press, 1978. pp: 219-235.

Goodwin, D. W. The genetics of alcoholism: A state of the art review. AlcoholHealth and Research World 2(3):2-12, 1978.

Hindman, M. Children of alcoholic parents. Alcohol Health and Research WorldWinter 1975-76.

Kaplan, H., and Pokorny, A. Self-attitudes and alcohol use among adolescents. In:Seixas, F. A.. ed. Currents in Alcoholism. Vol. 2.1974. pp. 285-298.

Mandell, W., and Ginzburg, H. Youthful alcohol use, abuse and alcoholism. In:Kissin and Beg leiter, eds. The Biology of Alcoholism. Vol. 4. New York: PlenumPress, 1976. pp. 167-204.

Morehouse, E. Working in the schools with children of alcoholic parents. Healthand Social Work 4(4), 1979.

Morehouse, E. R. Working with alcohol-abusing children of alcoholics. AlcoholHealth and Research World Summer: 14-19,1984.

Morehouse, E. Assessing and motivating adolescents who have cirinldng problems.In: Social Work Treatment of Alcohol Problems. Vol. 5. Treatment Series,Rutgers Center of Alcohol Studies, Publications Division. New Brunswick, N.J.:Lexington Press, 1983.

Morehouse, E., and Richards, T. An examination of dysfunctional latency agechildren of alcoholic parents and problems in intervention. Journal of Childrenin Contemporary Society. New York: Haworth Press, 1983.

National Institute of Mental Health. Plain Talk About Dealing With the AngryChild. Rockville, Md.: the Institute, 1980.

National Institute of Mental Health. Plain Talk About Adolescence. Rockville,Md.: the Institute, 1981.

National Institute of Mental Health. Plain Talk About Handling Stress. Rockville,Md.: the Institute, 1983.

National Institute on Alcohol Abuse and Alcoholism. Services for Children ofAlcoholics. Research Monograph No. 4. DHHS Pub. No. (ADM) 81-1007, Washing-ton, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1981.

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45

National Institute on Alcohol Abuse and Alcoholism. Chemical People ResourcePackage. Rockville, Md.: the Institute, 1983.

National Institute on Al-,ohol Abuse and Alcoholism. Facts for Planning: Alcoholand Youth. Rockville, Is/A.: National Clearinghouse for Alcohol Information, 1981.

National Institute on Drug Abuse. Communities: What You Can Do About Drugand Alcohol Abuse. Rockville, Md.: the Institute, 1984.

Unger, R.A. The treatment of adolescent alcoholism. Social Casework 59(1):27-35, 1978.

Woodside, M. Children of Alcoholics. A report to Hugh L. Carey, Governor, Stateof New York, 1982.

Books for Children

Brooks, C. The Secret Everyone Knows. San Diego, Calif., Operation Cork,1981.

Hornik, E.L. You and Your Alcoholic Parent. New York: Association Press,1974.

Seixas, J. Alcohol Whal`. It Is, What It Does. New York: Greenwillow Books,1977.

Seixas, J. Living With a Parent Who Drinks Too Much. New York: GreenwillowBooks, 1979.

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Appendix A.STUDENT ASSISTANCE PROGRAM

POLICY FOR HANDLINGSTUDENT ALCOHOL OR DRUG USE

If a student appears "under the influence" of alcohol or a drug in classor on school grounds, s/he is sent to the nurse's office. The nurseexamines the student, calls the parent, notifies the principal, and sendsthe student home for the remainder of the day on medical grounds. Whenthe student returns the next day, s/he reports to the student assistancecounselor for one to three required sessions to determine if there areproblems which led to the substance use. The counselor offers counselingor other help in remedying the problem.

If a student appears "under the influence" a second time, the same procedureis followed. The student assistance counselor determines the number,frequency, and kinds of contacts with the student including meeting with theparent or referring the student to other services.

The third incident will result in notifying the school principal and automaticsuspension results. When the student returns, s/he is required to beaccompanied by the parent and the parent(s) are required to meet with thestudent assistance counselor. If the parent fails to meet with the studentassistance counselor, the school principal will take further appropriateaction such as calling Child Protective Services.

Students or parents requiring treatment are referred to outside agencies butare followed by the student assistance counselor as well.

Any behavior requiring disciplinary action such as fighting, selling drugs,cutting class, in addition to intoxication, is handled in the usual way bythe school.

Copyright by Westchester County Department of Community Mental Health,1984. Reprinted with the author's permission.

AI.

47

LETTER TO PARENTS - MODEL

High School along with 29 other Westchester CountyHigh Schools and 4 Junior High Schools is implementing a Student Assistance Programfor she 1984-85 school year. This program is funded by the NYS Division of Alcoholismand Alcohol Abuse, the NYS Division of Substance Abuse Services, the WestchesterCounty Department of Community Mental Health, and the school district. The programwill provide alcohol and drug education and counseling services to students withschool, peer, family, alcohol and/or drug related problems. The program will alsoprovide a new procedure for early identification of students who are experiencingalcohol and drug related problems. It is anticipated that this combination willaccomplish the following goals:

1. To prevent the development of alcohol and drug abuse among students.

2. To reduce the incidence of alcohol and drug related problems among students.

3. To improve attendance and to reduce alcohol and drug consumption among studentswith alcohol and drug related problems.

(Name of Student Assistance Counselor) has bee,: selected to serve as the StudentAssistance Counselor at Higi' School. She/he will be working fulltime and will have evening hours available to see parents and make presentations tocommunity groups. (Name of Student Assistance Counselor) has a Masters Degree in

, previous experience in working with adolescents, and specializedtraining in prevention and early intervention strategies with adolescents withalcohol and drug related problems. She/he is being payed and supervised by theWestchester County Department of Community Mental Health and the school.

(Name of Student Assistance Counselor) will be available to see students who areusing alcohol or dr(js or have personal, school or family problems that cou] lead toalcohol or drug abuse or suicide. If you are worried about your child's behaviorand would like to speak to the Student Assistance Counselor and/or have the StudentAssistance Counselor see your child, please call him/her directly atAll calls will be confidential.

We are hopeful that this program will show some promising results. Data will becollected to assess the overall effectiveness of the program. As a result of theStudent Assistance Program, it is hoped that participants will: increase rates ofschool attendance, and self-report a decrease in quantity and frequency of alcoholand drug use.

Please feel free to call me if you have any questions about the program.

Principal's Signature

MHa 52 b1Winstanley 3/22/83

Copyright by Westchester County Department ofCommunity Mental Health, 1984. Reprinted withthe author's permission.

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48

161Appendix B.

TUESDAY, JULY 1, 1975

WASHINGTON, D.C.

Volume 40 Number 127

PART PI

-DEPARTMENT OFHEALTH,

EDUCATION,. AND-- WELFARE

Public Health Service

t.

CONFIDENTIALITY OFALCOHOL AND DRUG

ABUSE PATIENT RECORDS

-General Provisions

459-340 0 - 84 - 4

B-1

49

RULES AND EGUL&T1ONS.

TW. 42.-Public Health . criminal conduct Go, ental a- . t A nt sduct..y Stst.mest- CHAPItR l-PuM.IC HEALTH SERVICE. spouses hued on ptre medical xnodd ems. a

DEPARTMENT OF HEALTH EDUCATION haY. not met .wlth noticeably greaten. 2.1 statutory cut lty-drug abum..AND WELFARE - -, success than those based O $ purely pu. 5IZUtory autuoiity-41c011c sbum..

Intive approach, and It would be t'-1 m* c0nt111ngSUICI4AFTES A-4EitEAi. PfiOV1SIONS

tbm.e rules were so constructed me to b.. eathortty.'PART 2-COt4FIDENT*AUTY OF ALCOHOL come a barrier to the development of

AND DRUG ABUSL PATIENT RECORDS .:better ways to deal wlth those who era' 2.5 £inhstiattost and enforc.nsn$ InOn May 9 1975. the Department of caught UP In a PS 'of seriously anti.- rs11ra.Health, Education, and Welfare and the SOCIAl behavior. - 2 SportS of YI0l&Uo'ii.Special Action Once for Drug Abuse Pre- In addition to the foregoing major '.. TSII5ISm.ventlon published In the Pisrw. ErnIe- changes, the following minor. policy- '. - -.Tn (40 PR 20522) a notice of proposed-joInt nalemaking setting forth

changis 6 made.2.l1' si suit uaags.-roLs..Pro,islons relating to destruction or a.u-x DuAnjUons and ua*g.s-basIa .new Pert 2 of. 'flUe 42 of the Code 0f_ other disposition of records were dropped scpos.. - .

Federal Regulations governing the con- fromI 2.21 (12.22 In the May S proposal) 212 hppflcabtiity-rui... .-

fldentt*lity of alcohol and drug abuse

Interested persons were Invited to sab- The fixed limitation on the Pernilsat.. Du ?rsgwn, death.mit- written comments. ylgea, or agu- ble divatitm of written consent for dls-,.. SL1*-.bm.1. cn purpos..

nienta with respect to thrpropoaed regu- CloeWe Was dropped from 82.31 In favor 214' Penalty for violations-ruin.lationa within 30 days of he dAle of pub- of a limitation to much duration as may 2.14-I. Penalty (or ylolItion.-baili sadIlcatlon of that notice. All comments

-. submitted were carefully considered, andb. reasonably .necesaary to effecteate the

. . ' PUPs -purpos, for which the consent Is given. 9$iUXIS

at various stages In the sulemaklng'proc- 'the specification of crimes lii 92.65 .j basis an purpose.eaa th.'Adflhlzilstr*tOr of Veterans' -' for wnich a court order may be grante4

-

fairs and. the heads nf other Federal de- authorizing use of program reeords In Imomp.t.nt and d.cm.a.d' ps-Pariments and agencies substantially a- the investigation or proeecntic of a pa-' ... -tilts--basis end purpose.-fected by-tI.. proposed regulations were tistit was broadened to cover any "ex- 2.17. Sasurity pr.oauuons-ruh.s. ,

-.:.- -. treuwiy .erlouat' crime, with those listed 2.17-I emeurity prscsutlonj-basls and pus.-.

- U flsfly' adopted and set forth here-lna.fter the regulations contain two ma--

In the May 9. notic. being retained' as °' - -.examp1& - ''-'-22*-f

- jot substsntive changes from the May a,.Xr, ofPipally, a number of clarifying, tecl. ___ -

proposal. The aerate. tres.tmen nbs3. and conforming changes were s.is - Ia over agents and Ifliosmadis-.'"funding sources and u.jri..party payers made In the May 9 propoaaI' but these ........ ruled. -

(H 2.21 and. 2.37 'of the proposed regula- 'are without algnlflcent substantive effect. 2.1$-I Und.rco,er agents and Informants-tlos) was abandoned as unworkabls,primarily because the.problbitiona which

Accordingly, pursuant to the authority --bs snd purpose. .

of section- 40$ of the Drug Abuse OEce' 2.20 Xdsntiflcatlon cia--rules.the proposed regulations would have- and Treatment Act of 1972. as amended 2.20-4. Zdsnt80catlon cards-basis and ur-.placed 'on funding would have b Pub. L .92-282 (21 U.S.C. 1175) and

2.21 DijUon of dlac.ntinu.* oil.':dlrecuy -conflicted with requirements section 333 otthe Comprehensive Alcohol 'r,coJn.- -- which have been proposed in Implemen- Abuse and Alcoholism Preventioni Treat. 2.21-1 DIsposition of discontinued. prope.mtatlon of Title of the Social Security ment. -and RehabIlitation Act of isis. . . .: r.corge-baals and purpose:. - -

Act (see proposed 45 CFR 22i.63. 40 PR $5 amended by Pub. L 93-282 (42 U.S.C. 2.23 . ?oru emplOy... and oun.ra-rulss,16802, 16809. APr11 14. 1075). In' lieu of 45$3) ,and under the auth.rlty delegated 2.23-7 Ponn.p .mploye.s and othsrp-beslsth$ approach, I 2.37 nsa been revised the General Counsel of thg Special 2.23 zsiauo't 8nd. laws-rul.gto provide that funding sources and Action Office for Drug Abuse Prevention', 22b-1 '*si.atidnahlpt. stat. laws-tests and.third-party psyers mmlnlng ug or-alcohol abuse patient records ass sub-.

(39FR 17901 21 1974)' °. - .. -

-- ' . ' 2.24 slstionab1p to .sctlon 305(a)'Ject to m.trlctioi won toth. Aof aiapter ZTItle 42, Code of Federal- Pubilo ff.slth Sn-vies Act and sic-same extent and In tie urns manner as RultIonsJs amended- by Inserting non- 502(s), of Oaufroil.4 Sub.2any other -entity maintaining 'ords Immediately after Part l.thereof $ new 51&D.OSS ACtu1SL -

which aye within th&-.00pe of the au- 2Part 2 tnissd.as.set forth below

- thoiizthg OU sad titeP1St. ...- xgeeito. itete 'esereguiAtions .h." ..' ction 602(a) .t Contiollsd Sub-

- The.otber major changs-Is In the-area5 b.effective' on:August I 191$ .- --:--.-: P"of criminal justice system referrals, and-...the ounda for the rules finally adopted

-. -" -------- -: . sndc-..oascis.urs.wni, p.aemnt.cscs.ntD$teth June25, 1975;,- ..,-.

- -

--. Wrltt.n coasent r.quir.d-ruisa-ala. - 0 . PorPose .t3I-.- . :,... . R. Mouaax. -- 2.51-I' Wrltteá silent raqui!ed-basa, andsection (92.39-1) pertainIng thereto. In

- Assistant oratory 'or ....... - pwpoas. . . .-

.00nnectlon with that change, It must be' Pthtticnoa rsdiscics.r.-ruln.frankly acknowledged that the $5311- -'' fec Education and w- PeobiMUOn on z.distiojua-baiiamentaset forth In the corresponding........ala and purpose section (I 2.40-1)- of the

.. -. . -- ..,-. are.. -

2.35,.. lli.-g. *sstiósn and nd*bfli-May 9 propose! have merIt. Theflns! rule 'pproved: June ;6. 1975. "-' - .'- -

-,

L'ay In certain instances result In a corn-pi 'mise of the treatment process, If . -:- w.' Wniuozi

Eecreta,1, of eaZth;'Educatf on,,. 2.34 PzsvstIoa at -, certain inultipli.or other authorities In the crim- . - .d Wel/are - . ..,' .. .. .u011ments-rul.e.lxal justice system overreact to Informs- : '- s' 234-4 Prevention of sn-tan mtdtipts'don -whose communlcatlon'Is allowed.'

Dsted June 2711975. . . , .' .nrollmanta-bnia end purpose,.under the final rules but would have been iaerr- -' -. - -.

- 2.23 Legal counsel tar pctl.nt'-culse.:. prohibited under the proposed rules. '' aeneria CounsS, ecial Action ass-i Legal-counsel toe patlsnt-buls. and

'Against such an adverse effect, how-. OØIce for Drug Abuse reveii- j3a, Psuent'a family and others-rpm-.ever,, there must b. weighed the very real

- advantage which genuine cooperation be---

,. - ((on.. . . .'.' -' 2.114 stient'a family end othem-bssls-community 5OCt11 serrIc systems

- ........... - g prp. une ...........

-- 2. ThIrd party payers and nni- and the criminal justice systaia can yield Roms L. DPoxy,. :, ' -. ': asurcas-rums... ' .'for thom. whose lives are' crippled and ''-. Director, Special 'Ac(ion. 001cc 237-1 d. pty payer. and. fundingscarred by the consequences of their own .-. for Drug 4bUs6 It'eomuion.." -.- .,.ur -.Isls and purpose.

nnAt 1!GISTLI, VOL 40 NO 127-TUHDAY JULY I 1e75 -

B-2 ... - . .- -

50BET-. COPY'.',,AVAILABLE

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(2) whithW or not tie patient, with rs- Pg..Jticmi wid.ntIari material reivant to ti.ipect to whom any then ricord rSISZTId to a,.thos4ty. nUdity and Interpretation oX the sectionin ibis*UOfl (a) at this section Ii main-t*ined. (tile his written isasent. the content Attention is called to tha Interpr.t4- which precads. It. - . -

v rtgtil*tlnna, Ien by Spch1 (b) Stat*jtOTi rides hilly incorporated..1 inch record may b. aiac1ma as zonows:() 'lb msdlcsa personncl to the Intent Action Offic, for Drug Abuss Prevention ib. for 01 entmc, of reference.neosesery to mists henS d. medical .m- (37- PR 24635, No,ember 17, 1. ,. . the statutory hula for this part is iet out -

In full In 112.1 and 2.2, ths regulations-

(U) To qualined personnel to, the Pur- vised 35 FR. 33744, December 1973.to hereinafter In this part In Subparts B through B of this part arpos. of conduc riclentinc aeerch.

agement audits. Snanclal aUdits. O program the 1otg tons") Those Intended to Include all of the operativestatutory pro Vlslofls..,iluatiin, but inch personnel may not Id.n-

o,i*tioni have been given gp

-as controlling authority by ths provl- 2.6 Adndnlssnatlaci and inforcemeatpatient in any report at such rseeaasb. audit. stons of section 303(d) of Pub. L. 93-252.. Ia gsnaral.or .,aivation. se otherwise disclose patians U well as the references In hi 1.gisIs-

.identities in any manner.(0) U autbcrissd by an ipproptiati order history of that act to ths precedents

-'-Ilestablisbed under sction_401 of PUb. L'tt & court 61 ccsupstent tsdiaUo% grantedaltec' application chewing good. cause there.

to enforcs coinpllsncs with this part.92-251 Sucb.eferencea amiesr at ' which receive Federal grantsgooe osna. mi court shan 11 of Rouse. Committee Report No. 93- y be monitored for complianc, withwelsh the piblle intirist and the n5S fOrdisciosuri against the ln3ury a. atiut.

5 ° this and other sppUcabls Federal law asslonal Record for hay 6. 197& Tb. latteri cideatio th grant tn.tratjou..*o the phyalChafl.patlin$ relionshlp, and citation is to a d.tailed analysis of Similar-b. FDA ofto the irsatsc.nt services. Uposi the granting

of such cod.r, the court. In determIning th.bill In Its final form which was submitted

programs win Include inpec-for the Record by Its floor manager.. ton for complianc. with this part, whicheitsnt to which any disSlostir, Of all Of 507part of any relord is flSOifl. ahifl Chairman Sta(gera of the Interstate and

InCOIPOrat.d by eference In the nieth-Foreign Commerce Coumiitte., when thespprcpiiate 51t1(Uazdi against unsuthculisd stion. reguiauon (31 CPR 310.505).Or- anal action by the Rouss(a) cspt as authortlid by a oout order of Representatives. ., . ... 1 2.? Wepoets of violations.

panted under snbeestton (b) (2) (0) el this in vtoiat.tän may tie reported to thasection. us record referred to in lubsestipa(a) may be used to Initiate or substantiate united States Attoiney for the JudicIal(a) Policy objectives. ThS purpose ilstrlct In which th. violation occurs.any OrimIOSI shaxgii q&l5I$ a patlint Or-to th re atlona set forth In this pert Ii ViOlSUOiia on-the part of methadone pro..conduct y iormrigatlan at a patient.. to Implement the authorlatny legislation grams may be reported to the regional(d) The probihittons at thiS SSCUOGtaasio apply to tsOOrde concerning any in" Ins manner that, to bbs extent practica- ot the- Food end Drug Mminis..takes Into account two-streams-of4l,idUsZ who has been a patient. livispeetiveof whether or when be ceases to pst. tration. Violations on the part of a Fed-legal thought add social policy, One has grant., or contractor may be. ye.'.) 'gic, probiblt1 of this to do with anhare.lng the quality and ported to the Federal agency monitoringnot apply to any Interchigi of - attractiven of treatment systems. The thegrant or contract,(i) within the !ameà Forces or witsinthose sornpon.nte OX the Veterans' -Admin-

other is concerned with the Interests ofpatients as citizens, most particujarly Subpart B'Gsflatsl Previsions.

leicatloit furnishing health care torltireiis In reiszdt protectmg their rights 0!. 12.11 DeSnitloos and usdpee.Rules,'or - -, -. -. privacy. Within each stream there are al a legislation. lbs text(2) between such Oo*ipOflsiits and the; cross-currents, and It ihould corns as no thr- legislation" -Armed rorces. -. - '

(1) Any person, who Violates any provt-.surprise that areas of turbulence are to means sectionbe found at their 40$ of the Drug Abuse Office nd Treat-

stun of this l.stlon or any regulation ISsued (b) LIIIUU4 __ mint Act of 1972 (21 U.&C. 1175 aridpinlisant to this s.ction shsfl be ntid lotmore than 5500 in the case Sf

than 11,000 tO the mae St eachcontlined In this pert are not Intended sectIon 333 of the Comprehensive 4lccholto direct the manner In which EIb.bm Muss and Alcoholism Prevejition. Tivint-

Rehabuutatton (43and not moreuibelqusnt elsuso. ....... - mint, and Actof 197Gti's fUndiODS. iiith U re esrcb. treat-

U.S.C. 4552), as such sectiong med. hi:medt,(g) -'zept as provided In subsection (b)

a-.,and enluatbon should bs carried ininded .nd In effect from Urn. to. tlàis.out, but rather to defin, the minimumit t. section,

sgu3...one to carry out the purposes of this (b) ConstructIon 0! firms. The liefint-92r-wint.s for pentection 0 c0i" hens and gug of constrnfidentlilityolsectica, These regulations may contaIn suchdaSnitIonJ. and may provide for such isle..

- patient recccds which In thissection. are applicable for the put-hi satisfied In connection with tb.s con- poessot this pert. To the extent.thiat theyguards and procedures, Including proceduresfor tistIsnos

dáct ç( those functicna In order to CaliF refer to terms used In the authorizingand crIteria the and scoPe Of -.ocdes - undir subsection (b)(2) (0). as In

out the purposee of the itatlicrIZing legisiatlon, they axe also aplkreb1s. fordoss not mean. that b'the Judgment of the Secretary ale escanaryproper a. effectuate In. purposse of this. pupo.es of such leglslationi.o -7 1 legal re-

section, to prevent clrsumvention svssicnticareof, or. to facifliate complians Uteri-

(lulteinents Is always the wisest course. abuse" Includes ujbut In framing these regulations, allow-yjq The term "diIig abuse'.with. --... ance baa necessarily been made for-

Includes drug addiction.(h) The Adminisinatorof Viheans Affairs,through the Chief UsdIcel Otrecior. shall, to

-. diversity of inpbasls and- approach In , .the many different dictions and by terms dIsgnosia" end treazlnent In-th. maximum feasible estent cenilatsut W.-4

their responsibilities Unds titie se. Onited th pa$ 'sisj of puhfl and private chide Interviewing, counselling, and anyagencies which must find S way to !UE' other services oractivities for-carried onetatie Code, preicribe regulations fl1( tion within the limits here Prescribed. the purpogb of ores an Incident to diag-applicable the regulations pruidubedby the--Secretary under subsection (g) of this sso 12.5 Fáraat. - nods, treatment, :qr rehabilitation withicon a. reoorda maintained In oonflaettaflwith the provision of hiepitel car., nuosing

domiciliaryRech respect to drug abuse or alcohol abuse,

whether or not conducted hIs member.section setting forth lilies on any-gi'snhome cars, 504 ssj05services under such title $5 Is veterans suf. of the medical profeeslon.topic In Subparts B through B of thIs Pri)grn,fssIsg truce alcohol abuse or alcoholism, In.preemthlng and impleme*tlng regulstions

- .- --f011OWed setting forth (1) The term "program" when-refer-pursuant in this subsection, the Admlnhatra. - their basis arid putpoes. In many cases,. ring, to an, individual or orgariuzstlon.toe shin, from tints to tims, consultwith -the bads and purpose section Is Itiel! means either an -Individual or en or-ga-the Secretary In order a. ar'iev. the mini-

mum poseible c disation of the ragnia- an Intgrpretative rul, regarding the legal -niastlon furnishing dIssts, treatment,icons, end the implementation thereof, athorlty of hi rulernakera. in other or referral for alcohol abuse or dragwhichthai each pie -

. -- Instances, It sirmniarizes historical or - abuse '.

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in senses which are as different, yetrelated, as those in 11 2.11(f) (1) and2.11(f) (2). This part, however, has to beread both in conjunction with the Foodand-Drug Administration's MethadoneRegulation and the Drug Abuse Ofand Treatment Act of 1972. The Meths-done Regulation (21 CFR 310.505)clearly uses the term "program" in the

2.11(f) (1) sense. In section 103(b) ofthe Act (21 U.S.C. 1103(b) ), it is clearlyused in the 1 2.11(f) (2) sense, and theusage in section 40$(b) (2) (B) of the Acthas from its original enactment been ad-

. ministratively interpreted to include both-,- senses. As used in this part, the context

should indicate the intended meaningswith sufficient clarity to make this pref-erable to creating and defining new ter-

-- minology which would be different fromthat used in related regulations and theauthorizing. legislation.

(f) Construction of disclosures. Sec-tion 2.11(p) Is intended to clarify thestatus of communications which-are car-ried on within a program or _between aprogram and persona or organizationswhich are assisting it in providing pa-tient- care. The authorizing legislationwas not intended to prohibit programsfrom carrying on accepted practices Interms of obtaining specialized servicesfrom outside organizations. In conjunc-tion with the definition of qualified serv-ice organizations, set forth In 1 2.11(n),the provisions of 2.11(p) should pre-vent the development of abuses in thisarea. -

$ 2.12 Applicability.Rules.(a) ht, general. Except as provided in-

paragraph (b) of this section, this partapplies to records of the identity, diag-nosis, prognosis, or treatment of.any pa-tient which are maintained in connec-tion with the performance of any alcoholabuse or drug abuse prevention tune- .tidn-- (1) Which is conducted in whole or in.part whether directly. or by grant, con-tract, or otherwise, by any departnamtor agency of the United States.

(2) For the lawful conduct of whichin whole or Fsrt any license, registration.application, or other 'authorization is re-quired to be granted or approved by anydepartment or agency of _tb..s UnitedStates,

(3) Which is assistea by funds sup-plied by any department or agency of theUnited States, whether directly througha grant, contract, or otherwise, or in-directly by funds supplied to a State orlocal government: unit through the me-dium of contracts, grants any descrip-tion, general or special revenue sharing,or otherwise, or

(4) Which is assisted by Internal. Revenue Service of the Department of

the Treasury through the allowance ofincome tax deductions for contributionsto the program conducting such func-tion, or by a way of a tax-exempt statusfor such program.

(b) Armed Forces and Veterans' Ad-ministration. -

(1) The provisions of this nazi do notIMPLY to any interchange, entirely with-

-"BEM

:RULES AND REGULATIONS

in the Armed Forces, within those com-ponents of the Veterans' Adrainatrationfurnishing health care to veterans, or be-tween such components and the ArmedForces, of records pertaining to a per-son relating to a period when such per-son is or was subject to the Uniform Codeof Military Justice.

(2) Except as provided in Paragraph(b) (1) of this section, this part appliesto any communication between any Per-son outside the Armed Forces and anyPerson within the Armed Forces.

(3) Except as provided in paragraph(b) (1) of this section, this part applies/insofar as it pertains to an:, drug abusePrevention function, to any communica-tion between any person outside thosecomponents of the Veterans' Administra-tion funiishing health are to veteransand any person within such components,until such date 'as the Secretary ofHealth, Education and Welfare exercises -.his authority (conferred by an amend-ment-effective June 30, 1975) to prescriberegulations under section 40$ of Pub, L.-27-255 (21 U.S.C. 1175), After such date,this part applies thereto to such extentas the Administrator of Veterans' Af.-fairs, through the Chief Medical Direc-tor, by regulation makes the provisionsof this part applicable thereto.

(4) Except as provided In paragraph(b) (1) of this section, this part applies,insofe.r as it pertains to any alcoholabuse prevention function, to any corn-munication. between any person outsidethose components of iheVeterans' Ad-ministration furnishing health care toveterans and any person within suchcomponents, to such extent as the Ad-ministrator of Veterana' Affairs, throughthe Chief Medical Director, by regulationmakes the provisions of this part ap-plicable thereto. .

(c) Period covered as affecting (WU-cabilit. The provisions of this part applyto records of identity, diagnosis, Protrivnin, or treatment pertaining to MYliVt:s1 individual maintained .over anyperiod of 'hue which, irrespective ofwhen it bogins, does not end beforeMarch 21,..'4972, in the case of diagnosisor treatment for drug, abuse or beforeMay 14, 1974, in the case of diagnosis ortreatment for alcohol abuse.

(d).Apylicability determined by natureand purpose of records. The applicabilityof the provisions of this part is deter-mined by the nature and purpose of therecords in question, and not by the statusor primary functional capacity of the rec.ordkeeper.$ 2.1Z-1 Applieabillty.Basix and pee.

Does. -

slated by any department or agency ofthe United States". In the light of themultiplicity and extent of Federal PM-grams and policies which can he of as-sistance to drug and alcoholism pro-grams, this wording strongly suggests anintention to provide the broadest cover-age consistent with the literal terms ofthe statutes. Many programs commencewith direct Federal assistance, financial,technical, or both, and later continuewith State aid and private, tax-deducti-ble contribiitions. It would be manifestlycontrary to the general policy sought tobe effectuated by the legislation if theconfidential status of a program's rec-ords were to terminate, or even be calledInto question, by the cessation of directFederal assistance..

(c) With regard to I 212(aY(3), it'seems clear that whenever a State or -local government is assisted by the Fed-eral government by way of revenue !her...-Mg or other unrestricted grants, all ofthe programs and activities of the Stateor local government are thereby Indi-rectly wasted, and thus meet that aspectof the statutory criteria for coverage.

(d) Section 2.12(a) (N) follows the..dectrine.established in McGlotten v. Con-nally, ;dg P. Supp. 44$ (D.C. D.C., 1912),in which it was held that the deductiblestatus of contributions to an organiza-tion constitutes "Federal financial Y -sistance" within the meaning of section601 of the 1964 Civil Rights Act (41U.S.C. 2000d). The inclusion of the ad:-Jective "indirect" as a edifier of theterm "assistance" as us-a in the provi-sions of law authorizing this part sug-gests an intention to provide coveragm atleast as broad, if not broader than. sec-tion 601 of the Civil Rights Act in remisedof financial assistance. See, also, C.Reenv. Connally, 330 F. Supp, 1150 (D.C.: D.C.,1971) aff'd.sub. nom. Colt v Green, 404U.S. 997, 92 S. Ct. 564, 30 L. Ed. Pd 550(1971)..

(e) Section 2.12(b) essentially repeats

ofinterpretation given In I 1401.02(b)

of the previous regulation except that ittakes account of the special Provisionsinserted in the new law with referenceto the Veterans Administration;, andmakes clear that the exe cotton for corn-.municatians within the military-VA sys-tem does not generally apply to recordsPertaining to civilians,

(f) Section 2.12(c), which deals withthe question of how the period coveredby any given set of records affects theapplicability of these regulations to them,restates the principle set forth in 1 1401. --02(a) of- the previous regulations, andapplies it to records in the field of alcohol

--abuse as well as drug abuse. The author-izing legislation contains no effectivedate provisions. A construction whichwould apply 'the statutes to records ofcompletely closed treatment episodes,records neceisarlly made and maintainedprioto the enactment of the legislation,would create serious administrative prob-lem. It seems doubtful, in any case,whether such records have been "main-tained." within the meaning of the stat-utes, during anw-period of time after,their enactment. On the °I.:ter hand, if

(a) The broad coverage provided by12.12(a) is appropriate in the light ofthe remedial purposes of the statutesaswell as the-practical desirability of cer-tainty and uniformity. Sections 2.12(a)

simply follow theterms of subsection (a) of the statutes,with some explanatory material for thesake of clarity and explicitness.

(b) Sections 2.12(a) (3) and 2:12(a)(4) are based upon the use by Congressof the phrase "directly or indirectly as-

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legal capacity, under the applicable Statelaw to apply for and obtain such diagno-sis, counselling, administration of medi-cation, or other services as actually areor were provided to him by the Programwith respect to which he is or was aPatient any consent required for dis-closure under this part may be given onlyby the patient, notwithstanding the factthat the patient may be a minor.

(d) Initial contacts. When a minorapplies for services under circumstancesother than those described in paragraph(c) of this section, the fact of such an-Pdcation may not be disclosed, except asan incident- to communication au-theorized under paragraph (f) of this sec-tion, without consent of the applicant.to the spplicant's parent, guardian, orother person authorized under State lawto act on behalf of the applicant. Whensuch en applicant refuses consent, Itmust be explained to. the applicant thatwhile he or she has the right (subjectto the provisions of paragraph (f ) of this-section) to withhold such consent, theaervIcee applied for cannot be providedwithout IL -

(e) Collection or attempted collectiona/ - payment for services. Where Statelaw authorizes the furnishing of servicesto a minor without the consent of theminor's parent or guardian, no Inquirymay be made of the parent's or guard-Ian's financial responsibility. and no bill.

. statement, request for Payment, or anyother communication in respect of suchservices may be transmitted directly orindirectly to such parent or guardian.without the express written consent atthe patient. Such consent may not. bemade a condition of the furnishing ofservices except in the case of programwhich is not required by law, and doesnot In fact hold itself out as willing, tofurnish services irrespective of abilityto pay.

(f) Applicant lacking -capacity forrational choice. When, In the Judgmentof a program director a minor applicantfor services, because of extreme youth or

. mental or physical condition, lacks thecapacity to make a rational decision onwhether-to consent to the notificationof a parent or guardiarZand the situa-tion of the applicant pales a substantialthreat to the life or physical well beingof the applicant or any other Individual,and such threat might be reduced bycommunicating the relevant facts to aparent ar guardian- of the applicant,such facti may be so communicated bythe program director or by program per-sonnel authorized by the director to dosa

2.15-1 Moor patients. Buis andpurpose. -

(a) The statutes authorizing this partare totally silent on the issue of thecapacity of minor to give consent for ."disclosures, and there Is nothing In the

history to suggest that thequestion was ever considered by Con-gress. The question Is, however. onewhich arises repeatedly, and it is there-fore appropriately addressed under thegeneral rulemaking authority, conferred

fEDELIZ

, RULES AND REGULATIONS

by subsection (g) of the authorizinglegislation.

(b) Perhaps no legal issues are morehighly charted than those affecting therelationship of parent and child. SinceCongress has not evidenced an intentionto affect thiarelationship. It Is clear thatlocal law should govern, and the task ofrtilemaking is limited to that of insuring,as far as possible. that the results underFederal law are consistent with local

(c) Where a State has authorized the.

furnishing of treatment or other serv-ices of given type to minor withoutnotice .to or_ consent b7. the parent orguardian, it seems clear that a consist-ent Federal policy with. respect to dis-closure requires_ that consent for anydisclosure of the treatment record begiven by the minor. This Police, more-over, should not be frustrated by at-tempts to enforce parental financial re-y0=11)1110' in a situation where theState Itself has determined that-theminor should have a right to obtainservices without involving the parent. 2

(d) A much more difficult-problem ispresented in the case of a minor who ap-plies for services in a Jurisdiction whichhas, not determined that minor shouldhave the:right to obtain them withoutParental knowledge consent Thequestion may arise s to whether theclinician has an ethical or legal duty tonotify the parent which conflicts with aduty of nondisclosure. The rules in 1 2.16are based upon the theory that Federallaw should not invalidate a State Police'which prohibits . treatment withoutparental Consent but that keeping con-fidential a mere application for treat-ment Is noterdinarilY .a.sufficient trans-gression of such State policy as to re-quire in exception to the general Federalpolicy prohibiting disclosure of an appli-cation for services without the consentof the applicant.. .

Section 2.13(f). deals with the caseof the minor applicant who lacks the ca-pacity to make rational choice aboutconsenting to disclosure. It is based uponthe theory that where person is ac-tually as well as legally incapable ofacting in his own interest, disclosures toa person who is legally responsible forhim may be made to the extent that thebest interests of the patient clearly sorequire. Any other rule could subjectclinicians to an intolerable choice brtween

onthe provisions of this

part on the one hand, or failing to takeaction to avoid a preventable tragedyinvolving minor. on the other. Thestatutes authorizing this part should notbe read as requiring such choice.

2.16 Incompetent and deceased pa.tteata.--Rahrs.

(a) Incompetent patients other than.

minors. Where consent Is required forany disclosure under this part, such con--. sent in the-case of a patient who hasbeen adjudicated as lacking the capac-ity, for any reason other than insull1-dent age, to manage his or her own.af-fairs may be given by the guaxdian orother person authorized under State lawto act in the patient's behalf.

(b) Deceased patients.713 in general. Except as provided in

. paragraph (b) (2) of-this section, whereconsent is required for any disclosure ofthis part, such consent in the case ofrecords of a deceased patient may begiven by an executor, administrator, orother personal representative. If thereIs no appointment of a personal repre-sentative, such consent may be given bythe patient's spouse, or if none, by anyresponsible member of the patient'sfamily.

(2) Vital statistics. In the case of adeceased patient, disclosures requiredunder Federal or State laws involvingthe collection of death and other vitalstatistics may be made without consentt 2.16-1 Incompetent and decomod

patents..-Buts and purpose.Section 710 essentially repeats the

substance- of I 1401.04 of the previousregulations, broadened to-reflect the factthat the statutes now allow any 12011zsensual disclosures permitted by the reg-ulations, and to cover the situation ofdeceased Patients for whom no formalappointment of an executor, administra-tor, or other personal representative hasbeen made. Written comments were re-ceived to the effect that the power toconsent to disclosure in the case of adeceased patient should be limited to a .Personal representative. The expense ofprobate or administration in some Juris--.dictionr could cause financial harctshir rto survivors, and on balance It Is belleveg.1that where the assets of an. estate areInsufficient to justify the appoints:sae eatof a personal representative, the pu'ollc -interest is served by permitting otheim toconsent to disclosure.

2.17 §eeurity precaucions.--Rule;La) Precautions required. App'aPii-

ate precautions must be taken for thesecurity of records to which this Part

- applies. Records containing any: infermation pertaining to patients -hall bekept Ina secure room, or in locked filecabinet, safe, or other similar container,when not in use-(b) Policies and procedures. Depend-

tog-upon the type and sizeo,t the Pro-gram, appropriate policies end proce-dures should be instituted for the furthersecurity of records, For example, exceptwhere this function is personally per-formed by the program director, a singlemember of the program staff should bedesignated to process Inquiries and re-welts for patient information, and awritten procedure should be in effectregulating and controlling access bythose members of the staff whose re--Variabilities- require such access, andproviding for accountability. -

2.17-1 .Securite preamthins.Basisand purpose. _

.. The-enormous variations in both thesize and the type of programs to whichthis part is applicable preclude theformulation of specific requirementswith respect to the physical security of

'records.. Almost any requirement whichcould be laid down would, under somecircumstances, either be impracticable or

_..,

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27810 - RULES AND REGULATIONS

Initial publication of the previous regula-. flans (37 FR 24636) . In so saying, we areby no means insensitiie to the anxietiesrepeatedly expressed in both testimonyand comments on thls -.section, but webelieve that the prohibition contained in

2.19 and the procedures and criteria setforth in 1 2.57 provide measure ofrelief which is consistent with the struc-lure and intent of the underlyingstatutes.1 2.20 Identification carvs.Roles.

(a) Required use prohibited. No pro-gram may require or request any patientto carry in his or her possession, whileaway from the program premises, anidentification card or other form ofidentification which Is issued by the pro-gram or which would tend to identify thebearer as a participant in it or any similarprogram.

(b) Conditions o!voluntary use. Noth-ing in this section Prohibits a programfrom isr..mg an identification card to apatient if the patient's counsellor or otherauthorized member of the program staffhas explained to the patient that accept-ance and use of th card Is entirelyvoluntary and that neither an Initialrejection nor a subsequent discontinua-tion of its use will in any way Prejudicehis or her record or standing in the pro-gram. In the case of any patient to whoman Identification card or similar devicewas Issued prior to the effective date ofthis section. or subsequent thereto inviolation of this section, counsellor orother authorired member of the programstaff shall explain to the patient his rightto turn, it in without prejudice at anytime. -

(0) On- premises exemption. Nothingin this section prohibits a prograth frommaintaining and using on its premisescards, photographs, tickets, or other de-vices, or using passwords or other Infor-Mation, to assure positive identificationof Patients, correct recording of attend-ance or medication, or for other properPupeees, as long as 'no pressure isbrought on any patient to carry Any suchdevice when away from the programpremises.§ 2.20-1 Identification cardiaeis and

purpose.Section 2.20 Is in furtherance of one

of the basic purposes of the statutes au-thorizing this part, namely, protectionof patients from Improper disclosure oftheir status as such. Regrettably, thereappear to be areas where Possession of atreatment program Identification card

12.2I Dkposiden of discontinued pro.Ram records. Rules.

(a) General rule. When program dis-continues operations or Is taken over oracquired by another program, its recordsto which this part applies with respectto any patient may, with the written con-sent of that patient, be turned over to theacquiring Program or, if none, to anyother program specified in the patient'sconsent. Except its otherwise provided inthis section. any' records to which thispart applies, but for the transfer of whichpatient consent le not obtained. shall beeither completely purged of patientidentifying information. or destroyed. If-any effort to obtain consent for transferIs made, it shall be by means which mini-mize the likelihood of accidental or inci-dental disclosure to any third party ofthe patient's identity as such.

(b) Retention period. When recordsare required by law to be kept for aspecified period, and such period does notexpire until after the disdontinuation oracquisition of the program, and patientconsent for their transfer is not obtained,such records shall be sealed in envelopesor other containers marked or labelled asfollows: "Records of (Insert name of pro-gram] required to be maintained pursu-ant to (insert citation to 11.w or regula-tion requiring that records be kept] untila date not later than December 31, (in-sert appropriate year]." The same pro-cedure may be followed when it 13 de-termined to retain records for the periodof any applicable statute of limitations.

(c) Custodial retention. Recordsmarked and sealed in accordance withparagraph (b) of this section may be heldby any lawful custodian, but may be dis-closed by such custodian only under suchcircumstances and to such extent aswould be permissible for the program inwhich they originated. As soon as prac-ticable after the date specified on thelabel or legend required to, be affixedPursuant to Paragraph (b) of this sec-tion, the custodian shall destroy the rec-ords. In the_csse of any program termi-nated by reason of bankruptcy, the ex-Dense of compliance with this paragraphshall be an expense of administration ofthe bankrupt estate.

rest or subjected to search. In any part -of the country, the accidental display orcirculation of such card by reason of

. its loss or theft could have adverse con-sequences for variety of reasons. Sinceprograms have other means of achievingthe ends which identification cards aremeant to serve, patients who do not wishto assume whatever risks may be involvedin carrying such cards should not becompelled to do so.

112.21-1 Disposition of discontinued. program reeo. eds.-info 'and pm,

Pont - _

While arguments can be made for re-quiring the destruction. of records at theconclusion: of their useful rlinte-1 Pfethere is wide disagreement on its span,and 'there are in addition research con-siderations which argue for an evenlonger period of retention. Except in thecase of discontinued programs, it there-fore seems best to leave this issue fordetermination by the programs con-cerned. - .-

1 2.22 Fanner employee. and other....Roles.- -

The prohibitions of this part on dis-closure of patient records or informationcontained therein apply to all individuals

.-

who are personnel of treatment pro-grams, researchers, auditors, evaluators,service organizations, or others havingaccess to such records or Information,and continue to apply to such individ-uals with respect to such records or in-formation after the termination of theiremployment or other relationship or ac-tivity giving rise to such access.1 2.22-1 Former employees and

cabers.--Bssis and purpose.The probition contained in 1 2.22 is

arguably an interpretation of the au-thorizing legislation which would be nec-essary as matter of liw even in theabsence of this part; its validity se .anexercise of the .rulemaking power con-

. fernsd by subsection (g) of the authoris-ing legislation seems beyond dispute.§ 2.23 Rlationship "to State

Roles.

-The enactment of the provisions of lawauthorizing this part was not intendedto preempt_ the field of law coveredthereby to the exclusion of State lawsnot in conflict therewith. If disclosure'permitted under the provisions of thispart, or under court order issued pur-suant thereto, Is prohibited under Statelaw, nothing in this part or in the pro-visions of law authorising this Part maybe construed to authorize any violationof such State law. No State law, how-ever, may either authorize or compel anydisclosure prohibited by this part.

-12.23 -1 Relationship to ,State Sews,-Baas and purpose. '

Section 2.23 sets forth MibliClY an ifi--bsrpretation which, in Informal commu-nications, has consistently been given. to21 U.S.C. 1175 since its original entAct-'meat, and clearly has equal applicability

- to 42 17.S.C..4582. . .

I 2:24 Rebifionship to section 3094)of Public Health Service Act and sec-tion 502(c) of Controlled &thews:esAct.Rolea.

(a) Research privilege deseriPtio14ii%some instances, there may be concurrentcoverage of program or activity by theprovisions of -this part and by residetion or other administrative action underSection 303(a) of the Public Health /derv-ice Act (42 U.S.C. 242a(a) ) or section502(c) of the Controlled Substances Act.(21 U.S.C. 572(c) ). The latter two pro-vinous of law, referred to hereinafter inthis section as the research Privilege sec-tions, confer on the Secretary of Health,Education, and Welfare. and on the At-torney General, respectively, the power

. to authorize researchers to withholdfrom all persons-not connected with the -

research the names and other identify-ing Information concerning individualswho are the subject of such research. The

,Secretary of Health. Education, and Wel-fare may grant this privilege with respect.to any "research on mental health, in-cluding research on the use and effect of-alcohol and' other psychoactive drugs."The Attorney General's power is con-ferred as part of a section authorizing

FEDERAL REGISTER, VOL 40, NO. 127TUESDAY, JULY 1, ME

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- RULES AND REGULATIONS-

research related to enforcement of lawsunder his Jurisdiction concerning sub-stances which are or may be subJect tocontrol under tha Controlled SubstancesAct, but is not expressly limited to suchresearch. Regardless of whether a grantof research privilege is made by the Sec-retary or by the Attorney General. It isexpressly provided that persons who oh -tain It "may not be compelled in anyFederal. State, or local civil, criminal,administrative, legislative, or other Pro---ceeding to identify" the subjects of re-search for which the privilege was ob-tained.

(b) Comparison with authority for thispart. Although they deal, in e sense, withthe same subject matter, and may on oc-casion concurrently cover the sametIsnlittl01014 it is important to note thedifferences between the research priv-ilege auctions (21 U.S.C. 572(a) and 42U.S.C. 242a(a) ) and the provisions oflaw (21 H.S.C. 1175 and 42 U.S.C. 4662)which authorise this part. Briefly, thesedifferences are as follows:

(1) Although they contain broadgrants of express rulrhmaking authority,the provisions of law by which this Partis authorised are self-executing in thesense that they are operative irrespectiveof whether the rulemaking authority isexercised. The protection afforded by theresearch privilege sections, on the otherhand, can only come into existenee as aresult of affirmative 'administrativeaction.

(2) The provisions of law authorisingthis part, as well as the provisions of thispart itself, Impose afilirmative duties withrespect to the records to which theyapply, and the violation d such duties issubJect to criminal penalties. To theextent that a privilege is thereby created,it grows out of the duties thus imposed.The research privilege sections, by con-trast, impose no duties by their ownterms, and if any duties are implied fromtheir existence, they would have to beenforced on the basis of an implicit dullliability for damages or by equitable re-lied as there are no criminal or adminis-trative sanctions avaffahle.

<3) The exercise at the authority con-ferred by the research privilege sectionsis subject to administrative discretion,whereas in the care of the duties imposedunder this part there is judicial discre-tion, within the limiWand subject to pro-cedures and criteria prescribed be statuteand regulation, to grant. relief in par-ticular Mel.

(c) Grant Cl research privilege not af-fected by (b) (2) (C) order. The issusrieltof an order under subsection (b) (2) (C)of either of the sections authorising thispart (21 U.S.C. 1175 and 42 U.S.C. 4562)in no way affects the continuing effeo-tiveneu of any exercise of the authorityof the Secretary of Health, ilducation,and Welfare under 303(a) of the PublicHealth Service Act (42 U.S.C. 242a(a)or the Attorney General under section403(4) of the Controlled Subetances Act

U.S.C. 1172(c)).

5 2.24-1 Relationship to section 303(a)of Public Health Service Act and sec-tion 502(e) of Controlled SubstancesAct. Buis and purpose.

(a) In Pub. I., 93-252, the Congressexpressly amended (by sections 122(a)and 303(a), 55 Stat. 131. and 137) theProvisions of law which authorize thisPart, expressly amended (by section 122(b), aft Stat. 132) the research* privilegesection under- the Secretary's Jurisdic-tion, and made explicit reference (in sec-tion.303(d), erstat. 139) to the regula-tions previously issued by the SpecialAction Office for Drug Abuse Preventionreconciling the provisions of section 4011of the Drug Abuse Office and TreatmentAct of 1572 with the provisions of theresearch' privilege sections. When the billwhich became Pub. I.. 93-282 was beforethe House of Representatives for Its lastCongressional consideration beforetransmission to the President. its floormanager, Chairman Staggers of theCommittee on Intestate and ForeignCommerce, inserted in the Record a de-tailed analysis of the bill in Its final form(Congressional Record. daily edition,My 6,1974, page H3563).. This analysiscontained the following paragraph:

The nuationship of section 906(a) of thePublic Stealth Service Act, authorising theadministrative grant of absolute confiden-tiality for rtsearen, to w. aeon 404 Of the DrugAbuse Moo and Treats ast Ast of 1072, re-quiring that Federally-connected drug abusepatient records generally be kept oonadan-UNh has been sonsctly described la an in-terpretative regulation. 21 C.P.S. 1401.61 and140110, which was upheld In People a. Neu-man, XI N.T. 2d We. [reversing) 274ed 127, 255 NA Id Nil (1rn): certioraridenied. 14141 Lf.6.1110), 04 S. Ct. 927. L.Id. 2.1 1161 (1074). For reason, amongothers, section $03(d) of the gents amend-ment expreeely eontinues the eihectimnessof Lie current regulation promulgated bythe Director of the Special Action omos forDrug Strum Prevention. Thu, although MO*tion 402(o) of the Comprehensive DrugAbuse Prevention and Control Act of 1170is not explicitly referred to in this legisla-tion. the congressional intent is Meer thatthe authority conferred by that section wasnot moaned by Pub. L. 112-211, and is notintended la be modified by the bill now be-fore the House.

(b) Sections 2.24 and 2.65 restate, insubstance. the Interpretative rules(II 1401.61 and 1401.62 of the previousregulations) referred to in the passagequoted in paragraph (a) of this section,modified to reflect the amendment madeto section 303(i) of the Public HealthService Act <42 U.S.C. 242(a) ) by Pub.L. 93 -262.

Subpart CDleciosuresWIth Patient.;Consent

5 2.31 Written consent required.-..Rules.

(a) Form of consent. lescept as other-wise Provided, a consent for a disclosureunder this part must be in writing andmust contain the/allowing:

(1) The name of the NOM= whichis to make the disclosure.

27811 ..

(2) The name or title of the personor organization to which disclosure is tobe made.

(3) The name of the patient.(4) The purpose or need for the dis-

closure.(5) The extent or nature of informa-

tion to be disclosed.coio- A statement that the consent is

subJect to revocation at any time exceptto the extent that action has been takenin reliance thereon, and a specificationof the date, event, or condition uponwhich It will expire without express re-vocation.

(7) The date on which the consent Issigned

(5) The signature of the patient sand,when required under i 2.15, the signa-ture of a person authorized to give con-sent under that section; or, when re-quired under 1 2.15, the signature of aperson authorised to sign under thatsection in lieu of the patient.

(b) Duration of consent. Any consentgiven under this subpart shall have aduration no longer than that reasonablynecessary to effectuate the purpose forwhich, It is given.

(c) Di/cloture prohibited with defi-cient consent. No program may discloseany information on the basis of con-sent form

(1) which on its face substantiallyfails to conform to any of the require-ments set forth in paragraph (a), of thissection, or

(2) which is known, or in the exerciseof.reasonable care should be known, tothe responsible personnel of the programto be materially false fn respect to anyItem required to be contained thereinpursuant to. paragraph (a) of this sec-tion.

(d) Paistecation prohibited. No/personmay knowingly make, sign. or furnish toa program any consent form which ismaterially false with respect to any itemrequired to be contained therein pursu-ant to paragraph (a) of this section.

2.314 Written consent required.Basis and purpose. .

(sr The use of a consent form con-. tiiining all of the elements specified inI 2.31(a) it necessary to ensure compli-ance with the requirements of this sub-part. Under i 1401.21 of the previous reg-ulations, a much more abbreviated formwas permissible, because the circum-stances under which any consent couldbe given were very strictly limited. Nowthat the authorizing legislation permitsdisclosure with consent "to such extent,wader such circumstances, and for suchpurposes as may be allowed under regu-lations," the consent form should showon Its face information sufficient to indi-cate compliance with the regulations.

(b) Sections 2.31(b), 2.31(c), and 2.31(d) are an exercise of the general rule-making authority in subsection (g) ofthe authorizing legislation. Section 2.31(c) impoies a legal liability on programsand their personnel for disclosure of in-formation on the basis of a materially

11DIRAL UNISTIS, VOL 40, NO. 127--1115211AY, JIA7 1, FM

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27812 - RULES AND REGULATIONS

deficient consent, and 1 2.31(d) imposesliability on any person who submits a.falsified consent form to a program.§ 2.12 Prohibition on redisclosure.

Rules.(a) Notice to accompany disclosure.

Whenever a written disclosure 1-3 madeunder authority of this subpart, excepta disclosure to a program or other per-son whose records Pertaining to the pa-tient are otherwise subject to this part,the disclosure shall be accompanied by $written statement substantially as fol-lows: "This informatio has been . dis-closed to you from records whose confi-dentiality is protected by Federal- law.Federal regulations (42 CFR Part 2) pro-hibit you from making any further dis-closure of It without the specific writtenconsent of the person to whom it per-tains, or as 'otherwise permitted by suchregulations. A general authorization forthe release of medical or other informa-tion' is NOT sufficient for this purpose."An oral disclosure may be accompaniedor followed by such a notice.

(b) Consent required Jo? redisclosure.A person who receives information frompatient records and has been notifiedsubstantially In accordance with para-graph (a) of this section is prohibitedfrom making any disclosure of such in-formation except with the specific writ-ten consent of the person to whom itpertains, or as otherwise permitted under-this part.

(c) Restriction on redisclosure. When-ever information from patient recordsis -needed by any Person, such informa-tion must be obtained directly from theprogram maintaining, such records andnot from another Person to whom dis-closure thereof has been made, exceptwhere theinitial disclosure was inten-tionally and expressly made For the pur-pose of redisclosure (es for example inthe case of. an employment agency), orthe information Is no longer availablefrom the program and redisclosure isnot prohibited by any other provision ofthis Part,:1 2.32 -1'- Prohibition on rediselmura,..

Basis and purpose.(a) Seaton' 2.32 is intended to provide

a reasonable protection against real-closure of information disclosed withconsent in -accordance with this subpart._There is, of course, no problem. wherethe information becomes part of $ recordwhich is itself subject to this part becauseit is maintained In connection with theperformance of covered substanceabuse prevention function. The difliculbarises when the disclosure made tothose whose records are not otherwiseaffected by this part To attempt to makeall of the provisions of this part appli-cable to such molest ate with respect tosuch information might raise seriousproblems of legality. administrative feast-Witte, and fairness, but where they aregiven actual notice that specific patientconsent is normally required for real-closure, we Walk they can and should beboundby it

(b) Oral disclosures are not mania-tartly covered because they should rarelybe made to any recipient with whom theProgram does not have a continuingrelationship. Where such a relationshipexists or the program is otherwise sada-

--fied that the recipient understands andwill respect the confidential nature ofthe information supplied, there seemsno need to add to the already heavyload of paperwork with which programsmust contend.152.33 Diagnosis, treatment, and reha-

bilitation.--Dules.(a) Disclosure authorized. Where con-

sent is given in accordance with 5 2.31,disclosure of information subject to thispart mil be made to medical personnelor to treatment or rehabilitation pro-grams where such disclosure is neededIn order to better enable them to fur-nish services to the patient to whomthe information pertains.

(b) Traveling, incarcerated, or hotel-tensed patients on medication.. Where $patent on medication is at a erstancefrom his normal residence or treatmentprogram or is incarcerated or hos-pitalized, or, is otherwise unable to de-liver a written consent to his treatmentProgram at the time the disclosure isneeded, confirmation of the patient'sstatus and information necessary to ap-ProPriatelrcontinue or modify his medi-cation may be given to medical personnelIn a'-position to provide services to thepatient upon the oral representation ofsuch personnel that the patient has re-quested medication and consented tosuch disclosure.. Any program making adisclosure in accordance with this para-graph shall make a written memoran-dum showing the name of the patient,or the patient's case number assignedby the program, the date and time thedisclosure was made, the informationdisclosed, and the names of the Indi-vidual' by whom and to whom it wasmade. . . - . .

12.33 --1 Maenads; treatment, and vs.habilitation.Basis and purpose.

k (a) Section 2.33(a) is a restateinentof the policy set forth In 5 1401.22(a)of the previous regulations, expanded tomake explicit reference to nonmedicalcounselling and other treatment and re-habilitative services.- (b) Section 2.33(b) clarifies the cor-responding provision In 5 1401.22(a) ofthe previous regulations by specifyinghow and through whom oral consent canbe given, and limiting the disclosure tothat necessary_ to determine appropriatemedication.

2.34 Prevention of certain multiple--eneollnumts.Rules. . _

(a) Definitions. For the purposes ofthis section and 5 2.55

(1) The terms "administer", "con-trolled substance", "dispense" "main-tenance treatment", and "detoxificationtreatment" shall respectively have the

'meanings defined in paragraphs (2), On.(10), (27), and (28) of section 102 of the- _

, .

ITDIIIAL

_

Controlled Substances Act (21 rl.13.C.802) .

(2) The term "propain" meansprogram which offers maintenance treat-ment or detoxification treatment. -

(3) The term "vcrraissible central. registry" means w qualified service or-ganization which collects or accepts,from two or more programs (referredto hereinafter as member programs) allof which are iocated either within a

- given State or not more than 125 milesfrom She nearest point on the border ofsuch' State, patient identifying informa-tion about persons applying for main-tenance treatment or detoxificationtreatment Sor the purpose of enablingthe member programs to prevent anyindividual from beit-4 concurrently en.!rolled In more than one such program.

(b) Use of central registries Prohibitedexcept as expressly authorized. The fur-nishing, of Patient identifying' informa-tion by a yrogram. to any central regis-try which fails to meet the definition of$ permissible central registry set forthin paragraph (a) (3) of this section isprohibited, and the furnishing of patientidentifying information to or by anycentral registry except ea authorized inthis section is prohibited. Informationpertaining to patients held by a centralreglatry may be furnished or used in ac-cordance with paragraphs W. and(g) for the purpose of preventing mul-tiple enrollmenti, but may not be other-wise furnished or used in connection withany' legal. administrative, supervisory, orother action with respect to any patient.

(c) Safeguards and procedures re-quired. To minimize the likelihood ofdisclosures of inforthation to impostorsor others seeking to bring about un-authorized or Improper disclosure, anycommunications carried on by programspursuant to this section must be con-ducted (1) by authorized personnel des-ignated in accordance with 5 2.17 (b) and(2) in conformity with procedures estab-lished in accordance with that section.

(d) Disclosures with respect to pa-tients in treatment. A member Program.may supply patient identifying informa-tion and information concerning thetype of drug used or to be used in treat-ment and the dosage thereof, withrelevant dates, to a permissible centralregistry with respect to any patient- -

(1) When the patient is accepted fortreatment,

(2) When the type or dosage of thedrug is changed, and

(3) When the treatment is inter-rupted; reaumed, or terminated.

_ (e) 1,4aclosures with respect to applica-tions. When any person applies to Pro-gram for maintenance treatment or de-toxification treatment, then for the put-post of inquiring whether such personis currently enrolled in another programfor such treatment, the program mayfurnish patient identifying informationwith respect to such person

(1) To any .permissible central regis-try of which the program is a member, .-and _

IEOISTIR, VOL 40, NO. 127 TUESDAY, JULY 1, 1g75. .

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(2) To any other program which isnot more than 200 miles distant andwhich is not a member of any centralregistry of which the-inquiring programis a member.

(f) Program procedure in case of ap-parent concurrent enrollment. Wheiraninquiry Pursuant to paragraph (e) (2) Ismade of another treatment program andits response is aMrmative. the two pro-g rams may engage in such further cool- .munkation as may be necessary to estab-lish whether an error has been made, andif none, the programs should proceed Inaccordance with sound, clinicel practiceand any applicable regulations pertain-MI° the type of treatment involved.

(g) nepittry procedure is case of ap-parent concurrent enrollment. When anInquiry Pursuant to paragraph (e) (1) ismade of a permissible central registryand its response is aftIrmative. It may ad-vise the inquiring program Of the name,address, and telephone number of theother program. or It may advise the otherprogram of the identity of the Patientand the name, address, and telephonenumber of the inquiring program, or Itmay do both, and in any case the twoprograms may then communicate as pro-vided In paragraph (f) above.

(h) Advice to vatienti:VVIzen the poll-.eies and procedures of any Program in-volve any disclosures pursuant to thissection, before any patient is acceptedfuror continued in treatment (other thandetoxification treatment) after Septem-ber 30, 1975, written consent in accord-ance with 12.31 shall be obtained. Suchconsent shall set forth a current list ofthe names and addresses either of anyprograms or of any central registries towhich such disclosures MIT be made. Not-withstanding the requirement of 1 2.31(a) (2). such consent shall be effectivewith respect to any other such programthereafter established within 200 miles,or any registry serving such programs,-and shall so state. Such consent shall beeffective for as keg as the Patient re-

. mains enrolled in the program to whichit Is given.li 2.34-1 Prevention of certain multiple

enrollments. Oasis and purpose.Section 2.34 is based upon 9 1401.43 of

the previous regulations. It was omittedfrom the August 72. 1974 draft, but °oaf-manta u the omission made It clear thatin. certain areas of the country. centralregistries are functional component ofthe treatment system, and that regula-tions to guide their operations are

-needed.9 2.35 Legit counsel for patent. -Rules..

When bons fide attorney-client re-Istionship exists between an attorney-at-,law and a patient, disclosure pf any in-formation in the patient's records maybe made to the attorney upon the writ-ten application of the patient endorsedby the attorney. Information so disclosedmay not be further disclosed by the

2.35-1 legal easossel for patient.--Reels end purpose.

Section 2.35 eimplines and broadensthe statement of the policy embodied in

laltigull

RUM AND REGULATIONS

1401.21 at the previous regulations. Itspurpose is to assure the availability tothe attorney, with his ellengs consent. ofany information needed as a basis foradvice aad.counsel. The purpose of theProhibition an further disclosure by theattorney is to guard against the possi-bility that the attorney might be forcedto serve as a conduit for otherwise Pro-hibited disclosures to third Partimedi-nitrite, the attorney-client pwould suffice, but that privilege is sub-ject to waiver by the client, whereas thisprohibition is not. Where there is a needfor disclosure to a third party Of metgiven information about any patient. thisProhibition in no way affects the avail-ability of other sections of this Part toauthoress such disclosure by the program.1 2.36 idPatient's family sad ethers....Re.

Where consent is given in accordancewith 1 2.31,information evaluating hiscurrent or past status in a treatmentprogram may be furnished to any personwith whom the Patient has a personalrelationship imleas, in the judgment ofthe person responsible for the patient'streatment, the disclosure of such infor-mation would be harmful to the patient.

27813.

and when coverage exists, provide astandard which will minimize the liken-

-hood of violations. See also 1 2.12-1(g).1 2.33 Employers and employment

ageseles.--Rules.(a) Disclosure permitted. Where con-

sent is given In accordance with 12.31,a program may make disclosures In ac-cordance with this section.

(b) EUplbis recipients. A program maymake disclosures under this section topublic or private employment agencies.employment services, or employers.

(c) Scope of disclosure. Ordinarily,disclosures pursuant to this sectionshould be limited to a verification of thepatient's status in treatment or a gen-eral evaluation of progress In treatment.More specific information may be fur-nished where there is a bona fide needfor such Information to evaluate hazards

, which the employment may pose to thepatient or others, or when such informa-tion is otherwise directly relevant to theemployment situation.

(d) Criteria for approval. disclosureunder this section may be made if. in thejudgment of the program director or hisauthorized representative appointed asprovided in 1 2.1700, the following cri-teria are met:

(1) The Program has reboil to believe,on the basis of past experience or othercredible Infotmation (which may inappropriate cases consist of a writtenstatement by the employer), that suchinformation will be used for.the purposeof assisting in the rehabilitation of thepatient and not for the purpose of iden-tifying the Individual as .a patient in or-der to deny him employment or advance-ment because of his history of drug oralcohol abuse.3 (2) The information sought appears tobe reasonably necessary in view of thetype of employment involved.1 2.31 -1 Employers and employment

agenelee.--Basis and purpose.Section 2.31 is based on the minimizing

power tonferred by subsection (b) (1) ofthe authorising leg islation, and isadapted from 1 1401.26 of the previousregulations. Its purpose is to allowclosures reasonably necessary and ap-propriate to facilitate the employment ofPatients and former patients, while pro-tecting patients against unnecessary orexcessively broad disclosures. It wasurged in a comment received on the Au-gust 22, 1974 draft that disclosures toemployers be flatly prohibited on theground that the employer's sole legiti-mate concern is with on-the-job per-formance. While we are not unsympa-thetic to this view, a countervailing con-sideration is that in the cam of anemployee or applicant who Is blown bythe employer to have a problem withdrugs or alcohol, knowledge by the em-player of genuine effort by the em-Ploges to deal with It can make the dif-ference between a job and no job.

2.39 Criminal *sties system refer.Roles.

(a) Consent authorized. Where par-ticipation by an individual In a treatmentprogram is made a condition of such In-

,

, 1t75

1 2.364 Patient's family and outers.-.Raids and purpose.

Section 2.3e expresses the same Deliaas was embodied In 111401.27 of the pre-vious regulations, broadened to reflectthe expanded authority for consensualdisclosure under the authorizing legisla-tion. -1 2.37 Third-party payers. and funding

sourees.--fhiles.(a). Acsairitan of, information. Dis-

closure of patient information to third-PartY Payers or funding sources may bemade only with the written consent ofthe patient given In accordance with2.31 and any such disclosure must be

limited to that information which is rms.,sonably; necessary for the discharge ofthe legal or oontractual.obligations ofthe third -party Pager or familial source.

(h) Prohibition oat disclosure. Whamfunding source or third -Party Marmaintains records of the identity of re-cipients of treatment or rehabilitationservices for alconol or drug abuse such.records are, under the authorizing legis-lation. maintained in connection with theperformance of an alcohol or drug abusePrevention function and are subject tothe restrictions upon disclosure set forthIn Ma-part.9 2.37-1 Third-party payers and fund-

ing soarete.--Basis and purpose.Section 2.37 is based upon the general

authority to prescribe regulations to car-ry out the Dummies- of the authorizinglegislation. The great diversity of con-tractual arrangements and legal require-ments under which the operations ofthird-party Payers and funding sourcesare carried on precludes Prescription-of detailed records management instruc-tions In these regulations, even If thatwere otherwise desirable. The genuslprinciples set forth In 12.37, however.should debit the question of coverage,

annscnt, VOL; 41I, NO. 127-1111SDAT, JULY i

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dividual's release from confinement. thedisposition or status of any criminal pro-ceedings against' him or the executionor suspension of any sentence imposedupon him. such individual may consentto unrestricted communication betweenany program in which he is enrolled infulfillment of such condition and (1) thecourt granting probation. or other post-trial or pretrial conditional release, (2)the parole board or other authoritygranting parole. or (3)' probation orparole 'officers responsible for his super-vision.

(b) Duration of consent: Where con-sent is given for disclosures described inparagraph (a) of this section, such con-sent shall expire sixty days after it isgiven or when there is substantialchange in such person's status, which-ever is later. For the purposes of thissection, a substantial change occurs inthe status of a person who, at the timesuch consent is given. has been

(1) Arrested, when such person isformally charged or unconditionally re-leased from arrest;

(2) Formally charged, when thecharges have been dismissed with preju-dice. or the trial of such person has beencommenced;

(3) Brought to a trial which has'com-=fenced, when such person has beenscout tted or sentenc ed

(4) Sentenced, when the sentence hasbeen fully executed. '

(c) Revocation of consent. An indi-vidual' whose release from confinement,probation. or parole is conditioned uponhis participation in a treatment programmay not revoke a consent.given by him

accordance with paragraph (a) of thissection until there has been a formaland effective termination or revocationof such release from confinement, pro-bation, or parole.

(d) Restrictions on redisclOmre. Anyinformation directly or indirectly re-ceived pursuant to this section' may beused by the recipients thereof only inconnection with-their official duties withrespect to the particular individual withrespect to whom it was acquired. Such-recipients may not make such informa-tion available for general investigativepurposes, or otherwise use it in unrelatedproceedings or make it . available forunrelated purposes.t 2.39-1 Criminal justice system refer.r

tab.Basis and purpose.MO On the basis of extenstre.written

comment and oral communications re-ceived on the subject matter of i 2.39as proposed in the May 9, 1975 notice(designated as 1 2.40 in that notice), wehave concluded that the latitude allowedand the conditions imposed 2.39 asset forth above are necessary and properto effectuate the purposes of.the author-izing legislation. -

(is) From legal standpoint, it seemshighly doubtful whether, in a proceedingto revoke probation or parole, the dueprocess requirements laid down in Mor-rissey v. Brewer, 408 U.& 471, 92 B.Ct,2593, 33 L.Eci.2d 484 (1972) and Gagnonv. Scarpelli, 411 C.S. 778, 93 13.Ct. 1756,36 L.Ed.2d 636 (1973)' could be met byan unsupported general evaluation by a

RULES AND REGULATIONS- _

treatment program to the effect that a or not referred by the criminal justicepatient's status or progress in treatment system, before disclosures for the pur-was unsatisfactory. Thus, if such an oval- poses here involved can be made.by pro-uation were all that could be communi- grams. We have been urged to make ansated by program about a particular exception from the requirement of 2.31patient's conduct during the period he in the case of parolees and probationers.was in treatment. a condition requiring but such an exception would be whollysatisfactory participation in a treatment unsupported by the authorizing legisla-program would to all intents and pur- lion. In fashioning these regulations. it isposes become unenforceable. Moreover, if not our privilege to adorn tabula rasait were held to be enforceable, the opera- according to our own predilections:tive decision on the revocation issue rather, it is our duty to interlineate awould then be made by the program, as- statute with fidelity to its spirit, itssuably exacerbating rather than alleviat- terms, and its purposes.ing its role-conflict problem. It may thus 11 2.40 Situations not otherwise praTidtctbe the part of wisdom to confess that for Rule/.some degree of role - conflict is inherentin the situation of any program whichaccepts criminal justice referrals. If so,the issue then becomes that of findingthe most constructive way to handle-theconflict, rather than a sterile and futileeffort to avoid it altogether.

(c) We are persuaded that in mar-7instances a prohibition on free com-munication between prisbation officersand drug abuse program counsellorswould have profoundly deleterious effectson the rehabilitative process. Many pro-bation officers bring to their work it highdegree of training, professionalism, andexperience. They are under no illusionthat they are dealing with clientelle

. which will never stumble or relapse, andif they have the information necessaryto intervene at an early stage of suchan episode, their intervention can oftensnake the difference between success andfailure for the client.

(d) "There is, however, nothing in theseregulations which precludes treatmentprograms from entering into agreementsor arrangements with agencies or Last!.tutlons of the criminal justice system toregulate or restrict the subject matter orform of communications of informationabout patients. For example, such anarrangement might provide for free oral

-communication between counsellors andprobation officers, while restricting for-mal written reports by the program tospecified types of so-called hard datasuch as attendance and urinalysis results.In view of widely differing conditions andattitudes in.varjous parts of the country,substantial variations in such arrange-ments are not only expectable but chit;drable.

(a) Criteria for approval. In any sit-uation not otherwise specifically pro-'tided for in this subpart, where consentis given in accordance with f 2.31, a pro-gram, may make a disclosure for thebenefit of a patient from the records ofthat patient if, in the judgment of theprogram director or his authorized rep-resentative appointed as provided in

2.17, all of the following criteria aremet: -

(1) There is no suggestion in thewritten consent or the circumstancessurrounding it, as known to the program,that the consent was- not given freely,voluntarily, and without coercion.

(2) Granting the request for dis-closure will not cause substantial harmto the relationship between the patientand the program or to the program'scapacity to provide services in general.

(3) Granting the request for dis-closure will not be harmful to thepatient...

(b) Circumstances deviled beneficial.For the purposes of this section, thecircumstances under which disclosuremay be deemed to be beneficial to apatient include, but are not limited to,those in which the disclosure may assistthe patient in connection with any pub-lic or private claim, right, privilege,gratuity, grant or other interest accruing.to, or for the benefit of, the patient or thePatient's immediate family. Examples ofthe foregoing include welfare, medicare,unemployment, workmen's compensa-tion, accident or medical insurance, pub-lic or private pension or other retirementbenefits, and any claim or defense as-

7 rafted or which is an issue in any civil,(e) A further aspect of this matter, criminal, administrative or other pro-

wl:itch was not adequately considered or seeding in which the patient is partydealt with in the May 9 proposal, is the . or is affected.impact which the rules laid down, in

2.39 have on the bail decision. There isa high- correlation between the disposi-tion of the application for bail and thetype of sentence which may. be meted,out upon conviction. The contrast be-tween the recidivism rates for those whoreceive treatment and supervision, asagainst these who simply receive thepunishment of incarceration, It's power-ful argument against restrictions whichwould tend to narrow the circumstancesunder which conscientious judges cangrant bail. -

(f) It must be emphasized that 1 2.39in no way reduces the necessity to obtain to' cover up material potentially em-written consent from patients, whether barrassing to themselves. Bearing in

1,C111A1. HOMIER, VOL 40, NO. 12-171.15SOAT,.,JUIT 1, 1975 .

2.40-1 Situations not otherwise Pro-vided for, -Buis and purpose.

(a) Section 2.40 is based upon 11401.23of the previous regulations, amended toreflect the expansion made by the changein the law with respect to the permissiblescope of consensual disclosures.

(b) A strong case can be made for theproposition . that i 2.40 should, ineffect if not expressly, require a programto make any disclosure requested by apatient. The discretion vested in the pro -gram, it can be argued, is at best anexpression cf overprotective paternalism,and at worst, an invitation to programs

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mind, however, that persons who haveobtained the type of treatment to whichthis part applies are more vulnerable topressures of various kinds than are pa-tients in general, it seems preferable toretain some responsibility on the partof the program to protect the beet In=tercets of Its patients in this very sensi-tive area. This, like many other choiceswhich these regulations reflect, Is a de-termination which can be reviewed andrevised from time to time in the lightof experience.

Subpart DDiselosures Without PatientConsent

§ 2.51 Medical antergencies.--Ralen(a) In general. Disclosure to medical

personnel, either private or govern-mental, Is authorized without the con-sent of the patient when and to the ex-tent necessary to meet bona fide medi-cal emergency.

(b) Food and Drug Administration.Where treatment involves the use of anydrug, and appropriate officials of therood and Drug Administration deter-'mine that the life or health of patientsmay be endangered by an error.in themanufacture or packaging of such drug,disclosure of the identities of the reclp-tents of the drug may be made withouttheir consent to-appropriate officials ofthe Food and Drug Administration to en-able them to notify the patients or theirphysicians of the problem in order thatcorrective action may be taken.

(c) Incapacitated persons. Where apatient is Incapacitated and informationconcerning the treatment being givenhim by a program is necessary to make asoared determination of appropriateemergency treatment, such informationmay be given without the patient's con-sent to personnel providing such emer-ffenCY treatment.

(d) Notification of family or others.When any individual suffering from aserious medical condition faulting fromdrug or alcohol abuse Is receiving treat-ment at a facility which is within themime of this Part the pwating physicianmay, in his discretion, give notification of.such condition to member of the in-dividual's family or any other personwith whom the individual is knows tohave a responsible personal relationship.Such notification may not be made with-out such individual's consent at anytime such individual is capable of ra-tional communication.

(e) Record required. Any programmaking an oral disclosure under author-ity of this section shall make a writ-ten memorandum showing the patient'sname or case number, the date and timethe disclosure was made, some indica-tion of the nature of the eniergeneY, theinformation disclosed, and the mazes ofthe individuals by whom and to whom itwas dbuloised.

2.51 -1 Medical emergencies.--Ilasisand purpose.

Ths piortaions of 12 .51 are adaptedfrom *1401.42 of the previous regula-tions, and are breed on subsection (b) (2)(A). of the authorizing legislation. The

RULES AND REGULATIONS 27E45

provision in the previous regulationswith respect to patients who may be in-carcerated Is now covered in 12.33(b).

Paragraph (d) of 12.51 is based uponthe theory that the disclosure there al-lowed is of the patient's endangeredcondition, not his identity as drug oralcohol abuse patient, and that the hu-manitarian necessity of such notifica-tion outwelghts its potential for acci-dental violation of confidentiality.

2.52 Research, audit, and evalna-tion.--Rules.

(a) Research, audit, and evaluation.Subject to any applicable specific pro-vision set forth hereinafter in this sub-part, the content of records pertaining toany patient which are maintained inconnection with the performance of afunction subject to this part may be dis-closed, whether or not the patient givesconsent, to qualified personnel for thepurpose of conducting scientific research,management audits, financial audits, crprogram evaluation, but such personnelmay not identit7, directly or indirectly,any individual patient in any report ofsuch research, audit, or evaluation, orotherwise disclose patient identities inany manner. For the purposes of thissubpart and for the purposes of subsec-tion (b) (2) (B) of the authorizing legis-lation, the term "qualified persortael"means persons whose training and ex-perience are appropriate to the natureand level of the work in which they areengaged and who, when working as part04. an organization, are performing suchwork with adequate administrative safe-guards against unauthorized disclosures.

(b) Use of disclosures of Patient Iden-tifying information.

(1) Where a disclosure made to anyperson pursuant to paragraph (a) of thissection includes patient identifying In-formation with respect to any Patient,such information may not be further dis-closed. and may not be used in connec-tion with any legal, administrative, su-pervisory; or other action whatsoeverwith respect to such patient, except asProvided in paragraphs (b) (2) ind (b)(3) of this section.

(2) The inclusion of patient identify-ing information in any written or oralcommunication between a person towhom a disclosure has been made pur-suant to paragraph (a) and the programmildng such disclosure does not consti-tute the identification of patient in areport or otherwise in violation of para-graph (a).

(3) Where a disclosifre IS made pur-suant to paragraph (a) of this sectionto person qualified to determine, on thebasis of such disclosure, the presence of asubstantial risk to the health and wellbeing, whether physical or psychological,of any patient, and, in the judgment ofsuch person, such a risk exists and thesituation cannot be dealt with solely bymeans of communications as describedin paragraph (b) (2) of this section with-out intensifying or prolonging the riskas compared with other means of dealingwith it, then the initial disclosure underparagraph (a) and any subsequent dis-

.

closure or rediaclosure of patient identi)-tying information for the purpose of re-ducing the risk to the patient involvedshall be subject to the provisions of12 .51.§ 2.52-1 Research, audit, and evalua-

doa.Basia and purpose.(a) General purpose. Subsection (a)

of this section is adapted directly fromsubsection (b) (2) (B) of the authorizinglegialation. The purpose of each is thesame: To facilitate the search for truth.whether in the context of scientific in-vestigation, administrative management,or broad lames of public policy, while atthe same time safeguarding the personalprivacy of the individuals who are theintended beneficiaries of the process orprogram under investigation. This sub-part in particular, and this part as awhole, are intended to aid in carryingout that purpose.

(b) The succeeding sections of thissubpart deal with problems which arisein connection with disclosures made forcertain specific purposes which havebeen interpreted as falling within thegeneral purposes embraced by 12.52.Those sections will be best understood,however, in the light of some discussionof the underlying premises of the generalrule, and its relationship to two otherlegal concepts: the right of privacy, andthe duty to obtain informed consent fromresearch subjects.

(c) The Right 0/ Privacy. So far as Isrelevant to this discussion, we may con-sider the right of privacy In two aspects.One, a protection against improper goo- .ernmental.activity, is the right to be se-cure against unreasonable searches andseizures guaranteed by the FourthAmendment, with some expansion fromthe penumbras of the Fifth and SixthAmendments. The protections affordedto patients by the authorizing legislation,not to mention these regulations, go farbeyond those which are constitutionallyrequired.

(d) The other aspect of the right ofprivacy, which has sometimes been de-scribed as the right to be left *lone, isthe notion that an individual has a rightnot to be hurt by intrusions into his es-sentially personal concerns, or to haveessentially private information exploitedfor commercial gain, whether or not theintrusion or exploitation is in connectionwith any possible governmental actionagainst him. The courts have spoken of aright of privacy in wide variety of con-texts, but they have repeatedly and ex-Pllcitly rejected the notion that anyonehas right to go about his daily affairsencapsulated-in an impenetrable bubbleof anonymity. The courts have been care-ful to weigh the competing interests, andthe social interest in valid research andevaluation is clearly of sufficient momentto be considered in this Process.

(e) In defense of the position thatdisclosure of patient identifying infor-mation even for carefully guarded ad-entilz research should be permitted onlyon a consensual basis, two dominant linesof argument. somewhat interrelated.have emerged. One is that retrospective

Mita It101574, VOL 40; NO; 127TIMODAY, SAY L 1175

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studies are of questionable value in anycase, and the other is that a samplingtechnique involving infcrmed consent onthe part of the members of the samplecon always be used to develop the in-formation sought. Neither line of argu-ment will withstand careful scrutiny.

(f) It Ls- true, of course, that theefficacy of a given therapeutic agent canoften. best be evaluated by means of awell-designed prospective study in whichspecial recordkeeping procedures, specialcriteria for patient selection, and anappropriate control have all been estab-lished with a view to the purpose of thestudy. There are, however, many-impor-tant investigations which simply do notlend themselves to such a format. Soine-times the desirability or even the pos-sibility of a particular study does notsuggest Itself except in retrospect.Another important consideration is thefact that knowledge that an investiga-tion is going on may influence the be-havios, of patients, clinicians, or both.Where such knowledge can influence themake-up of a sample, It will normally doso in the direction of favorable outcomes,but to an unknown degree, thus tendingto invalidate the results reported.(g) While the sample technique has its

uses, especially with populations that areunmanageably large, it is often less dif-ficult and expensive, and less likely to'interfere with the actual conduct andoutcomes of treatment or rehabilitationprocesses, to use the full population understudy. Even more important than eco-nomy and administrative convenience incarrying out a study, there may be anoverriding advantage in terms of elimi-nating any question es M the validity ofthe results of the study on the ground ofbias in the selection of the sample.

(h) informed Consent. The duty toobtain informed consent Is obvious andcompelling lir situations where. an WM-vidual 1s exposed to the PosaltilltY ofharm, either physical or psychological, -as a consequence of medical procedures,research.- or similar activities. Wheresuch a situation exists the person con-ducting the research or medical Pro-cedure violates his duty to the subjector patient if he proceed, without obtain-ing the voluntary informed consent fromthe individual or his legally authorizedrepresentative. Thus, in conducting anactivity which places the subject orpatient at risk_ the practitioner maynot give precedence to a hidden agenda.even for so lofty a motive as theadvancement of knowledge. In this re-gard, see the Department of Health, Edu-cation and Welfare's Protection of Hu-man Subjects Regulations, 45 CFR Part46. Those regulations are applicable toall Department of Health, Education andWelfare grants and contracts supportingresearch, development and related -ac-tivities involving, human subjects.

(I) It Is apparent that the foregoingrationale for requiring informed con-sent does not apply to the.same degreein situations involving the disclosure ofclinical records for research in the formof follow -up or retrospective studies. Un-der these circumstances the risk to the

. .

RULES AND REGULATIONS

subject Is that some disclosure or misuseof information from which he could beidentified might result in embarrassment,lost opportunities, or other forms ofpsychological or social Injury. Whilethat possibility of harm could be re-duced by requiring consent to every re-view of clinical records for research pur-poses, a similar result can be achieved bythe less restrictive method of limitingfurther disclosure of identifying infor-mation by the researcher. Given the 'ap-Plicability of this alternative, equally_effective means for protecting a patientor subject from the possibility of aharmful public disclosure, it is unreason-able to insist upon informed consent toevery review of clinical records for thepurposes of conducting legitimate re-search, particularly since such insistencecould lead to the ultimate absurdity ofprohibiting efforts to identify the natureand source of an unknown plague simplybecause the patients or researcher lackedthe clairvoyance to have consent formssigned prior to the onset of theaffliction.

(I0 In sum, there are restraints on cer-tain means of governmental acquisitionof information about individuals whichare operative irrespective of how the in-formation Is used, and there are re-straina on the uses of informationwhich are independent of how or bywhom It is acquired, but they do not andshould not add up to the proposition thatthe use of information about a person.Is either morally or legally the absoluteprerogative of that person to determine.

(k) For all of these reasons, the au-thorizing legislation expressly Drovideffthat patient consent is not required withrespect to disclosures for research, audit,and evaluation, nor does It prohibit in-dividual patient identification in connec-tion with-such disclosures. While it isentirely appropriate to impose see"guards and procedures in connectionwith these activities, It would be whollyinappropriate to use the rulemakingprocess to impose an' absolute require-ment. of patient consent with respect toactivities which by statute may beconductee without it.

(1) Classification of activities. It isclear that Congress intended a balancingof the social interest in the validity ofthe results of inquiry, on the one hand,with the individual interest in anonym-ity, on the other, all within the limitsset by_the legislation and the constitu-tion. With that objective in mind, wemay now turn to the various categoriesof activities which come within the pur-view of this subpart.

(m) These activities may be classified'first, in regard to whether participationis voluntary from the standpoint of theprogram, and second, as to whether theobjective Is to ascertain compliance withnridetermined standards (examinationsas defined in 2 2.54, and Program evalua-tion as defined in § 2.11(g) (I)), or toascertain the validity of a given standardor hypothesis -(scientific research, and.Program evaluation as defined in 1 2,11(g) (2) 2, The application of the fore-going classifications logically results in

the creation of four categories of activi-ties. Three of them are specifically dealtwith in the succeeding sections of thissubpart and need not detain us here; thefourth is disc Issed below.

(n) Scientific research and evaluation.Beyond the bare restatement of the au-thorizing legislation set forth in 1 2.52,these regulations are deliberately silentwith respect to purely voluntary scientificresearch and program evaluation in thesense defined in 2.11(g) (2). Testimonyand written comments received on theAugust 22, 1974 draft regulations werenoteworthy in two respects. First, noinstances of abuse on the part of personsat-miring patient identifying informs-.ion under these circumstances werecited. Second, 'while there was some well -founded criticism of the attempt in thatdraft to provide guidelines for determin-ing what is scientific research and whois qualified to do It, no usable alterna-theeIndeed, almost no alternatives atallwere forthcoming.- (o) In one of the written comments,

the writer cautioned against any assump-tion "that our major remaining problemsin drug and alcohol abuse treatment areprevention of illicit diversion and Pro-tection of confidentiality," and suggested

-"that we still have a problem In discover-ing; testing and evaluating improvedtreatment techniques. To do this," hecontinued, "one should place minimalobstacles in the way of bona fide clinicaland epidemiologic research!"

(P) The result of leaving the rule as ItIs in the statute, without attempting tosharpen its outlines or define Its terms,will be to leave It for Interpretation ona case-by-case basis by those who mustapply it in practice: the researchers whoseek the information, and the .Programswhich supply It. This does not foreclosethe possibility of amending the regula-tions on the basis of experience if It ap-pears either that clinicians are becomingso cautious that research and evaluationstudies are being choked off, or thatabuses are occurring in the use of In-formation disclosed. But until a need formore detailed regulation in this area isdemonstrated, we think Its impositionwould do more harm than good.§ 2.53 Governmental agencies.Rules. -

(a) In general. Where research, audit,or evaluation functions are Performed byor on behalf of a State or Federal gov-ernmental agency, the - minimum quali-fications' of personnel performing suchfunctions may be 'determined by suchagency, subject to the provisions of thispart, with particular reference to the or-ganizational requirements and limita-tions on the categories of records-sub-ject to review by different categories ofpersonnel.

(b) Financial and administrative rec-ords. Where program records are re-viewed by personnel who lack either theresponsibility for, or appropriate trainingand supervision for, conducting scien-tific research, determining adherence totreatment standards, or evaluating treat-ment as such, such review should be con-fined as far as practicable 'to adminbi-

MBA REGISTER, VOL 40, NO. 127TUESDAY, JULY 1, 1973. .

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trative and financial records. Under nocircumstances should such personnel beshown caseworker or counsellor n0140, orsimilar clinical records. Programs shouldorganize their records so that financialand administrative matters can be re-viewed without disclosing clinical infor-mation and without disclosing patientidentifying information except whennecessary for audit verification.

(c) Scientific research and long-termevalwition studies. No State and noagency or political subdivision of aState may require, as a condition tofunding, licensing, or otherwise, that anyprogram furnish patient identifying in-formation for the purpose of conductingscientific research or long-term evalua-tion studies unless the recipient of suchinformation is legally required to holdsuch information in confidence, is pro-hibited from taking any administrative,investigative, or other action with re-spect to any individual patient on thebe= of such information, and is pro-hibited from identifying, directly or in-directly, any individual patient in anyreport of such research or evaluation, orotherwise disclosing patient identitiesin any manner.

(d) Opinion and description to befurnished program. Before any patientidentifying information is required to besubmitted by a program under the cir-cumstances described in paragraph (c),the program shall be furnished

(1) An opinion by the attorney generalor other chief legal officer of the Stateto the effect that the conditions specifiedin paragraph (c) are fulfilled with re-

- spect to such program or with respect' toall programs in such State similarlysituated, and

(2) A description of the administra-tive procedures and physical limitationson access or other measures to providefor the security of the data, but suchdescription shall not be in such detail asto furnish guidance for wrongful at-tempts to breach such security.

(e) txclativeness of Procedures. Noseats or local governmental agencymay require any treatment program tofurnish patient identifying informationto itself or any other recipient except inconformity with this section or 12.54.No Federal agency may require anytreatment Program' to furnish patientidentifying information to itself or anyother recipient except in conformitywith this section (other than paragraph(d) (1) thereof) or 12.54.I 2,53-1 Governmental agencies Buis

and purpose.Section 2.53 is an implementation of

the authority contained in subsection(g) of-the authoriling legislation to pro-vide safeguards and procedures to effec-tuate the PUrposes of such legislation.It makes clear that whenever infor-mation is required of a program,whether by Iaw or by the terms ar con-ditions of a contract or grant, the pro-cedures and safeguards required underthis section are applicable.

45 9- 3 40 0 - 84 - 5

RULES AND REGULATIONS 27817

I 2.54 Patient identifying information ten notice to this effect is furnished toIn romeakee with examinations.-- the program within two years after theRules. record was acquired, not later than the

termination of such proceeding.(f) Notice 14 final disposition. When

an examiner disposes of records as re-quired by paragraph (d) of this section;cr_not later than the time prescribedby paragraph (e) of this section, which-ever is earlier, the examiner shall furnishto the program concerned writtenstatement -

(1) That there has been compliancewith this section and with the provisionsof this part prohibiting any disclosure Ofpatient identifying information from re-cords held-by auditors or evaluators, or

(2) Specifying the particulars in whichthere has been failure of compliance.

(a) Definitions. For the purposes ofthis section

(1) The term "examination" meansNV examination to which this section ismade applicable by paragraph (b) of thissection.

. (2) The term "examiner" means anyindividual or any public or private or-ganisation, including any Federal, State,or local governmental agency, which con-ducts an examination to which this sec-tion applies,

(b) Applicablfity, This section appliesto any examination of the records of atreatment program which is carried outfor the purpose of or as aid to ascer-taining the accuracy or adeqtr.z. of its 1 2,54-1 Patient identifying Informs.financial or other records, the don in connection with mum sins.ciency or effectiveness of it-, financial. ad- dom.Dash and purpose.ministrative; or medical .-e''..aagenient, orits adherence to flnanci 1, legal, medical,administrative, or other standards, re-gardless of whether such examinationis called an audit, an evaluation, an in-sPection, or by any other name.

(c) Statement required for disclosureof patient identifying Information in con-nection with examination. No programmay make, and no examiner may require,any disclosure of patient identifying in-formation in connection with an exami-nation unless the examiner furnishes tothe program written statement

(1) that no record of patient identify-ing information will be made or retainedby or on behalf of the examiner in con-nection with the examination Withoutnotice to the PrOZram in accordance withparagraph (c) (2) of this section, or

(2) setting forth the specific PUrPosafor which a record of patient ldentffylnginformation is being retained by or onbehalf of the =emitter, the location atwhich such information will be kept, andthe name, official title, address, and tele-phone number of responsible individualto whom any inquiries by the' programabout the disposition of such recordshould be directed.

(d) Disposition of record of patientidentifying information in connectionwith examination. After any record ofpatient identifying information retained'in connection with an examination hasserved its purpose, or within tha time pre-scribed in paragraph (e) of this section,whichever is earlier, the examiner shalldestroy or return to the program all rec-ords (including any copies thereof) con-taining patient indentifying informationwhich have been In its Possession In con-nection with such examination.

(e) Maximum time allowed for dispo-sition. The action required by paragraph(d) shall be completed

(1) Except as Provided in paragraph(e) (2) of this section ant more then twoyears after the record was acquired by oron behalf of the examiner, or

(2) Where the record is needed in con-nection with formal legal proceedingagainst the program commenced or to be address of the patient to whom it refers.commenced not more than two years -Upon request at any time and withoutafter the record was acquired, and writ- advance notice, but subject to the pro-

Confidence on the part of treatmentprOgram Personnel in the integrity ofauditing and regulatory processes is im-portant to the effective functioning of thetreatment system. It is the purpose of

2.54 to foster practicer' which will bothjustify and engender such confidence.12.55 Supervision and regulation of

narcotic maintenance and detoxifies.lion programaItalie.

(i) Definition of "registrant". For thepurposes of this section, the term"registrant" means a person who(1) has pending an application for regis-tration under section 303(g) of the Con-trolled Substances Act (21 U.S.C. 123(g) ) , or (2) has been registered undersuch section and whose registration has -not expired or been surrendered or re-yoked.

(b) Drug Enforcement Administra-tion. Duly authorized agents of the DrugEnforcement Administration. shall haveaccess to the premises of registrants forthe purpose of ascertaining compliance(or ability to comply) with standards es-tablished by the Attorney General undersection 303(g) (2) of the Controlled Sub-stances Act (21 U.S.C. 1123(1) (2) ) re-specting the security of stocks of narcoticdrugs and the maintenance of records (inaccordance with section 307' of the Con-trolled Substances Act, 21 U.S.C. $27) onsuch drugs. Registrants shall maintainsuch records separate from and in addi-tion to patients' clinical records requiredto be maintained under 21 CFR 310.505(d) (7) (iii), which shall not be availableto such agents except as authorizedunder court order in accordance withSubpart B of this part. Records main-tained by registrants for the purposes ofsection 307 of the Controlled SubstancesAct (21 U.S.C. 1127) need not identifypatients by name, address, social securitynumber, or otherwise except by anidentifying 'number assigned by theregistrant, but where such system isUsed. the registrant shall maintain on acurrent basis cross-index referencingeach identifying number to the name and

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27818 RULES AND REGULATIONS

visions of 1 2.54, such agents shall begranted immediate access to any suchindex. Such agents may use names andaddresses so obtained strictly for the pur-poses of auditing or verifying programrecords. and shall exercise all reasonableprecautions to avoid inadvertent disclos-ure of patient identities to third parties.Names and other identifying informationso obtained may not be complied or usedin any registry or personal data bank ofany description.

(c) Food and Drug Administration.Duly authorized agents of the Food andDrug Administration shall have access tothe premises of registrants and to allrecords maintained by registrants, for thePurpose of ascertaining compliance (orability to comply) with standards es-tablished'. by the Secretary of Health,Education and Welfare under section 4of the Comprehensive Drug Abuse Pre-vention and Control Net of 1970 (42U.S.C. 257a), sections 303(g) (1) and 303(g) (3) of the Controlled Substances Act(21 U.S.C. 823(g) (1) and 823(g) (3)),and sections 505 and 701(a) of the Fed-eral Food, Drug, and Cosmetic Act (21U.S.C. 355 and 371(a) ). When necessaryin the conduct of their duties, .and sub-ject to the provisions of 12.54, agentsmay use names and addresses of patientsstrictly for the purposes of auditing orverifying program records, and shall ex-ercise all reasonable precautions to avoidinadvertent disclosure of patient identi-ties to third parties. Names and otheridentifying information on patients ob-tained pursuant to this section or by anyother compulsory process may not becompiled'or used in any registry or per-sonal data bank of any description. Ex-cept as authorized under this paragraphor by a court order granted Under Sub-part E of this part, (1) such agents maynot, either orally or in writing; exceptin conversation with personnel of theregistrant while on the premises of theregistrant, identify any patient otherwisethan by reference to an identifying num-ber assigned by the registrant, -and (2)such agents may not remove from thepremises of the registrant any notes.documents, or copies thereof which con-tain patient.identifying Information.

(1) State drug law enforcement agen-des. Duly authorized agents of any Statedrug law enforcement agency havingjurisdiction. and specific responsibilityby statute or otherwise for the enforce-ment of criminal laws relating to con-trolled substances (as defined in theControlled Substances Act) shall haveaccess to the premises of any registrantfor the purposes (with respect to coraresponding provisions, If any, of Statelaw) and subject to the restrictions andlimitations set forth in paragraph (b)of this section, and subject to 1 2.54. -

(e) State health authorities.(1) Definition cg "qualified State

health agency". As used in this para-. ,graph. the term "qualified State health

agency" means an agency of State gov-ernment (1) which has express legalresponsibility to ascertain that regis--trants under its jurisdiction comply withappropriate treatment standards; (11)

which is legally' and administrativelyseparate from any agency of State gov-ernment responsible for investigation ofviolations of, or enforcement of, criminallaw generally or criminal laws relatingto controlled substances; (ill) whosepersonnel are qualified by training orexperience to conduct Inspections ofhealth care facilities to ascertain com-pliance with treatment standards; and(iv) whose personnel are by State law,or by published administrative directiveenforced by effective sanctions, requiredto maintain the confidentiality of anyinformation concerning the identity ofpatients which they may acquire in thecourse of their official duties

(2) Access. Duly authorized agents ofa qualified State health agency shallhave access to the premises of registrantsand to all records maintained by regis-trants, for the purpose of ascertainingcompliance (or ability to comply) withtreatment standards. (including thoserelating to quantities of narcotic drugswhich may be provided for unsuperviseduse by individuals in treatment) estab-lished under State law. Such access, andthe use of any information thereby ob-tained. shall be subject to the restric-tions and limitations set forth in para-graph (c) of this section, and subjectto 1 2.54. -

2.55-1 Supervision and regulation ofnarcotic maintenance and detoxifica-tion programs.Basis and purpose.

(a) Section 2.55 is addressed to thegeneral problem described in the follow-ing passage from the legislative historyof Pub. L. 93282:

A major element of the task of fashioningnew regulations pursuant to the expressrulemaking authority conferred by this In-hibition will be to reconcile the sometimesconflicting interests of research, audit, andevaluation with rights of privacy and theconSdentiality of the relationship betweenpatient and clinician. Such a reconciliationbecomes particularly crucial where the func:. -tions of research, audit, or evaluation areconducted by a governmental agency withregulatory powers and responsibility, andthe treatment involves the us* of drugsuch as methadone which is in researchstatus or which is readily susceptible of mis-use or illicit diversion.

Because of the difficulty and complexityof the task, the rulemaking authority is in-tentionally cast In terms broad enough topermit the limitation of the scope, content,or circumstances of any clitcloams undersubsection (b), whether (b) (1) or (b) (2),in the light of the necessary purposes forwhich it is made or required. (Congressional.Record, daily edition, May e, 1574, peg.H3513).

(b) It has been the consistent inter-pretation of the Special Action Officefor Drug Abuse Prevention that the only.provision of the authorizing legislationwhich permits disclosures to complianceofficers, whether of DEA, FDA, or stateagencies, is subsection (b) (2) (B). Thatsubsection. strictly prohibits any furtherdisclosure of names or other identifyinginformation concerning patients, and thestatutory prohibition has been but-tressed by provisions of these regula-tions, notably' 1 2.54, providing safe-

guards and procedures to assure that thestatutory prohibition is respected.

(c) In testimony and written com-ment on the August 22, 1974 draft ofthese regulations. it has been urged thataccess to patient identifying information

.by law enforcement personnel, even forthe limited purposes allowed by statuteand regulation, should be prohibited ex-cept pursuant to a court order obtainedunder 21 U.S.C. 1175(13)(2) (C). Webelieve that such a prohibition isbeyond our power to impose.

(d) Section 307(b) of the ControlledSubstances Act (21 U.S.C. 827) provides,

-in pertinent part, "Every recordrequired under this section shallbe kept and be available, for at least twoyears, for inspection and copying byofficers or employees of the United Statesauthorized by the Attorney General." It

. is a well known principle of statutoryconstruction that amendments and re-peals by implication are not favored. InPeople V. Newman, 32 N.Y.2d 379, 345N.Y.S.2d 502, 298 N.E.2d 851 (1973),cert. denied 414 U.S. 1103, 94 S.Ct. 927,39L. Ed. 2d 118 (1974), the United Statesfiled amtcus briefs with the Court of Ap-peals of New York and with the UnitedStates Supreme Court, arguing that sec-tion 408 of Pub. L. 92-255 (21. U.S.C.1175) did not effect an implied amend-ment or repeal of the provisions of Pub.L. 91-513 (21 U.S.C. 872(c) and 42 U.S.C.242a(a) ) which confer on tho AttorneyGeneral and the Secretary of Health,Education, and Welfare the power togrant the so-called research privilegediscussed in 12.24. This position wasexpressly adopted by the New Yorkcourt.. We cannot now take the incon-sistent position that section 408 of Pub.L. 92-255 did indeed amend by implica-tion section 307 of Pub. L. 91 -813, par -ticularly in the face of a contrary 'con-temporaneous administrative interpreta-tion by both the Special Action Officefor Drug Abuse Prevention and the De-partment of Justice. In short, if the rightof access and copying conferred on Fed-eral agents by 21 U.S.C. 827 is to beamended to provide that it may onlybe exercised pursuant to a court orderin the case of maintenance and de-toxification programs; that is a changewhich must be wrought by the Congress.

(a) In the case of inspections carriedout by health supervisory agencies, wethink that denial of access to any docu-ments showing patient identifying in-formation may have a serious adverseeffect on the validity of the inspectionprocess. Even if a program keeps its ownrecords in terms of patient-identifyingnumbers assigned by the program, thepatient file may containmay, indeed,be required to containdocumentssigned by the patient or originating outsside the program. Where signatures,names, and addresses are all obliterated,it is impossible for the inspector to checkthe me even for apparent internal con-sistency. We believe that outright for-gerY is and will remain a rarity&but thetemptation to cover Improper or inade-quate documentation by "accidentalmistillngs" may' be something elseagain.

FEDERAL REGISTER, VOL 40. NO. 137TUESDAY, Ju 1, 1975

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(f) Prom a legal standpoint, the term"audit" has long comprehended thenotion of external verification. In acommercial setting, this means that atleast some inventory will actually becounted, at least some receivables will beverified by contacting the customers,and so on. To rule that this crucialaspect of the audit process cannot becarried out with respect to a treatmentprogram until after the auditor goesthrough the procedure of obtaining aspecific court order under subsection(b) (2) (C) would seem to contravene theintent of subsection (b) (2) (B).

(g) In all of this. our dubious mustbe illuminated by a balanced considera-tion of the best interests of the patientno less than a desire to foster the im-plementation of cherished values insociety at large. If protection of thepatient's right to privacy is achieved-bymeans which seriously impair our abilityto protect him from exploitation andmalpractice, not to mention the diversionof funds intended for his benefit, itwould be a hollow victory indeed. Webelieve that the procedures and safe-guards which these regulations imposeon the conduct of audit* and evaluationswill avoid that result, while affordingsubstantial and meaningful new protec-tion to the confidentiality of patientrecords.

2.56 Prohibition on disclosure of pa.tient identities from research, audit,or evaluation records--Rules.

Where the content of patient recordshas been disclosed pursuant to this sub-part for the purpose of conducting scien-tific research, management audits, finan-cial audits, or program evaluation.information contained therein whichwould directly or indirectly identify anyPatient may not be disclosed by the re-cipient_ thereof either voluntarily or inresponse to any legal process whetherFederal or State,. This prohibition doesnot affect the accessibility of the originalrecords under authority of a court orderreferred to in subpart E.,1 156-1 Prohibition on disclosure of

patient identities from research,audit, or evaluation reeordsBasisand purpose.

Section 2.58 restates the Prohibition onfurther disclosure which is contained insubsection (b) (2) (B) of the authorizinglegislation. The relationship of the pro-visions authorizing court orders to theprovisions authorizing disclosure for re-search, audit, and evaluation, is dealtwithin I 2.82.

Subpart E--Court OrdersI 2,61 Legal effect of order--Rules.

Subsection (b) (2) (C) of the sectionswhich authorize this part (21 11.S.C.1175and 42 T.S.C. 4582) empowers the courts,in appropriate circumstances, to author-ize disclosures which would otherwise beprohibited by subsection (a) of thosesections. Subsection (b) (2) (C) operatesonly as mechanism for the relief of theduty imposed by subsection (a)' and notas an affirmative grant of Jurisdiction to

AND REGULATIONS

authorize or compel disclosures pro-hibited or privileged by other provisionsof law, whether Federal or State. Anorder or provision of an order based onsome other authority, or subpoena, orother appropriate legal proems, is re-quired to compel disclosure. To illustrate,if a person who maintains records sub-ject to this part is merely requested. oris even served with a subpoena, to dis-close information contained therein in amanner prohibited in the absence ofcourt order, he must refuse such a re-quest =lees, and until, an order is issuedunder subsection (b) (2) (C). Such anorder would remove the prohibition, butcould .not.,of its own force, require dis-closure. If there were no subpoena orother compulsory process, or a subpoenahad been issued but had expired or beenquashed, the custodian of the recordswould have discretion as to whether todisclose the information sought unlessand until disclosure were ordered bymeans of appropriate legal or adminis-trative process, the authority for whichwould have to be found in some sourceother than subsection (b) (2) (C) of thesections authorizing this part.

2.61-1 Legal effect of orderBasisand purpose.

..(a) Section 2.81 is restatement athe interpretative rules embodied in

1401.81 and 1401.52 of the pre-vious regulations. Both the position-ing of the authority to issue court ordersIn S. 2097 as initially Passed by the Senate(92nd Congress, 1st Session, December 2,1971) and the explicit cross-reference insection 40$(a) of Pub. L. 92-256 makeclear tile coat:unions' intent that sec-tion 405(b) (2) (C) operate as mecha-nism for the relief of the 4011(a), stric-tures and not as an afermative grant ofJurisdiction to authorize disclosures pro-hibited by other provisions of law,whether Federal or State.

(b) The amendment made by Pub. L.93-282 to section 333 of the AlcoholismAct (42 T.S.C. 4582) was enacted withthe same language and structure as sec-bon 40S in this regard in order to makethe interpretative rules set forth in I 2.61applicable to it.

orji 2.63 Inapplicability to secondary ree-

ds--Bules.The authority which subsection-

(b) (2) (C) of the sections which author-ise this part (21 V.S.C. 11.75 and 42 T.S.C.4512) confers on courts to hub ordersauthorizing the disclosure of records ap-plies. only to records referred to in sub-section (a) of such sections, that is, therecords maintained by treatment or re-search programs which have patients,and not to secondary records generatedby the disclosure of the subsection (a)records to reeearchers, auditors, or eval-uators pursuant to subsection (b) (2) (B).{ 2.62-1 Ina plicability to secondary

asis and purpose.

(a) The interpretative rule set forthin 1 2.82 is an essential and basic limita-tion on the scope.a (b) (2) (C) orders.It was part of the original regulationsunder section 408 of Pub. L. 92-255 pub-

-271419

lisped November 17, 1972 (37 FR 2038),and was carried forward =change 1 inthe amended regulations published De-cember 8, 1973 (38 FR 33746). the specialstatus of which has already been notedin i 13. Bee, also, 2.81-1.

(b) Although this rule is well sup-ported by the history and technicalstructure of the legislation, the Trollerconsiderations in its favor are even morecompelling. In 2.52-1, we have dis-cussed the urgent necessity for access.even without patient consent, to patientrecords on the part of qualified person-nel engaged in scientific research andevaluation. Where this access includesPatient identifying information, as itsometimes must if vital work is to bedone, there must not be any questionwhatsoever about the legal inviolabilityof its confidential status in the handsof the researcher. Granted,. there mayoccur rare occasions when the originalrecords are for some reason not avail-able, where (b) (2) (C) order would lieas to the original records, and wherethere would seem to be some advantagein the administration of Audios for suchan order to permit disclosure of identi-fying information by the researcher. Butcompared to the damage which the merepotentiality for access does to the wholeresearch enterprise, the advantage interms of ability to deal with rare andanomalous cases seems almost trivial.Even in those cases, denial of access tothe party seeking the information leaveshim in no worse position than if the re-search or evaluation, which was cer-tainly not Undertaken for his benefit, hadnever been done at AIL

(c) Where tho secondary records aregenerated under the circumstances de-scribed in { 2.54, of course, this ariament does not apply. In that situation,if preliminary examination suggests thatthe records may be needed for canon-s:ace or other administrative or Judicialproceedings, the person conducting theaudit or other examination shouldpromptly seek the authority of courtorder to copy the original records. Theum of secondary records thus generatedunder authority of a court order wouldthen be limited by the terms and Pur-poses of the order, rather than subsec-tion (b) (2) (B) of the authorizing legis-lation, and thus the rule set forth in1 2.82 would not aPPIY.

{ 2.63 Limitation_ to objective datelining.

(a) Limitation to object*/ data. Ex-cept as provided in paragraph (b) of thissection, the scope of an order issued Pur-suant to this subpart may not extend tocommunications by a patient to person-nel of the program, but shall be limitedto the fact. or data of enrollment, dis-charge, attendance, medication, andsimilar objective data, and may includeonly such objective data as is necesser7to fulfill the purposes for which the order1 issued.

(b) gxception. When a patient inlitigation offers testimony or other evi-dence pertaining to the content of hiscommunications with a program, anorder under this subpart may authorise

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27820

the submission of testimony or otherevidence by the program or its Per-sonnel.g 2.63-1 Limitation to objective data.-...

Basis sad purpose.In the three-year period subsequent

to the original enactment of 21 U.S.C.1175. not a single occasion was reportedto the Special Action Office for DrugAbuse Prevention on which an attempt

made to secure a (b) (2) (C) orderauthorizing the disclosure of a confi-dential communication by a patient toa counsellor or other member of the staffof a treatment progr:m. In all of thecomments and testimony received on thedraft regulations published August 22,1974, there was nothing to suggest anycircumstances under which a court orderauthorizing such a disclosure would beeither desirable or appropriate. Yet themere possibility that such an order mightbe issued Is to some a source of anxietywhich impairs the effectiveness of treat-ment. Such an ongoing relative effectclearly outweighs the remote theoreticalpossibility that some peculiar circum-stance might arise in which judicial au-thorisation for such a disclosure mightba nought, Accordingly, the limitationimposed by 1 2.63 on the scope of (b) (2)(C) orders to preclude that possibility,and hence to eliminate its adverse in-fluence on treatment services, appearsto be a proper exercise of rulemakingpower.

2.64 Procedures and criteria in gen-eralRules. .

(a) identity of .patient: Applicationsfor court orders to authorize disclosureof records pertaining to a known patientshall- not use the real name of the patientunless the patient consents theretovoluntarily and intelligently. In the cueof an es parte application initiated bythe Patient, the application should beinstituted in the name of a fIctious per-son, such as Jon Doe, unless the patientrequests otherwise. The same procedureshould be followed in the case of sepa-rate proceeding held in conjunction witha pending criminal or civil action. Anycourt order should identify the patientfictitiously, and the disclosure of thepatient's real name should be comnumi-ated to the program in such manner asto protect the confidentiality of the Pa-tient's identity.

(b) Notice. In any proceeding nototherwise provided for in this subpart,in which the patient or the program hasnot been made a party, each shall begiven appropriate notice and an oppor-tunity to appesr in person or to file aresponsiVestatement, deposition or otherform of response consistent with localrules of procedure. The court shall givedue consideration to any such statement,deposition ,or other response in exercis-ing its discretion as to the existence ofgood cause and, if deemed necessary ordesirable, consistent with local rules ofProcedure, it may order the program di-rector 'to appear and give direct testi-mony.

(c) Hearings. All hearings and all evi-dence in connection therewith shall be

RULES AND REGULATIONS

held or taken in the judge's chambers,unless the patient requests an open hear-ing or the court determines that suchhearing Is consistent with the public in-terest and the proper administration ofjustice.

(d) Good cause. No order shall be is-sued unless the record shows that goodcause exists, and in assessing good cause,the court shall weigh the public interestand the need for disclosure against theinjury to the patient, to the physician-patient relationship, and to. the treat-ment services.

(e) Need for disclosure. If other atm-.petent evidence or sources of informationars available, the court should ordinarilydeny the application

(f) Adverse effects. If there is evidencethat disclosure would hays an adverseeffect upon succssful treatment or re-habilitation of the patient ,or would im-pair the effectiveness of the program, orother Programs similarly situated, in thetreatment or rehabilitation of other Pa-tients, the application should be deniedunless the court finds that the adverseeffects are outweighed by other factors.

(g) Content- of order. Any order au-thorising disclosure shall

(1) Limit disclosure to those parts ofthe patient's record deemed essential tofulfill the objective for which the orderwas granted;

(2) Limit disclosure to those personswhose need for information Is the basisfor the order; and

(3) Include any other appropriatemeasures to keep disclosure to a mini- .morn for the protection of the patient,the physician-patient relationship andthe treatment services.

(h) Applications not otherwise pro-vided for. In any case not otherwise pros-'Tided for in this subpart, application foran order authorizing disclosure of rec-ords to which this part applies may be

- made by any person who has a legallycognizable interest in obtaining such dis-closure.g 2.64-1 Procedures and criteria in atm.

eraL--Basis and purpose..Section 2.64, in accordance with sub-

section (g) of the authorizingsets out procedures and criteria for theissuance of (b) (2) (C) orders in general,subject to the more sPecific provisionswith respect to particular types of pro-ceedings covered in the succeeding sec-tions of this subpart.g 2.65 Investigation- and prosecution of

patients.Rules.(a) Applicability. This section applies

to any application by an investigative,law enforcement, or prosecutorial agencyfor an order to permit disclosure of pa-tient records for the purpose of conduct-ing an investigation or prosecution of anindividual who Is, or who Is believed tobe, a present or former patient in aprogram.

(b) Notice. Except where an orderunder 1'2.68 Is sought In conjunctionwith an order under this section, anyProgram with respect to whose recordsan order is sought under this sectionshall be notified of the application and'

afforded an opportunity to appear andbe heard thereon.

(c) Criteria. A court may authorizedisclosure of records pertaining to apatient for the purpose of conductingan investigation of or a prosecution fora crime of which the patient Is suspectedonly if tis.7. court finds that all of thefollowing criteria are met:

(1) The crime was extremely serious,such as one involving kidnapping, homi-cide, assault with a deadly weaPon, armedrobbery, rape, or other acts causing ordirectly threatening loss of life or seri-ous bodily injury, or was believed to havebeen committed on the premises of theprogram or against personnel of the pro-iram

(2) There Is a reasonable likelihoodthat the records in question will disclosematerial information or evidence of sub-tandal value in connection with the in-vestigation or prosecution.

(3) There Is no other practicable wayof obtaining the Information or evidence.

(4) The actual or potential injury tothe Physician- patient relationship in theprogram affected and in other programssimilarly situated, and the actual orpotential harm to the ability of such pro-grams to attract and retain Patients, isoutweighed by the public interest in au-.thorizing the disclosure sought.

(d) Scope. Both disclosure and dis-semination of any information from therecords In question shall be limited underthe terms-of the order to assure that noinformation will be unnecessarily dis-closed and that dissemination will be nowider than necessary. Under no circum-stances may an order under this sectionauthorize a program to turn over patientrecords in general, pursuant to a sub-poena or otherwise, to a grand jury ora law enforcement, investigative, or pro-secutorial agency.

(e) Counsel. Any application to whichthis section applies shall be denied unlessthe court makes an explicit finding tothe effect that the program has been af-forded the opportunity to be representedby counsel independent of counsel forthe applicant, and in the case of anyprogram operated by any department oragency of Federal, State, or local Gov-ernment, is in fact so represented.g 2.65-1 Investigation and prosecution

of patients--Basis and purpose.(a) The need for objective criteria for

the issuance of court orders in connec-tion with investigation or prosecution ofPatients seems particularly pressing. Inthe absence of such criteria, the assur-ance of confidentiality otherwise pro-vided for by the authorizing legislationmay be felt to be of little value.

(b) It has not been found possible toframe entirely satisfactory rules for thescope of orders under 1 2.65, but an illus-tration may be helpful. Where a witnessto a crime is believed capable of identify-ing a suspect by appearance, and the cri-teria_ set forth in 1 2.65(c) are met, andthe program has photographs of its pa-tients, the witness alone may be permit-ted to view the photographs, with nonames attached. If the witness failed toidentify any photograph as being a plc-

FEDERAL 'REGISTER, VOL 40, NO. 127TUESDAY, JULY I, 1575

B--20

68

_tun of the suspect, that would end thematter. If there was such an identifica-tion. the program would be authorizedto give any information In Its possessionas to the suspect's Identity and where-abouts to appropriate authorities.

(C) It Is ILA the purpose of this nanoto substitute a mechanical formula forJudicial discretion, but rather to providecriteria which define the area withinwinch discretion Is to be exercised. Thereason for Including all crimes commit-ted on program premises or against Pro-gram personnel is not any special solici-tude for programs as opposed to othervictims of crime, but le rather the re-sult of the special difficulties which thebroad definition of "records" In 12.11(o)creates for program personnel as com-plaining witnesses.

(d) In regard to 2.65(e), experiencehas demonstrated that independentcounsel may be of crucial importance.The leading case construing 21 U.S.C.1175, People v. Neuman, 32 N.T.2d 379,348 N.T.B.2d 502, 296 N.11.2d 651 (1973) ;certiorari denied, 414 U.B. 1163, 04 13.Ct.927, M L. Ed.2d .116 (1974), would neverhave been presented to the courts but forthe fact that legal counsel for Dr. New-men was furnished on a Pro bono Public°basis by a print* law firm. In an entirelyditrYr=.-6 case. a United States DistrictCourt appears to have issued wholly In-appropriate order under 21 U.B.C. 1175 ina case In which the treatment programInvolved was operated by an agency ofthe United States. Government, andeither was unrepresented, or was repre-sented by the same attorney who repre-sented the agency seeking the order. It Ispossible, of course, that the order wouldhave been issued in any event. but Itseems clear that there was no adequatePresentation to the court of arguments ortestimony in opposition. It 1 difficult tosee how the purposes of subsection (b)(2) (C) of the authorizing legislation canbe carried out if there Is inadequate Pres-entation of the issues to the courts whichmust decide them.

2.66 Investigation and prosonnion of_ programRubes. -

(a) Applicability. This section appliesto any application by an administrative,regulatory, supervisory, investigative, lawenforcement, or prosecutorial agency foran order to permit disclosure of patientrecords or the making of copies thereof(including patient identifying informa-tion) for the purpose of conducting anInvestigation or an administrative or ju-dicial proceeding with respect to anyprogram or any principal, agent, or em-ploye* thereof In his capacity as such.

(b) Notice. An application under thissection may, In the discretion of thecourt, be granted without notice, butupon the implementation of any order sogranted. the program shall be affordedan oppoetinity to seek the relocation oramendment of such order.

(c) Scope. Both disclosure and dis-semination of any information from the

RULES AND REGULATIONS 27821

records In question shall be limited underthe terms of the order to assure thatPatient identities will be protected to themaximum practicable extent. and thatnames and other identifying characteris-tics of Patients are expunged from anydocuments placed In any public record.No information obtained pursuant to anorder under this section may be used toconduct any Investigation or prosecutionof a patient, or be used as the basis foran application for an order under I 2.65.

2.66-1 Investigation and prosecutionof progreme...peds and arPose

The principal purpose of 1 la is toenable a regulatory agency whose inspec-tion or other source of information hasdisclosed a need for follow-up, or whichhas been refused access to patient rec-ords, to obtain the necessary authoriza-tion for access and copying. There mayalso be rare instances, such as those In-volving financial fraud, tax evasion. orother Offenses where access by other in-vestigative agencies Is necessary, subrJect

isthto the requirements and protections

of part.I 2.6T Undercover agents and infers.

antsRules. -

(a) Applicability. This section applies-to any application by an administrative,regulatory, supervisory, Investigative, orlaw enforcement myna for an order topermit such agency to have an Under-cover agent or informant in a programunder circumstances which would other,.wise be prohibited under 19.19.

(b). Notice. An order under this sec-tion may be granted without noticewhere the criminal conduct for the in-vestigation of which It Is granted Is be-lieved to be carried on by the programdirector or by any employee or agentof the PrOgrain with the knowledge ofthe program director or under suchcircumstances that in the exacta Mreasonable care the program directorshould know of each conduct. Under anyother circumstances, an order under thissection may be granted only after theprogram director has been afforded no-tice and opportunity for hoofing. .

(c) Criteria. An order under this sec-tion may be granted only where there Isreason to believe that program or anyPrincipal. agent, or allP10)110 thereof isengaged In serious crimitiel misconduct,and that other means of securing evi-dence- of such criminal misconduct arenot available or would hot be effective.

(d) Scope. An order granted pursuantto this section may authorise the use bythe applicant of an undercover agentor informant. either as a patient or, asan employee, of the program in question.

(e) Time periods. An order under thissection may not authorize the use of anundercover agent for an initial periodexceeding 60 days. At any time prior to-the expiration of such 10-day period,the applicant IIPP17 for an order ex-tending such period for an additionalperiod not to exceed 60 days, but In noevent may the use of an undercover agent

In any program.be authorized for morethan 160 days In any period of 12 con-secutive months.

(f) Duty of agent. Except to the ex-tent expressly authorized In an orderunder this section, which shall be limitedto disclosure of information directly re-lated to the purpose for which the orderIs granted, an undercover agent or in-formant shall for the purposes of thisPart be deemed an agent of the programwithin which he Is acting as such, andas such shall be subject to all of the'pro-hibitions of this part applicable to Me-ddling of any information which hemay acquire.I 2.6T-1 Undercover agars and Inform.

ants-..Basis and purpose.The legal rationale =denying this

section has been set forth In 219-1. ItIs expected that this section will find Itsprincipal and palms its exclusive 11,P-Dilation in the area of drug law enforce-ment. Experience has demonstrated thatmedical personnel, no matter how ore-donated, can engage in the illicit saleof drop on large scale, and that theuse of %macaw agents and informantsls normally the only effective means ofsecuring evidence sufficient to support asuccessful prosecution.

(PM noun-171N Med S-27-71;11:SS awl

MI6 21Food and Drugs -

CHAPTER 111--SPECIAL ACTION OFFICEFOR DRUB ABUSE PREVENTION

PART 1401CONSTDENTIALITT DRUGABUSE PATIENT RECORDS

Relocation of PetOn May 9, 1975, there was published

in the nowt Rama (40 PR 20542)a notice of proposed rulemaking propos-ing the revocation of Part 1401 of Title21 of the Code of Federal Regulations byman of the proposed incorporation ofIfs subject matter in a new 1 'at 2 of Title42 of the Code of Federal ,,egulations.

Interested persons were Invited to sub-mit written comments, views, or argu-ments with respect to the proposed revo-cation. within 30 days of the date of pub-lication of that notice. None werereceived, except to the extent that theywere implicit in those submitted on theproposed new Part 2 of Title 42 of theCode of Federal Regulations, which wereduly conaldered.

Accordingly, pursuant to the authorityof section 406 of the Drug Abuse Officeand Treatment Act of 1972, as amendedby Pub. L. 93-282 (21 U.B.C. 1175), andunder the authority delegated to theGeneral Counsel (39 PR 17901, May 21,1974), Part 1401 of Title 21 of the Codeof Federal Regulations Is revoked, effec-tive Aura 1, 1975.

Dated: June 25, 1973.Oman Caws. rz.

General Counsel, Special AdiosOffice for Drug Abuse Pro-%Wake.

pit Mole-17170 rIlimill-117-78;111441 cast

RaAL glOrinit, VOL 46, NO. 127TUISOM, JULY 1, 1976

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69

Appendix C.tate and Territorial * * * * *

Alcoholism ProgramDirectors

MS260

NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM

This directory of State and Territorial Alcoholism Program Directors isintended as a communication aid. Because names, addresses, and telephonenumbers may change, periodic updates are made. For further informationcontact:

National Clearinghouse for Alcohol InformationP.O. Box 2345

Rockville, Maryland 20852(301) 468-2600

ALABAMA

Department of Mental HealthKen Wallis, Receiver and Acting

Commissioner200 Interstate Park DriveP.O. Box 3710Montgomery, AL 36193(205) 271-9209

ALASKA

Department of Health and SocialServices

Office of Alcoholism and Drug AbuseMatthew Felix, CoordinatorPouch H-05F, 114 Second StreetJuneau, AK 99811(907) 586-6201

ARIZONA

Arizona Department of Health ServicesDivision of Behavioral Health ServicesBureau of CoMmunity ServicesAlcohol Abuse and Alcoholism SectionAlex Arrpdondo, Manager2500 East Van Buren StreetPhoenix, AZ 85008(602) 255-1238, 255-1239

C-1

ARKANSAS

Arkansas Office on Alcohol and.Drug Abuse Prevention

Paul T. Behnke, Director1515 W. 7th Avenue, Suite 310Little Rock, AR 72202(501) 371-2603

CALIFORNIA

Dept. of Alcohol and Drug ProgramsChauncey Veatch III, Esq., Director111 Capitol Mall, Suite 450Sacramento, CA 95814(916) 445-1940

COLORADO

Alcohol and Drug Abuse DivisionRobert B. Aukerman, Director4210 East 11th AvenueDenver, CO 80220(303) 320-6137

CONNECTICUT

Connecticut Alcohol and DrugAbuse Commission

Donald J. McConnell, ExecutiveDirector

999 Asylum Avenue, 3rd FloorHartford, CT 06105

(203) 566-4145

7o

DELAWARE

Division of Mental HealthBureau of Alcoholism and Drug AbuseSally Allhouse, Chief1901 North DuPont HighwayNew Castle, DE 19720

(302) 421-6101

DISTRICT OF COLUMBIA

Office of Health Planning andDevelopment

Simon Holliday, Chief1875 Connecticut Ave., N.W., Suite 836Washington, DC 20009

(702) 673-7481

FLORIDA

Alcoholic Rehabilitation ProgramDepartment of Health and

Rehabilitation ServicesDonald Kribbs, Supervisor1317 Winewood Boulevard, Room 148ATallahassee, FL 32301

(904) 488-0396

GEORGIA

Division of Mental Health, MentalRetardation and Substance Abuse

Georgia Department of Human ResourcesWilliam B. Johnson, Director47 Trinity Avenue, S.W.Atlanta, GA 30334

(404) 656-4918

GUAM

Territory of GuamMental Health and SubstanceAbuse Agency

Dr. David L.G. Shimizu, Interim DirectorP.O. Box 8896Tamuning, Guam 96911

477-9704/5

C-2

HAWAII

Department of HealthAlcohol and Drug Abuse Branci,Joy Ingram-Chinn, Branch ChiefP.O. Box 3378Honolulu, HI 96813(808) 548-4280

IDAHO

Bureau of Substance AbuseDepartment of Health i WelfareCharles E. Burns, Director450 West State StreetBoise, ID 83720(208) 334-4368

ILLINOIS

State of IllinoisDepartment of Mental Health and

Developmental DisabilitiesRoalda J. Alderman, Superintendent,

Alcohol Division160 North LaSalle Street, Room 1500Chicago, IL 60601(312) 793-2907

INDIANA

Division of Addiction ServicesDepartment of Mental HealthJoseph E. Mills, III, Director429 North PennsylvaniaIndianapolis, IN 46204

(317) 232-7816

IOWA

Department of Substance AbuseMary L. Ellis, Director505 Fifth AvenueSuite 202Des Moines, IA 50319

(515) 281-3641

71

KANSAS

Alcohol and Drug Abuse ServicesDr. James A. McHenry, Jr., Commissioner2700 West Sixth StreetBiddle BuildingTopeka, KS 66606(913) 296-3925

KENTUCKY

Department of Human ResourcesMichael Townsend, ManagerAlcohol and Drug BranchBureau for Health Services275 East Main StreetFrankfort, KY 40621(502) 564-2880

LOUISIANA

Office of Mental Health andSubstance Abuse

Burn Ridgeway, Assistant SecretaryP.O. Box 4049655 North 5th StreetBaton Rouge, LA 70821(504) 342-2557

MAINE

Office of Alcoholism and DrugAbuse Prevention

Neill Miner, DirectorBureau of RehabilitationState House Station #11Augusta, ME 04333(207) 289-2781

MARYLAND

Alcoholism Control AdministrationJohn Bland, Director201 West Preston Street, 4th FloorBaltimore, MD 21201(301) 383-2781, 2782, 2783

C-3

459-340 0 - 84 - 6

MASSACHUSETTS

Division of AlcoholismEdward Blacker, Ph.D., Director150 Tremont StreetBoston, MA 02111(617) 727-1960

MICHIGAN

Office of Substance Abuse ServicesRobert Brook, Administrator3500 North Logan StreetP.O. Box 30035Lansing, MI 48909

(517) 373-8603

MINNESOTA

Chemical Dependency Program Div.Cynthia Turnure, Executive DirectorCentennial Office Bldg., 4th Floor658 Cedar StreetSaint Paul, MN 55155(612) 296-4610

MISSISSIPPI

Division of Alcohol and Drug AbuseAnn D. Robertson, M.S.W., Director1102 Robert E. Lee Office BuildingJackson, MS 39201

(601) 359-1297

MISSOURI

Division of Alcoholism & Drug AbuseR.B. Wilson, Director2002 Missouri BoulevardP.O. Box 687Jefferson City, MO 65101(314) 751-4942

MONTANA

Alcohol and Drug Abuse DivisionState of MontanaDepartment of InstitutionsMichael A. Murray, Administrator1539 - Eleventh AvenueHelena, MT 59601(406) 449-2827

NEBRASKA

Division on Alcoholism and Drug AbuseCecilia Willis, DirectorBox 94728Lincoln, NE 68509(402) 471-2851, x415

NEVADA

Bureau of Alcohol and Drug AbuseDepartment of Human ResourcesRichard Ham, Chief505 East King StreetCarson City, NV 89710

(702) 885-4790

NEW HAMPSHIRE

Office of Alcohol and Drug AbusePrevention

Geraldine Sylvester, DirectorHealth and Welfare BuildingHazen DriveConcord, NH 03301(603) 271-4627, 271-4630

NEW JERSEY

Division of AlcoholismNew Jersey Division of HealthRiley Regan, Director129 East Hanover StreetTrenton, NJ 08625(609) 292-8947

C-4

NEW MEXICO

Alcoholism BureauJoe Gallegos, Acting ChiefBehavioral Health Services DivisionP.O. Box 968Santa Fe, NM 87504-0968(505) 984-0020, x493

NEW YORK

New York Div. of Alcoholismand Alcohol Abuse

Robert V. Shear, Director194 Washington AvenueAlbany, NY 12210(518) 474-5417

NORTH CAROLINA

Division of Mental Health, MentalRetardation and Substance Abuse Services

Alcohol and Drug Abuse SectionSteven L. Hicks, Deputy Director325 North Salisbury StreetRaleigh, NC 27611(919) 733-4670

NORTH DAKOTA

State Department for HealthDepartment of Human ServicesDivision of Alcoholism and Drug AbuseTom R. Hedin, DirectorBismarck, ND 58505(701) 224-2767

NORTHERN MARIANA ISLANDS

Dr. Torres HospitalBen Kaipat, Medical OfficerSaipan, Mariana Islands 969506112, 6222

7 3

OHIO

Ohio Department of HealthBureau of Alcohol Abuse and RecoveryWayne Lindstrom, Chief246 North High StreetP.O. Box 118Columbus, OH 43215

(614) 466-3445

OKLAHOMA

Alcohol and Drug Abuse DivisionThomas Stanitis, M.A., M.H.S.,

Deputy CommissionerP.O. Box 53277, Capitol StationOklahoma City, OK 73152(405) 521-0044

OREGON

Mental Health DivisionPrograms for Alcohol and Drug ProblemsJeffrey N. KushnerAssistant Administrator2575 Bittern Street, N.E.Salem, OR 97310(503) 378-2163

PENNSYLVANIA

Office of Drug and Alcohol ProblemsLuceille Fleming, Deputy Secretary

for Drug and Alcohol ProgramsP.O. Box 90, Department of HealthHealth and Welfare Building, Room 809Harrisburg, PA 17120(717) 787-9857

PUERTO RICO

Puerto Rico Dept. of AddictionControl Services

Astrid Oyola de BenitexAssistant Secretary for AlcoholismBox B-Y, Rio Piedras StationRio Piedras, PR 00928(809) 763-5014 or 763-7575

C-5

RHODE ISLAND

Department of Mental Health, MentalRetardation and Hospitals

Division of Substance AbuseWilliam Pimentel, A6sistance DirectorSubstance Abuse Administration BuildingCranston, RI 02920(401) 464-2091

AMERICAN SAMOA

Human Services ClinicAlcohol and Drug ProgramFualaau Hanipale, DirectorLBJ Tropical Medical CenterPago, Pago, American Samoa, 96799633-5139

SOUTH CAROLINA

South Carolina Commission on Alcoholand Drug Abuse

William J. McCord, Director3700 Forest DriveSuite 300Columbia, SC 29204

(803) 756-2521

SOUTH DAKOTA

Division of Alcohol and Drug AbuseLois Olson, DirectorJoe Foss Building523 East CapitolPierre, SD 57501

(605) 773-3123

TENNESSEE

Tennessee Dept. of Mental Health andMental Retardation

Robert Currie, Ass.t. CommissionerAlcohol and Drug Abuse ServicesJames K. Polk Bldg., 505 Deaderick St.Nashville, TN 37219(615) 741-1921

TEXAS

Texas Commission on AlcoholismRoss Newby, Executive Director1705 Guadalupe StreetAustin, TX 78701

(512) 475-2577

TRUST TERRITORY OF THE PACIFIC ISLANDS

Masao Kumangai, M.D., DirectorHealth ServicesOffice of the High CommissionerSaipan,.Mariana Islands 96950Trust Territory of the Pacific Islands9854, 9355

UTAH

Division of Alcoholism And DrugsJudy Brady, Director150 West North Temple, Room 350P.O. Box 2500Salt Lake City, UT 84110-2500

(801) 533-6532

VERMONT

Alcohol and Drug Abuse DivisionRichard Powell II, Director103 South Main StreetOsgood BuildingWaterbury ComplexWaterbury, VT 05676(802) 241-2170

VIRGINIA

Division of Substance AbuseWayne Thacker, DirectorOffice of Substance AbuseP.O. Box 1797203 Governor StreetRichmond, VA 23214(804) 786-5313

C-6

VIRGIN ISLANDS

Division of Mental HealthAlcoholism and Drug Dependency

Patricia Todman, Ph.D., Director

P.O. Box 7309St. Thomas, US VI 00801

(809) 774-4888

WASHINGTON

Bureau of Alcoholism i Substance AbuseGlen Miller, DirectorMailstop 08-44WOlympia, WA 98504(206) 753-5866

VEST VIRGINIA

Alcoholism and Drug Abuse ProgramDivision of Behavioral Health ServicesJack Clohan, Jr., DirectorState Capitol1800 Kanawha Boulevard EastCharleston, WV 25305

(304) .348-2276

WISCONSIN

State Bureau of AlcohOl and OtherDrug Abuse

Larry W. Monson, Director1 West Wilson StreetP.O. Box 7851Madison, WI 53707

(608) 266-2717

WYOMING

Division of Community ProgramsJean DeFratis, Director of Alcohol

and Drug Abuse ProgramsHathaway Building, 3rd FloorCheyenne, W1 82002(307) 777 -7115, x7118

75

OFFICIAL MEMBERS OF THE NATIONAL PREVENTION NETWORK

SEPTEMBER, 1984

ALABAMA

Ms. Gail Ellerbrake-WillettAlabama Department of Mental HealthP.O. Box 3710Montgomery, AL 36193-5001(205)271-9246

ALASKA

Ms. Loren JonesOffice of Alcoholism and Drug AbuseDepartment of Health andSocial Services

Pouch H-05-FJuneau, AK 99811

(907) 586-6201

AMERICAN SAMOA

Ms. Fualaau HanipaleAlcohol and Drug ProgramLBJ Tropical Medical CenterPago Pago, American Samoa96799

ARIZONA

Mr. Jim FauselCommunity Training SectionArizona Dept. of Health Services2500 E. Van BurenPhoenix, AZ 85008(602) 255-1233

C-7

ARKANSAS

Mr. William "Dave" DavisDepartment of Human ServicesOffice on Alcohol and DrugAbuse Prevention

1515 Building - Suite 3101515 W. Seventh StreetLittle Rock, AR 72202(501) 371-2603

CALIFORNIA

Mr. Michael S. Cunningham, M.A.California Dept. of Alcohol

and Drug Programs111 Capitol MallSacramento, CA 95814(916) 323-2087

COLORADO

Mr. Fred GarciaColorado Dept. of HealthAlcohol and Drug Abuse Division4210 E. 11th AvenueDenver, CO 80220(303) 320-6137 X387

CONNECTICUT

Ms. Marlene HainesConnecticut Alcohol & Drug AbuseCommission

999 Asylum Avert o,Hartford, CT 06105.(203) 566-7458

76

DELAWARE

Mr. Harris TaylorBureau of Alcoholism and Drug Abuse1901 North DuPont HighwayNew Castle, DE 19702(302) 421-6101

DISTRICT OF COLUMBIA

Mr. Randy RowelOffice of Health Planning and

Development Commission ofPublic Health

1875 Connecticut Ave., N.W.Seventh FloorWashington, D.C. 20009(202) 673-7529

FLORIDA

Mr. Don A. Walsh "D"H.R.S. Alcohol, Drug Abuse

and Mental Health Program1317 Winewood Blvd.Tallahassee, FL 32301(904) 488-0900

Mr. Donald Kribbs "A"PDADMA1317 Winewood Blvd.Tallahassee, Florida 32301

GEORGIA

Mr. Steve DavidsonAlcohol & Drug Abuse

Services of the GeorgiaDivision of Mental Health/Mental Retardation

Room 712878 Peachtree Street, N.E.Atlanta, GA 30309(404) 894-4740

C-8

GUAM

Mr. Ralph VillaverdeDept. of Mental Health &

Substance AbuseP.0 Box 8896Tamuning, Guam 96911(671)646-9261,9262,9263

HAWAII

Mr. Roger MessnerOffice of Primary PreventionDepartment of HealthState of Hawaii3627 Kilauea Ave., Rm. 421Honolulu, HI 96816(808) 737-4637

IDAHO

Mr. Charles E. BurnsBureau of Substance AbuseDepartment of Health & Welfare450 West State StreetBoise, ID 83720(208) 334-4368

ILLINOIS

Mr. Randall Webber "D"Illinois Dangerous Drugs Commission300 North State StreetChicago, IL 60610(312) 822-9860

Mrs. Ruth K. Moll "A"Division of Alcoholism,DMHDD

901 Southwind RoadSpringfield, IL 62703

INDIANA

Mr. Joseph E. Mills, IIIIndiana Dept. of Mental Healtn429 N. Pennsylvania AvenueIndianapol's, IN 46204(317) 232-7818

77

IOWA

Dr. Alvera SternIowa Department of SubstanceAbuse

Suite 202, Insurance Exchange Bldg.505 5th AvenueDes Moines, IA 50319(515) 281-6567

KANSAS

Ms. Cynthia GalyardtSRS Alcohol and Drug Abuse Services2700 West 6th StreetTopeka, KS 66606(913) 296-3925

KENTUCKY

Ms. Barbara StewartSubstance Abuse BranchDepartment for Health Services275 East Main StreetFrankfort, KY 40601

(502) 564-2880

LOUISIANA

Ms. Brenda LandsOffice of Mental Health and

Substance AbuseP.O. Box 4049Baton Rouge, LA 70821

(504) 342-2545

MAINE

Mr. Richard LinehanOffice of Alcoholism and

Drug Abuse PreventionDepartment of Human ServicesState House Station #11Augusta, ME 04333

(207)289-2781

C-9

MARYLAND

Ms. Darlind DavisAlcohol & Drug Abuse

Prevention UnitDepartment of Health & Mental

Hygiene201 West Preston StreetBaltimore, MO 21201

(301) 383-4081

MASSACHUSETTS

Mr. Milton J. Wolk "0" & uA"Massachusetts Dept. of Public HealthDivision of Alcoholism150 Tremont StreetBoston, MA 02111

(617) 727-1960

MICHIGAN

Ms. Ilona MilkeOffice of Substance Abuse Services

3500 North Logan StreetP.O. Box 30035Lansing, MI 48909(517) 373-7873

MINNESOTA

Mr. Lee GartnerState Alcohol and Drug Authority4th FloorCentennial Office BuildingSt. Paul, MN 55151(612) 296-8573

MISSISSIPPI

Ms. Suzanne D. ScottDepartment of Mental HealthDivision of Alcohol & Drug Abuse1102 Robert E. Lee Bldg.Jackson, MS 39201

(601) 359-1297

78

MISSOURI

Mr. Richard HaytonDivision of Alcohol and Drug Abuse2002 Missouri BoulevardP.O. Box 687Jefferson City, MO 65102

(314) 751-4942

MONTANA

Mr. Darryl L. BrunoState of MontanaDepartment of InstitutionsAlcohol and Drug Abuse Division1539 11th AvenueHelena, MT 59620(406) 444-4927

NEBRASKA

Mr. Steve McElravyDivision on Alcoholism and

Drug AbuseNE Dept. of Public InstitutionsP.O. Box 94728Lincoln, NE 68509(402) 471-2851

NEVADA

Ms. Ruth A. Lewis, Ed.D.Human Resources/Rehab.Bureau of Alcohol and Drug Abuse505 East King StreetRoom 500Carson City, NV 89710(702) 855-4790

NEW HAMPSHIRE

Ms. Ricia McMahonN.H. Office of Alcohol & Drug

Abuse PreventionHealth and Welfare BuildingHazen DriveConcord, NH 03301

(603) 271-4638

C-10

NEW JERSEY

Mr. Charles Currie "D"New Jersey StateDepartment of HealthDiv. of Narcotic & Drug Abuse

Control Prevention Unit129 East Hanover StreetTrenton, NJ 08608

Mr. Thomas Graham, Chief "A"Division of Alcoholism129 East Hanover St.Trenton, NJ 08608(609) 292-4414

NEW MEXICO

Mr. Jeffrey J. TrujilloHealth and Environment

DepartmentP.O. Box 968Santa Fe, NM 87504-0968(505) 984-0020, X388

NEW YORK

Mr. J. Neil Hook "D"Office of Alcoholism and

Substance AbuseExecutive Park SouthStuyvesant PlazaAlbany, NY 12203

Ms. Joan Lorenson "A"NY Division of Alcoholism and

Alcohol Abuse194 Washington AvenueAlbany, New York 12210(518) 457-5840

NORTH CAROLINA

Ms. Rose KittrellN.C. Div. of Mental Health/ Mental

Retardation/Substance Abuse ServicesOffice of PreventionAnderson Hall/Dorothea Dix HospitalRaleigh, NC 27611

(919) 733-7640

79

NORTH DAKOTA

Ms. Rose BasarabaDivision of Alcohol and Drug AbuseState of North DakotaState CapitolBismarck, ND 58505(701) 224- 2769

OHIO

Mr. Glenn Wieringa "D"Ohio Department of Mental Health30 E. Broad StreetColumbus, OH 43215(614) 466-9926

Mr. Frank Underwood AN

Bureau on Alcohol Abuseand Alcoholism Recovery

Ohio Dept. of HealthP.O. 118Columbus, OH 43216(614) 466-3445

OKLAHOMA

Mr. Terry FifeAlcohol & Drug ProgramsDepartment of Mental HealthP.O. Box 53277, Capitol Station4545 North Lincoln Blvd.Suite 100 East TerraceOklahoma City, OK 73152(405) 521-0044

OREGON

Dr. Carol J. BrownlowOffice of Programs forAlcohol & Drug Problems

2575 Bittern Street, N.E.Salem, OR 97310(503) 378-2163

C-11

PENNSYLVANIA

Mr. Phillip M. BrownOffice of Drug Abuse ProgramsDepartment of HealthP.O. Box 90, Room 929Harrisburg, PA 17120

(717) 783-8200

PUERTO RICO

Ms. Ana I. EmmanuelliDept. of Addiction Control ServicesBox B-Y, Rio Piedras StationRio Piedras, Puerto Rico 00928(809) 763-3133(809) 758-6757

RHODE ISLAND

Mr. Robert HolmesDept. of Mental Health, Mental

Retardation and HospitalsDiv. of Substance AbuseSubstance Abuse Admin. Bldg.Cranston, RI 02920(401) 464-2091

SOUTH CAROLINA

Mr. James A. NealSouth Carolina Commission on

Alcohol and Drug Abuse3700 Forest DriveColumbia, SC 29204(803) 758-3866

SOUTH DAKOTA

Ms. Valera JacksonDivision of Alcohol and Drug AbuseJoe Foss Building523 E. Capitol StreetPierre, SD 57501

(605) 773-3123

SO

TENNESSEE

Ms. Jennie HeywoodDepartment of Mental Health

and Mental RetardationDivision of Alcohol and Drug Abuse505 Deaderick StreetJames K. Polk Building4th floorNashville, TN 37219(615) 741-4241

TEXAS

Ms. Carlene Phillips "D"Drug Abuse PreventionDiv. Texas Dept. of Community AffairsP.O. Box 13166Capitol Station

Ms. Peggy Frias-Lynch "A"Texas Commission on Alcoholism201 E. 14th St., 8th FloorAustin, Texas 78701Austin, TX 78711(512) 443-4100

TRUST TERRITORIES

Masao Kumangai, M.D.Health ServidesOffice of the High CommissionerSaipan, Trust Territories 96950

UTAH

Mr. Robert J. Courtney, Jr.Utah State Division ofAlcoholism and Drugs

150 West North TempleRm. 350P.O. Box 2500Salt Lake City, UT 84103(801) 533-6532

C-12

VIRGIN ISLANDS

Ms. Julia P. PankeyDept. of Health, Division ofMental Health

Alcoholism and Drug DependencyP.O. Box 520Christiansted, St. CroixVirgin Islands 00820(809) 773-1311, ext. 221 or 331

VERMONT

Mr. Rufus`ChaffeeOffice of Alcohol & DrugAbuse Programs

103 South Main StreetWaterbury, VT 05676(802) 241-2170

VIRGINIA

Ms. Marcia Penn

Prevention/Information ServicesDept. of Mental Health/MentalRetardation

P.O. Box 1797Richmond, VA 23214(804) 786-1530

WASHINGTON

Mr. Paul H. TemplinBureau of Alcohol & Substance Abuse08-44WOlympia, WA 98504(206) 753-3203

WEST VIRGINIA

Ms. Mary S. Pesetsky,Office of Behavioral Health ServicesWest Virginia Dept. of Health1800 Washington Street, EastCharleston, WV 25305(304) 348-2276

81

WISCONSIN

Mr. Vince RitaccaInterim Prevention RepresentativeState Bureau of Alcohol & Other

Drug Abuse1 West Wilson StreetP.O. Box 7851Madison, WI 53707

(608) 266-2754

WYOMING

Mr. Richard DavinDept. of Health & Social ServicesDiv. of Community ProgramsHathaway Bldg., Room 362Cheyenne, WY 82002

(307) 777-7118

"A" - ALCOHOL"D" - DRUGS

C-13

82

1.

Appendix D.COUNSELOR EVALUATION FORM

Please rate your counselor's skills during the 1984-83 school year in the followingareas. Also, please describe the strengths and weaknesses in each area. Pleaseuse the back of this form if you need more space.

Ability to involve a cross section of thestudents.

2. Attendance at student activities.

3. Ability to identify student crises andintervene appropriately.

4. Responsiveness to parent and community groups.

3. Initiation of alcohol and drug relatedprevention activities for students.

6. Willingness to put in extra time when needed.

7. Sensitivity and responsiveness to faculty.

8. Sensitivity and responsiveness to pupilpersonnel staff.

9. Sensitivity and responsiveness to nonprofessional staff.

10. Ability to follow through on suggestionsmade in supervision.

Excellent Good Fair Poor

Copyright by Westchester County Department of Community Mental Health, 1984.Reprinted with the author's permission.

D-1

83

11. Ability to identify problems with theoperation of the program and bring them toyour attention.

12. Willingness to keep you informed of programactivities.

13. Willingness to keep you informed of studentcrises.

Personal Characteristics

14. Attendance

15. Appearance

16. Maturity

17. Creativity

16. Energy & Enthusiasm

18. Overall assessment of your counselorsperformance this year.

20. How does this year compare to your counselor'sperformance in (a) previous year(s)?

D-2

/2

Excellent Good Fair Poor

84

/3

General Comments

I do do not want my counselor to return next year.

This year's evaluation was discussed with my counselor on

Signature of Principal

Signature of Counselor

D-3

85

Appendix E.

Evaluation Summary

Of the 1,972 students participating in Student Assistance Programactivities during the 1982-1983 school year, a sample of 232 students who

took the pre/post test was selected for study. The purpose. 61,3

evaluation study was to measure the effectiveness of *:se alcohol andother drug abuse prevention and intervention procedures employed by theStudent Assistance Program to decrease the quantity and frequency ofalcohol and other drug use. This was one of the objectives of

the program. The other objective was to improve school attendance of

participating students.

A nonexperimental Two Group Pretest-Posttest Design was selected totest the effectiveness of intervention for alcohol and other drug taking

behavior. School records were used to measure changes in school

attendance. A significant drop in absenteeism occurred for studentsparticipating in the Student Assistance Program. A summary of findings

for alcohol and drug taking behaviors of participating scudents followsas do a sample questionnaire and a summary reporting form.

E 1

459-340 0 - 84 - 7

86

ANDREW P. O'ROURKECounty Executive

DEPARTMENT OF COMMUNITY MENTAL HEALTH

EUGENE ARONOWITZCommissioner

STUDENT ASSISTANT PROGRAM1984/85 SCHOOL YEAR

QUESTIONNAIRE INSTRUCTIONSTO PROGRAM PARTICIPANTS

TAKING PART IN THIS STUDY IS COMPLETELY VOLUNTARY. STUDENTS AREBEING ASKED TO COMPLETE THESEQUESTIONNAIRES SO THAT WE CAN EVALUATETHE STUDENT ASSISTANT PROGRAM.

ALL INFORMATION IN THIS QUESTIONNAIRE IS STRICTLY CONFIDENTIAL. TOINSURE CONFIDENTIALITY, THE QUESTIONNAIRES ARE PUT IN SEALED ENVELOPESAND MAILED DIRECTLY TO OUR EVALUATOR. NO ONE, EXCEPT THE EVALUATOR,WILL HAVE ACCESS TO THESE QUESTIONNAIRES.

COMPLETING THIS QUESTIONNAIRE IS VOLUNTARY.

IF THERE ARE ANY QUESTIONS YOU DO NOT WANT TO ANSWER, YOU MAY LEAVETHE QUESTION BLANK. IF YOU DO NOT WANT TO COMPLETE THE QUESTIONNAIRE,YOU MAY LEAVE THE WHOLE QUESTIONNAIRE BLANK. PLEASE DO NOT SIGN YOURNAME ANYWHERE ON THE QUESTIONNAIRE.

THANK YOU FOR YOUR COOPERATION.

MHa 52 b20

Copyright by Westchester County Department of CommunityMental Health, 1984. Reprinted with the author'spermission.

112 East Post Road 2nd Floor Whits Plains, N.Y. 10601

E-2

87

DATE:

PRE-TEST

STUDENT ASSISTANT PROGRAM QUESTIONNAIRE

1984/85 SCHOOL YEAR

PLEASE DO NOT WRITE YOUR NAME ON THIS QUESTIONNAIRE. Your answers are to remain

completely confidential. When you finish the questionnaire, put it in the envelopeand seal it.

FOR YOUR INFORMATION, one drink is one can or bottle of beer, one glass of wine, oneshot glass of liquor, or one mixed drink.

oneoho of wino(S ounces) hos

ounce of actual alcohol

one an of bar(12 ounces) has

)5 ounce of actual alcohol

one shotoloss(lHounces of 16 proof

herd liquor) hos)5 ounce of actual alcohol

1. Have you ever tried any of the following? (Check one box for each)

a. Alcohol (beer, wine, liquor) .

b. Marijuana/hashish

c. LSD, acid, mescaline

d. PCP (angel dust)

e. Cocaine

f. Glue, gases, sprays

g. Heroin

h. Methadone

MHa 52 b21 E-3

88

Yes No

2. Have you ever taken any of the following medication without a doctor prescribingor telling you to?

a. Amphetamines (speed, ups)

b. Barbiturates (downs)

c. Quaaludes

d. Tranquilizers (for example, Valium)

e. Codeine, Demerol

Yes No

3. Have you ever taken a drug for "kicks" or to get "high", but you did not knowwhat it was?

Yes No

4. Within the last 30 days, on about how many DIFFERENT DAYS (if any) did you takeany of the following? (If none, enter 0). Please answer with a number between0 and 30.

a. Alcohol (beer, wine, liquor) days

b. Marijuana/hashish days

c. LSD, acid, mescaline days

d. PCP (angel dust) days

e. Cocaine days

f. Glue, gases, sprays days

g. Heroin days

h. Methadone days

5. Within the last 30 days, on about how many DIFFERENT DAYS (if any) did you takeany of the following medications without a doctor prescribing or telling you to?(If none, enter 0). Please answer with a number between 0 and 30.

a. Amphetamines (speed, ups) days

b. Barbiturates (downs) days

c. Quaaludes days

d. Tranquilizers (for example, Valium) days

e. Codeine, Demerol days

MHa 52 b22 E-4

89

6. Within the last 30 days, on about how many DIFFERENT DAYS (if any) did you takea drug for "kicks" or to get "high", but you did not know what it was? (If none,

enter 0). Please answer with a number between 0 and 30.

days

7. About how much do you usually drink in one day (from when you wake up until thetime you go to sleep) on an average Friday, Saturday, or holiday? (One drink isone can or bottle of beer, one glass of wine, one shot glass of liquor, or onemixed drink.)

drinks in one day on an averageFriday, Saturday, Sunday or holiday

8. Within the last 30 days, about how much did you drink in one day on an averageFriday, Saturday, Sunday or holiday (from when you woke up until the time youwent to sleep)? One drink is one can or bottle of beer, one glass of wine, oneshot glass of liquor, or one mixed drink.

drinks on one Friday, Saturday, Sundayor holiday within the last 30 days

9. About how much do you usuall drink on an average weekday or weeknight (Monday,Tuesday, Wednesday, Thursday ? One drink is one can or bottle of beer, one glassof wine, one shot glass of liquor, or one mixed drink.

drinks usually on one average weekday orweeknight

10. Within the last 30 days, about how much did you usually drink on an averageweekday or weeknight (Monday, Tuesday, Wednesday, Thursday)? One drink is onecan or t3ttle of beer, one glass of wine, one shot glass of liquor, or one mixeddrink.

drinks on one weekday or weeknightwithin the last 30 days

11. Were you ever "high" at school from the following? (Check one box for each)

Yes No

a. Alcohol (beer, wine, liquor)

b. Marijuana/hashish

c. LSD, acid, mescaline

d. PCP (angel dust)

MHa 52 b23 E-5

90

11. (continued)

e. Cocaine

f. Glue, gases, sprays

g. Heroin

h. Methadone

i. Amphetamines (speed, ups)

j. Barbiturates (downs)

k. Quaaludes

1. Tranquilizers (for example, Valium)

m. Codeine, Demerol

Yes No

12. Within the last 30 days, on how many DIFFERENT DAYS (if any) were you "high"at school from the following? (if none, enter 0.) Please answer with a numberbetween 0 and 30.

a. Alcohol (beer, wine, liquor) days

b. Marijuana/hashish days

c. LSD, acid, mescaline days

a. PCP (angel dust) days

e. Cocaine days

f. Glue, gases, sprays days

g. Heroin days

h. Methadone days

i. Amphetamine.' (speed, ups) days

j. Barbiturates (downs) days

k. Quaaludes days

1. Tranquilizers (for example, Valium) days

m. Codeine, Demerol days

MHa 52 b24 E-6

91

13. Did you ever combine or use at the same time alcohol and marijuana/hashish?

Yes No

14. Within the last 30 days, on how many DIFFERENT DAYS (if any) did you combinealcohol and marijuana/hashish? (If none, enter 0). Please answer with anumber between 0 and 30.

days

15. What was the most drinks you ever had in one day (from when you woke upuntil the time you went to sleep)?

drinks

16. Within the last 30 days, what was the most drinks you ever had in one day(from when you woke up until the time you went to sleep)?

drinks

17. Within the last 30 days, on how many DIFFERENT DAYS (if any) did you drinkthat many drinks or just about that many drinks? (If none, enter 0). Pleaseanswer with a number between 0 and 30.

MHa 52 b25

days

THANK YOU!

E-7

f t 92

APPENDIX E cant d

WISTOISTEI COUITT DIPAITMENT Of COMMUNITY MENTAL RAVESTUDENT ASSISTANCE PROGRAM

OUTCOME FVALUATION FACT SHEET 1982-83 SCHOOL YEAR

Use of Alcohol._ Within 30 Days of Pre/Post Test

22.7% (49 of 210 did not report use of alcohol on either the pre or post-test77.3% (167 of 216) reported use of alcohol on the pre-test and/or the post-test

55.1% (92 of 167) reported use of it on the pre-test, but not on the post-test12.6% (21 of 167) did not report use of it on the pre-test, but did on the post-test32.3% (54 of 167) reported use of it on both the pre and post-test

70% (49 of 70) of those who did not report use of alcohol on the pre-test continuedthis pattern of behavior

63% (92 of 146) of those who reported use of alcohol on the pre-test, did not on thepost-test

Use of Marijuana,_ Within 30 Days of Pre/Post Test

67.4% (155 of 230) did not report use of marijuana on either the pre or post-test32.6% (75 of 230) reported use of marijuana on the pre-test and/or the post-test

82.7% (62 of 75) reported use of it on the pre-test, but not on the post-test12% (9 of 75) did not report use of it on the pre-test, but did on the post-test5.3% ( 4 of 75) reported use of it on both the pre and post-test (but reported a

decrease in the number of days on which it was used)94.5% (155 of 164) of those who did not report use of marijuana on the pre-test

continued this pattern of behavior93.9% (62 of 66) cf those who reported use of marijuana on the pre-test did not on

the post-test

"High" at School on Alcohol, Within 30 Days of Pre/Post Test

59.5% (135 of 227) did not report being "high "at school on alcohol on either the preor post-test

40.5% (92 of 227) reported being "high" at school on alcohol on the pre-test and/orthe post-test

29.3% (27 of 92) reported being "high" at school on alcohol on the pre-test, butnot on the post-test

41.3% (38 of 92) did not report being "high" at school on alcohol on the pre-testbut did on the post-test

29.3% (27 of 92) reported being "high" at school on alcohol on both the pre andpost-test

78% (135 of 173).of dhose who did not report being "high" at school on alcohol on thepre-test continued this pattern of behavior

50% (27 of 54) of those who reported being "high" at school on alcohol on the pre-testdid not on the post-test

"High" at School on Marijuana, Within 30 Days of Pre/Post Test

78.4% (182 of 232) did not report being "high" at school on marijuana on either thepre or post-test

21.67. (50 of 232) reported being "high" at school on marijuana on the pre and/or thepost-test

947. (47 of 50) reported being "high" at school on marijuana on the pre -test, butnot on the post-test

6% (3 of 50) did not report being "high" at school on marijuana on the pre-test,but did on the post-test

98.47. (182 of 185) of those who did not report being "high" at school on marijuana onthe pre-test continued this pattern of behavior

1007. (47 of 47) of those who reported being "high" at school on marijuana on the pre-test,did not on the post-test

Copyright by Westchester County Department of Community Mental Health, 1984.Reprinted with the author's permission.

E-8

93

Usual ivantity of Alcohol Consumed in One DAy on Average Weekend /Holiday

16.9% (30 of 178) did not report consumption of alcohol on the p.e or post-test83.1% (148 of 178) reported consumption of alcohol on the pre-test .nd /or the post-test

22.3% (33 of 148) reported consumption of it on the pre-test (avt-age of 3.4 drinksin one day) but not on the post-test

8.1% (12 of 148) did not report consumption of it on the pre-test,but :lid (averageof 3.2 drinks in one day) on the post-test

69.6% (103 of 148) reported consumption of it on both the pre and post-'test (but

stayed at virtually the same level of consumption)

71.4% (30 of 42) of those who did not report consumption of alcohol on the pre-test

continued this pattern of behavior24.3% (33 of 136) of those who reported consumption of alcohol on the pre-test (average

of 3.4 drinks in one day) did not on the post-test

Quantity of Alcohol Consumed in One Day on Average Weekend/Holiday, Within 30Days of Pre/Post Test

22.4% (49 of 219) did not report consumption of alcohol on either the pre a post-test77.6% (170 of 219) reported consumption of alcohol on the pre-test and/or the post-test

54.7% (93 of 170) reported consumption of it on the pre-test (average of 3.2 drinksin one day) but not on the post-test

8.8% (15 of 170) did not report consumption of it on the pre-test, but did (averageof 4.5 drinks in one day) on the post-test

36.5% (62 of 170) reported consumption of it on both the pre and post-test (butthe level of consumption decreased by almost two drinks per day)

76.6% (49 of 64) of those who did not report consumption of alcohol on the pre-testcontinued this pattern of behavior

60% (93 of 155) of those who reported consumption of alcohol on the pre-test (averageof 3.2 drinks in one day) did not on the post-test

E-9

94

Month of:

School:

# of Days in School:

STUDENT ASSISTANCE PROGRAMMONTHLY STATISTICAL REPORT

I. REFERRAL PATHWAYS FORSTUDENTS REFERRED DURING{}HUNTED MONTH

1. Self2. Principal3. School Administrator (Dean

Vice/Assistant Principal,etc.)

4. Program Counselor5. Faculty6. Guidance Counselor7. ParentB. Relative (not parent)9. Friend/Peer10. School Psychologie11. School Nurse12. School Social Worker13. PPS Team14. Unknown15. Other

TOTAL

II. STUDENT CENSUS

Date Submitted:

Counselor:

1.

Total(1=2+3)

2.

StudentsReferred+ Seen

During Month

3.

StudentsReferredBut NotSeen

4.

Students SeenBut

PreviouslyReferred

1. Number of students who re-entered program during month2. Number of NEW students who entered program during month3. Number of students terminated during month4. Total number of students seen by counselor during month5. Total Lumber of students seen to date (cumulative)

III. COUNSELING INTERVENTIONSWith

StudentsOnly

WithParentsOnly

WithStudents and

Parents

1. Individual Sessions - Total No. ....

2. GROUPS

# of Sessions

IndividualsAssigned

Sum Attendance

1 2 3 4 5 6 7 9 10 11 12 13 14 15 P

IV. OUTSIDE AGENCY CONTACTSNumber

Number Attending

1. Outside agency visits/private practitioners2. Visitors to school

MHa m38 13-1

Copyright by Westchester County Department of Community Mental

Health, 1984. Reprinted with the author's permission.

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95

-2-. EDUCATION ACTIVITIES

NumberNumber Attending

1.

2.

3.

4.

5.

6.

Class Presentations

Public /community speaking engagementsSchool presentations (PTA/faculty, etc.)Committee/Task Force meetingsFaculty/Guidance consultationsOther: Specify

VI. STAFF HOURS (Please do not report in 1/2 hour. Round offto nearest whole number)

Number ofHour!

1. Prevention/Edu.lation2. Consultation

A

VII. TELEPHONE CONTACTSRUM MEWS

COLUMN I COLUMN II COVUMN III

Total NuMt;ee

No. of IndividualParents of

ProgriFTWETETpantsN. of

Other nients

VIII. OUTSIDE AGENCY REFERRALS

REFERRALS

Referred To (list allnames o al ageincies & /orprivate practitioners)

If previously referred,indicate date & number

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

MHa m38 13-2

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96

First Month of School Activities List

We would appreciate your cooperation in sharing with us some of your feelings andreactions to the counselor and/or program. Please do NOT sign your name. For eachstatement, circle the number which best corresponds to your feelings or beliefs:

If you STRONGLY AGREE with the statement, circle 5.If you AGREE with the statement, cirle 4.If you NrilAtR AGREE OR DISAGREE with the statement, circle 3.If you DISAGREE with the statement, circle 2.If you STRONGLY DISAGREE with the statement, circle 1.If you DON'T KNOW how to respond to the statement, circle DK.

For statements 10, 11, and 16 if the statement does not apply to your situation (forexample, if you have NEVER had a drink, taken drugs or participated in a group session),circle NR, meaning NOT RELEVANT.

1. The counselor helped me with my problems. 5 4 3 2 1 DK

2. The counselor was often too busy to see me when Ineeded help. 5 4 3 2 1 DK

3. In the beginning, I felt uncomfortable when I sawthe counselor. 5 4 3 2 1 DK

4. I did not want to tell my family/friends when I startedseeing the counselor. 5 4 3 2 1 DK

5 I feel better about myself since I started seeing thecounselor. 5 4 3 2 1 DK

6. In general, I am doing better in school since I startedseeing the counselor. 5 4 3 2 1 D'

7. My grades improved since I started seeing the counselor. 5 4 3 2 1 DK

8. I am absent from school less often since I started seeingthe counselor. 5 4 3 2 1 DK

9. I cut classes less often since I started seeing the

counselor. 5 4 3 2 1 DK

10. I have cut down drinking since I started seeing the

counselor. 5 4 3 2 1 DK NR

11. I have cut down taking drugs since I started seeingthe counselor. 5 4 3 2 1 DK NR

12. I have been getting along better with my parentssince I started seeing the counselor. 5 4 3 2 1 DK

13. I have been getting along better with my friends sinceI started seeing the counselor. 5 4 3 2 1 DK

MHa 36 2b2 Copyright by Westchester County Department of Community Mental Health,1984. Reprinted with the author's permission.

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97

14. Most of the students at my school know about theprogram/counselor. 5 4 3 2 1 DK

15. The sessions I had alone with the counselor helped me. 5 4 3 2 1 DK

16. The group sessions with other students helped me. 5 4 3 2 1 DK

Please write a brief response to the following questions.

1. What did you most like about the counselor?

NR

2. What did you most dislike about the counselor?

3. What did you most like about the counseling sessions you had?

4. What did you most dislike about the counseling sessions?

5. Any additional comments?

MHa 36 2b5Thank you very much.

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U.S. GOVERNMENT PRINTING OFFICE : 1984 0 459-340

98