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Ethical Issues in Substance Abuse Counseling

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Elizabeth Ball

on 7 November 2014

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Transcript of Ethical Issues in Substance Abuse Counseling

Dual Relationships
Informed Consent
Confidentiality and Privacy
Professional responsibility of Clinicians
The Recovering Counselor
Client increased risk of suicide
Boundaries of professional practice in making treatment decisions
Client's increased risk for legal issues
Counselor's specializing in substance abuse are often faced with unique situations that result in ethical challenges that other counselors do not typically address.
Ethical Considerations
The Counseling Relationship
Dual Relationship: when professionals assume two roles simultaneously or sequentially with a person seeking help (Doyle, 1997)
The phenomenon of the "recovering counselor" increases the likelihood of substance abuse counselors being involved in dual relationships with clients
The recovering counselor and current or former client may find themselves attending the same 12-step meeting ex. AA, NA, Al-Anon
Case Study: What should a therapist do if they find themselves attending the same Alcoholics Anonymous meeting as a client?
Confidentiality & Privacy
The ACA, NAADAC, state licensing boards, and HIPPA enforce standards of confidentiality and privacy on mental health professionals
Additional provisions enforced by federal law that protect individuals seeking treatment for substance abuse
Ethical concerns regarding confidentiality when working with individuals involved with the criminal justice system
Substance abuse counselors need to be aware of duty to warn regulations as well as reporting requirement for abuse of a minor
Substance abuse counselors need to be aware of group work concerns
Addiction Counselor Credentials
In Texas individuals wishing to specialize in substance abuse counseling must obtain their Licensed Chemical Dependency Counselor (LCDC) credential
Minimum of an associate's degree
4,000 hours of approved supervised internship
Pass the written chemical dependency counselor examination
Submit two letters of recommendation from LCDCs

Elizabeth Ball, Amy Sowell, Brittany Stevens
Ethical Issues in Substance Abuse Counseling
Multiple Credentials and Association Memberships
Counselors are required to follow the ethical codes of the licensing board as well as professional organizations they belong to
Licensed Chemical Dependency Counselor (LCDC)
National Association of Alcoholism and Drug Abuse Counselors (NAADAC)
The various ethical codes involved in having multiple licenses and association memberships presents the dilemma of which code to follow?
Wise for counselors to follow the provisions described by the state board governing their license

Texas Department of State Health Services (2013):
Includes provisions that discourage the counselor from practicing outside their competency
American Counselor Association (2014):
Section C.2 of ACA's code of ethics
Counselor's must not provide treatment that exceeds their competency
Competency is based on the "education, state and national professional credentials, and appropriate professional experience" of the counselor
Codes Regarding Professional Competency
Scott (2000) states that there is lack of agreement concerning the level of education required to treat addictions
Some states do not even require a bachelors degree
Standards for providing this type of counseling are the lowest in the field
Also disagreement regarding the competency of counselors who possess a Master's degree and state license
Counselors with little training or experience in addictions lack the knowledge of this complicated specialty and are not able to effectively treat individuals suffering from addiction
Counselors need to have training and experience with addiction, not just substance abuse

Lack of Agreement on Professional Credentials
Texas Department of State Health Services, 2013
Ethical Codes Regarding Dual Relationships
Texas State Board of Examiners of Professional Counselors:
Non-therapeutic relationships with clients is prohibited
American Counseling Association (2014)
Prohibits non-therapeutic relationships with clients as well as entering into therapeutic relationships with whom the counselor had a previous relationship with
LCDC in the Texas
Therapists can not engage in a sexual, personal, or business relations with a lcient of member of the client's immediate family for at least two years after services are terminated
Dual relationships should be evaluated carefully and avoided as much as possible
The recovering counselor acts as therapist during treatment and peer during self help meeting. Therefore, the therapist is involved in a dual relationship and needs to look elsewhere for recovery needs
Other Ethical Considerations of the
Recovering Counselor
As with all substance abuse, there is a risk in relapse for recovering counselors
NAADAC (2013) suggests that all addiction counselors are cognitive of their use of psychoactive chemicals. If impairment occurs in a recovering counselor they are expected to report their impairment, discontinue professional practice, and seek professional treatment.
Recovering Counselor:
Substance abuse counselors who consider themselves to be in recovery from substance abuse
Texas State Board of Examiners of Professional Counselors (2011) prohibits the use of alcohol or drugs in a manner that affects the licensees ability to provide counseling treatment
LCDC counselors must not engage in substance abuse counseling if impaired by, intoxicated by, or under the influence of drugs and alcohol
Confidentiality when working with involuntary clients
Counselors may feel ethically conflicted due to perceived lack of confidentiality
Not uncommon for counselors treating mandated substance abuse clients to be required to inform their client's probation officer of their progress
Duty to Warn & Reporting
In Texas, a counselor
breech client confidentiality to warn a medical or law enforcement personnel if a client discusses the intent to harm a third party
If a client discusses future or past harm to a protected population (minors, elderly, or disabled individuals) the counselor has an obligation to report the abuse to the necessary authorities
Texas State Board of Examiners of Professional Counselors, 2011
Substance abuse counselors should be concerned with Chapter 261 of the Texas Family Code which defines abuse as "the current use by a person of a controlled substance...in a manner or to the extent that the use results in physical, mental, or emotional injury to a child"
What do you do?
A 25 year old mother of an 18 month old is referred to your practice after her third DUI. She expresses to you that she has driven under the influence with her child in the car. What do you do?

Group Treatment/Group Therapy
One of the most popular forms of group therapy is "self help," 12 step programs such as AA/NA/Alanon
Not supervised by licensed professionals therefore members are not afforded confidentiality and privileged communication
In groups led by a professional counselor the counselor is bound to the confidentiality agreement but the group members are not
Group leaders are required to stress the importance of maintaining the confidentiality of the group, group members are not bound by law to do so
Group members may gossip outside of group and even tell outside individuals about group happenings without repercussion

Scott, 2000
Informed Consent
Does consent count if the client is under the influence?
People often enter treatment in varying degrees of cognitive dysfunction and frequently under the influence of alcohol/drugs.
It is important that once the clients have been initially treated, especially if they have been through detox, the counselor respects their rights of consent to further treatment or withdrawal from treatment all together

Treating Minors
Hartsell and Bernstein (2013) several states allow minors to consent to treatment for substance abuse and suicide prevention without consent from their legal guardians
Challenging do to the specificity of the provision
Anything that falls outside the realm of substance abuse or suicide prevention is unethical to discuss without the consent of the minors guardian
Substance abuse counselors treating minors without consent of the client's legal guardian needs to be aware of the ethical concerns that may arise by discussing topics not directly related to their clients substance abuse
Court Mandated Clients
Working with involuntary substance abuse clients in the criminal justice system is challenging
Treatment goals are enforced by rules and regulations of the mandate
Important to inform client the limitations of confidentiality
NAADAC states addiction professionals do not need to obtain informed consent documentation prior to conducting an assessment when it is mandated by governmental or judicial entities; such mandate eliminates the requirement for informed consent
Scott, 2000
Treatment Decision Boundaries
Choosing the best treatment for a client is part of the counselors responsibility in caring for the clients welfare...
Some methods of treatment work for some people, but no treatment has been demonstrated to work for all people
It is the counselors responsibility to terminate treatment when a client is not benefiting from their services
When necessary it is the therapists responsibility to refer the client to more appropriate treatment
Client's Increased Risk of
Legal Issues
High correlation between addictive behavior and criminal activity
Physical Assault
Domestic Violence
Sexual Assault
Drug possession charges
Some counselor's may have personal ethical issues with crimes committed by client
Could you treat an individual who had killed a child while driving under the influence?
Marriages do not always survive addiction treatment, counselor may have to testify in divorce and custody hearings
Clients Increased Risk for Suicide
Suicide is a reality faced by every professional counselor in their career. This is especially true of those working with clients suffering from addiction/substance abuse.
Suicide is a leading cause of death among individuals who abuse alcohol and drugs
People with alcohol use disorder are 10 times more likely to commit suicide then the general population
What can you do?
Hartsell & Bernstein, 2008
Informed consent for multiple client therapy should include additional disclosures required by ethics codes and should be documented with a written and signed lawyer-approved consent form
Confidentiality must be thoroughly and completely discussed with each group participant
Helpful to remind group members each week/session
Written commitment to preserve confidentiality of all information discussed to the group should be signed by each participant
Consequences for breaches of confidentiality should be established and an understanding of them should be acknowledged in writing
The inability to guarantee absolute confidentiality should be disclosed to each participant
Counselor Responsibility
Are we held responsible if a client leaves our office and commits suicide?
NO! As long as we DOCUMENT!
As clinicians we need to make sure we go through the proper channels if a client expresses intent or ideation.
Ask them if they have a plan, get them to sign a suicide agreement, make sure they have no intent to harm self or others when they leave your office
Duty to Warn: In Texas, a counselor
breech client confidentiality to warn family members if a client has threatened suicide
People with substance use disorders who are in treatment are particularly high risk of suicidal behavior (including ideation and attempts)
Enter treatment when substance use is out of control
Enter treatment when a number of life crisis are occurring ex. divorce, legal issues
Enter treatment at peak of depressive symptoms
Mental health problems (ex. depression, PTSD, anxiety disorders) associated with suicide often occur among people who have been treated for substance use disorders
Substance Abuse and Mental Health Services Administration, 2009
Nature and culture of addiction
Level of privacy protection for voluntary substance use treatment
American Counseling Association. (2014). ACA code of ethics. Retrieved from
Berg, R.C, Landreth, G.L., & Fall, K. (2013). Group counseling: Concepts and procedures.
(5th Ed.). New York, NY: Taylor & Francis
Butcher, J., Hooney, J., & Mineka, S. (2014). Abnormal psychopathology. Upper Saddle River,
NJ: Pearson Education, Inc.
Doyle, K. (1997). Substance abuse counselors in recovery: Implications for the ethical issue of
dual relationships. Journal of Counseling & Development, 75(6), 428-432. doi:10.1002/j.1556-6676.1997.tb02358.x
Hartsell, T.L. & Bernstein, B.E. (2013). The Portable lawyer for mental health professionals
(3rd Ed.). Hoboken, NJ: John Wiley & Sons, Inc.
Hecksher, D. (2007). Former substance users working as counselors: A dual
relationship Substance Use & Misuse, 42(8), 1253-1268. doi:10.1080/10826080701446711
Investigation of Report of Child Abuse or Neglect, Tex. Fam. Code. §261.001. (2005).
McCrady, B. S., & Bux, D. R. (1999). Ethical issues in informed consent with substance
abusers. Journal of Consulting and Clinical Psychology, 67(2), 186-193 doi:10.1037/0022-006X.67.2.186
Moleski, S. M., & Kiselica, M. S. (2005). Dual relationships: A continuum ranging from the
destructive to the therapeutic. Journal of Counseling & Development, 83(1), 3-11. doi:10.1002/j.1556-6678.2005.tb00574.x
National Association of Alcoholism and Drug Abuse Counselors. (2011). Ethical standards:
Specific principles. Retrieved from http://www.naadac.org/assets/1959/naadac_code_of_ethics_brochure.pdf
National Conference of State Legislature. (2013). Mental health professionals’ duty to
protect/warn. Retrieved from http://www.ncsl.org/research/health/mental-health- professionals-duty-to-warn.aspx
Requirements for LCDC Licensure, Tex. Admin. Code. §140.408 (2012). Retrieved from https://www.dshs.state.tx.us/lcdc/lcdc_rules.shtm
Scott, C. G. (2000). Ethical issues in addition counseling. Rehabilitation Counseling
Bulletin, 43(4), 209-214. doi:10.1177/003435520004300405
Texas State Board of Examiners of Professional Counselors, Tex. Admin. Code 681. §681.41.
(2013). Retrieved from http://www.dshs.state.tx.us/counselor/lpc_rules.shtm
Ward, K. (2002). Confidentiality in substance abuse counseling. Journal of Social Work Practice
in the Addictions, 2(2), 39-52. doi:10.1300/J160v02n02_05
Working with involuntary, substance abusing clients in the criminal justice system: An interview with Wendy Weil. (2006). Journal of Social Work Practice in the Addictions, 6(4), 131-135. doi:10.1300/J160v06n04_08

Are recovering addict's good counselor's?
Suicide Agreement
This also applies to overdose
Only obligation is to provide the best treatment to have action not happen
Documentation is your best line of defense
Full transcript