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Raising the bar on ethical standards: counselor conduct shouldn't be based merely on meeting statutory requirements.

As I was doing research for this article, I was chatting with a friend online. I told her I was preparing to write about ethics in the practice of addictions counseling, around 1,500 to 2,000 words. Her response: "All you need is five words: Don't sleep with your clients!"

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While I laughed, I also began to think. I considered the coursework I have had in this area. I have attended "trainings" in ethical decision-making for addictions counselors. I have had undergraduate coursework in ethical issues in the human services professions. And I have had graduate coursework in counseling issues and ethics. While these experiences shared some obvious commonalities (such as my friend's tongue-in-cheek distillation of the entirety of ethical practice), there were significant differences as well.

In the paragraphs that follow, I will address some of the differences that exist in ethics education at the three levels. I also will consider what the differences mean to us as addictions counselors, what the differences mean to other mental health professionals, and what the differences could very well mean to our clients. Finally, I will propose a change in how the average addictions counselor approaches ethical decision-making--a change that could have long-standing positive consequences for the field and, more importantly, for those we serve.

Divergent approaches

The ethics education I received on the "training" level was what I would call "proscriptive" ethics. In a two-day, generally 14 clock-hour session, with the NAADAC Code of Ethics in one hand and the state of Colorado's mental health statute in the other, an instructor went over a list of prohibited activities and related the consequences chat could result from a breach. There are, of course, parts of the list that get repeated over and over: confidentiality of client information, dual relationships with clients, sexual relationships with clients, and duties to report in cases of suicidal/homicidal (with an identified target) ideation.

The goal of such training seems to be quite specific: "Chemical Dependency counselors can reduce the risk of malpractice [suits] by understanding and following the ethical codes and legal laws to the best of their ability." (1)

Despite the approach of such training, some evidence suggests that counselors with minimal required ethics training have "difficulty extending ethical principles to situations that they were not taught to deal with" (2), and some research indicates that they are not as prepared to deal with ethical dilemmas as are those who receive more stringent ethics training. (3)

In my baccalaureate education, ethics training was presented in a "prescriptive" manner. Rather than a negative presentation of what is forbidden, there was more of a positive presentation of what to do in a given circumstance--a prescription for each ethical conundrum presented in a case scenario. While the mental health statute and the "avoidance of malpractice" tenets were taught, more emphasis was placed on the codes of ethics, which the instructor reviewed in detail with us. There were a great many cases presented, and students were expected to be able to relate which sections of the ethics code applied in each case.

This prescriptive method of ethics education has a number of advantages over the prescriptive training done in workshops. It is generally 45 clock-hours in length (a three semester-hour course length), which affords much more time for examining case studies and addressing ethical concerns that arise for students over the period of the course. Another significant advantage is that it is generally less adversarial. The proscriptive method can create a belief that ethical behavior is done to avoid punishment rather than to offer the best possible care; the prescriptive method promotes the client's best interests and welfare.

Still, the prescriptive method relies more on an "event-response" sort of training and might limit appropriate responses in unfamiliar situations, as also noted above. Cynthia Scott (4) addresses some of the special situations arising in addictions counseling where this might occur, and Toriello and Benshoff note that training in critical thinking and "rational decision-making" aids in developing sensitivity to ethical dilemmas. (3) The critical thinking and rational decision-making aspects tend to be left out of prescriptive teaching approaches.

Finally, at the graduate level of ethics education, a "descriptive" method was used. Again, the proscriptive and prescriptive aspects of counseling ethics were incorporated. The mental health statute was reviewed and prohibited activities were clearly communicated and discussed. The code of ethics (in this case, the code of the American Counseling Association, which is considerably longer and more detailed than that of NAADAC) was parsed and its principles taught. Additionally, though, there was significant instruction about the theoretical underpinnings of not only the code of ethics, but of the basics of ethical decision-making. These principles (taken for this article from the American Psychological Association's Web site at www.apa.org) include:

* Beneficence and nonmaleficence;

* Fidelity and responsibility;

* Integrity;

* Justice; and

* Respect for people's rights and dignity.

Admittedly, these principles are incorporated into the NAADAC code, and their spirit is inherent in the mental health statutes of each state. However, when they are brought out and highlighted as the ethical framework upon which what we do is built, I believe that it strengthens the effect of the code. Another important part of the above principles is that they represent an aspirational rather than a mandatory ethical foundation. (5)

Proscriptive ethics (don't do these things or you will be punished) and prescriptive ethics (event response) both presuppose either statutory or other supervisory enforceability (from a clinical supervisor or professional association). As for statutory enforceability, I believe many if not most counselors would agree that meeting statutory minimum standards of practice does not equate with practicing ethically and with integrity. If one is not a member of the professional association, the association does not have the power to sanction. And while clinical supervision is laudable, the statute does not require it for all counselors beyond a certain certification level in all states. (It is interesting to note that counselors not receiving clinical supervision have been found to have greater tolerance for dual relationships. (6))

Aspirational ethics, on the other hand, present the idea or doing the right thing because it is the right thing, rather than because it is the mandatory thing. Kleinig makes the following observation: "Ideally, treatment providers will, out of a commitment to the internal expectations of the therapeutic role, hold themselves to account for the quality of service provided. It is because such internal constraints do not always function effectively that various external mechanisms ... are needed and may be mandated via a code of ethics." (7)

Thus, a descriptive form of ethics education, which provides not only the mandatory proscriptions and prescriptions for ethical behavior but an aspirational code of ethics, leads to an internal rather than external locus of control for ethical decision-making. (5)

Application of principles

With these ideas in mind, then, I believe it might be helpful--if not imperative--to initiate a conversation about expanding the curricula of training workshops and baccalaureate programs of ethics education to include aspirational ethics and the foundation principles noted above. Addiction professionals need to know not just what is prohibited and what is recommended, but how to make ethical decisions in unfamiliar situations. Further, we need to know why a certain action or inaction is deemed ethical or not.

Also, it might behoove the profession to consider expanding the ethics code under which we operate to be as broad as those of other mental health professions. It is an exciting time to be an addictions counselor. Parity regulations, Medicaid benefits for substance abuse treatment, public awareness programs and changes in the criminal justice system that call for more treatment and less incarceration for substance offenders all point to substantial growth in the populations we serve. As we strive to have the addictions counseling profession recognized as an equal among providers of behavioral health services, it is imperative that we maintain the highest possible standards of counselor preparedness and individual integrity. In this way we can ensure that we are providing our clients the quality of service they deserve.

References

(1.) Manhal-Baugus M. Reducing risk of malpractice in chemical dependency counseling. J Addictions Offender Counseling 1996;17:35-42.

(2.) Sias SM, Lambie GW, Foster VA. Conceptual and moral development of substance abuse counselors: implications for training. J Addictions Offender Counseling 2006;26:99-110.

(3.) Toriello PJ, Benshoff JJ. Substance abuse counselors and ethical dilemmas: the influence of recovery and education level. J Addictions Offender Counseling 2003;23:83-98.

(4.) Scott CG. Ethical issues in addiction counseling. Rehab Counseling Bulletin 2000;43:209-14.

(5.) Newman JL, Gray EA, Fuqua DR. Beyond ethical decision making. Consult Psychol J: Prac Res 1996;48:230-36.

(6.) Hollander JK, Bauer S, Herlihy B, et al. Beliefs of board certified substance abuse counselors regarding multiple relationships. J Mental Health Counseling 2006;28:84-94.

(7.) Kleinig J. Ethical issues in substance use intervention. Subst Use Misuse 2004 Feb;39:369-98.

BY JOSEPH S. STANLEY, BS, CAC III

Joseph S. Stanley, BS, CAC III, is a Senior Certified Addictions Counselor in Colorado and a master's candidate in counseling psychology and counselor education at the University of Colorado, Denver. He is an addictions counselor at Denver Health Medical Center's Outpatient Behavioral Health Services. His e-mail address is Joseph.Stanley@dhha.org.
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Author:Stanley, Joseph S.
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Date:Sep 1, 2009
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