Ethical Principles and Issues within Addiction Counseling
Jennifer Spivey
Liberty University

Abstract
Addiction counselors have many ethical and legal considerations in when providing services to substance abusers. There are ethical principles that including justice, autonomy, nonmaleficence, beneficence, and fidelity. Along with these principles there are federal and state regulations when providing services. As an addiction counselor there should be ethical guidelines to follow with informed consent, compensation, confidentiality, and collection and protection of data. Furthermore, addiction counselors must avoid coercion, provide alternative treatment options, protect vulnerable clients, and select representative participants for addictions research. The ultimate goal of addictions counseling is to benefit the clients and society as a whole.
Keywords: ethical, principles, addiction, counselor
Introduction
There are many counselors that are faced with ethical issues on a regular basis. These issues are intensified for an addiction counselor. There are a number of reasons for ethical issues for addiction counselors. One is that there is a high correlation between addiction and criminal activity. There is also the concern that ethical issues such as informed consent can be complicated by problems arising out of substance abuse. The counselor’s ability to cope with these and other issues is dependent, to a large degree, on their ability to weigh up the inherent risks and benefits of a multiplicity of options and make a moral and principled decision. Principles are informed by personal and professional values. The Code of Ethics adopted by the American Counseling Association (2005) sees these values as deeply ingrained in the counselor and developed out of personal dedication, rather than the mandatory requirement of an external organization. There are five ethical principles which are the root of the ethical issues. These principles are justice; autonomy; beneficence; nonmaleficence and fidelity and help in clarifying and resolving conflicting issues which substance abuse counselors face daily and which may not be adequately addressed in the guidelines. This paper will present the terms of the principles and the ethical issues that counselors undergo.
Justice
There are clients that place great demands on a counselor’s resources that other clients may not be needy about. This can be an ethical issue and the counselor should be able to clearly justify proper actions. Counselors need to recognize and accept that bias is normal and that there will inevitably be those who may be regarded as ‘favorite’ clients and others with whom they will instinctively prefer to limit contact. However, personal issues and personality conflicts cannot stand in the way of working with clients. In order to practice within the principle of justice it is important to avoid allowing personal prejudices to interfere with the client /counselor relationship and to ensure that no client is discriminated against or denied access to treatment that other clients have. There should be a concise understanding of the concept of counter transference, which refers to the conscious or unconscious reactions to what the client may present in treatment. Counter transference can involve either being overly involved in caring for the client or being repulsed by the client’s needs, even resulting in the counselor becoming frustrated or getting into arguments and power struggles with the client, and so obviously has an impact on the counselor’s impartiality. However, by understanding that these feelings are often a part of the counseling process, the counselor may be able to overcome them, using his own reactions to provide him with an understanding of the reactions the client induces in others. If the addiction counselor was to failing this, a consultation with a supervisor may be necessary. Although it may be difficult for a counselor to treat everyone impartially there are safeguards that can be instituted to ensure an equitable level of service. Standards can be set in place which require every new client to receive an intake interview within 24 hours, for example, or an agency can work towards clarifying its criteria for services so that they are weighed more heavily on objective information rather than on the personal impressions of a substance abuse treatment counselor. These types of policies can help ensure a general level of fairness, regardless of a counselor’s personal feelings.
Autonomy
The principle of autonomy is one which addresses the concept of independence, or the individual’s freedom of choice and action. This principle respects the unconditional worth of the individual and promotes self-governance, self-determination and self-rule. Autonomy also encompasses the client’s voluntary commitment to participating in the counseling sessions, although, in the case of substance abuse, the client may not have been given an option, as counseling may be the requirement of a court order or probationary condition. The concept of informed consent is based on this principle.
The addiction counselor has to take into account two important considerations when encouraging clients to take responsibility for their own decisions to avoid ethical issues. The first is helping their clients understand that their values may not be in accordance with the values of the community in which they live, and to ensure that the decisions taken will not interfere with the rights of others. The second is to determine whether the client is competent to make rational decisions and has the information necessary to make a sound personal choice.
This ethical issue of competence within a client can be one of the most complex dilemmas in the profession of counseling. Competency issues are seldom clear cut and the process of proving incompetence can be burdensome and time consuming. There are several factors that can temporarily make a client seem incompetent. A client may seem unable to make independent decisions one day and then, the next day, be quite lucid. Substance abusers, for instance, can experience temporary poor judgment due either to active substance use or ongoing problems with decision making due to the results of long-term use.
When deciding whether a client has the ability to maintain autonomy, then, it is best for the substance abuse counselor to consider not only the initial impression but the duration and severity of the behavior. There should be thorough reports by other persons in the client’s life that can help with the assessment of the client’s mental functioning, as can consultation with other medical or psychiatric professionals and the existence of a strong baseline assessment. It is also important to realize that a client may be fully competent in some areas of life but demonstrate only partial competency in others. For example, the client may be quite capable of caring for themselves physically but may no longer be able to make sound financial decisions. The client could have an impairment that causes them to be at the lowest level of the performance curve and should be considered incompetent, although the seriousness of the possible consequences of the client’s decision obviously needs to be considered. Legally the capacity to consent to treatment depends upon the ability to communicate decisions, to understand the information given, to appreciate the consequences of the decision and to be able to reason about treatment choices. In cases of severe incompetence legal instruments previously signed by the client, such as a health proxy, may have to come into play or, in extreme cases, a court appointed guardian may be necessary.
The second part of the issue of incompetence is the question of whether or not the client has the necessary information to make a sound decision. The principle of justice comes into play here as the counselor’s bias or personal values could impact on the information given to the client. Emphasizing one aspect of treatment, for example, could influence the decision in favor of the counselor’s preference and so violate the principle of autonomy. If the addiction counselor has a strong desire to aim toward one form of therapy this bias should be acknowledged to the client, but no attempt should be made to manipulate his decision.
Beneficence
The principle of beneficence refers to the responsibility of substance abuse counselors to improve and enhance the welfare of their clients. In other words, beneficence means to do good, to be proactive in seeking their clients’ welfare, and also to prevent harm whenever possible. It is important for the addiction counselor to take into consideration the social norms and culture of the client to avoid ethical issues. What may seem beneficial to the counselor may conflict with the client’s cultural and/or religious background. The counselor, then, needs to consider whether, in applying the principle of beneficence, he is not inadvertently attempting to impose his own agenda and so nullifying the principle of autonomy.
Nonmaleficence
The principle nonmaleficence is expressed as ‘above all do no harm’. This principle is often seen as the most critical of the five principles and refers not only to the intentional infliction of harm but also to acting in such a way as to risk harming others. Legally and morally, a counselor could be considered negligent if he fails to meet the standards necessary to provide his clients with the care to which they are due and, as a consequence of this failure, harms the client in any way. This principle emphasizes the importance of the counselor’s recognition of the limitations of his ability and the need to avoid offering services or using techniques which are beyond his professional competence when treating the substance abuse issues of a client. Another aspect of this principle involves the termination or transfer of clients. It is essential that there is an understand all the guidelines regarding transfers and terminations are not clear from the start and followed through consistently, then the counselor may be guilty of violating the principle of nonmaleficence. Intentional harm can include issues of client abuse such as breaching boundaries in terms of sexual contact or financial exploitation. However, harm can be inflicted in more subtle ways and unintentional ways. For this reason it is important to consider whether any decisions or actions taken have an effect of harming the client physical, psychological, financial, legal, or spiritual.
Conflicting interpretations based on counselors’ own personal values and beliefs can cause confusion in the application of this principle. An example of abstinence, is where the counselor may claim that a risk reduction approach harms a client by enabling his addiction, keeping the client from truly hitting bottom and seeking help. However an example of a risk reduction based counselor would claim that an abstinence-based model harms the client because it does not allow for compassion or for meeting the basic needs of individuals who are in the throes of addiction. Also, risk reduction would claim that the abstinence-based model actually prohibits recovery because it does not take into account that recovery is a process, rather than a rigid philosophy.
Fidelity
The last principle is fidelity is when the core of the relationship between the professional counselor and his client. Fidelity implies loyalty, honesty and trustworthiness. For successful counseling to take place the client has to be able to trust the counselor and be comfortable in the therapeutic relationship. Although fidelity is a fairly simple concept, requiring telling the truth and keeping promises, it is easily violated and becomes unethical. When a substance abuse treatment counselor takes on a client, there is an implicit contract with the client which assumes that the counselor will work to resolve the client’s concerns and that the information will be shared in a truthful manner between the counselor and the client. If the counselor feels that there is any possibility that the confidentiality of the contract may be broken it is important that he is very clear about this from the beginning. The possibility that the relationship may be terminated if the client breaks certain of the agency rules also needs to be emphasized from the start.
Another issue of fidelity is the counselor’s responsibility towards the primary client. When involved with a complicated family system, it is easy to overlook the individual needs of the client is, especially when working with clients whose competency is in question or when there is conflict. Sometimes it can be more convenient just to let someone else speak for the client. Nevertheless it is the counselor’s responsibility to ensure that, until the competency issue is resolved, she is representing the primary client and acting according to the client’s wishes.
Ethics and legal issues There are ethical guidelines that are based from the five ethical principles in addiction counseling. Addiction counselors have to follow federal and state regulations. There are specific guidelines that must be followed when counseling adolescents. Confidentiality is essential because it is mean to protect clients from further discrimination or legal sanctions. There are negative association with substance abuse that includes including social stigma, legal or educational consequences, employment challenges, and impaired family relations. With these negative associations there has been an establishment of special federal regulations to protect substance use treatment clients. United States federal legislation (Code of Federal Regulations, Title 42, 1995) regulates confidentiality and release of information for participants in addiction treatment programs that are federally funded; violations of confidentiality regulations can result in criminal punishment (Lambert, 2011 p. 33). There are prohibiting factors to the military and Department of Veterans to receive data. The same ethical standards which apply to other clients apply equally to adolescents but issues of confidentiality and consent to treatment can present additional ethical dilemmas. Standards B.5.a., B.5.b. and B.5.c. of the American Counseling Association’s Code of Ethics acknowledge the rights and responsibilities of parents and guardians, particularly with respect to different cultures, while at the same time emphasizing the need for counselors to protect the confidentiality of minors and to include them in decisions about disclosing privileged information to the families. There are many states that has regulation that require parental consent to any form of treatment. However, the increased access to treatment and right for consent may lead the adolescent to be more open and compliant, since they also hold the legal right to release information and can better protect their own privacy. Counselors who provide treatment for substance abuse to adolescents, then, need to take into account two disparate issues: whether they are legally entitled to admit an adolescent into a treatment program without the consent of a parent or guardian and whether they can share concerns about the adolescent’s substance abuse with parents or guardians without violating federal regulations which protect their client’s confidentiality. As long as the adolescent is willing to have treatment information shared with his parents or guardians these questions do not come up. The difficulty arises, however, when the adolescent refuses to allow any such communication. If any of the ethical issues arises in a treatment program that requires parent consent then: either the adolescent must be refused admittance to the program, or he can be admitted despite the legal ruling of the State.
Conclusion
Although the focus of this paper has been on ethics for substance abuse counselors it is notable that a common thread runs through the ethical codes of all the health service professions, and, indeed, those of many in the business and legal world as well. These codes are based on the moral principles of justice, autonomy, beneficence, nonmaleficence and fidelity. Addiction counselors might at times feel overwhelmed by the complexity of the ethical dilemmas which they face, almost on a daily basis. The principles and guidelines above should provide a basis for decision making but, in the end, it is the personal and professional values and integrity of the counselor, “rather than the mandatory requirement of an external organization” (ACA 2005) which will make those principles live.
References
Adamson, N. , Eriksen, K., Hoffman, R., & Kress, V.E.(2013). Informed consent, confidentiality, and diagnosing: ethical guidelines for counselor practice. Journal of Mental Health Counseling, (35)1, 15.
American Counseling Association ACA. (2005). Code of ethics and standards for practice, Alexandria, VA.
Code of Federal Regulations CFR (2002) Retrieved 26 September 2014 from www.access.gpo.gov/nara/cfr/waisidx_02/42cfr2_02.html. Greenwell.L., Hamilton, Z., Podus, D., Pearson, F.S., Prendergast, M.L., & Vazan, P. (2012). Meta-analyses of seven of the National Institute on Drug Abuse's principles of drug addiction treatment. Journal of substance abuse treatment, (43)1, 1.
Kleinig, J. (2004). Ethical Issues in Substance Use Intervention. Substance Use & Misuse, (39)1, 369 – 398.
Lambert, S.F. (2011). Ethical and Legal Issues in Addictions Outcome Research. Counseling Outcome Research and Evaluation, (2)1, 25-36.
Scott, C. & White, W. L. (2005). Ethical issues in the conduct of longitudinal studies of addiction treatment. National Library of Medicine. Journal of substance abuse treatment (28)1, 91-S101.
Sullivan, Maria A; Birkmayer, F., Boyarsky, B. K., Frances, R., Fromson, J.A.,& Sullivan, M.A.(2008). Uses of coercion in addiction treatment: clinical aspects. The American journal on addictions / American Academy of Psychiatrists in Alcoholism and Addictions (17), 36-47. unknown author, (2003). Ethical considerations in caring for women with substance use disorders. Obstetrics and gynecology clinics of North America, (30)3, 559-582.
Yamuna, S. (2013). Counseling adolescents. Indian journal of pediatrics, (80)11, 949-958.