11/20/18

1

ETHICSISSUESSUD&MENTALHEALTHCOUNSELING

BYTIMOTHYB.WALSH,MN,LP;DPAVicePresident

MinnesotaAdult&TeenChallenge

*EXCEPTOTHERWISEINDICATED:ADAPTEDFROMISSUESANDETHICSINTHEHELPINGPROFESSIONS8THEDITIONGERALDCOREY,MARIANNESCHNEIDERCOREY&PATRICKCALLANANWITHMICHELLEMURATORI,JOHNSHOPKINSUNIVERSITY

FirstthingsFirst:HelperSelfAwareness1.Encouragetheclientstostepbackandsorttheirthoughtsandfeelingsinthemoment2.Consideryourhistory,experiences,beliefs,values,actionsandinteractionsandhowtheseareinteractingwiththeclient3.Assessyourself-whatisgoingon(Interpretwhatisgoingon-Whatdoesitmean?Whereisitcomingfrom?)4.Ask,HowwillIintentionallyreflectinthismomentforthebenefitoftheclient?

•  50to75%ofallclientswhoarereceivingtreatmentforasubstanceusedisorderalsohaveanotherdiagnosablementalhealthdisorder

•  Further,ofallpsychiatricclientswithamentalhealthdisorder,25to50%ofthemalsocurrentlyhaveorhadasubstanceusedisorderatsomepointintheirlives

•  64%ofclientsmeetcriteriaforamentalhealth&SUD(MnDHS)

Source:“IntegratedTreatmentforCo-OccurringDisorders”.Webconference.Hazelden,NAADAC,et.al

PsychiatricDisordersinAddictionTreatment

Source:Cacciolaetal,2001;Ross,GlaserandGermanson1988

Co-occurrenceofMHDisorders&SUD TheMentalHealthandAddictionInteractionMakeadistinctionbetweenmentalhealthsymptomsyouhavewhileyouareactivelyaddicted,andthoseyouexperiencewhileyouareabstinent/clean/sober

MentalHealthSymptomsIhavewhileinmyaddiction

MentalHealthSymptomsIhavewhileIamsober/straight

11/20/18

2

•  Or,anunderlyingmentalhealthissue:Youdon’tnoticethementalhealthproblembecauseyouareintoxicated

•  Youmaybemedicatingyourself.Thatmeansyouareacting

likeyourownpsychiatristandpharmacistandtakingsubstancesthatyouthinkwillhelpyourmentalhealthsymptoms(depression,anxiety,agitation,etc.

•  Yourdrugandalcoholabusecanleadtomentalhealth

symptoms(underlyingpre-disposition)“IntegratedTreatmentforCo-OccurringDisorders”.Webconference.Hazelden,NAADAC,et.al

SANITYVS.INSANITY•  Theinsanityofaddictivebehaviorsvs.co-occurring

disorder

•  AbuseandAddictiontosubstancescancausesymptomsofmentalhealthdisorders(called“SubstanceInduced”)

•  Theaffectsofthedrugcancarryonevenafterstoppinguse.“PersistingPerceptiondisorder”e.g.HallucinationsFalsePerceptions

REASONSFORMALPRACTICELAWSUITS

•  Failuretoobtainordocumentinformedconsent•  Refusaltocounselclientsduetovaluedifferences

•  Clientabandonmentorprematuretermination•  Markeddeparturesfromestablishedtherapeuticpractices

Corey,9e,©2015,

REASONSFORMALPRACTICELAWSUITS(CONTINUED)

•  Sexualmisconductwithaclient•  Practicingbeyondthescopeofcompetency•  Negligentassessmentormisdiagnosis•  Repressedorfalsememory•  Unhealthytransferencerelationships•  Failuretoassessandmanageadangerous

client Corey,9e,©2015,

SEXUALEXPLOITATION604.201CAUSEOFACTIONFORSEXUALEXPLOITATION•  Acauseofactionagainstapsychotherapistforsexualexploitationexistsfora

patientorformerpatientforinjurycausedbysexualcontactwiththepsychotherapist,ifthesexualcontactoccurred:

•  (1)duringtheperiodthepatientwasreceivingpsychotherapyfromthepsychotherapist;or

•  (2)aftertheperiodthepatientreceivedpsychotherapyfromthepsychotherapistif(a)theformerpatientwasemotionallydependentonthepsychotherapist;or(b)thesexualcontactoccurredbymeansoftherapeuticdeception.

•  Thepatientorformerpatientmayrecoverdamagesfromapsychotherapistwhois

foundliableforsexualexploitation.Itisnotadefensetotheactionthatsexualcontactwithapatientoccurredoutsideatherapyortreatmentsessionorthatitoccurredoffthepremisesregularlyusedbythepsychotherapistfortherapyortreatmentsessions.

11/20/18

3

SEXUALEXPLOITATION604.20DEFINITIONS•  §Subd.2.Emotionallydependent."Emotionallydependent"meansthatthenatureofthepatient'sorformer

patient'semotionalconditionandthenatureofthetreatmentprovidedbythepsychotherapistaresuchthatthepsychotherapistknowsorhasreasontobelievethatthepatientorformerpatientisunabletowithholdconsenttosexualcontactbythepsychotherapist.

•  §Subd.3.Formerpatient."Formerpatient"meansapersonwhowasgivenpsychotherapywithintwoyearspriortosexualcontactwiththepsychotherapist.

•  §Subd.4.Patient."Patient"meansapersonwhoseeksorobtainspsychotherapy.•  §Subd.5.Psychotherapist."Psychotherapist"meansaphysician,psychologist,nurse,chemicaldependency

counselor,socialworker,memberoftheclergy,marriageandfamilytherapist,mentalhealthserviceprovider,licensedprofessionalcounselor,orotherperson,whetherornotlicensedbythestate,whoperformsorpurportstoperformpsychotherapy.

•  §Subd.6.Psychotherapy."Psychotherapy"meanstheprofessionaltreatment,assessment,orcounselingofamentaloremotionalillness,symptom,orcondition.

MARRCH,2018

STANDARDETHICSFORMINNESOTAASSOCIATIONOFRESOURCESFORRECOVERYANDCHEMICALHEALTH(MARRCH)

•  To ensure the highest quality of service delivered to clients and to insure professional integrity, I will:

1)  Adhere to all state and federal laws and rules that govern client care and counselor

licensure requirements, including reporting abuse/neglect of vulnerable persons (children/adults), misconduct by individuals or agencies, client confidentiality, data privacy, and relationship between clients and professionals

2)  Maintain an objective, non-possessive and respectful relationship with clients at all times, especially in the areas of the client’s physical, sexual, financial, or emotional boundaries.

3)  Adhere to non-discriminatory behavior with clients on the basis of race, color, gender, sexual orientation, affectional preference, age, religion, national origin, cultural background, marital status, political belief, mental or physical handicap, or any other personal preference, characteristic, condition, or status.

4)  4)Maintain a willingness and the ability to recognize when it is in the client’s and/or their family’s best interest to refer or release him/her to another professional, program, or agency.

MARRCH,2018

MARRCHETHICS•  5)Empowerclientsandtheirfamiliestomoveforwardtowardself-sufficiency.•  6)Maintainknowledgeofcommunityresourcesandmakeappropriatereferrals.•  7)Respecttherightsandviewsofotherprofessionalsandagencies.•  8)Abidebymyagency’spolicies,proceduresandregulationsthatmaintainandimprove

thedeliveryofservices.•  9)Assesspersonalcompetenceandoperateonlywithinmyskillsand/ortraining.•  10)Accuratelyrepresentmyownqualificationsandaffiliations.•  11)Continuemyprofessionalgrowththroughongoingeducationand/ortraining.•  12)Recognizemyindividualresponsibilityforappropriateprofessionalandrespectful

conductinpersonalandprofessionalareas•  13)Maintainanongoingpersonalgrowth,recoveryand/orpersonalenhancement

program.•  14)Maintainappropriateboundariesbetweenmyselfandmycolleagues,myagencyand

otherprofessionalsoragencies.•  15)ObtainclinicalsupervisionwhenappropriateandincompliancewiththeStateof

Minnesotalicensingregulations.

RESOLVINGANETHICALDILEMMAProvidethefactsoftheethicaldilemma

EdensGroupinMARRCHEthicalStandardsGuide

MARRCHRESOURCES•  MARRCH Ethics Statement •  https://www.marrch.org/page/ethics_statement •  MARRCH Ethics Guide •  https://www.marrch.org/page/ethics_guide •  MARRCH Ethics Consultation Form and contact •  https://www.marrch.org/page/ethics_consult_form •  MARRCH Ask the Ethics Committee Column •  https://www.marrch.org/page/ethics_submit_a_q

ETHICSCODES&STANDARDS1.Agency’sCodeofConductorPractice2.ProfessionalCode(s)ofEthics3.Industry/FieldStandard4.LicensingBoards’Code(s)ofProfessionalConduct*Client/YourCulturalvalues?*YourPersonalvalues?

11/20/18

4

PROFESSIONALMONITORINGOFPRACTICE

  Theethicsofyourregulatingboardandprofession:•  BBHT•  MnBoardofMarriageandFamilyTherapy•  BoardofPsychology•  MnBoardofSocialWork

• Whoseresponsibilityisit?

PROFESSIONALORGANIZATIONSANDCODESOFETHICS

American Association of Christian Counseling Association for Addiction Professionals (NAADAC): Code of Ethics, ©2008 American Psychological Association (APA): Ethical Principles of Psychologists and Code of Conduct, ©2002 American Association for Marriage and Family Therapy (AAMFT):

Code of Ethics, ©2001 National Association of Social Workers (NASW): Code of ,

BASICMORALPRINCIPLESTOGUIDEDECISIONMAKING

  Autonomy:promotingclientself-determinationvs.“emotionaldependence”(MS604)  Beneficence:whatisgoodfortheclient

  Non-maleficence:notharmingclients

  Justice:beingequitableandjust(notsameness)

  Fidelity:todowhatyousayandsaywhatyoudo

  Veracity:tobetruthfulanddealhonestlywithclients  EXAMPLE:ADULTVS.VULNERABLEADULT

Corey,8e,©2011,

TRANSFERENCE  Theprocesswherebyclientsprojectontotheirtherapistspastfeelingsorattitudestheyhadtowardsignificantpeopleintheirlives  The“unreal”relationshipintherapy

–  Counselorsneedtobeawareoftheirpersonalreactionstoaclient’stransference

–  Allreactionsofclientstoatherapistarenottobeconsideredastransference

–  Dealingappropriatelywithtransferenceisanethicalissue

Corey,8e,©2011,

COUNTERTRANSFERENCE Anyprojectionsbytherapiststhatdistortthewaytheyperceiveandreacttoaclient Occurswhenclinicians

– demonstrateinappropriateaffect– respondinhighlydefensiveways– losetheirobjectivitybecausetheirownconflictsaretriggered. Canbeeitheraconstructiveoradestructiveelementinthetherapeuticrelationship

Source:Corey,8e,©2011,

COUNTERTRANSFERENCE&SELF-DISCLOSURE

  Whentodisclose Whyareyoudisclosing?Whatisthepurpose?  Forwhosebenefitareyoudisclosing? Whatisthebenefit? Willthisdisclosurechangethetherapeuticrelationship? Whatisthepossibledownsideornegativeeffects?

11/20/18

5

EXAMPLESOFCOUNTERTRANSFERENCE– Beingoverprotectivewithaclient(Example:nochallenge/noprogress)

– Rejectingaclient(Example:Ican’tworkwithhim/her)

– Needingconstantreinforcementandapproval(Example:youreceiveconstantpraiseandadmirationfromclients)

– Seeingyourselfinyourclients(Example:allclientsneedtofollowmyplanforrecovery)

– Developingsexualorromanticfeelingsforaclient

– Givingadvicecompulsively

– Desiringasocialrelationshipwithclients(Example:businessdealings)Source:Corey,8e,©2011,Brooks/Cole–

CLIENTDEPENDENCE

  Emotionaldependence  Clientexclusivelyreliesoncounseloradvice,guidance,direction  Clientfeelsthattheycanonlybehelpedbyaparticularcounselor  Clientattributestheirprogressexclusivelytocounselor  Clientreservesallcoreissues,deepconcerns,secrets,etc.forthecounselor

COMPETENCE:BURNOUTANDIMPAIRMENT

  Burnout– astateofphysical,emotional,intellectual,andspiritualdepletioncharacterizedbyfeelingsofhelplessnessandhopelessness  Impairment

– thepresenceofachronicillnessorseverepsychologicaldepletionthatislikelytopreventaprofessionalfromdeliveringeffectiveservicesandresultsinconsistentlyfunctioningbelowacceptablepracticestandards

– WHATSHOULDYOUDO????????????

ETHICALPRINCIPLE:CULTURALRESPONSIBILITY  Counselorshaveanethicalresponsibilitytoprovideprofessionalservicesthatdemonstraterespectfortheculturalworldviews,values,andtraditionsofculturallydiverseclients.

  Totheextentthatcounselorsarefocusedonthevaluesofthedominantcultureandinsensitivetovariationsamonggroupsandindividuals,theyareatriskforpracticingunethically.

  EXAMPLE:ChristianBi-culturalitye.g.IamChristianAND…

ETHICALPRINCIPLE:CLIENT’SRIGHTTOINFORMEDCONSENT

  Informedconsent–  involvestherightofclientstobeinformedabouttheirtherapyandto

makeautonomousdecisionspertainingtoit--ashareddecision-makingprocess–  requiresthattheclientunderstandstheinformationpresented,gives

consentvoluntarily,andiscompetenttogiveconsenttotreatment–  aprocessthatcontinuesforthedurationoftheprofessional

relationshipasissuesandquestionsarise

–  Whattreatmentareyouusing?Whatresearchsupportsit?Whatarethebenefits?Whatarethepotentialrisks?

Source:Corey,8e,©2011

ETHICALPRINCIPLES:LIMITSOFCONFIDENTIALITY

– Therapeutic milieu; need to know – Group members remaining confidential – Clinical supervision consultation – When a client has given consent for ROI – When a client poses danger to self or others; duty to warn???? https://

www.revisor.mn.gov/statutes/cite/148F.13 – When a client discloses intention to commit a crime???? – When a counselor suspects abuse or neglect of a child or vulnerable

adult – When a court orders counselor to make records available?????? (CFR

42) Source:Corey,8e,©2011

11/20/18

6

ETHICALPRINCIPLE:COMPETENCE  Professionalcodesofethicsoncompetencehavecommonthemes.  Counselorspracticeonlywithintheboundariesofcompetence,basedon:–  education–  training–  supervisedexperience–  stateandnationalprofessionalcredentials–  appropriateprofessionalexperience

ETHICALPRINCIPLE:WHENTOTRANSFERORMAKEAREFERRAL

  When:– Counselorsbecomeawarethattheydonothaveskillstoofferclientneededservices

– Counselors’donotpossessthecompetencyforeffectiveservice.  How:

– counselorsmusthavethoroughknowledgeofthetypeandcaliberofserviceavailableinthecommunity  Who:

– clientmustagreethatproblemexistsandbewillingtoworkwithreferral

ETHICALPRINCIPLE:TREATMENTMODELFIDELITY  EVIDENCEBASEDPRACTICES  THERAPEUTICCULTURE:CULTUREOFHONOR  MOTIVATIONALINTERVIEWING  FAITH-INTEGRATION;SPIRITUALPRACTICES  AA/NA(OXFORD)TRADITIONSANDPRINCIPLES  CBT/DBT  RELAPSEPREVENTION  RECOVERYSYSTEMS  TRAUMA:SPIRITUALPRACTICES+BASK(GINGRICH)  YOURFIDELITY??

ETHICALPRINCIPLE:CLIENT-CENTEREDNESSANDRESPONSIVITY

  APAPresidentialTaskForce’sDefinition,2006:“theintegrationofthebestavailableresearchwithclinicalexpertiseinthecontextofpatientcharacteristics,culture,andpreferences”  Characteristics:age,developmentallevel,gender,culture/ethnicity,IQ,motivation,spiritualmaturity,seriousmentalillness….WHATELSE???????  Individualizedtreatmentplan  RESPONSIVITYPRINCIPLE:DIFFERENCESTHATMAKEADIFFERENCEREGARDINGOUTCOME  Whoisyourclient?Ingrouptherapy,couples,familypsychotherapy

ETHICALPRINCIPLE:CONTINUITYOFCAREVS.CLIENTABANDONMENT

  ETHICALRESPONSIBILITYFORCONTINUITYOFCARE  ETHICALRESPONSIBILITYTONOTABANDONTHECLIENT

  CIRCUMSTANCES?

  WHATTODO???

DILEMMAS•  Disclosure:CDvs.MH•  “LevelofCare”andSeriousMentalIllness•  MATs&Client’sGoalofAbstinence•  ContinuityofCare&Multi-disciplinarytreatment•  Multi-modaltreatmentandtreatmentmodelintegrity•  “Needtoknow”,clientconfidentiality,andintegratedtreatmentmodels

•  Step12vs.boundaries•  “RecoveryCommunity”vs.dualrelationships

11/20/18

7

DILEMMAS•  TheinteractionofSUD&MI•  “Responsiveness”andclientautonomyvs.spiritualintegration

•  “VulnerableAdult”statusvs.clientautonomyandself-determination

•  Individualandgrouptherapy;boundariesbetweenthetwo?

•  Client’sprimaryissueisseriousmentalillness

WRAPUP