Ethics for Substance Abuse Counselors
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
Principles are informed by personal and
professional values. The Code of Ethics
adopted by the American Counseling Association (2005) sees these values as
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
It makes sense, then, to examine these
principles first, before investigating some of the guidelines available to the
(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.
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).
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.
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).
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).
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.
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).
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.
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).
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
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.
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
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
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.
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.
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.
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
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).
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.
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
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.
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
description of any reasonably foreseeable risks or discomforts
description of any benefits to the subject or to others
disclosure of appropriate alternative treatments, including medications
statement describing the extent to which confidentiality of records identifying
the client will be maintained
explanation of the limitations on confidentiality
explanation of whom to contact for answers to pertinent questions and whom to
contact in the event of an emergency
statement that participation is voluntary (unless mandated)
to the client
and terms of early withdrawal from treatment
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).
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).
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
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
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.
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
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.
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.
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.
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.
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.
shall not under any circumstances engage in sexual behavior with current or
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.
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
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”
These issues need to be discussed with
clients before a professional relationship can be established (Refer to
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
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 &
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).
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
- Mandatory reporting of family
- Excessive alcohol use or illegal
drug use when witnessed by children
- Reporting of pedophiles
- Reporting of the abuse of
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).
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.
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).
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
- 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
- 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
- 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
Purves (2004) gives five reasons why he
considers record keeping valuable, these are:
- to record information about the
- to enable the therapist to retain
a reasonable memory of what happened during the session;
- 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;
- to provide data for evaluating the
service provided, and
- 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
access to records
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
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.
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).
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
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.
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:
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).
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).
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).
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
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.
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
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.
kind of treatment to be provided – the more intensive the treatment
required, the more risky it would be to admit the adolescent without
liability for refusing admission – when State law required substance abuse
treatment programs to treat clients in need.
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
The Treatment Improvement Protocols
Series 41 (2005) suggests a number of types of clients who would probably not
benefit from group therapy. These
- People who refuse to participate;
- People who cannot honor group
agreements, including preserving the privacy and confidentiality of group
- People who make the therapist feel
- People who constantly drop out or
violate the group norms;
- People who are in the throes of a
- People who cannot control their
- 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
- Groups provide opportunities for
modeling social skills and techniques and for practicing these skills in a
- 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
- They are effective in treating
social problems which accompany substance abuse, such as depression,
isolation and shame.
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
- 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
- Information may be shared in the
group only after each member has signed a consent form.
Safeguarding the group from incompetent, unethical or
- 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
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
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
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
A Step-by-Step Model for Making Ethical Decisions
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.
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.
- Identify the Problem
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.
- Clinical issues
involve the clinical needs of the client and require an assessment of the
client’s original and ongoing condition.
- Legal issues
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.
- System issues
counselor needs to know the agency’s policies and procedures.
- Cultural issues
are significant for understanding the client’s response to a treatment plan.
- Ethical issues
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
- Apply a Code of Ethics
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.
- Determine the nature and
dimensions of the dilemma
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
- 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
- Consult current professional
literature covering the issue in question.
- 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.
- Consult the relevant professional
- Consider all possible options
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
- 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.
- 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.
- 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.
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.
American Counseling Association ACA. (2005). Code of
ethics and standards for practice. Alexandria,
American Group Psychotherapy Association AGPA
(2002). AGPA and NRCGP Guidelines
for Ethics. Retrieved 25
February 2008 from http://www.agpa.org/group/ethicalguide.html
Association of Alcoholism and Drug Abuse Counselors. AzAADAC (n/d) Twelve
Core Functions of Counseling.
Retrieved 22 February
2008 from http://azaadac.org/index.htm
Association for Addiction Professionals NAADAC (2004). Code of
Ethics. Retrieved 21 February 2008 from http://naadac.org/documents/index.php?CategoryID=23
Barnett, J. (2007). Seeking
an Understanding of Informed Consent. Professional Psychology: Research and
Practice. April 2007, vol 38, pp 179-182.
Barnett, J. & Zur, O. (2007). Codes of Ethics on Termination in Psychotherapy and Counseling.
Retrieved 25 February 2008
Code of Federal Regulations CFR (2002) Retrieved 23 February 2008 from
Falls, L. (2006). Ethics
in Addiction counselling. Retrieved 20 February 2008 from www.shsu.edu/~piic/fall2006/Fall-addiction.ppt
S. & Humensky, J. (2003). Privacy Issues in Mental Health and Substance
Abuse Treatment: Information Sharing between Providers and Managed Care
Organizations: Final Report. Department
of Health and Human Services. Retrieved 23 February 2008 from http://aspe.hhs.gov/datacncl/reports/MHPrivacy/appendix-a.htm
Forester-Miller, H. & Davis, T. (2008). A Practitioner’s Guide to Ethical Decision
Making. Retrieved 20
February 2008 from http://www.counseling.org/Counselors/PractitionersGuide.aspx
Freeman, A. (2004).
Clinical Applications of Cognitive Therapy. Springer.
Glosoff, H.L. & Kocet, M.M. (n/d). Highlights of the 2005 ACA Code of Ethics. Retrieved 23 February 2008 from
Gondim, P.T. (n/d). Confidentiality
and Professional Ethics in Counseling. Retrieved 20 February 2008 from
Heymont, G. (2007). Of
Cows and Confidentiality. Retrieved 24 February 2008 from http://dictationtherapyfordoctors.blogspot.com/2007/09/of-cows-and-confidentiality.html
K.S. (1999). Foundations
of Ethical Practice, Research, and Teaching in Psychology. Lawrence Erlbaum Associates.
Minzer, B.L. (2006). Record Keeping Requirements and Client Access
to Clinical Records. Posternak. Retrieved 22 February 2008 from http://www.pbl.com/resources.php?ArticleID=22
National Association of Social Workers (NASW). (1999) Code of
Ethics. Retrieved 23 February 2008 from http://www.socialworkers.org/pubs/code/code.asp
National Institute on Alcohol Abuse and Alcoholism (NIAAA). ( 2005). Social Work Education for the Prevention and Treatment of Alcohol Use
Disorders Retrieved 21 February 2008 from http://pubs.niaaa.nih.gov/publications/Social/Module9Legal&EthicalIssues/Module9.html
S.L. & Phillips, K.A. (n/d). Ethics,
Laws and Adolescents: Confidentiality, Reporting, and Conflict. Retrieved 23 February 2008 from
Bioethics. (n/d). Ethics in Medicine. University of Washington School
of Medicine. Retrieved 20
February 2008 from http://depts.washington.edu/bioethx/tools/princpl.html
Purves, D. (2004). The Ethics and Responsibilities of Record
Keeping and Note Taking in R. Tribe & J. Morrissey (Eds). Handbook of Professional and Ethical Practice for Psychologists,
Counselors and Psychotherapists . Psychology Press.
Reamer, F.G. (2001). Tangled Relationships: Managing Boundary Issues in the Human Services.
Columbia University Press
The Stanford Encyclopedia of Philosophy. (2008). The Principle of Beneficence in Applied
Ethics. Retrieved 21 February 2008 from http://plato.stanford.edu/entries/principle-beneficence
Texas Administrative Code (2004) Ethical Standards. Retrieved 21 February 2008 from
Improvement Protocol (TIP) Series 32 (1999).
Treatment of Adolescents with
Substance Use Disorders. US
Department of Health and Human Services. National Library of Medicine.
Retrieved 24 February 2008
Improvement Protocol (TIP) Series 37 (2000). Substance Abuse Treatment for Persons with HIV/AIDS.. US Department
of Health and Human Services. National Library of Medicine. Retrieved 21 February 2008 from http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.64746
Treatment Improvement Protocol (TIP) Series 41 (2005). Substance Abuse Treatment:Group Therapy. US Department
of Health and Human Services. National Library of Medicine. Retrieved 25 February 2008 from http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.78366
Truscott, D. & Crook, K.H. (2004). Ethics for the Practice of Psychology in Canada. University
Weddle, M. & Kokotailo, P. (2005). Confidentiality and
Consent in Adolescent Substance Abuse: An Update. Virtual Mentor.
Volume 7, Number 3. Retrieved 23 February 2008 from http://virtualmentor.ama-assn.org/2005/03/pfor1-0503.html
Wozny, D.A. (n/d). Living
the ACA Code of Ethics. Integrating Ethics in Counselors’ Personal Lives.
Retrieved 20 February 2008
Young, R.M (2004). Mental
Space. Retrieved 21
February 2008 from http://human-nature.com/rmyoung/papers/paper55.html
(2004). To Cross or Not to Cross: Do boundaries in therapy protect or
harm. Psychotherapy Bulletin, 39 (3),
27-32. Retrieved 21 February 2008 from http://www.zurinstitute.com/boundariesintherapy.html
(2006). Therapeutic Boundaries and Dual Relationships in Rural Practice:
Ethical, Clinical and Standard of Care Considerations. Journal of Rural Commnity Psychology. Vol E9, No.1. Spring 2006.