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

^Ethical Issues in Addiction Counseling

Cynthia G. Scott
University of North Florida

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

ounselors and psychologists base their professional


values and practices on a foundation of ethical
standards that are similar, but not identical, across
disciplines. The ethical standards of each counseling
discipline are clearly articulated in their respective professional associations and are well known to most practitioners and academics in the counseling field. Addictions
counselors, however, not only operate under a somewhat
different set of ethical standards, they are also faced with
unique situations resulting in ethical challenges with their
clients that other counselors do not typically have to
address. Because of this, it is especially important that addictions counselors understand and work toward addressing these issues within the context of the foundational
ethical standards of the counseling profession.

UNIQUE ETHICAL ISSUES


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

the necessary professional credentials, (c) the questionable propensity of group work in the addictions field,
(d) special issues of confidentiality and privileged communication, (e) boundaries of professional practice in
making treatment decisions, and (f) unusual circumstances of informed consent.

Lack of Communication
and Continuity
Addiction treatment is an anomaly in the counseling field
and atypical of other therapeutic fields because it has
often relied more on faith than science or empirical findings (Chiauzzi & Liljegren, 1993). Although scientific understanding of addiction is still in its infancy (Thombs,
1999), the state of research, particularly in the field of
chemical addictions, is evolving at a rapid pace.
For instance, for the past decade, researchers have
viewed addiction as a complex, progressive behavior pattern having biological, psychological, sociological, and
behavioral components (Donovan, 1988). More recently,
research has pointed to chemical addiction as a brain disease triggered by frequent use of drugs that change the

Dpro-ecl

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Rehabilitation Counseling Bulletin

biochemistry and anatomy of neurons and alter the way


they work in the brain's desperate attempt to carry on
business-as-usual in order to make neurons less responsive
to drugs, thus restoring homeostasis while under extreme
chemical siege (Powledge, 1999).
Further, Peele (1996) suggested distinct "susceptibility" and "exposure" constructs. The susceptibility construct emphasizes the important role genetic factors play
in the development of dependence and how they influence one's vulnerability to the disorder. The exposure position holds that chemicals and their actions on the brain
are the primary causes of addiction.
Finally, evidence clearly shows that individuals with
alcohol addiction who enter treatment do so with varying
degrees of cognitive dysfunction due to sustained use of alcohol over time. This dysfunction affects their ability to
absorb and profit from treatment interventions administered in the early weeks after detoxification (Goldman,
1990). The repercussions for treatment due to this confounding factor are highly relevant.
Yet, in most conventional addiction treatment programs, there is little integration of theory and research
into clinical practice for either chemical or behavioral addictions (Caldwell, 1991; Lamb, Greenlick, & McGarty,
1998). Research and related knowledge about alcohol and
other drug addiction burgeoned in the 1990s; however,
this knowledge has been little used to guide addiction
treatment. The gap has grown so great that the National
Institute on Alcohol Abuse and Alcoholism (NIAAA)
sponsored a 1990 conference entitled "Linking Alcholism
Treatment Research with GUnical Practice" (Gordis,
1991). It was unique in that it allowed researchers and
practitioners to address each other. In commenting on the
meeting, Gordis, the director of NIAAA, noted.
In theory, alcohol researchers seek knowledge
about alcohol-related health conditions, and
practitioners use this knowledge to help their
patients recover. In practice, however, we often
find that alcohol researchers and alcohol practitioners travel in two largely unrelated circles;
they speak different languages, attend different
meetings, and generally view problemsand
their solutionsfrom very different perspectives, (p. 173)
Treatment practices in addictions are not typically
conceptualized from research findings. Most continue to
use a traditional orientation, based on what has been done
in the past, regardless of relapse rates that run from
50% to 90% (Hunt, Bannett, & Branch, 1971; Hunt &
Matarazzo, 1973; Marlatt, 1985; Marlatt & Gordon, 1980).
Moreover, research has indicated that there is a significant portion of the abusing population who stop their
abusive 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 theory, research, and clinical practice is a strong tradition
within most treatment communities of relying on personal experience, clinical anecdotes, and testimonials to
help others. Practitioners tend to rigidly cling to their favorite theory, most often without a full understanding of
all its concepts and implications. At the same time, other
theories may be unwittingly disregarded. Glearly, the classic disease models have helped many individuals who are
chemically dependent. However, as judged by the large
number of people with addictions who refuse treatment,
drop out of treatment, and/or relapse, it can be reasonably
asserted that these models are not a "good fit" for many, or
perhaps even most, individuals with chemical dependencies. It is imperative that practitioners consider alternative models of recovery for clients who cannot work
within the disease model.
Yet, all too often, clients who resist the tenets of the
classic disease model are labeled as being in denial. A
growing body of literature suggests that the acceptance of
such a label is not an essential first step and may in fact be
counterproductive (Fingarette, 1988). Often times individuals who have been labeled as having alcoholism or an
addiction are passing through a difficult stage in life when '
seeking relief, and acting out through some form of
compulsivity makes sense; these people are not forever
dependent.
The tendency to reduce all client resistance to denial
often obscures the possibility that the problem may lie in
the treatment model, not in the client. Rather than forcing a model on clients, it may be more effective to help
clients discover their own paths to recovery. Thus, counselors should possess the flexibility to guide clients in different directions as well. Personal experience, clinical
anecdotes, and testimonials are of limited use because
they speak to an assumption that all individuals with addiction problems are alike. The conceptual line of thinking is, "It worked for me, so it will work for everyone." It
has been clear for some time, however, that addiction to
alcohol 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 approaches and research. These include the inability of
many practitioners to understand research reports, the
limited access counselors have to important research literature, and unawareness by some counselors that a body
of research even exists (Huey, 1991).
In Section A of its Gode of Ethics, the National
Board of Gertified Counselors (NBGG, 1997) mandates
that "Gertified counselors engage in continuous efforts to
improve professional practices, services, and research.

Volume 43, No. 4 (Summer 2000)


Certified counselors are guided in their work by evidence
of the best professional practices" (p. 3). Given this ethical standard, the schism that exists between research and
clinical practice in the field of addictions counseling is
troubling. Counselors should make every attempt to frame
treatment decisions within the context of current research. Moreover, they must adopt an attitude of life long
learning in understanding and seeking access to relevant
research related to addictions counseling.

Lack of Agreement on
Professional Credentials
The clinical standards for providing addictions counseling
have historically been lower than those necessary to perform other kinds of counseling. In many states, the minimum formal education requirements for entry-level
addictions counselors do not even include the baccalaureate degree. Moreover, some states exempt addictions
treatment personnel from licensure or other standards,
and some states have developed separate standards for individuals counseling clients with addiction problems.
George (1990) stated.
Those who currently work as chemicaldependency counselors have tended to adopt
one of two extreme positions; that chemical
dependency counselors must be recovering addicts (or, at the very least, have a recovery program as codependents), or that chemical
dependency counselors must have a minimum
of a master's degree in such related fields as
counseling, social work, or psychology. Unfortunately, this polarization often results in unnecessary conflict among counselors and a lack
of respect and appreciation for what each
group offers to the treatment process, (p. 216)
For most counseling-related professions, the standard is
that counselors providing treatment should have a master's degree or higher, and, where required, they should
meet the licensure standards as professional counselors
(Cottone &. Robine, 1998).
As the research on addictive behaviors unfolds, its
complexity becomes increasingly evident. Because of this,
it is important that counselors working in the addictions
field have specialized training in many complex areas, including both chemical and behavioral addictions, relapse
prevention and other cognitive strategies, neuropsychological processes in addiction, assessment, and individualized treatment planning.
Further, because treatment practices have changed
very little, even though there is training available in these
areas, treatment plans are typically uniform rather than
individualized for people based on their personal needs

211

and clinical presentation. Milkman and Sederer (1990)


summarized the inappropriateness of uniform addiction
treatment by quoting Mark Twain: "When your only tool
is a hammer, then every problem is a nail" (p. 249).
Given the current state of knowledge regarding the
complexity of the addictive process related to both chemical and behavioral addictions, not only should addictions
counselors be held to the same standards as other counseling professionals, they should also have the necessary
specialized coursework, continuing education, and experience necessary to keep them literate in and abreast of current information about addiction and its treatment.
Another phenomenon seen in the addictions counseling field is counselors working in addictions treatment
who hold the standard credentials of a professional counselor with the requisite master's level training, and even
licensure, yet have little training or experience in addictions. Because they lack the necessary knowledge of this
complicated specialty, they are ill equipped to perform the
necessary functions unique to helping individuals with
addictions.
Several credentials can be obtained as an adjunct to
a master's degree. Both the National Board of Certified
Counselors (NBCC) and the Commission on Rehabilitation Counselor Certification (CRCC) offer a specialty
designation of master of addiction counseling (MAC).
This credential requires the broader certification of the
sponsoring certifying board (the NCC or the CRC, respectively) and in addition may require specialty coursework or continuing education related to addictions or
chemical dependency treatment, experience under supervision in a setting where addictions are treated, and/or
passing a specialty examination developed by the board.

Questionable Propensity of
Group Work
Most conventional treatment programs in addictions are
forced to rely heavily on group work because they lack the
resources for more individualized care. This occurs in two
separate ways: through self-help groups such as Alcoholics
Anonymous, Narcotics Anonymous, and other 12-step
groups, and through group counseling that occurs in both
inpatient and outpatient treatment programs. Both practices raise ethical concerns.
Although the growth of self-help groups validates
the idea that people who have encountered and resolved
certain difficulties possess unique resources for helping
others like themselves (Corey, Corey, & Callahan, 1998),
self-help groups are not supervised by licensed professionals. Thus, group members are not afforded the protection
of the professional license, particularly related to confidentiality and privileged communication (Cottone &
Robine, 1998). Additionally, the model of treatment put
forth in 12-step groups such as Alcoholics Anonymous is

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Rehabilitation Counseling Bulletin

not linked to research in addictive behavior and has not


changed or been evaluated since its inception in the
1930s (Thombs, 1999). Research does not indicate any
greater success rate with 12-step groups than with other
forms 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 clients
group therapy is not a good treatment modality. Yalom
(1995) noted, "There is considerable clinical consensus
that patients are poor candidates for a heterogeneous outpatient 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 addictions may have cognitive impairments, addictions to
alcohol or other drugs, paranoia or experiences of
psychosiseither from the effects of certain drugs such as
amphetamines and cocaine or from co-existing psychopathological conditionsand given the high correlation
between alcohol addiction and antisocial personality disorder (American Psychiatric Association, 1994), many of
them may be poor candidates for group therapy. Screening
clients to assess their appropriateness or inappropriateness
for group therapy thus is paramount. In many treatment
centers, individuals are automatically put into groups with
little or no screening. This can jeopardize not only their
own treatment but the treatment of other group members
as well.

ecution of a client unless a court order has been issued according to federal guidelines, even if the client gives consent. Even when consent is granted, federal guidelines
require consent forms to meet federal standards.
Gottone and Robine (1998) described confidentiality issues in group treatment settings. Because many people with addictions problems also have legal problems,
depending on the state statutes and/or federal regulations,
communication in a group setting may not be considered
confidential or privileged, even if a licensed professional
is involved. Typically, if group treatment is cited in a licensure statue, a licensed counselor or psychologist is
bound to keep communication confidential. Group members are not bound by these laws and statutes. Even if
group members sign a contract promising not to disclose
information discussed in the group, it is often not legally
binding. Group members can gossip outside the group
and report information communicated in the group to
otherseven authoritiestypically without repercussion.
Thus, if unlawful activity is communicated within the
confines of the group, the counselor may be bound to confidentiality, providing the crime does not fall under an exception to the statute's confidentiality provisions, but
group members can inform authorities and even testify as
to what was said without legal consequences. In addition,
even if the counselor is bound by licensure statutes, privileged communication may not stand because many states'
provide for privileged communication for civil, but not
criminal, court cases (Gottone & Robine).

Confidentiality and Privileged


Communication

Treatment Decision Boundaries

Gottone and Robine (1998) described a number of issues


related to confidentiality and privileged communication
in addictions treatment. First, they noted that treatment
in programs directly or indirectly receiving federal funds
requires additional ethical precautions because federal
laws protect these individuals beyond what is typically offered by state laws related to confidentiality or privileged
communications: "The intent of these [federal] laws is to
engage people in treatment for chemical dependency
problems who otherwise might be cautious about the legal
implications of seeking such treatment" (p. 388). Federal
laws regulate service providers receiving federal funds directly, by way of either state distribution or tax-exempt
status, and mandate that these providers are bound by federal confidentiality laws that supersede state or licensure
statue regulations.
The federal confidentiality laws protect information
about any client applying for or receiving services or referral for other treatment. Information about a client who
is protected by federal confidentiality laws may be disseminated only with client consent, and federal law prohibits
the use of information in criminal investigations or pros-

Glearly, some methods of treatment work for certain people; however, nothing has been demonstrated to work for
all people. Interestingly, though, judgments about treatment are often made by people whose qualifications to
make such judgments are questionable, no matter how
well-intentioned they are. Judges often mandate that people convicted of driving offenses while using alcohol or
other drugs attend Alcoholics Anonymous (AA) or Narcotics Anonymous meetings. Peele (1996) described this
as the "disease law enforcement model."
Similarly, insurance companies sometimes mandate
treatment centers to require participation in AA as a prerequisite to client/patient coverage. Treatment centers
frequently make AA attendance a mandatory event and
sometimes even make continued treatment contingent on
said attendance. There is often a feeling of helplessness
from all involved about what to do in response to someone's abuse. Because of this, mandates often go unexamined. However, mandating a form of treatment and
labeling nonconformity to or questioning of the treatment
mandate as "denial" often increases resistance to treatment before the individual has an opportunity to examine
treatment alternatives that may be more cognitively and

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Volume 43, No. 4 (Summer 2000)


philosophically aligned to his or her identity and needs
(Ghiauzzi & Liljegren, 1993).
A client's welfare is the responsibility of the counselor. Gounselors must do their best to serve their clients,
recognizing that services may not be providing the intended purpose. If the client is not benefiting from these
services, it is the counselor's responsibility to stop treatment and, when necessary, refer the client for more appropriate treatment if it is available (Gottone & Robine,
1998).
All professional codes of ethics consider dual relationships unethical, but they vary in terms of the conditions
under which these relationships can occur. Thus, counselors are sometimes confused about the boundaries and
limits of their relationships with clients (Ghapman,
1997). Gounselors who work in addiction treatment programs often struggle with a unique set of relational issues.
Many addictions counselors are also in recovery and
attend 12-step programs in the community. Thus, they
often find themselves in a dual role with clients, acting as
a therapist in treatment and a peer in groups such as Alcoholics Anonymous. Gounselors who use these groups
for their own support must be able to disclose honestly
without restraint. When a client attends the same meeting, however, a dual relationship usually emerges (Ghapman, 1997). Because the client has more personal
information about the counselor than he or she would
within the normal confines of their professional association, this can shift the power differential of the relationship. Professional boundaries are often compromised, and
the counselor's anonymity is compromised as well. Finally,
if the counselor relapses, it can affect the client's sense of
self-efficacy about his or her own recovery, potentially
triggering a relapse.
Gounselors in recovery must make every attempt to
avoid this kind of scenario and keep their recovery separate from that of their clients. Although this is sometimes
unavoidable (e.g., in small communities), the intention of
these contacts is critical. The counselor is ethically obligated to make every effort to avoid such contacts (Gottone &. Robine, 1998).

Special Circumstances of
Informed Consent
Treatment services are often initiated when a person is illequipped to make an informed decision. As previously
noted, people often enter treatment with varying degrees
of cognitive dysfunction (Goldman, 1990) and frequently
under the influence of alcohol and/or other drugs. Both of
these factors affect not only their ability to absorb and
profit from treatment but also whether or not they can
make educated decisions on their own accord. For these
reasons, it is important that once clients have been
initially treated, particularly if they have gone through

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

CONCLUSION
All counselors find themselves in ethically questionable
positions at some point in their careers. Addictions counselors face some especially challenging ethical situations
that are truly unique to the discipline and the client population they serve. For this reason, addictions counselors
must be sure they understand the ethical mandates put
forth not only by their credentialing bodies but also by
any federal regulating agencies that might supersede the
statutes of their own professional organizations. Moreover,
if there is any question relating to ethical behavior, they
must err on the side of conservativism, always putting
their client's welfare and safety first.

ABOUT THE AUTHOR


Cynthia Q. Scott, PhD, GRG, is an assistant professor in
and director of the addictions specialty of the Rehabilitation
Counseling Program at the University of North Florida.

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