ethics

Ethics for Substance Abuse Counselors

 Introduction

Any counselor is faced with ethical dilemmas on a regular basis. These dilemmas are exacerbated for a substance abuse counselor.  There are a number of reasons for this.  One is that there is a high correlation between addiction and criminal activity.  There is also the concern that ethical issues such as informed consent can be complicated by problems arising out of substance abuse (Falls 2006).  The counselor’s ability to cope with these and other issues is dependent, to a large degree, on their ability to weigh up the inherent risks and benefits of a multiplicity of options and make a moral and principled decision (Wozny n/d). 

Principles are informed by personal and professional values.  The Code of Ethics adopted by the American Counseling Association (2005) sees these values as

 

Deeply ingrained in the counselor and developed out of personal dedication, rather than the mandatory requirement of an external organization.

 

Many principles have been identified in the abundance of writings arising out of the study of ethics.  However, Kitchener (1984) identified five moral or ethical principles which form the cornerstone of our ethical guidelines.  These principles – justice; autonomy; beneficence; nonmaleficence and fidelity – help in clarifying and resolving conflicting issues which substance abuse counselors face daily and which may not be adequately addressed in the guidelines (Forester-Miller & Davis 2008).

It makes sense, then, to examine these principles first, before investigating some of the guidelines available to the counselor. 

Ethical Principles

Justice

Kitchener (1984) pointed out that justice does not just imply impartiality but includes fairness, which sometimes requires “treating equals equally and unequals unequally but in proportion to their relevant differences”.  In other words there are times when it is both necessary and appropriate to treat an individual differently.  Clearly some clients make much greater demands on a counselor’s resources than others.  If this situation should arise, however, it is vital that the counselor is able to clearly justify his/her actions.

On the other hand, it has to be admitted that impartiality is a noble aspiration but one which is very difficult to attain.  Counselors need to recognize and accept that bias is normal and that there will inevitably be those who may be regarded as ‘favorite’ clients and others with whom they will instinctively prefer to limit contact.  However, personal issues and personality conflicts cannot stand in the way of working with clients. 

In order to practice within the principle of justice it is important to avoid allowing personal prejudices to interfere with the client /counselor relationship and to ensure that no client is discriminated against or denied access to treatment that other clients have.   This calls for an understanding of the concept of counter transference, which refers to the conscious or unconscious reactions to what the client may present in treatment.  Counter transference can involve either being overly involved in caring for the client or being repulsed by the client’s needs, even resulting in the counselor becoming frustrated or getting into arguments and power struggles with the client, and so obviously has an impact on the counselor’s impartiality.    However, by understanding that these feelings are often a part of the counseling process, the counselor may be able to overcome them, using his own reactions to provide him with an understanding of the reactions the client induces in others (Young, 2004).   Failing this, a consultation with a supervisor may be necessary.

Although it may be difficult for a counselor to treat everyone impartially there are safeguards that can be instituted to ensure an equitable level of service.   Standards can be set in place which require every new client to receive an intake interview within 24 hours, for example, or an agency can work towards clarifying its criteria for services so that they are weighed more heavily on objective information rather than on the personal impressions of a substance abuse treatment counselor. These types of policies can help ensure a general level of fairness, regardless of a counselor’s personal feelings (TIP Series 37 2000).

Autonomy

 

The principle of autonomy is one which addresses the concept of independence, or the individual’s freedom of choice and action.  “This principle respects the unconditional worth of the individual and promotes self-governance, self-determination and self-rule” (TIP Series 37 2000).  Autonomy also encompasses the client’s voluntary commitment to participating in the counseling sessions, although, in the case of substance abuse, the client may not have been given an option, as counseling may be the requirement of a court order or probationary condition.  The concept of informed consent is based on this principle. 

The substance abuse counselor has to take into account two important considerations when encouraging clients to take responsibility for their own decisions. The first is helping their clients understand that their values may not be in accordance with the values of the community in which they live, and to ensure that the decisions taken will not interfere with the rights of others.  The second is to determine whether the client is competent to make rational decisions and has the information necessary to make a sound personal choice (Forester-Miller & Davis 2008).

This issue of competence can be one of the most complex ethical dilemmas.  Competency issues are seldom clear cut and the process of proving incompetence can be burdensome and time consuming.  There are several factors that can temporarily make a client seem incompetent.  “A client may seem unable to make independent decisions one day and then, the next day, be quite lucid.”   Substance abusers, for instance, “can experience temporary poor judgment due either to active substance use” or ongoing problems with decision making due to the results of long-term use (TIP Series 37 2000). 

When deciding whether a client has the ability to maintain autonomy, then, “it is necessary to consider not only the initial impression but the duration and severity of the behavior.”  Reports by other persons in the client’s life can help with the assessment of the client’s mental functioning, as can consultation with other medical or psychiatric professionals and the existence of a strong baseline assessment.  

It is also important to realize that a client may be fully competent in some areas of life but demonstrate only partial competency in others.  For example, “the client may be quite capable of caring for herself physically but may no longer be able to make sound financial decisions” (TIP Series 37 2000).  Appelbaum (2007) points out that only clients with an impairment that places them at the lowest level of the performance curve should be considered incompetent, although the seriousness of the possible consequences of the client’s decision obviously needs to be considered.  Legally the capacity to consent to treatment depends upon the ability to communicate decisions, to understand the information given, to appreciate the consequences of the decision and to be able to reason about treatment choices (IAppelbaum 2007).

In cases of severe incompetence legal instruments previously signed by the client, such as a health proxy, may have to come into play or, in extreme cases, a court appointed guardian may be necessary.   

The second part of the issue of incompetence is the question of whether or not the client has the necessary information to make a sound decision.  The principle of justice comes into play here as the counselor’s bias or personal values could impact on the information given to the client.  Emphasizing one aspect of treatment, for example, could influence the decision in favor of the counselor’s preference and so violate the principle of autonomy.  If the substance abuse counselor has a distinct leaning toward one form of therapy this bias should be acknowledged to the client, but no attempt should be made to manipulate his decision (TIP Series 37 2000).

Beneficence

The principle of beneficence refers to the responsibility of substance abuse counselors to improve and enhance the welfare of their clients.  In other words, to do good, to be proactive in seeking their clients’ welfare, and also to prevent harm whenever possible (Forester-Miller & Davis 2008).  The NAADAC Code of Ethics (2004) acknowledges “that the ability to do good is based on an underlying concern for the well being of others”.  In layman’s terms the word conjures up acts of altruism, kindness and charity.  In ethical terms it has an even broader connotation.  According to The Stanford Encyclopaedia of Philosophy  (2008) it “refers to a normative statement of a moral obligation to act for the benefit of others, helping them to further their important and legitimate interests, often by preventing or removing possible harms.”

In attempting to adhere to this principle, however, it is important to take into consideration the social norms and culture of the client.  What may seem beneficial to the counselor may conflict with the client’s cultural and/or religious background.  The counselor, then, needs to consider whether, in applying the principle of beneficence, he is not inadvertently attempting to impose his own agenda and so nullifying the principle of autonomy. 

Nonmaleficence

In its most familiar form nonmaleficence is expressed as ‘above all do no harm’.  This principle is often seen as the most critical of the five principles and refers not only to the intentional infliction of harm but also to acting in such a way as to risk harming others (Forrester-Miller & Davis 2008).  Legally and morally, a counselor could be considered negligent if he fails to meet the standards necessary to provide his clients with the care to which they are due and, as a consequence of this failure, harms the client in any way (Principles of Bioethics n/d).  This principle emphasizes the importance of the counselor’s recognition of the limitations of his ability and the need to avoid offering services or using techniques which are beyond his professional competence when treating the substance abuse issues of a client.  (Texas Administrative Code 2005).  

Intentional harm can include issues of client abuse such as breaching boundaries in terms of sexual contact or financial exploitation.  However, harm can be inflicted in more subtle ways and unintentional ways.  For this reason it is important to consider whether any decisions or actions taken have “the potential to produce harm of a physical, psychological, financial, legal, or spiritual nature before implementing them” (NAADAC Code of Ethics 2004).

Conflicting interpretations based on counselors’ own personal values and beliefs can cause confusion in the application of this principle.  An example of differing interpretations – the debate over abstinence versus risk reduction approaches to drug treatment – is quoted below. 

Advocates of abstinence may claim that a risk reduction approach harms a client by enabling his addiction, keeping the client from truly "hitting bottom" and seeking help. Risk reduction advocates argue that the abstinence-based model harms the client because it does not allow for compassion or for meeting the basic needs of individuals who are in the throes of addiction. Advocates for risk reduction may claim that the abstinence-based model actually prohibits recovery because it does not take into account that recovery is a process, rather than a rigid philosophy.

(TIP Series 37 2000).

 

Yet another aspect of this principle involves the termination or transfer of clients.  This will be examined in detail under the heading ‘Termination of Treatment’.  Nevertheless, it is important to point out here that if rules regarding transfers and terminations are not clear from the start and followed through consistently, then the counselor may be guilty of violating the principle of nonmaleficence.

Fidelity

The last, but not least, of Kitchener’s five principles, fidelity is, according to Truscott and Crook (2004), the principle at the core of the relationship between the professional counselor and his client.   Fidelity implies loyalty, honesty and trustworthiness.  For successful counseling to take place the client has to be able to trust the counselor and be comfortable in the therapeutic relationship (Forester-Miller & Davis 2008). 

Although fidelity is a fairly simple concept, requiring telling the truth and keeping promises, it is easily violated.  When a substance abuse treatment counselor takes on a client, there is an implicit contract with the client which assumes that the counselor will work to resolve the client’s concerns and that the information will be shared in a truthful manner between the counselor and the client (TIP Series 37 2000).  There are, however, a number of situations, which will be discussed under ‘Duty to Report’ which may lead to a breach of confidentiality.    If the counselor feels that there is any possibility that the confidentiality of the contract may be broken it is important that he is very clear about this from the beginning.  The possibility that the relationship may be terminated if the client breaks certain of the agency rules also needs to be emphasized from the start.

Another issue of fidelity is the counselor’s responsibility towards the primary client. When involved with a complicated family system, it is easy to overlook the individual needs of the client is, especially when working with clients whose competency is in question or when there is conflict.  Sometimes it can be more convenient just to let someone else speak for the client.   Nevertheless it is the counselor’s responsibility to ensure that, until the competency issue is resolved, she is representing  the primary client and acting according to the client’s wishes (TIP Series 37 2000).

In the following section some of the ethical guidelines which are based on these five principles will be explored.   These include the concepts of informed consent; boundaries; confidentiality and record keeping.  The ethical considerations involved in working with adolescents and in group therapy will also be addressed, as will the ethics involved in terminating treatment.  Finally a model for making ethical decisions will be presented.

Informed Consent

All states have statutes mandating that health professionals obtain or document informed consent before commencing treatment.  A failure to do so may put the counselor at risk of a malpractice liability, despite the quality of care given.  Ethically these requirements for informed consent should extend to substance abuse counselors as well as to general health practitioners. (NIAAA 2005).

The requirement for informed consent can be complicated when dealing with clients who are substance abuses as clients who are under the influence of drugs or alcohol may not be able to think clearly.  The other complication, which was mentioned under the principle of autonomy, is the fact that many substance abusers are required by court to accept counseling (Falls 2006).  In these cases, although it is still important to ensure the client is fully informed of the process, consent is redundant.

Where clients have the freedom to choose whether or not to enter into, or remain in a counseling relationship the counselor has a responsibility to disclose, verbally and in writing, the rights and responsibilities of both parties (ACA Code of Ethics 2005 A.2.a.),  as well as the risks and benefits inherent in the treatment. 

 

These include:

·         A description of any reasonably foreseeable risks or discomforts

·         A description of any benefits to the subject or to others

·         A disclosure of appropriate alternative treatments, including medications

·         A statement describing the extent to which confidentiality of records identifying the client will be maintained

·         An explanation of the limitations on confidentiality

·         An explanation of whom to contact for answers to pertinent questions and whom to contact in the event of an emergency

·         A statement that participation is voluntary (unless mandated)

·         Costs to the client

·         Consequences and terms of early withdrawal from treatment

(NIAAA 2005).

 

Informed consent is based on the assumptions that the client is competent to make informed decisions and understands the information being given (Refer to Autonomy).  The counselor also needs to ensure that the client is not under any coercion or undue influence. As has already been noted, this becomes a problem when the client has been mandated to counseling.  It is also difficult to address this issue when the client has impaired cognitive capacity due to chronic substance abuse or when the client is young or from another culture and may have difficulty understanding the consent form (NIAAA 2005). 

The importance of taking into account the impact of diverse language, age and developmental levels and cultural backgrounds on the informed consent process cannot be overemphasized.  Each client or group of clients present “unique challenges with regard to informed consent” which have to be addressed competently in order to make certain that the clients’ needs and rights are met (Barnett 2007).

Boundaries

There seems to have been little consensus on the meaning and nature of therapeutic boundaries over the years and, indeed, this issue has been debated from Freud onwards.  What is acknowledged is the fact that boundaries exist and are an inherent part of the therapeutic process and, whether these include issues of the length of therapy, self-disclosure by therapists, confidentiality, giving of gifts, touch or personal communications between counselor and client, they need to be addressed (Zur 2006).

 

According to Reamer (2001), there are five categories of boundary issues:

 

·         Intimate relationships such as sexual relationships, physical contact, counseling a former lover and intimate gestures;

·         Personal benefit, for example, monetary gain, goods and services or useful information;

·         Emotional and dependency needs of the counselor;

·         Altruistic gestures which could be misinterpreted and

·         Unexpected situations such as meeting sister’s new boyfriend who turns out to be a client

 

Zur (2004), however, points out the importance of distinguishing between “harmful boundary violations and helpful boundary crossings.”  Boundary violations occur when a counselor misuses his position to exploit a client, usually financially or sexually, for his own benefit.  Boundary crossings, on the other hand, when carried out with the client’s welfare in mind, are often part of the treatment process and can be very effective.

 

Changes to the ACA Code of Ethics (2005) related to boundary issues appear to accept this duality, reflecting “a paradigm shift that is taking place in the counseling profession” (Glosoff & Kocet 2005).    An example is the dilemma of whether or not to accept gifts from clients.  Here there is an acknowledgement that in some cultures gifts are given as a token of respect or gratitude.  In this case counselors are encouraged to take into account the client’s motivation in presenting the gift when deciding whether or not it is ethical to accept it. 

In addition, whereas previously there was “an emphasis on the need to avoid any type of non-professional relationship with clients” (Glosoff & Kocet 2005), there is now a recognition that not all types of dual relationships may be harmful.

Dual relationships

In a dual relationship dual or multiple roles exist between a therapist and a client, that is, a secondary relationship exists in addition to the professional or therapeutic one.   Dual relationship issues are probably among the most challenging of ethical dilemmas. 

Several types of dual relationships can be identified: a social dual relationship refers to a friendship between counselor and client; a sexual dual relationship where the counselor and client are involved in a sexual relationship; a professional dual relationship, where counselor and client are professional colleagues;  a business dual relationship, where counselor and client are business partners or have a employer/employee relationship; or a communal dual relationship where the counselor and client belong to the same community.  The degree of the relationship can also be varied, ranging from occasional encounters to situations where the client and counselor are very involved and share overlapping and multiple relationships  (Zur 2006).

 

In the past, conventional wisdom on dual relationships suggested that they   should be avoided if possible. Reamer (2001) pointed out that there were major problems with prohibitions on dual-relationships, claiming that the concept was poorly defined and that the ban tended to be too broad, often being defined as a prohibition against all dual-relationships instead of singling out those which were exploitative, manipulative, deceptive or coercive. 

Aside from exploitative or manipulative relationships, potentially harmful dual relationships can occur when, for example, a substance abuse counselor is presented with a client with whom he has had a past social or sexual encounter. Assuming a professional role with such a client raises a number of ethical issues regarding disclosure and trust. In fact, some clients, particularly in small or rural communities, may avoid accessing services because they are afraid of seeing someone they know. 

Often, however, such a relationship is unavoidable, for example, if there is no other provider available to the client.  In this situation the dual relationship is preferable to no relationship at all.  The counselor will need to make his professional role very clear, and ensure that the client understands that the information shared will remain confidential. “It may also be necessary throughout the treatment process to frequently check the client's comfort level and to continually emphasize the role and boundaries of the counselor” (TIP Series 37  2000). 

In the NAADAC Code of Ethics. (2004) the following declaration underlines the position of the association with regard to dual relationships:


I understand that I must seek to nurture and support the development of a relationship of equals rather than to take unfair advantage of individuals who are vulnerable and exploitable.

 

I shall not engage in professional relationships or commitments that conflict with family members, friends, close associates, or others whose welfare might be jeopardized by such a dual relationship.

Because a relationship begins with a power differential, I shall not exploit relationships with current or former clients for personal gain, including social or business relationships.

I shall not under any circumstances engage in sexual behavior with current or former clients.

I shall not accept substantial gifts from clients, other treatment organizations, or the providers of materials or services used in my practice.

The emphasis here too is clearly on dual relationships which could disrupt the therapeutic process.

Standard A.5.d. in the 2005 American Counseling Association’s Code of Ethics acknowledges, albeit cautiously, that there may be “potentially beneficial interactions between counselors and clients that go beyond the traditional professional counseling” (Glosoff & Kocet  2005).  The American Counseling Association’s recognition of potentially beneficial nonprofessional interactions between a client and the counselor includes instructions to document “the rationale for the interaction, the potential benefit, and anticipated consequences for the client …” and to ensure that the interaction is initiated with the appropriate client consent (ACA  2005).

Despite this shift in perspective it remains true that many dual relationships are destructive, unethical and often illegal. One of the changes in the American Counseling Association’s Code of Ethics in respect of the prohibition on sexual or romantic relationships with former clients extends the time limit from two to five years and includes relationships with romantic partners or family members of former clients.

Confidentiality

The 2005 Code of Ethics of the American Counseling Association refers to the client’s right to expect confidentiality (A.3.a), requiring counselors to “…respect their client’s right to privacy and avoid illegal and unwarranted disclosures of information” (B.1.a).   Since clients need to feel secure in the knowledge that they are able to confide freely in their counselor for the counseling process to be effective, full confidentiality would be the ideal. 

In fact, confidentiality has been described as the “hallmark of the therapeutic relationship” because it enables clients to seek the help of a counselor for problems such as alcohol and drug abuse without worrying about the consequences of disclosure (Kitchener 1999).  Because of the economic and social stigma attached to substance abuse these potential clients would probably not seek treatment without the assurance of confidentiality.

Unfortunately there are a number of aspects of a counseling relationship which undermine this ideal and relative confidentiality is the most that any honest counselor can offer, to the extent that it has been suggested that to promise complete confidentiality would in itself be unethical.  These aspects include keeping records of sessions and of the client’s personal data; release of information to supervisors; protection of third persons from endangering situations and court orders which require the disclosure of information (Gondim n/d).  The increasing use of computerized data also compromises the confidentiality of the information. In addition “the nature of managed care requires more extensive justification for treatment, and the number of individuals that need information about a person's treatment is increasing” (NIAAA  2005).

These issues need to be discussed with clients before a professional relationship can be established (Refer to Informed Consent).

The fact that complete confidentiality is unattainable does not imply that the counselor has no control over the disclosure of confidential information.  In consultation with supervisors or professional colleagues it is important to use discretion, revealing only those aspects of a session which are relevant to the discussion.  Similarly, in documenting details of a therapeutic session only essential details need to be recorded (Refer to Record Keeping).  Personal details revealed by the client but not relevant to the treatment should be omitted.  Necessary treatment information on a client coming into treatment for substance abuse would include, for example, “the client’s substance abuse history, motivation for entering treatment, any medical or emotional issues that relate to the treatment and the plan for service” (NIAAA  2005).

Duty to Report

Remembering that a breach of confidentiality could be a malpractice issue it is important that counselors are aware of the circumstances which legally require disclosure and to ensure that they “comply with all laws, policies, and ethical standards pertaining to confidentiality” (ACA 2005).  Unfortunately this is not always easy and counselors “can quickly get squeezed between the pressures of statutes, rights of family members, professional ethics, and personal integrity” (Pitcairn & Phillips n/d).

In situations where counselors find themselves faced with an ethical dilemma in this regard,   Reamer (1999) advises that they deal with it by consulting with colleagues and recording their discussions in the client’s record. (NIAAA 2005). While consultation with a supervisor would be the ideal choice, consultation with peers or other professionals could be equally valuable.  For cultural issues consultation within the community which represents the culture is vital.  However, when sharing   information without the clients written consent the counselor must ensure that no personal details are revealed and the client’s right to confidentiality is strictly maintained.

The American Counseling Association Code of Ethics (ACA 2005) give two overriding exceptions to the requirement of confidentiality: “disclosure to protect clients or identified others from serious and foreseeable harm” and a court ordered disclosure, and Section 611.004 of the Texas Health and Safety Code indicates that a “professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others or there is a probability of immediate mental or emotional injury to the patient”   (NIAAA 2005).

Protection from harm could extend to contagious and life-threatening diseases, according to the American Counseling Association Code of Ethics (B.2.b.), which states that in this case counselors may “be justified in disclosing information to identifiable third parties” once the diagnosis has been confirmed and if they are known to be at a high risk of contracting the disease.  Before doing so the counselor should ascertain whether the client intends to inform the third party or to engage in any behaviors which may harm them (ACA 2005).

Reporting of incidents of suspected child abuse and neglect to the appropriate State or local authorities is mandatory and  the CFR (Code of Federal Regulations) 42 Part 2 Confidentiality of alcohol and drug abuse patient records holds that medical emergencies are also grounds for breaking confidentiality when medical personnel require the information about a client in order to treat a condition “which poses an immediate threat to the health of any individual and which requires immediate medical intervention.  (CFR 2002).                      

There are further limitations to confidentiality although most of these are not federal laws but are limited to specific states.  Those which are relevant to substance abuse include:

  • Mandatory reporting of family violence
  • Excessive alcohol use or illegal drug use when witnessed by children
  • Reporting of pedophiles
  • Reporting of the abuse of elders. 

   (NIAAA 2005).

If a court ordered disclosure is issued counselors are obliged to comply with the order, however the American Counseling Association Code of Ethics (B.2.c and d.) require that counselors ensure that clients are informed and obtain written consent from them before disclosing confidential information and that only essential information be released (ACA 2005).

A contentious issue in respect of the confidentiality of a client’s records is that which occurs when the client requests reimbursement for the treatment from a third-party, such as an insurance company.  In this case the payers may feel that they have the right to ascertain that the appropriate treatment has been given and may request information to enable them to do so. Nevertheless, this information may only be divulged to the third party if the client signs an authorization.  Once this has been done, however, and despite “the additional confidentiality requirements for substance abuse records”, there is no restriction on the type or extent of information disclosed. 

Third party intervention is becoming more and more frequent with mandatory treatment referrals by the Drug Courts in lieu of criminal charges.   Employee Assistance Programs (EAPs) often make the participation in substance abuse treatment programs a condition for continued employment and ‘driving under the influence’ (DUI) laws “also require mandatory treatment as a requirement for regaining or maintaining a driver’s license.”   In these cases clients are required by the programs to waive their confidentiality rights and counselors have no option but to carry out the instructions of those who make the referrals (NIAAA  2005).  Here too, negotiation around those areas where information must be disclosed and those areas which may remain confidential is a possibility worth pursuing.

Where clients are in a federally assisted substance abuse treatment program, their medical information is subject to a Federal law which restricts its use and disclosure (Felt-Lisk & Humensky 2003).  

 

Finally, the American Counseling Association Code of Ethics (A.9.c.) also provides guidelines for dealing with confidentiality in terms of terminally ill clients.  When such a client indicates that she is considering taking her own life the counselor’s decision as to whether or not to disclose this would be based on the applicable laws for the State and “the specific circumstances of the situation”.   Here again the counselor is faced with an ethical dilemma which might conflict  with his professional ethics and personal integrity and a decision should not be entered into without seeking consultation from a supervisor or the appropriate professional (ACA 2005).

Record Keeping

The issue of record keeping has come up a number of times under the topic of confidentiality.  There is little doubt that a counselor is obliged, if not by law than by professional and ethical standards, to keep separate, adequate and accurate written records  for each client. 

Having no records is unprofessional, and could be considered a demonstration of sub-standard care.  The Arizona Association of Alcoholism and Drug Abuse Counselors emphasize the importance of report and record keeping, claiming that, if performed properly, it could enhance the client’s entire treatment process AzAADA n/d).

According to Barry Mintzer (2006), writing for the National Association of Social Workers, the records should include:

  • A description of the client’s prior history of services
  • A description of the client’s present reasons for seeking assistance
  • An assessment or diagnosis of the client’s mental, emotional or behavioral condition, disorder or addiction
  • Documentation of any changes in the assessment or diagnosis
  • A treatment plan which sets forth the treatment goals and objectives
  • Documentation of any changes in the treatment plan
  • A description of the frequency and duration of the services provided
  • Progress notes containing the assessment of the client’s progress in treatment
  • Recommendations for further treatment where appropriate
  • Documentation of fees charged and payment obtained
  • Documentation that the client has been informed of his confidentiality rights
  • Copies of any client authorizations for release of information or records
  • Any other information reasonably necessary to permit proper assessment and treatment of the client in the future, including the termination process.

 
Unfortunately, primarily because of the increase in litigation against healthcare professionals in the United States, some practitioners prefer to keep no records at all, or only the most innocuous information, in order to protect themselves.  In addition to being unethical “the failure to keep adequate records and notes may be regarded as a failure to demonstrate adequate professionalism” (Purves 2004).   In fact, Minzer (2006) points out that in malpractice cases, “failure to keep records can itself be evidence of malpractice” whereas keeping adequate records provides you with the ammunition to defend yourself in the event of litigation in respect of malpractice or ethical complaints.

Purves (2004) gives five reasons why he considers record keeping valuable, these are:

 

  1. to record information about the client;
  2. to enable the therapist to retain a reasonable memory of what happened during the session;
  3. to demonstrate that ‘due care and attention’ was given to the client if the counselor is ever required to defend his practice, for example, should litigation occur;
  4. to provide data for evaluating the service provided, and
  5. to explore issues arising from the session and as a record of supervision discussion about the client.

However, the American Counseling Association’s Code of Ethics (ACA 2005) calls for counselors to obtain permission from their clients before recording sessions or reviewing session transcripts with supervisors or peers (B.6.b.).  It is also important to keep in mind the fact that a client has the legal right to demand access to his records at any time.  In the light of this it is essential that counselors ensure that their note taking is accurate, responsible and appropriate.

Client access to records

The American Counseling Association’s Code of Ethics (B.6.d.) requires that counselors provide “reasonable access to records and copies of records when requested by competent clients” (ACA 2005).   This access can only be limited when there is ‘compelling evidence’ that access to their records could be harmful to the client.  The client’s request for access does not have to be in writing but the request and, where relevant, the rationale for withholding access should be documented by the counselor.

The National Association of Social Workers (NASW 1999 revised) suggest in their Code of Ethics that, if a counselor is concerned that accessing their records could result in serious misunderstanding or harm to the client, he should provide assistance in interpreting the records and consulting with the client regarding these records.  

Security of records

It is clear that record keeping, no matter how desirable impinges on the clients’ right of confidentiality.  For this reason it is important that the counselor take every possible precaution to ensure that the confidentiality of records is preserved.   American Counseling Association’s Code of Ethics (B.6.a and g.) require a secure location for the storage of records, to which only authorized persons have access.  After the termination of treatment, counselors are required to “ensure reasonable future access, maintain records in accordance with state and federal statutes governing records and dispose of client records and other sensitive materials in a manner that protects client confidentiality” (ACA 2005).

The Texas Administrative Code also covers the continuing confidentiality of records, stating that “communication between a licensee and client and the client's records, however created or stored, are confidential under the provisions of the Texas Health and Safety Code, Chapters 181, Texas Health and Safety Code, Chapter 611, and other state or federal statutes or rules, including court room rules of evidence” (Rule §781.411) (Texas Administrative Code 2004).

In his article, Of Cows and Confidentiality, George Heymont (2007) gives a chilling example of the possible consequences of a break down in the security of confidential information:

In February 1995, a 13-year-old girl (whose mother worked in a hospital admissions office in Jacksonville, Florida) accessed the records of several patients who had recently been admitted to the hospital. As a practical joke, the teenager called the patients’ families and informed them that those patients had tested positive for the HIV virus. After being told that she was HIV positive and had had a positive pregnancy test, one of the victims of this teenager’s prank attempted suicide.

 Aside from this which, one hopes, is an isolated incident, Heymont claims that the confidentiality of clients’ records in the United States is relatively inviolate for three reasons:

Firstly, people in health management have been trained to ‘regard confidentiality as a sacred cow’, secondly, the high risk of litigation carrying punitive legal costs for breaching confidentiality and, thirdly, because there is no financial incentive for disclosing confidential data.

At the same time he warns that, with growing use of technology for recording confidential information comes the risk that others accessing the same technology “may apply different standards to the use of data” (Heymont 2007).

Ethics and Adolescents

The same ethical standards which apply to other clients apply equally to adolescents but issues of confidentiality and consent to treatment can present additional ethical dilemmas.  Standards B.5.a., B.5.b. and B.5.c. of the American Counseling Association’s Code of Ethics acknowledge the rights and responsibilities of parents and guardians, particularly with respect to different cultures, while at the same time emphasizing the need for counselors to protect the confidentiality of minors and to include them in decisions about disclosing privileged information to the families (Glosoff & Kocet n/d).

Despite the admonition to preserve the confidentiality of adolescents, in most states adolescents require parental consent to any form of treatment, although some do permit minors to participate in substance abuse treatment without their parents’ permission. The Code of Federal Regulations (42) provides for the maintenance of confidentiality with minors as long as the parents are not paying for the treatment. It does, however, allow for the parents to be advised of the adolescent’s participation if the minor is considered incapable of making rational decisions or is deemed to be in danger (NIAAA  2005).

Counselors who provide treatment for substance abuse to adolescents, then, need to take into account two disparate issues:  whether they are legally entitled to admit an adolescent into a treatment program without the consent of a parent or guardian and whether they can share concerns about the adolescent’s substance abuse with parents or guardians without violating federal regulations which protect their client’s confidentiality (TIP Series 32 1999).

As long as the adolescent is willing to have treatment information shared with his parents or guardians these questions do not come up.  The difficulty arises, however, when the adolescent refuses to allow any such communication.   In this case other than for the two exceptions allowed by the Code of Federal Regulations (42) above, federal confidentiality regulations prohibit disclosure to anyone, including parents.  Should this happen in a State that requires parental consent there are only two alternatives:  either the adolescent must be refused admittance to the program, or he can be admitted despite the legal ruling of the State.

Treatment Improvement Protocol Series 32 Treatment of Adolescents with Substance Use Disorders suggests that the following issues should be taken into account when making the decision:

  • The age of the adolescent – adolescents are accorded increased autonomy by the State as they get older, therefore admitting an eighteen year old without parental consent is very different to admitting a fourteen year old under the same conditions.
  • The maturity of the adolescent -   the emotional and social maturity of the adolescent together with his reasoning ability should be taken into account as well as his chronological age.
  • The family situation - despite the importance of family involvement in the treatment of substance abuse, the family situation may be such that involving them or even notifying them of the treatment may be both impractical and clinically unwise.
  • The kind of treatment to be provided – the more intensive the treatment required, the more risky it would be to admit the adolescent without parental consent.
  • Possible liability for refusing admission – when State law required substance abuse treatment programs to treat clients in need.
  • Possible liability for admitting adolescent without parental consent – it is possible that a provider could be sued if an adolescent is admitted to the treatment program without parental consent in a State which requires it.

(TIP Series 32 1999).

It is obvious, then, that there is a conflict between the concept of an adolescent’s right to confidentiality and the parents’ legal rights to access information on a minor’s treatment with the counselor precariously trying to negotiate a balance between ethical and legal requirements (Pitcairn & Phillips n/d).  Weddle and  Kokotailo (2005) point out that over the past three decades “our understanding of the cognitive development of adolescents and awareness of the prevalence of risk-taking behavior” has led to an acceptance that we must provide adolescents with confidential health services.  This is particularly important in the light of studies which show that adolescents are less likely to seek treatment for sensitive issues such as substance abuse if they know, or believe, that their parents will be informed.  Consequently treatment is often delayed or fails to take place increasing the risk of escalating substance abuse with the concomitant increase of complications.

Ethics in Group Therapy

As substance addiction is rapidly becoming a major health crisis world wide, demand for effective treatment of substance abuse has escalated.   Because it is considered both effective and economically viable, group therapy has become the treatment of choice for many counselors.  There is no doubt that group therapy is a powerful type of intervention but it is not necessarily the best choice of treatment for every client.  Counselors need to select prospective participants in order to ensure that each client’s needs and goals are compatible with those of the group, and, wherever possible, to screen out those clients whose presence would impede the progress of the group or whose own progress would be jeopardized by group therapy (A.8.a.) (ACA 2005).

The Treatment Improvement Protocols Series 41 (2005) suggests a number of types of clients who would probably not benefit from group therapy.  These include:

  • People who refuse to participate;
  • People who cannot honor group agreements, including preserving the privacy and confidentiality of group members;
  • People who make the therapist feel uncomfortable;
  • People who constantly drop out or violate the group norms;
  • People who are in the throes of a life crisis;
  • People who cannot control their impulses;
  • People who experience severe discomfort in groups.

For those clients for whom group therapy is appropriate there are many advantages.  Besides the practical issues like lower costs and more readily available treatment, thereby reducing the suffering and possible deterioration in the client’s condition, group therapy also provides the following benefits

  • Groups provide opportunities for modeling social skills and techniques and for practicing these skills in a safe environment;
  • Group members provide support for individual members in times of trouble;
  • Membership of a group shows individuals that their problems are not unique;
  • They provide positive peer reinforcement;
  • They are effective in treating social problems which accompany substance abuse, such as depression, isolation and shame.

(TIP Series 41 2005; Freeman 2004).

There are five models of group therapy which are commonly used with substance abuse.  The Treatment Improvement Protocols Series 41 (2005) list them as:

  • Psycho educational groups which educate clients about substance abuse;
  • Skills development groups which help clients develop the skills necessary to cope with resisting addictive substances;
  • Cognitive-behavioral groups which seek to change thoughts and actions which lead to substance abuse;
  • Support groups which encourage each other and share information about maintaining abstinence;
  • Interpersonal process groups which attempt to uncover developmental issues that contribute to addiction or interfere with recovery.

The same ethical standards which apply to individual clients apply equally in a group situation but issues of confidentiality and counselor competence need to be addressed here. 

The American Group Psychotherapy Association gives guidelines for ethical standards in group therapy.  These cover the following issues:

 

The responsibility to respect “the dignity and uniqueness of each patient/client as well as the rights and autonomy of the individual patient/client” 

·         The client needs to be informed about the nature of group therapy and of the risks, rights and obligations involved in this type of therapy;

·         Clients should only be included in this type of therapy if it is appropriate for them

Safeguarding the client’s right to privacy

  • The counselor and the members of the group must all agree to protect the identity of each individual;
  • The counselor must inform the group members about the limits of privileged communication as they apply to group therapy;
  • No identifiable information about the group members may be used by the counselor in teaching, publications or presentation;
  • Information may be shared in the group only after each member has signed a consent form.

Safeguarding the group from incompetent, unethical or illegal practice

  • The counselor must be qualified and competent to practice group therapy;
  • Group members should be protected from misrepresentation, misinformation and false advertising concerning the counselor’s qualification and skills

(AGPA 2002).

 

The American Counseling Association adds the need for counselors to “take reasonable precautions to protect clients from physical, emotional, or psychological trauma” in a group setting (A.8.b.)(ACA 2005). 

Group therapy should be terminated immediately should it become obvious the client is uncomfortable in the situation and is not making any discernable progress.

Termination of treatment

Principal 8 in The Association for Addiction Professionals’ Code of Ethics states: “I shall terminate a counseling or consulting relationship when it is reasonably clear that the client is not benefiting from the relationship” (NAADAC 2004).   Termination is also appropriate when clients no longer need assistance or are even being harmed by continuing counseling.  The latter could occur if the counselor is suffers from ‘burn-out’ and is consequently unable to treat clients with the flexibility and respect required.  If the counselor is at risk of being harmed by the client, or by a third party with whom the client has a relationship, or if the client reneges on the fees agreed upon by both parties these are also considered acceptable grounds for termination (A.11.c.) (ACA 2005).  

There are, however, other criteria for terminating client treatment, not all of which are as ethically appropriate.  Substance abuse treatment programs often establish policies against continuing to work with clients who continue to relapse.  In this case denial or lack of motivation are considered reasons for termination and sobriety may be a condition for continued treatment.  Intoxicated clients are also often refused treatment on the grounds that doing so implies support of their condition and so undermines their motivation for sobriety.  The argument against these as criteria for termination is that often the symptoms which are being rejected are part of the disease process and it follows then that it must be unethical “to terminate treatment if a client manifests these symptoms (NIAAA  2005).

It goes without saying that termination of treatment should only be carried out in the best interests of the client.  Termination of a professional relationship in order to pursue a personal, business or intimate relationship is unacceptable and, in fact, any termination of treatment which is motivated by satisfaction of the counselor’s needs is a form of exploitation (Barnett and Zur 2007).

Whatever the reason for termination, ethically a counselor may not abandon or neglect a client.  Informed consent is as essential for ending treatment as it is for beginning it and the termination process needs to be seen as an essential part of the treatment.  Barnett and Zur (2007) point out that discussions around termination should, wherever possible, be conducted in advance and “be addressed in a thoughtful and sensitive manner.”  Where necessary appropriate arrangements must be made for transfer or referral of clients and this should be done in full consultation with the clients themselves.

A Step-by-Step Model for Making Ethical Decisions

Although the majority of the ethical issues covered above are complex enough to need  individual evaluation of the relevant dilemmas, a routine method for approaching the decision making process is helpful in clarifying the issues and so helping to resolve the dilemma.

The model provided below is drawn from the National Association of Social Workers’ training manual and a model produced by Forester-Miller and Davis (2008) which incorporates the work of Van Hoose and Paradise (1979), Kitchener (1984), Stadler (1986), Haas and Malouf (1989), Forester-Miller and Rubenstein (1992), and Sileo and Kopala (1993).  The model consists of seven sequential steps.

  1. Identify the Problem

This requires the counselor to gather as much information as possible, separating facts from assumptions, hypotheses or suspicions.  Decide whether the problem is a clinical, legal, system, cultural or ethical issue.

 

    1. Clinical issues

These involve the clinical needs of the client and require an assessment of the client’s original and ongoing condition.

    1. Legal issues

If legal issues exist the counselor needs to review the State and local laws regarding the issue, or, where necessary, consult with his supervisor or an attorney in the case of liability questions.

    1. System issues

The counselor needs to know the agency’s policies and procedures.

    1. Cultural issues

These are significant for understanding the client’s response to a treatment plan.

    1. Ethical issues

    The counselor needs to evaluate her own feelings about a situation, especially where basic principles appear to be compromised.  Identification of counter transference issues (Refer to section on Justice) with help the counselor to view the issue objectively.

    1. Apply a Code of Ethics

    After clarifying the problem the counselor needs to look at the basic ethical principles of autonomy, nonmaleficence, beneficence, justice, and fidelity to establish whether there is a true ethical dilemma at stake.  If any of the principles have been compromised a code of ethics, such as that provided by the American Counseling Association (ACA 2005) should be consulted to see whether the issue is addressed there.  If there are specific standards covering the issue and providing a clear course of action this should enable the counselor to resolve the problem. 

    1. Determine the nature and dimensions of the dilemma

     

    Ethical dilemmas are often complex and resist a simplistic solution. If there are a number of possible options ensure that the problem has been examined from various perspectives.

      1. Although each of the principles is of equal value it is necessary to decide which principles apply in the situation and determine which will take priority in these particular circumstances.
      2. Consult current professional literature covering the issue in question.
      3. Consult with a supervisor or with professional colleagues and review the information which has been gathered with them.  They might be able to identify additional aspects of the dilemma.
      4. Consult the relevant professional associations.

    1. Consider all possible options

    Evaluate each option, listing the pros and cons and considering the impact each course of action might have on the welfare of the client, the counselor, the agency and any others who may be affected.  Determine which option or combination of options will best address the problem.

    1. Decide on a course of action

    Stadler (1986 in Forester-Miller & Davis 2008) “suggests applying three simple tests to the selected course of action to ensure that it is appropriate.”  The test of justice – whether you would treat others the same way in the same situation; the test of publicity –whether you would be happy to have your behavior reported in the press and the test of universality – whether you would recommend the  course of action you have chosen to another counselor in the same situation.   

    1. Implement the course of action

    Once satisfied that the appropriate course of action has been chosen then it should be implemented.  Evidence of the process leading up to the implementation should be documented and the client should understand the rationale behind the counselor’s decision. 

    1. Evaluate the decision

    Making a decision and carrying out the appropriate action in an ethical dilemma is often difficult and it is very likely that not everyone will be comfortable with the implementation of the chosen course of action.   It is important to evaluate the situation after the initial crisis has passed to assess whether the decision had brought about the anticipated consequences. 

    Conclusion

    Although the focus of this paper has been on ethics for substance abuse counselors it is notable that a common thread runs through the ethical codes of all the health service professions, and, indeed, those of many in the business and legal world as well.  These codes are based on the moral principles of justice, autonomy, beneficence, nonmaleficence and fidelity.   Substance abuse counselors might at times feel overwhelmed by the complexity of the ethical dilemmas which they face, almost on a daily basis.  The principles and guidelines above should provide a basis for decision making but, in the end, it is the personal and professional values and integrity of the counselor, “rather than the mandatory requirement of an external organization” (ACA 2005) which will make those principles live.

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