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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Guidance for addiction counselors in understanding and applying ethical standards Filled with proven strategies to help you examine your current practice for ethical snags and refresh your ethical thinking, Ethics for Addiction Professionals leads you in examining, building, and rebuilding aspects of your ethical practice with the goal of helping you become the strongest clinician possible--ethically speaking.Up-to-date and comprehensive, this practical guide examines real-life examples of ethical issues in clinical practice and illustrates potential pitfalls and the actions needed when faced with dilemmas. Helping addiction counselors learn how to deal with and apply ethical standards, Ethics for Addiction Professionals explores the gray area of common dilemmas and provides guidelines on how to determine the best course of action when the best course is unclear. * Covers basic principles that affect current ethical concerns and dilemmas * Includes illustrative real-world case studies * Features well-defined professional codes of ethics * Treats ethics as a set of guidelines designed to protect the client, the clinician, and the profession as a whole
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Veröffentlichungsjahr: 2013
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Table of Contents
Title Page
Copyright
Dedication
Preface
What's This Book About?
Acknowledgments
Chapter 1: Introduction
How the Book Is Organized
Part 1: Protecting the Client
Chapter 2: Key: Recognize Your Strengths and Limitations
Chapter 3: Principle: Client Welfare
Loyalty
Referrals
Collaboration
Chapter 4: Principle: Cultural Diversity
Race/Ethnicity/National Origin
Spirituality and Religion
Age
Gender Identity and Expression
Sexual Orientation
Disabilities
Economic Condition
Drug and Method of Choice
Diagnosis
Chapter 5: Principle: The Counseling Relationship
Empathy
Boundaries
Dual Relationships
Chapter 6: Pitfall: Conflicted Agendas
Practical Application
Part 2: Protecting the Clinical Information
Chapter 7: Key: Respect the Tiers of Ethics
Chapter 8: Principle: Proper Use of Written Clinical Material
Developing Written Material
Storing Written Material
Dispensing Written Material
Publishing Written Material
Using Technology
Chapter 9: Principle: Proper Use of Spoken Clinical Material
Counseling
Teaching/Training
Communication
Quiz
Chapter 10: Pitfall: Confused Roles
Roles With Our Clients
Roles With Our Colleagues and Other Professions
Roles With Our Profession
Practical Application
Perspective: Are We a Profession?
National Standards
Self-Confidence
Are We a Profession?
Part 3: Protecting the Clinician
Chapter 11: Key: Seek Continuous Learning
Chapter 12: Principle: Responsibility
Professional Member Role
Practitioner Role
Teacher Role
Supervisor Role
Chapter 13: Principle: Competency
Training
Applied Theory
Supervision
Therapist Qualities
Self-Care
Chapter 14: Pitfall: Clinician Burnout
Weariness
Bleeding the Personal
Slipping on SDEPS
Passion Deficiency
Underchallenged Versus Exploitation
Supervision
Practical Application
Tips for Good Supervision
Part 4: Protecting the Community
Chapter 15: Key: Make the Rule
Chapter 16: Principle: Workplace Standards
The Clinical Setting
Policies and Procedures
Personnel
Advocacy
Feeling Crispy?
My Hero
Chapter 17: Principle: Professional Rapport
Bond
Boundaries and Dual Relationships
Evaluating Others
Chapter 18: Principle: Societal Obligations
Choose a Time Level
Choose an Access Level
Choose a Work Type
Ideas for Volunteer Work
Chapter 19: Pitfall: Cutting Corners
Administrative Corner Cutting
Clinical Corner Cutting
Interprofessional Corner Cutting
Supervisory Corner Cutting
Profession Corner Cutting
Practical Application
Conclusion
Learn the Code. Love the Code. Live the Code
Ethics Exam
References
About the Author
Author Index
Subject Index
Cover Design: Andrew Liefer
Cover Images: © imagewerks/Getty Images
This book is printed on acid-free paper.
Copyright © 2014 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
Published simultaneously in Canada.
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Library of Congress Cataloging-in-Publication Data:
Berton, Jennifer D.
Ethics for addiction professionals / Jennifer D. Berton.
1 online resource.
Includes bibliographical references and index.
Description based on print version record and CIP data provided by publisher; resource not viewed.
ISBN 978-0-470-90719-1 (pbk) – ISBN 978-1-118-41830-7 (ebk) – ISBN 978-1-118-41540-5 (ebk) 1. Alcoholism counselors–Professional ethics–United States. 2. Drug abuse counselors–Professional ethics–United States. I. Title.
HV5279
174′.936229186–dc23
2013027939
Preface
The major problem with ethics—hold on, let me climb up on my soapbox—okay, listen, the major problem is that it is not taught (Taleff, 2010). I realize that sounds wrong when you consider how many ethics trainings each clinician will attend throughout his or her career. Ethics trainings are attended more than trainings on any other topic because it is the only specific topic that must be included in the recredentialing process every 2 years, and it has been suggested this requirement should increase (Gallagher, 2010). This means that an individual clinician who has been working in the field for 25 years will attend a minimum of 42 hours of ethics trainings during that time. Despite the significant requirement, ethics education has used more of the “water-cooler technique” of teaching, discussing ethical principles through vignettes after they have occurred, as a group of workers meet at the water cooler to discuss important agency issues and gossip. The heavy use of vignettes is only problematic when it is the only resource used; vignettes are quite appropriate and helpful when they are used to illustrate a fact, theory, or principle. But in most ethics education, vignettes are used to discuss appropriate clinical action; the principle is implied with the assumption that the clinician has already mastered it. Addiction professionals are supposed to innately understand the ethical decision (Taleff, 2010). Ethics, it seems, is the one area of clinical practice a new clinician is expected to know before becoming a credentialed clinician.
Think about that. Many ethical principles are assumed obvious, as if to be human means you have a general sense of right and wrong behavior. The problem with this thinking is that it isn't true. If you ask any clinician if having sex with a client is ethical, I can't imagine any clinician showing support, yet clinicians have sex with clients every year, and it is among the most violated ethical principle in the helping professions, and the most common complaint against addiction counselors (St. Germaine, 1996). And just as cheating is considered a symptom of a deeper problem in a marriage, having sex with a client is an indication of a deeper problem that started long before the sex: a blurring of boundaries and power. Now if I asked every one of those clinicians who are appalled at the idea of having sex with a client to name a time in their career when they blurred some boundary with a client, every one of those clinicians (if honest) would likely have some story to tell. Thus, even if someone has a good level of personal morals, this does not necessarily indicate that he or she will be an ethical clinician, and so it is not enough to expect that someone interested in becoming a clinician will have a basic sense of ethical behavior. Ethics must be taught.
Because many professionals do not have a college degree (Whitter et al., 2006), or obtained a degree in an unrelated field, a large part of the professional population does not get a college education related to ethics and therefore must rely on individual professional trainings to teach basic ethical principles and standards (Gallagher, 2010). If ethical trainings do not teach ethical principles and demonstrate how to build an ethical practice, these clinicians may be out in the workforce, giving direct practice to clients, without having learned the basic ethical tools required of addiction professionals. When we hear of ethical missteps, we may sympathize with the affected clients and blame the clinicians involved, but the clinicians may not have received the education and the support they need to prevent these errors.
Where you are in your career, reader, will not affect the usefulness of the fun we are about to have. If you are a student just entering the profession, let me just say….Welcome! You are the future promise of our work, thus we are all breathing a collective professional sigh of relief that you have made the choice to study our ways. No matter how great existing clinicians are now, the beauty of what we do will fade away if not for you. You will find loads of useful information and resources in this book that will help you understand and develop all of the tools necessary to build the most ethical practice. If you are actively taking an ethics class right now that uses this book, look up right now and beam a smile at your teacher as a thank you for taking your education seriously—Ha, tricked you! You shouldn't be reading this book in class, you should be rapt with attention to whatever great nuggets of knowledge are zooming your way from your teacher. Close this book and listen for now, but come back here after class.
If you are a seasoned professional, you may be thinking, “Oh great, another book about ethics. Ethics is so exciting, I can't wait to dig in” (can you feel the sarcasm?). Well unroll your eyes for a second, and let's think about why that sentiment likely washed over many of you. Ethics historically has been seen as a dry, boring subject. There are two main reasons why it is so perceived. First, many trainings and speakers on the topic have been tedious and unvaried. This is most unfortunate because the topic of ethics contains some of the most emotional material in our clinical practice. It is meant to be living, breathing, dynamic, and engaging. Attendees leaving a training should be in healthy turmoil, not bored into slumber. Trainings need not regurgitate the code of ethics but bring it to life in clinical example (Gallagher, 2010), yet the principles of the code should be included in trainings. In the past, the variety of available ethics trainings typically didn't meet the need for ongoing continuing education requirements, resulting in the majority of clinicians attending the same ethics trainings year after year. This only contributes to the feeling of tediousness, and leads to the second reason ethics trainings are ill-perceived: that clinicians feel the training is unnecessary.
Many clinicians feel they have learned the ethical tools they need and are resentful of the ongoing requirement for additional ethics training. I can't tell you how many times I've heard clinicians sigh with annoyance that they have to go to ethics trainings every 2 years, especially the well-seasoned clinician. “Ugh,” they whine, “I've been a clinician forever. I've pretty much seen it all. I would hope by now I know how to act ethically.” Perhaps you have had similar thoughts at some point in your career. But if this statement were true, then statistically one would see a decrease in ethical violations by career length, yet my experience with investigating ethical violations showed no indication that ethical violations are more likely to occur in the beginning of one's career. In fact, the research shows those clinicians with less formal education were found to be more sensitive to ethical dilemmas (Gallagher, 2010). Thus, ethics should be taught.
Seasoned clinicians may be less sensitive to ethical dilemmas because they become complacent in their ways. Consider driving a car: New drivers do make errors, but they are also more likely to drive “by the book,” since they just learned the book. Seasoned drivers make all sorts of mistakes according to driver's education instruction. (How many of you really put your hands on the wheel at the 10 o'clock and 2 o'clock position all the time?) You don't worry, because you feel your experience makes you a safe driver even if you aren't driving perfectly. Similarly, seasoned clinicians may commit small violations believing them to be innocuous and may feel satisfied that generally they are skilled professionals who do a heap of good in the lives of the clients they serve.
Yet small violations can easily turn into bigger violations, often with a subtle progression that can remain unnoticed by the clinician until it is too late. We try to show our clients that a relapse doesn't just happen; it is the result of a progression of smaller transgressions and rule bending until the relapse has fertile ground. Similarly, if a clinician commits a serious violation, one can look back into the smaller ethical missteps that paved the way for the bigger one. Concurrently, deciding whether a violation is small and harmless is a subjective process. Certainly what may seem innocent to one will appear damaging to another.
A classic example of this would be the use of professional nepotism. If Johnny needs aftercare placement in a sober house, and clinician Mary says, “No problem, Johnny, I know the house director. Let me give him a call and see if I can get you in faster,” has she acted ethically? She worked hard to serve her client, using her networking skills to get his needs met. But what of the other equally well-deserving clients who had positions on the waiting list? Who was bumped out of a spot in the house, not because Johnny was in a greater need, but because his counselor happened to know the house director? Mary's actions may have seemed quite harmless to Mary, but would likely appear obnoxious and unprofessional to the counselors who have clients on that waiting list, and unfair to those clients forced to step aside.
The other snag with these small innocuous-seeming violations is they require a rather egocentric perspective in order to appear acceptable. Certainly if one is looking at the individual case, many ethically slippery scenarios would seem like no big deal. But zoom out your perspective and the game changes. What if instead of this one ethical decision with the client in front of you, we are looking at all of your ethical decisions over time in one lump. How will your one decision look in the context of all your decisions? Let's zoom further. Now you are looking through the lens of the profession and you can see that all the decisions clinicians make reflect back on the profession. If you are only seeing the client in front of you, your perspective is too narrow. And if you are thinking this way, it is likely that other clinicians are as well. And if all the clinicians are walking around making small transgressions then what happens to our profession? But what of the agency, the state, and the profession itself? What may seem like a great action for an individual client can in turn hurt the profession as a whole.
You can see how complex ethical discussions become, and we haven't even scratched the surface! Don't tear your hair out just yet, this is only the beginning…lots more opportunities for hair pulling in later chapters. For now, the three grounding ideas to take with you are: (1) Wherever you are on your career path, whether a student just starting out fresh, a seasoned practitioner who has been in the field for awhile, or at any point in between, this book was written for you. If you are in other professions we hope you find this book helpful both in your own ethical practice, regardless of discipline, and in your understanding of our profession; (2) No matter how new or seasoned a clinician you are, I guarantee that you violate ethical principles from time to time (because we all do), and here is a reason you need continuous ethical trainings; (3) Ethical principles cannot be assumed, they can and must be taught (and often retaught) to every clinician in our profession. If you can entertain these ideas, even skeptically, then read on!
What's This Book About?
Despite the importance of keeping ethics for addiction professionals fresh and bountiful, there is a surprising scarcity of published works devoted specifically to addiction professionals (Geppert & Roberts, 2008; Taleff, 2010). We have been increasing addiction research in recent years, but notably not in the area of ethical standards (Gallagher, 2010). We borrow from great published works on ethics from other helping professions: social work, psychology, marriage and family counseling, even psychiatry (Bass et al., 1996; Corey, Corey, & Callanan, 2007; Pope & Vasquez, 2010). Yet it has been acknowledged that the addiction field is unique, with its own set of complex ethical issues (Geppert & Roberts, 2008; Taleff, 2010). A consistent, rigorous examination of our own professional ethics is vital to assuring we are giving the best care as a profession (Gallagher, 2010). Why is this not reflected in available material?
There are a few notable offerings for addiction professionals looking for material on ethics. Bissell and Royce (1987) cracked the field open with the first Ethics for Addiction Professionals. Published works on addiction ethics then went surprisingly dormant until the past decade. Geppert and Roberts (2008) published The Book of Ethics: Expert Guidance for Professionals Who Treat Addiction, a compelling and diverse exploration into the intersection between ethics and a variety of specific clinical settings in the addiction profession. Taleff (2010) published Advanced Ethics for Addiction Professionals, which teaches readers how to make sound ethical decisions by merging ethics with critical thinking skills.
Those of you familiar with the Bissell and Royce (1987) book may be scratching your heads wondering why this book has adopted the same title. As discussed, there are few books on ethics for addiction professionals specifically. Those that exist are specialized (Geppert & Roberts, 2008; Taleff, 2010), and since the Bissell and Royce book was published in 1987, those books that give a total overview of ethics are outside of our profession (Corey et al.; Pope & Vasquez, 2010; Reamer, 2001 2006a, 2006b 2012). As we work toward strengthening our professional identity, one significant element is to solidify our own ethical practice within this profession. Thus it seemed time to introduce an updated Ethics for Addiction Professionals. Over time, as the profession grows and our ethics subsequently adapt, new books, or book editions, will be required to reflect the growth. We should not simply rest on what has been, but instead continue to seek out new material that makes us stronger. As mentioned, ethics is an ever changing field, and our profession must adopt these changes if we are to have a solid future as a vibrant and vital contribution to the helping professions (Powell & Brodsky, 2004).
Although there are several books and articles specific to addiction ethics, the vast majority of published material is within other helping professions. This book aims to contribute to the field of addiction-specific ethics. Furthermore, the material that has been published often has loads of information but without a clear and concise way of organizing and understanding the information. In fact, some literature includes a table of contents that is so jam-packed with complex sections filled with detailed items it can be overwhelming and confusing to read. This book is organized in a simple way so that readers are able to remember it, and tick off the important categories on one hand.
Much of the published material on ethics does not adequately discuss the Code of Ethics on which our profession is based. Does this surprise you? It should! Many books and articles fail to examine the principles of the code or provide a link between the principles and the theory or topic of discussion. Yet the principles are supposed to be the foundation of our practice, the guidelines that dictate our professional conduct. As such, it should be familiar to all of us, a trusty document that sets us on the right path and aids us in healthy decision making. This book is designed to both highlight the ethical principles in the code, and link them to ethical keys and common pitfalls.
It has been suggested that addiction professionals can sway easily in a debate, without putting care into their decisions, and can make decisions based on a refusal to judge others and a need to be open-minded and inclusive (Taleff, 2010). Teaching how to think critically is a vital part of developing your ethical practice, however there have to be standards set in place so that even if people are thinking logically they have a guide in how to act responsibly. If ethical situations were black and white, teaching how to think would be sufficient in producing the best ethical actions. However, because there are so many gray areas in addiction ethics, and the issues are so complex, addiction professionals can use some concrete teaching about professional parameters of conduct, in addition to thinking critically.
Many books on ethics are designated as either introductory material for the newcomer in our field, or advanced material for the well seasoned. The problem here is that ethical principles don't employ a hierarchical level system. The keys to an ethical practice and the traps we can fall into are not structured within a basic to advanced range. The principles in our Code of Ethics are not categorized with length of time in the profession, nor are they steps that build on each other. Therefore, what you are offered in ethical training material should be applicable wherever you are in your occupational journey. This book is aimed at you, reader, and designed to meet you wherever you are right now. If you are new to the field of addiction treatment, welcome! This book will guide you in developing your ethical practice. If you are a well-seasoned clinician, welcome! This book will guide you to revamp your ethical practice, examine your current practice for ethical snags, and hopefully refresh your ethical thinking so you come out all new and squeaky-clean. If you are in between a newbie and a sage one, this book will guide you in examining, building, and rebuilding aspects of your ethical practice with the goal of helping you become the strongest clinician possible, ethically speaking.
Like Taleff (2010) and Mottley (2012), this book is based on ethics trainings presented in the field. But perhaps this book is most like another ethics book written for the general helping professions, Issues and Ethics in the Helping Professions (Corey et al., 2007), which has exams, encourages self-assessment as the first step to building an ethical practice, and discusses the importance of knowing and using your Codes of Ethics. It is a helpful book that should be in the literary repertoire of all addiction professionals, even though they do not include the addiction profession as one of the helping professions in their book.
Specifically, it is our hope that when you set down this book you will have achieved six objectives:
I realize that some of you may be skeptical at this point, doubting whether you have anything new to learn, questioning the claim that we all make ethical errors, or believing that ethics are nuggets of knowledge we innately or intuitively know, and thus questioning the necessity of this book. I get it, I'm not offended by your reaction, and I know I have my work cut out for me, but if you give this book a chance you may be surprised. In fact, I have a sneaking suspicion you may even enjoy yourself. Well, come along and see for yourself. Let's begin.
Acknowledgments
I would like to thank:
I would especially like to thank my family and friends for cheering me on (you must be exhausted and hoarse), especially to B&S for picking up every last piece of my life without which I would have slipped away long ago. And Sophie and Lily, for reminding me that nothing in life is quite as important or fulfilling as a good belly laugh and a heapin' bowl of mac 'n'; cheese. I love you more than the moon, more than the stars, more than….
Chapter 1
Introduction
Before we begin our examination of addiction ethics, let's take a moment to define a few terms, a common burden in ethical literature (Geppert & Roberts, 2008; Taleff, 2010). How can we define ethics? Generally, ethics is defined as a set of principles that guide our actions (Barsky, 2010; Corey, Corey, & Callanan, 2007; Geppert & Roberts, 2008; Pope & Vasquez, 2007; Reamer, 2006b; Taleff, 2010).
In a deeper description, Taleff (2010) gives seven criteria for defining ethics: (1) Ethics require other people; (2) Intent makes a difference; (3) Ethics aim to resolve dilemmas; (4) Thinking is necessary for ethics and morality; (5) Ethics ask you to be impartial; (6) Ethics require us to care about the suffering of others; and (7) Ethics judge human behavior (Taleff, 2010). Scott (2000) further defines six ethical situations that are unique to addiction counseling: (1) the lack of communication and continuity between research and clinical practice; (2) the lack of agreement over the necessary professional credentials; (3) the questionable propensity of group work in the addictions field; (4) special issues of confidentiality and privileged communication; (5) boundaries of professional practice in making treatment decisions; and (6) unusual circumstances of informed consent. We will discuss all of these unique situations throughout the book.
Throughout this book, we will define ethics using the four pillars of ethics borrowed from the medical ethics field (Miller, 2008), constructs that are well utilized in the ethical literature (Castillo & Waldorf, 2008; Corey et al., 2007; Miller, 2008; Taleff, 2010; Venner & Bogenshutz, 2008). As in the book Geppert and Roberts (2008) edited, these pillars will be used throughout each section as a thread that forms the basis of our ethical practice. The four pillars are beneficence, autonomy, nonmaleficence, and justice. Other authors have included additional pillars in their work, such as compassion, truth telling (Castillo & Waldorf, 2008; Geppert & Roberts, 2008; Taleff, 2010), volunteerism (Castillo & Waldorf, 2008, p. 106), privacy, rights, confidentiality (Taleff, 2010), respect for persons (Taleff, 2010; Venner & Bogenshutz, 2008), fidelity, and veracity (National Association for Addiction Professionals [NAADAC], 2011). This book will stick with the four pillars that are consistent in the literature, as the other principles are in some literature but not all, and are concepts that are discussed elsewhere throughout the book.
Beneficence refers to actions intended to benefit others: kindness, charity, and goodness. Autonomy is self-directed freedom and independence. Nonmaleficence is the well-known adage: “Do no harm.” Justice in this context is defined as the equal and fair treatment across groups or members of the same group. Treatment must uphold existing laws and be fairly given. The four pillars can be interrelated, with each leading into another, as you shall see in the examples we explore. Most of the time, a clinician is tasked with balancing between beneficence and nonmaleficence, which can often be a challenge.
The most successful ethical clinicians ground their clinical practices with these four pillars and tirelessly evaluate their clinical decisions for the best balance between them. The idea is to give treatment interventions that promote justice across the clinical population, that are beneficial to the client, that cause no harm, and that ensure that the client is given the opportunity to understand and contribute to the definitions of the best treatment. Think this is easy? Not so, unfortunately. You must attempt this balance in your practice every day, knowing that sometimes you will succeed and sometimes you will fail. And at times, you can do harm even with very good intentions, violating nonmaleficence without realizing it (White & Kleber, 2008). The following chapters will provide loads of examples revealing how important and difficult this balance is to achieve and maintain.
Before we dive in, let's briefly point out the differences between ethics and two similar constructs, law and morality.
Ethics versus the Law: If ethics are a set of parameters that guide our behavior, the law consists of a clear set of predefined rules that are punishable in a court, and defined at the state or federal level (Barsky, 2010; Washington & Demask, 2008). Law is “intentionally definitive” (Nassar-McMillan & Niles, 2011, p. 93). Ethics are not exhaustive, but instead are general guidelines, the least of what we must do (Nassar-McMillan & Niles, 2011). Just because something is legal, it is not necessarily ethical. For example, there are laws that incarcerate those who use illegal drugs, yet there are those who believe in the disease model of addiction that would see imprisonment as unethical (Washington & Demask, 2008). Clinicians will have to consider both ethics and the law when attempting to determine the best course of action in any given clinical situation.
Ethics versus Morality: Ethics are a set of principles that guide our actions and pilot our professional conduct. Morals, on the other hand, are a person's basic, core feelings of right and wrong (Barsky, 2010; Taleff, 2010). Consider how we differentiate guilt from shame; many conjoin them into one phenomenon, yet they are distinct emotions. Guilt refers to an emotion about a committed action: For example, you may feel guilty about lying to your mom. Shame refers to an emotion about who you feel you are: You may feel shame because you are a liar who lies to his or her own mom. How badly you feel about being a liar depends on the subjective value you assign and internalize. Guilt is about the actions we take; shame is about the core of who we are. It is the same with the differentiation between ethics and morality. Like guilt, ethics are about our actions. Like shame, morality is about our feelings (Taleff, 2010, p. 40). In this way our morality is one guiding force in our ethics. There are other guiding forces: The federal and state governments, our licensing body, and the agencies in which we work are all examples of entities to whom we must answer.
Okay, so moving forward we will understand ethics as a set of principles that guide our professional behavior—built on the pillars of beneficence, autonomy, nonmaleficence, and justice—that are guided by the law, morality, and other influences we will discuss.
How the Book Is Organized
This book is organized in a way that attempts to not only help you organize ethical principles in your head, but enable you to quickly and easily refer back to a section when it is needed in the future. The material is grouped into four sections of ethics: those that are aimed at protecting the client, those that protect the clinical information, those that protect the clinician, and those that protect the community. Within each section there is a corresponding Key to an Ethical Practice (Keys), two or three Principles from the Code of Ethics (Principles), and one of the common Pitfalls that cause Ethical Dilemmas (Pitfalls). The Principles are the guides to building each Key, and the Pitfalls are the traps we risk falling into if we fail to build each Key. Figure 1.1 is a conceptual model to help you get a sense of the material.
Figure 1.1 How the Book Is Organized
The Four Keys to an Ethical Practice
The four Keys highlight the necessary foundation to a healthy ethical practice. Key 1 requires a clinician to complete an in-depth exploration of his or her own strengths and limitations, both personally and professionally. Key 2 requires the clinician to explore the concepts of perfectionism and resistance to education, and how they can lead to unethical behavior. Key 3 requires a clinician to understand and abide by the different entities, or ethical tiers, that influence our decision making. Key 4 requires the clinician to establish a norm of behavior against which exceptions may occur.
The Four Keys to an Ethical Practice
The 10 Ethical Principles
The Code of Ethics is a document that all counselors sign on becoming a credentialed member of the field, and to which one must reattest every 2 years as part of the recredentialing process. It is the expectation that credentialed or licensed counselors will adhere to each principle in their clinical practice, and clinicians are required to abide by the principles in order to obtain and maintain their state credential. If a counselor is accused of violating the Code of Ethics, his or her behavior is examined by an appointed Ethics Committee that determines what sanctions, if any, are appropriate, including suspension or revocation of license or credential.
But Houston, we have a problem. There is no universally accepted Code of Ethics in our field. Our national organization, the National Association of Addiction Professionals (NAADAC), has a code that is used in many states, but it is each state-level association that decides the Code by which all credentialed counselors in that state must abide. States vary significantly in their adopted codes.
The principles used in this book are the common elements extracted from the state codes. While many state codes differ in detail, these 10 principles can be found in every code because they are the foundation on which we build our ethical practice. They are the guidelines we turn to when counsel is needed.
After I organized this book into the sections you find here, I came across a book by the great Frederic Reamer, ethicist extraordinaire of the social work profession. His book, Ethical Standards in Social Work: A Review of the NASW Code of Ethics (2006), is organized in the same way as this book. Because social workers have one universal code of ethics adopted by all states, Reamer (2006a) was able to do what I could not, organizing the chapters around specific existing principles in their Code. Social workers can open his book and have their Code specifically explained to them, so that they can learn the interplay between the written code and the practical issues they experience every day on the job. Furthermore, if they are caught in an ethical dilemma, they can use the book both to understand the issues surrounding the dilemma and to explore the exact code that pertains to the dilemma. It is what I hoped to achieve with this book, but our lack of a consistent code prevented my success. Perhaps in the future, our profession can adopt one code that will unify and strengthen us. In the meantime, the principles included here are the backbone of what a universal code needs.
The 10 Ethical Principles
The Four Pitfalls That Cause Ethical Dilemmas
An ethical dilemma can mean two things, which can occur independently or simultaneously. The first is a situation where the correct action is difficult to discern because at least two courses of action are possible. The second is a situation where the clinician realizes an ethical error has been made and is unsure how to best rectify the situation. Both types of dilemmas are potentially crippling to one's practice and can be agonizing for a clinician. Avoiding dilemmas is a sensible goal, yet even the most vigilant of ethical clinicians will struggle through a dilemma at some point in their careers. Therefore, it is equally important to learn both how to avoid these dilemmas and how to cope with them if they occur.
The first step is to identify common pitfalls that cause these dilemmas. Clinicians are not suddenly hit with ethical dilemmas; they are led into the dilemma through specific traps. There are four common pitfalls that cause ethical dilemmas (referred to from now on as Pitfalls), which violate one of the aforementioned four Keys and correspond to at least one of the 10 ethical Principles. If clinicians can learn to avoid these four Pitfalls, they will maintain a strong ethical practice. However, because it is impossible to perfectly avoid every possible ethical trap, it is also important to recognize each trap and learn the necessary steps to rectify it.
The Four Common Pitfalls
In every pitfall chapter there is a practical application that exposes a “hot topic,” a common clinical example of the themes represented in the pitfalls. In the pitfall of conflicted agendas the hot topic of self-disclosure will be discussed; in confused roles, the scope of practice will be addressed; in Clinician Burnout, faulty supervision will be examined; and in cutting corners, the notion of accepting gifts will be argued.
Questions
In the introduction to each section there are questions for you to answer. It is important that you explore these questions prior to reading the chapters in that section. Remember that a basic premise of this book is that Ethics can and must be taught. These questions are a vital part of that education, because they will get to your primal thoughts before they can be tainted (in a good way) by theories and opinions. And it is your primal thoughts that will most inform ethical missteps in your future; therefore you need to understand what you organically bring to your professional table. The more aware you are of how you think and feel, the better you will be able to maximize your strengths and bolster yourself against limitations, thereby limiting your ethical risk. Please complete the questions! Try to avoid the answer “it depends.” Think honestly about how you most typically operate. The more thoroughly you explore your answers to each question, the more ethical your practice will be, the better a clinician you will become, and the more satisfied you will be in your work and in yourself. And isn't that, in the end, the point?
Part 1
Protecting the Client
Protecting the Client
Addiction counselors are taught to put the client's needs first. Quite simply, without clients we would have no work, since our work centers on helping individuals reach those specific life goals involved in overcoming addiction and creating and maintaining a healthy lifestyle. The work we do is good work, worthwhile, honorable, rewarding, challenging, and oh-so-necessary, as the discouraging drug-related stories on the 6 o'clock news shows prove. While the majority of our work can often feel like paperwork, politics, or piddling tasks, our most significant work is the direct practice with the client. Thus, ensuring that we create a solid foundation of ethics related to the client is vital to our practice. There are a few snags in the credo of putting clients first that we will discuss later in the book, yet since most of the time, counselors should put their clients first, focusing on those ethics that protect the client is a good place to begin.
Ethics that protect the client are based on the four pillars of ethics borrowed from the medical ethics field (Castillo & Waldorf, 2008; Corey, Corey, & Callanan, 2007; Geppert & Roberts, 2008; Miller, 2008; Taleff, 2010; Venner & Bogenshutz, 2008). As discussed in the preface…wait. Did you skip the preface? Did you merely skim the introduction? Nah, you gotta read those sections because they set us up for the rest of the book. Go back and read them; I'll wait. Okay, so now you know that the four pillars are beneficence, autonomy, nonmaleficence, and justice. Let's see how we can apply them to the protection of the client.
From a client perspective, beneficence indicates a client's right to receive healthy, beneficial care. It is the clinician's responsibility to strive for goodness in all decisions made related to client care. From a client perspective, autonomy refers to a client's ability to make informed decisions about his or her own welfare without being coerced by others. It is the responsibility of the clinician to develop a fertile atmosphere around the client that will encourage his or her freedom.
From a client perspective, nonmaleficence indicates a client's right not to be harmed by the treatment intervention. Addiction is harming enough; treatment is about improving and getting well. It is the counselor's responsibility to refrain from harming the client, both through his or her own treatment and through other treatment he or she recommends to the client. If a treatment intervention is not working, the onus is on the counselor to alter the treatment so that the client is no longer harmed. From a client perspective, justice refers to the client's right to have access to the same treatment, and to be as fairly and evenly treated as another client. It is the counselor's responsibility to give treatment, including access to treatment, sensibly and with fairness.
In your state's code of ethics several principles are aimed at protecting the client. You have a principle that deals with the welfare of the client, and one that demands nondiscriminatory treatment in all your professional behavior. You will also have a principle that addresses the ethical use of the therapeutic relationship between counselor and client. The principle headings may be titled differently, or they may be combined, but the essential points will be in the code.
The key to adhering to these principles is to recognize your own strengths and to understand your limitations. What, you say? How can it be that the key to protecting your clients is to focus on yourself? It may sound wrong, but the best way to help others is to know yourself so well that you protect the relationship from harm caused by your own issues and challenges. If you are aware of your own strengths and limitations, you can effectively address them so that your treatment can be better focused on the client's needs. The better you know yourself, the less likely you are to have personal agendas conflict your practice. If you don't develop this key to your practice you will be in danger of falling into an ethical pitfall that can lead to an ethical dilemma and can affect your ability to protect your client. Specifically, you could be pulled into action by different agendas that clash with your ethical practice. Let's take a closer look.
Part One Questions
Chapter 2
Key: Recognize Your Strengths and Limitations
It may sound strange to begin our focus on the client with a discussion about you, the clinician. But the first rule in building or reworking your ethical practice is to evaluate aspects of both your personal and your professional self. The strength of your practice lies in the development of your self-awareness and why you make the decisions that you do (Taleff, 2010). To promote client autonomy, clinicians need to learn where their own values have the potential to conflict with the goals of the client (Manuel & Forcehimes, 2008). The better you know yourself, the better your treatment of your clients. How can this be? Because no one can truly separate their personal thoughts, feelings, and experiences from all of their professional work, nor would you want to. While the training can be universal, every clinician is unique. Skilled clinicians use those unique characteristics as assets in their practice, rather than ignoring or attempting to suppress them. Skilled clinicians also learn what aspects of their personal make-up are potential risks to their ethical practice and make the best possible plans to prevent their interference.
Clinicians often use their own life experiences as a guide to understanding and treating clients (Corey, Corey, & Callanan, 2007). Yet clinicians often fail to consider their own values as potentially conflicting with their clinical work (Manuel & Forcehimes, 2008). It is possible this is caused by our tendency to focus on the client more than ourselves, as if these are mutually exclusive. When we are aware of both our strengths and our limitations, we can work to ensure a future where we maximize our strengths and prevent our limitations from allowing us to slip into unethical behavior. Awareness of all the parts of ourselves is the first key to developing an ethical practice. A thorough personal inventory can both enhance the treatment that you give and ensure the prevention of poor treatment, effectively addressing both beneficence and nonmaleficence simultaneously. So let's get out the mirror and get started.
The first requirement is to recognize that one has both strengths and limitations. It often seems easier to name strengths and limitations in others than it is to name them in ourselves; however, in order to be a sound clinician, we must assess both attributes in ourselves, professionally and personally. Which is easier for you, to name your strengths or to list your limitations? We may find it easier to do one or the other, and this may differ if we are examining professional versus personal attributes. Personal limitations may come to the brain more easily; perhaps it feels like bragging when we speak of our personal strengths. This may be reversed when we address professional traits; revealing strengths may feel easier then admitting limitations. Perhaps one feels broadcasting limitations would put one's job in jeopardy, and therefore we become accustomed to emphasizing our positive points and downplaying our challenges. It is helpful to understand how this works for you: which characteristics are easier for you to name, and which are a challenge, as you may need to spend extra time exploring them in order to reach your ethical potential.
Unresolved personal issues of the clinician lead to exploitation of clients (St. Germaine, 1996). Because traits ignored can become ethical pitfalls, spend some time taking a thorough inventory of your personal and professional characteristics, identifying which situations you feel will highlight your strengths and which situations may bring out your limitations. Often a single characteristic could be in both categories at once. For example, if June grew up with an alcoholic mother and felt that no one helped her cope effectively with her mother's illness and its consequences, then June would likely identify “self-perseverance or self-care” as a personal strength and “sensitivity to the needs of a child of an alcoholic” as a professional strength. But she could also write down “possible difficulty empathizing with alcoholic mothers, especially those with daughters” as a possible professional limitation.
This is not meant to predict with certainty that June will have difficulty treating an alcoholic mother; perhaps she will be able to maintain a safe, therapeutic distance. Still it is helpful to know that this is a potential pitfall for June, because once she is aware, she can bring it up with her supervisor at the beginning of her work experience. Then if an alcoholic mother should appear on her caseload, June and her supervisor can regularly check in about June's ability to effectively handle the case and her own emotional health. You would not advise June never to work with alcoholic mothers, as it is not realistic to do so, and it assumes June will have trouble when perhaps she will not. We can't predict what groups or situations will challenge June; we can only look at any possible risks and plan for them.
We can never remove the possibility of an ethical snag influenced by a personal or professional limitation; they occur sometimes without warning. However, we can increase our odds of preventing them the more we can be aware of ourselves. Later in your career, others may try to point out to you characteristics you are exhibiting that you struggle to see. Knowing that you may struggle will help you recognize the struggle when it occurs, and may help you be less defensive and more allowing of the possible limitation, which will make you a more ethical clinician.
You have already completed the initial questions at the beginning of this chapter, but now that you have been given a bit more explanation, let's dig a little deeper, shall we? Take out a piece of paper and draw a vertical line down the middle. No really, this is helpful. Go get some paper and a pen (see, that was a trick because you should already have a pen and paper so you can adequately answer the section questions. Sneaky, huh?). On the left side, write down your personal strengths, including your supportive characteristics, experiences, and relationships. Under personal strengths you want to list the characteristics that make you, well…you. What are some of your most positive qualities? What are the situations or events that had the most positive influence on you so far? With whom have you had treasured relationships in your life? Then write down your professional strengths, including again your characteristics, experiences, and relationships. Once you have given a thorough inventory of your personal and professional strengths, consider what implications these strengths have for your career. How can you apply each strength at the workplace; what populations or type of treatment services would seem like a good match with each strength? How do you think your personal strengths can be applied to your job?
On the right side of the paper, you want to take the same inventory of your personal and professional limitations, again including applicable characteristics, experiences, and relationships. List the personal limitations you see in yourself; note the challenging experiences and the damaged relationships in your life and the corresponding practical applications. Make a note of any poor supervision in the past. What work implications can be derived from your self-assessment; what suggestions can be made for populations you might consider working with or those that are potentially risky? A sample assessment can be found at clinicalethicsblog.com
For example, a clinician who has suffered a parent's death may want to steer clear of running a grief group or counseling someone who also lost his or her parent until that clinician can adequately discuss the potential risk and ensure the ethical care of the client. What of a clinician who stresses out easily? This fact doesn't mean that he or she should refrain from running groups or working with high-stress populations. But knowing how one handles or mishandles stress is the difference between a clinician walking into a potentially risky situation blind and ignorant, and therefore unprepared, and a self-aware clinician walking into a potentially risky situation more confident because the potential risks have been previously identified and strategized with a supervisor or advisor.
Some characteristics, experiences, or relationships can have both beneficial and detrimental implications. Consider a clinician who had to fight to make ends meet and reach his or her dreams. This is a positive experience because it shows perseverance, resourcefulness, and courage. Yet it can also be a limitation because this clinician may have difficulty either helping people in similar situations who do not show the perseverance the clinician showed in life, or helping people who are given the opportunities and financial support in life for which the clinician had to fight. Again, this is not meant to state the clinician will have difficulty, merely that it is a risk for which to prepare.
Spend some time brooding over your self-assessment chart (great discoveries come from a little brooding). Now let's return to the initial questions in the introduction to Part 1, using your ethical self-awareness chart. The first question, Why did you get into this profession? seems simple to answer, as most people have a fairly good idea of how they entered the profession, although often time and reflection can help you develop a deeper answer than you may have first given. The reason for this question may be a bit of a surprise. The reason you got into the profession in the first place is definitely part of your strengths, but it is also part of your limitations. Before I ruffle your feathers too much, read on for my explanation. The reason you got into the profession is the very light that burns in the deepest part of you, the fire that guided you into your career. This is a strong, solid core within you, and therefore it is obviously close to your heart. Whatever it is that guided you into the profession is a huge strength within you, a beacon to which you return when you doubt yourself or your work, when the challenges make you forget why you started this professional journey.
But often those things that make up our strengths are also firmly seated in our limitations and potential risks. Because our reasons are close to our hearts, it is easy to be influenced, even blinded, by them. Have you ever been attracted to a person and slightly bent your rules for him or her when you wouldn't for someone else? Have you ever felt strongly about something, but felt even stronger when a family member was involved? We have our norms, and then we have our exceptions, and those exceptions usually come about because they speak to those things closest to our hearts. The same concept occurs with our career influences. Those influences have acted as beacons to drive us to success. We have been guided by them, we have relied on them, we have been nurtured by and have nurtured them. Thus, we can easily be swayed by them, and each of you will have to watch yourself and use supervision to ensure the risk does not become a reality.
The second question, Who are you really good at helping? asks you who you believe you are good at helping, and you can't write everybody or anybody; be specific! This question is easier to answer once you have completed your self-assessment, as often individuals, groups, and situations come into focus as you examine your strengths and limitations. Use your answers to this question as a guide for possible career directions to try. Your initial thoughts may have changed or deepened after completing your self-assessment, so go ahead and add to those answers. Many of you will have a much easier time writing about who you think you can help. If you take all of your supportive characteristics, experiences, and relationships in both personal and professional arenas, what kind of people or situations are suggested by the list? For example, early experiences caring for siblings could suggest an affinity with younger clients, so working in a group setting for adolescents or designing programs for the adolescent population may be a good match.
It is important to realize that this is only a guide and not a guarantee. You may learn that a job that seemed so perfect on paper is less than perfect in reality, and there is no shame in that; in fact it will help you hone in on how and where to put your gifts to work. And as our positive influences can also blind us, so too must we be careful of closing our eyes to any warning signs that come up within the populations we feel we can help. It is possible for us to stay so focused on moving toward the job we think we should be doing that we end up missing other golden opportunities along the way. Keep your eyes open, take risks, surprise yourself. But stay true to who you are.
The other part of this second question, Who are you not good at helping? may be harder to answer for most people. It requires putting aside your ego, taking a nice helping of humble pie, and admitting to yourself the simple truth that even the most skilled and talented clinician cannot help every person. You are not going to be attracted to every person you see in life, nor will you be friends with every person you meet, so why would you expect to be able to personally counsel every client who walks through the door? Perhaps some clinicians confuse discrimination, which we try to avoid, with a difficulty in accessing empathy for certain types of people or situations. This is natural, and does not indicate that you think these people or situations are inferior or judge them in some way, nor does it suggest that you would behave as anything less than professional when working with the people or situations.
It does indicate, however, that there are certain subpopulations that simply don't mesh with you. There is a wide range of possible reasons for this: Perhaps you are not inspired, perhaps you are scared, perhaps you can't separate your personal experiences to effectively treat them, perhaps it brings up too many uncomfortable emotions for you, perhaps you find it too challenging or exhausting. What one clinician may find too exhausting, another clinician may find energizing. Remember, you can help
