RCB 43:4 pp. 209-214 (2000) 209

^Ethical Issues in Addiction Counseling

Cynthia G. ScottUniversity of North Florida

Although all counselors face ethical challenges, addictions counselors encounter ethicalissues that are, in many respects, unique to their discipline. This article provides anoverview of these issues, which include but are not limited to (a) the lack of communi-cation and continuity between research and clinical practice, (b) lack of agreement overthe necessary professional credentials, (c) the questionable propensity of group work inthe addictions field, (d) special issues of confidentiality and privileged communication,(e) boundaries of professional practice in making treatment decisions, and (0 unusualcircumstances of informed consent. In addressing these issues, addictions counselorsmust not only uphold the ethical standards of their profession, they must also be cog-nizant of any federal statutes that may supersede their state regulations and act in ac-cordance with them.

C ounselors and psychologists base their professionalvalues and practices on a foundation of ethicalstandards that are similar, but not identical, across

disciplines. The ethical standards of each counselingdiscipline are clearly articulated in their respective profes-sional associations and are well known to most practi-tioners and academics in the counseling field. Addictionscounselors, however, not only operate under a somewhatdifferent set of ethical standards, they are also faced withunique situations resulting in ethical challenges with theirclients that other counselors do not typically have toaddress. Because of this, it is especially important that ad-dictions counselors understand and work toward address-ing these issues within the context of the foundationalethical standards of the counseling profession.

UNIQUE ETHICAL ISSUES

The following discussion addresses six ethical situationsthat are unique in addictions counseling. These include(a) the lack of communication and continuity betweenresearch and clinical practice, (b) lack of agreement over

the necessary professional credentials, (c) the question-able propensity of group work in the addictions field,(d) special issues of confidentiality and privileged com-munication, (e) boundaries of professional practice inmaking treatment decisions, and (f) unusual circum-stances of informed consent.

Lack of Communicationand ContinuityAddiction treatment is an anomaly in the counseling fieldand atypical of other therapeutic fields because it hasoften relied more on faith than science or empirical find-ings (Chiauzzi & Liljegren, 1993). Although scientific un-derstanding of addiction is still in its infancy (Thombs,1999), the state of research, particularly in the field ofchemical addictions, is evolving at a rapid pace.

For instance, for the past decade, researchers haveviewed addiction as a complex, progressive behavior pat-tern having biological, psychological, sociological, andbehavioral components (Donovan, 1988). More recently,research has pointed to chemical addiction as a brain dis-ease triggered by frequent use of drugs that change the

Dpro-ecl

210 Rehabilitation Counseling Bulletin

biochemistry and anatomy of neurons and alter the waythey work in the brain's desperate attempt to carry onbusiness-as-usual in order to make neurons less responsiveto drugs, thus restoring homeostasis while under extremechemical siege (Powledge, 1999).

Further, Peele (1996) suggested distinct "susceptibil-ity" and "exposure" constructs. The susceptibility con-struct emphasizes the important role genetic factors playin the development of dependence and how they influ-ence one's vulnerability to the disorder. The exposure po-sition holds that chemicals and their actions on the brainare the primary causes of addiction.

Finally, evidence clearly shows that individuals withalcohol addiction who enter treatment do so with varyingdegrees of cognitive dysfunction due to sustained use of al-cohol over time. This dysfunction affects their ability toabsorb and profit from treatment interventions adminis-tered in the early weeks after detoxification (Goldman,1990). The repercussions for treatment due to this con-founding factor are highly relevant.

Yet, in most conventional addiction treatment pro-grams, there is little integration of theory and researchinto clinical practice for either chemical or behavioral ad-dictions (Caldwell, 1991; Lamb, Greenlick, & McGarty,1998). Research and related knowledge about alcohol andother drug addiction burgeoned in the 1990s; however,this knowledge has been little used to guide addictiontreatment. The gap has grown so great that the NationalInstitute on Alcohol Abuse and Alcoholism (NIAAA)sponsored a 1990 conference entitled "Linking AlcholismTreatment Research with GUnical Practice" (Gordis,1991). It was unique in that it allowed researchers andpractitioners to address each other. In commenting on themeeting, Gordis, the director of NIAAA, noted.

In theory, alcohol researchers seek knowledgeabout alcohol-related health conditions, andpractitioners use this knowledge to help theirpatients recover. In practice, however, we oftenfind that alcohol researchers and alcohol prac-titioners travel in two largely unrelated circles;they speak different languages, attend differentmeetings, and generally view problems—andtheir solutions—from very different perspec-tives, (p. 173)

Treatment practices in addictions are not typicallyconceptualized from research findings. Most continue touse a traditional orientation, based on what has been donein the past, regardless of relapse rates that run from50% to 90% (Hunt, Bannett, & Branch, 1971; Hunt &Matarazzo, 1973; Marlatt, 1985; Marlatt & Gordon, 1980).Moreover, research has indicated that there is a signifi-cant portion of the abusing population who stop theirabusive behaviors on their own without help. Some indi-

viduals abstain from the substance or activity altogether,whereas others return to normal use (Peele &. Alexander,1985).

One of the single greatest barriers to integrating the-ory, research, and clinical practice is a strong traditionwithin most treatment communities of relying on per-sonal experience, clinical anecdotes, and testimonials tohelp others. Practitioners tend to rigidly cling to their fa-vorite theory, most often without a full understanding ofall its concepts and implications. At the same time, othertheories may be unwittingly disregarded. Glearly, the clas-sic disease models have helped many individuals who arechemically dependent. However, as judged by the largenumber of people with addictions who refuse treatment,drop out of treatment, and/or relapse, it can be reasonablyasserted that these models are not a "good fit" for many, orperhaps even most, individuals with chemical dependen-cies. It is imperative that practitioners consider alterna-tive models of recovery for clients who cannot workwithin the disease model.

Yet, all too often, clients who resist the tenets of theclassic disease model are labeled as being in denial. Agrowing body of literature suggests that the acceptance ofsuch a label is not an essential first step and may in fact becounterproductive (Fingarette, 1988). Often times indi-viduals who have been labeled as having alcoholism or anaddiction are passing through a difficult stage in life when 'seeking relief, and acting out through some form ofcompulsivity makes sense; these people are not foreverdependent.

The tendency to reduce all client resistance to denialoften obscures the possibility that the problem may lie inthe treatment model, not in the client. Rather than forc-ing a model on clients, it may be more effective to helpclients discover their own paths to recovery. Thus, coun-selors should possess the flexibility to guide clients in dif-ferent directions as well. Personal experience, clinicalanecdotes, and testimonials are of limited use becausethey speak to an assumption that all individuals with ad-diction problems are alike. The conceptual line of think-ing is, "It worked for me, so it will work for everyone." Ithas been clear for some time, however, that addiction toalcohol and other drugs is not a unitary disorder(Gloninger, Christiansen, Reich, & Gottesman, 1978;McLellan, Luborksky, Woody, Druley, &. O'Brien, 1983).There are other problems related to counseling ap-proaches and research. These include the inability ofmany practitioners to understand research reports, thelimited access counselors have to important research lit-erature, and unawareness by some counselors that a bodyof research even exists (Huey, 1991).

In Section A of its Gode of Ethics, the NationalBoard of Gertified Counselors (NBGG, 1997) mandatesthat "Gertified counselors engage in continuous efforts toimprove professional practices, services, and research.

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Certified counselors are guided in their work by evidenceof the best professional practices" (p. 3). Given this ethi-cal standard, the schism that exists between research andclinical practice in the field of addictions counseling istroubling. Counselors should make every attempt to frametreatment decisions within the context of current re-search. Moreover, they must adopt an attitude of life longlearning in understanding and seeking access to relevantresearch related to addictions counseling.

Lack of Agreement onProfessional CredentialsThe clinical standards for providing addictions counselinghave historically been lower than those necessary to per-form other kinds of counseling. In many states, the mini-mum formal education requirements for entry-leveladdictions counselors do not even include the baccalaure-ate degree. Moreover, some states exempt addictionstreatment personnel from licensure or other standards,and some states have developed separate standards for in-dividuals counseling clients with addiction problems.George (1990) stated.

Those who currently work as chemical-dependency counselors have tended to adoptone of two extreme positions; that chemicaldependency counselors must be recovering ad-dicts (or, at the very least, have a recovery pro-gram as codependents), or that chemicaldependency counselors must have a minimumof a master's degree in such related fields ascounseling, social work, or psychology. Unfor-tunately, this polarization often results in un-necessary conflict among counselors and a lackof respect and appreciation for what eachgroup offers to the treatment process, (p. 216)

For most counseling-related professions, the standard isthat counselors providing treatment should have a mas-ter's degree or higher, and, where required, they shouldmeet the licensure standards as professional counselors(Cottone &. Robine, 1998).

As the research on addictive behaviors unfolds, itscomplexity becomes increasingly evident. Because of this,it is important that counselors working in the addictionsfield have specialized training in many complex areas, in-cluding both chemical and behavioral addictions, relapseprevention and other cognitive strategies, neuropsycho-logical processes in addiction, assessment, and individual-ized treatment planning.

Further, because treatment practices have changedvery little, even though there is training available in theseareas, treatment plans are typically uniform rather thanindividualized for people based on their personal needs

and clinical presentation. Milkman and Sederer (1990)summarized the inappropriateness of uniform addictiontreatment by quoting Mark Twain: "When your only toolis a hammer, then every problem is a nail" (p. 249).

Given the current state of knowledge regarding thecomplexity of the addictive process related to both chem-ical and behavioral addictions, not only should addictionscounselors be held to the same standards as other coun-seling professionals, they should also have the necessaryspecialized coursework, continuing education, and experi-ence necessary to keep them literate in and abreast of cur-rent information about addiction and its treatment.

Another phenomenon seen in the addictions coun-seling field is counselors working in addictions treatmentwho hold the standard credentials of a professional coun-selor with the requisite master's level training, and evenlicensure, yet have little training or experience in addic-tions. Because they lack the necessary knowledge of thiscomplicated specialty, they are ill equipped to perform thenecessary functions unique to helping individuals withaddictions.

Several credentials can be obtained as an adjunct toa master's degree. Both the National Board of CertifiedCounselors (NBCC) and the Commission on Rehabilita-tion Counselor Certification (CRCC) offer a specialtydesignation of master of addiction counseling (MAC).This credential requires the broader certification of thesponsoring certifying board (the NCC or the CRC, re-spectively) and in addition may require specialty course-work or continuing education related to addictions orchemical dependency treatment, experience under super-vision in a setting where addictions are treated, and/orpassing a specialty examination developed by the board.

Questionable Propensity ofGroup WorkMost conventional treatment programs in addictions areforced to rely heavily on group work because they lack theresources for more individualized care. This occurs in twoseparate ways: through self-help groups such as AlcoholicsAnonymous, Narcotics Anonymous, and other 12-stepgroups, and through group counseling that occurs in bothinpatient and outpatient treatment programs. Both prac-tices raise ethical concerns.

Although the growth of self-help groups validatesthe idea that people who have encountered and resolvedcertain difficulties possess unique resources for helpingothers like themselves (Corey, Corey, & Callahan, 1998),self-help groups are not supervised by licensed profession-als. Thus, group members are not afforded the protectionof the professional license, particularly related to confi-dentiality and privileged communication (Cottone &Robine, 1998). Additionally, the model of treatment putforth in 12-step groups such as Alcoholics Anonymous is

212 Rehabilitation Counseling Bulletin

not linked to research in addictive behavior and has notchanged or been evaluated since its inception in the1930s (Thombs, 1999). Research does not indicate anygreater success rate with 12-step groups than with otherforms of treatment or with no treatment at all (Donovan,R. Jessor, & L. Jessor, 1983; Filmore & Midanik, 1984;Osejo, 1981; Stall & Biemacki, 1986; Vaillant, 1983).Moreover, group theory clearly states that for many clientsgroup therapy is not a good treatment modality. Yalom(1995) noted, "There is considerable clinical consensusthat patients are poor candidates for a heterogeneous out-patient intensive therapy group if they are brain damaged,paranoid, hypochondriacal, addicted to drugs or alcohol,acutely psychotic, or sociopathic" (p. 219).

Because individuals who enter treatment for addic-tions may have cognitive impairments, addictions toalcohol or other drugs, paranoia or experiences ofpsychosis—either from the effects of certain drugs such asamphetamines and cocaine or from co-existing psycho-pathological conditions—and given the high correlationbetween alcohol addiction and antisocial personality dis-order (American Psychiatric Association, 1994), many ofthem may be poor candidates for group therapy. Screeningclients to assess their appropriateness or inappropriatenessfor group therapy thus is paramount. In many treatmentcenters, individuals are automatically put into groups withlittle or no screening. This can jeopardize not only theirown treatment but the treatment of other group membersas well.

Confidentiality and PrivilegedCommunicationGottone and Robine (1998) described a number of issuesrelated to confidentiality and privileged communicationin addictions treatment. First, they noted that treatmentin programs directly or indirectly receiving federal fundsrequires additional ethical precautions because federallaws protect these individuals beyond what is typically of-fered by state laws related to confidentiality or privilegedcommunications: "The intent of these [federal] laws is toengage people in treatment for chemical dependencyproblems who otherwise might be cautious about the legalimplications of seeking such treatment" (p. 388). Federallaws regulate service providers receiving federal funds di-rectly, by way of either state distribution or tax-exemptstatus, and mandate that these providers are bound by fed-eral confidentiality laws that supersede state or licensurestatue regulations.

The federal confidentiality laws protect informationabout any client applying for or receiving services or re-ferral for other treatment. Information about a client whois protected by federal confidentiality laws may be dissem-inated only with client consent, and federal law prohibitsthe use of information in criminal investigations or pros-

ecution of a client unless a court order has been issued ac-cording to federal guidelines, even if the client gives con-sent. Even when consent is granted, federal guidelinesrequire consent forms to meet federal standards.

Gottone and Robine (1998) described confidential-ity issues in group treatment settings. Because many peo-ple with addictions problems also have legal problems,depending on the state statutes and/or federal regulations,communication in a group setting may not be consideredconfidential or privileged, even if a licensed professionalis involved. Typically, if group treatment is cited in a li-censure statue, a licensed counselor or psychologist isbound to keep communication confidential. Group mem-bers are not bound by these laws and statutes. Even ifgroup members sign a contract promising not to discloseinformation discussed in the group, it is often not legallybinding. Group members can gossip outside the groupand report information communicated in the group toothers—even authorities—typically without repercussion.Thus, if unlawful activity is communicated within theconfines of the group, the counselor may be bound to con-fidentiality, providing the crime does not fall under an ex-ception to the statute's confidentiality provisions, butgroup members can inform authorities and even testify asto what was said without legal consequences. In addition,even if the counselor is bound by licensure statutes, priv-ileged communication may not stand because many states'provide for privileged communication for civil, but notcriminal, court cases (Gottone & Robine).

Treatment Decision BoundariesGlearly, some methods of treatment work for certain peo-ple; however, nothing has been demonstrated to work forall people. Interestingly, though, judgments about treat-ment are often made by people whose qualifications tomake such judgments are questionable, no matter howwell-intentioned they are. Judges often mandate that peo-ple convicted of driving offenses while using alcohol orother drugs attend Alcoholics Anonymous (AA) or Nar-cotics Anonymous meetings. Peele (1996) described thisas the "disease law enforcement model."

Similarly, insurance companies sometimes mandatetreatment centers to require participation in AA as a pre-requisite to client/patient coverage. Treatment centersfrequently make AA attendance a mandatory event andsometimes even make continued treatment contingent onsaid attendance. There is often a feeling of helplessnessfrom all involved about what to do in response to some-one's abuse. Because of this, mandates often go unexam-ined. However, mandating a form of treatment andlabeling nonconformity to or questioning of the treatmentmandate as "denial" often increases resistance to treat-ment before the individual has an opportunity to examinetreatment alternatives that may be more cognitively and

Volume 43, No. 4 (Summer 2000) 213

philosophically aligned to his or her identity and needs(Ghiauzzi & Liljegren, 1993).

A client's welfare is the responsibility of the coun-selor. Gounselors must do their best to serve their clients,recognizing that services may not be providing the in-tended purpose. If the client is not benefiting from theseservices, it is the counselor's responsibility to stop treat-ment and, when necessary, refer the client for more ap-propriate treatment if it is available (Gottone & Robine,1998).

All professional codes of ethics consider dual relation-ships unethical, but they vary in terms of the conditionsunder which these relationships can occur. Thus, coun-selors are sometimes confused about the boundaries andlimits of their relationships with clients (Ghapman,1997). Gounselors who work in addiction treatment pro-grams often struggle with a unique set of relational issues.

Many addictions counselors are also in recovery andattend 12-step programs in the community. Thus, theyoften find themselves in a dual role with clients, acting asa therapist in treatment and a peer in groups such as Al-coholics Anonymous. Gounselors who use these groupsfor their own support must be able to disclose honestlywithout restraint. When a client attends the same meet-ing, however, a dual relationship usually emerges (Ghap-man, 1997). Because the client has more personalinformation about the counselor than he or she wouldwithin the normal confines of their professional associa-tion, this can shift the power differential of the relation-ship. Professional boundaries are often compromised, andthe counselor's anonymity is compromised as well. Finally,if the counselor relapses, it can affect the client's sense ofself-efficacy about his or her own recovery, potentiallytriggering a relapse.

Gounselors in recovery must make every attempt toavoid this kind of scenario and keep their recovery sepa-rate from that of their clients. Although this is sometimesunavoidable (e.g., in small communities), the intention ofthese contacts is critical. The counselor is ethically obli-gated to make every effort to avoid such contacts (Got-tone &. Robine, 1998).

Special Circumstances ofInformed ConsentTreatment services are often initiated when a person is ill-equipped to make an informed decision. As previouslynoted, people often enter treatment with varying degreesof cognitive dysfunction (Goldman, 1990) and frequentlyunder the influence of alcohol and/or other drugs. Both ofthese factors affect not only their ability to absorb andprofit from treatment but also whether or not they canmake educated decisions on their own accord. For thesereasons, it is important that once clients have beeninitially treated, particularly if they have gone through

detoxification, that counselors respect their rights of con-sent to further treatment or to withdraw from treatmentof their own volition (Gottone &. Robine, 1998).

CONCLUSION

All counselors find themselves in ethically questionablepositions at some point in their careers. Addictions coun-selors face some especially challenging ethical situationsthat are truly unique to the discipline and the client pop-ulation they serve. For this reason, addictions counselorsmust be sure they understand the ethical mandates putforth not only by their credentialing bodies but also byany federal regulating agencies that might supersede thestatutes of their own professional organizations. Moreover,if there is any question relating to ethical behavior, theymust err on the side of conservativism, always puttingtheir client's welfare and safety first.

ABOUT THE AUTHOR

Cynthia Q. Scott, PhD, GRG, is an assistant professor inand director of the addictions specialty of the RehabilitationCounseling Program at the University of North Florida.

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