I Need Treatment But Worry About My Privacy

Reader’s Question

My wife has had an eating disorder for all of our 25-year marriage. She was a “functional” exercise bulimic for the first 20 years, but the condition has spun out of control in the last 5 years and now has serious self-harm implications. The apparently insoluble self-harm has been devastating to our marriage, and I can see very troubling behaviors such as severe withdrawal and lack of motivation developing within myself. Her psychiatric team has told me I should seek help for myself.

I fully agree that I need help, and I have an excellent insurance plan that would offset the costs (a necessity considering our financial situation), but with the Electronic Medical Records collection mandate within the United States law, there is no way I am going to initiate treatment at this time and have the records of the treatment handed to the government who have no incentive to protect my privacy. Being an IT guy, I have absolutely no doubt that centralized medical record keeping in the hands of the government will be an absolute disaster, and the end of medical confidentiality.

I don’t know where to turn.

Psychologist’s Reply

Your letter serves as a good reminder that mental and emotional disorders affect more than the individual who receives the diagnosis. As such, information, support, and counseling are frequently needed by loved ones of those with chronic psychiatric illness. Unfortunately, the same cultural stigma surrounding psychiatric treatment applies to those loved ones as well. This stigma forms the heart of your concern because if emotional and psychological treatment were considered the same as treatment for a physical illness, there would be no more concern about confidentiality than there is when seeing a family physician.

I have known individuals who have paid cash (“out of pocket”) for counseling, even though they had insurance that would have covered it, because they did not want the paper trail inherent in the billing and insurance payment process. As you noted, however, many of us cannot afford that option, and it defeats the purpose of having mental health insurance coverage. So, let’s consider the two aspects of the medical record that would result from mental health treatment: a diagnosis used to justify insurance payment, and record of treatment on a session-by-session basis.

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For insurance companies to reimburse treatment, providers have to assign a diagnosis covered by those insurers. Fortunately, for cases such as yours, the diagnostic system includes the option “Adjustment Disorder.” This refers to individuals who are having substantial symptoms, usually involving either depression and/or anxiety, in response to a defined stressor, and that stressor might be a family member’s behavior or disorder. In many ways this might be the least stigmatizing diagnosis because who hasn’t had difficulty adjusting to something at some point?

With regard to the treatment notes generated, the purpose is threefold: to document for insurers that treatment was provided, to provide a record should the provider’s behavior be called into question in a future legal inquiry, and to help the provider keep track of the direction and progress of treatment. With these three goals in mind, and with a limited amount of time available, most counselors attempt to provide enough detail, but no more than is necessary. So, the concern that counselors transcribe every juicy detail revealed by clients is unrealistic. Also, because clients have a legal right to demand a copy of those notes at any time, counselors remain sensitive to what is included and how things are worded.

Other options include support groups and online resources for loved ones of people with mental illness (some being specific to eating disorders, or self-harm), and those may be helpful to you. If, however, you’re experiencing your own depressive symptoms, you may need a professional who can focus on you. I encourage you to start with discussion of your privacy concerns when you first meet with a mental health professional. You certainly won’t be the first client that professional has encountered with similar concerns. After discussion, you may decide to allow that professional to work with you to ensure that the two of you are comfortable with the diagnosis and documentation entailed in the process of using insurance coverage for what it is intended to provide.