Mandated Treatment for Substance Abuse: Recognizing Ethical Issues
The SASSI Is Useful in Addressing Ethical Issues of Mandated Client
Elsewhere on this website is the SASSI Institute's position paper regarding the use of the SASSI to screen applicants for general assistance and welfare to work programs.
Why is a "position paper" required? Why do special ethical issues arise when we consider substance abuse screening in the context of providing other services such as general assistance? Surely it is in people's best interest to know whether or not they have a disorder, thereby allowing them to take appropriate action to arrest its progress.
But there are two key facets of substance-related disorders that highlight ethical issues that may arise in the provision of health care and other human services: (a) Some people who suffer from substance abuse are not able or willing to acknowledge relevant behavior. (b) The negative impact of substance abuse extends beyond the individual to significant others and society. Therefore, people who suffer from substance abuse and dependence are often nudged, pushed or coerced into screening and assessment, and ultimately into treatment. When this happens, there are forces in play other than the needs of the client, and ethical dilemmas may arise.
The issue goes beyond mandating substance abuse services for applicants for general assistance and welfare to work programs. Criminal justice, employment, school, and medical programs often refer people for substance abuse screening. A broad range of mental health practitioners recognizes the need for screening and treatment of substance dependence as a requisite part of counseling for such things as anxiety, depression, and family/couples problems. When people are pressured into receiving addictions services, practitioners are faced with the challenge of balancing the stated needs of clients with their broader, often unstated needs, and with the needs of significant others, referral sources, and society.
To increase awareness of the forces at work and the issues that should be considered when a client presents for addiction assessment and treatment at the insistence of some other party, Glenn and I wrote an article on the ethical dilemmas that may arise when individuals are mandated to receive addictions services, published as Chapter 9, "Mandated Addiction Services: Potential Ethical Dilemmas" in Practicing in the New Mental Health Marketplace by Small and Barnhill (editors); see full citation in the last paragraph on this page.
This article is based on interviews with people who are involved in the process of referring clients for mental health services related to substance misuse. The interviewees were chosen from criminal justice, employee assistance, school, and civil liberties programs. Four specific topics were addressed in each interview - voluntary consent for treatment, conflict of interest, information exchange with referral sources and other interested parties, and clients' unstated needs.
The issues that were raised in the interviews and the suggestions that were offered by the interviewees were quite complex, and often subtle. However, we were able to extract a list of guidelines for addressing the ethical issues that may arise as a result of mandated treatment for substance abuse. The following is a summary of some of the guidelines as they are presented in the article:
1. Be aware of the circumstances that enter into the treatment contract and how they affect the relationship between clients and practitioners. As a result of the pressure to receive treatment, clients may feel resentment toward the counselors. To be effective, counselors have to be able to recognize and acknowledge the pressures clients face.
2. Be aware of potential conflicts of interest that may not be obvious. Substance abuse is of central concern in political and ideological debates. Counselors need to be aware of their own views and the views of their funding agencies and referral sources in order to focus on the needs of clients.
3. Attend to the clients' unique profile of needs. It is often difficult to adequately appreciate the reality of the clients' lives and circumstances. As counselors we must be aware of the manner in which our assumptions about mental health and optimal functioning affect the services we offer. It is important for us to try to be aware of the forces at work in our clients lives, and thereby tailor our treatment programs to meet the reality of their needs.
4. Consider the extent to which clients' voluntary actions are indeed voluntary. Even if they sign voluntary consents to treatment and exchange authorizations, clients who are coerced into treatment to avoid job loss, legal penalties, or loss of revenue may not be acting in a fully voluntary manner.
5. Scrutinize policies to determine if they address the problem rather than unnecessarily constrain individual liberties. Substance abuse is a focus of political and ideological debate. Public policies and social programs therefore reflect a wide range of potentially conflicting agendas. As counselors, our primary concern should be to serve our clients' needs. We therefore should scrutinize the policies and procedures by which we provide service to ensure that our clients' needs remain the primary focus.
6. Seek appropriate consultation. The ethical issues that arise when substance abuse treatment is mandated are complex. We often need to seek guidance from fellow professionals, and we need to be forthright in presenting relevant information.
7. Act in accord with established professional principles and guidelines.
8. Be willing to intervene in an effort to modify the behavior of the referral source as well as that of the client. Referral sources have their own needs, and may develop policies that lead to inappropriate referrals. It is sometimes necessary to confront that reality.
9. Recognize that clients may have unstated needs. Clients who are coerced into treatment may have a particularly strong sense of powerlessness and a sense of being disrespected. This can lead to increased resistance and difficulty acknowledging substance abuse. Counselors have an ethical responsibility to help clients recognize the impact of their substance use on their lives even if they do not initially perceive substance abuse as a significant factor.
10. Maintain a posture of respect toward the client. The therapeutic alliance between the practitioner and the client is fostered by an attitude of respect, which is of particular importance when clients are coerced into treatment.
The article includes a comprehensive presentation of the issues discussed with the interviewees, and a larger and more detailed list of guidelines. You may obtain a copy by contacting the SASSI Institute. The article is contained in a book entitled Practicing in the New Mental Health Marketplace: Ethical, Legal and Moral Issues edited by Richard Small and Laurence Barnhill (1998: ISBN 1557984948). The book is divided into two parts. The first part, "Practice Issues," addresses the ethical and moral issues that arise in the practice of providing mental health services. The second part, "Business and Legal Issues," addresses the contemporary legal and business forces that operate in the business of providing mental services. The book is published by the American Psychological Association and can be ordered from APA Order Department, P.O. Box 92984, Washington DC 20090-2984.
The profile is of Sally (not her real name), a 27-year-old single mother of two small children. Sally was ordered by the court to report for a substance abuse assessment following an arrest for illegal possession of a controlled substance. Sally is also being investigated by the county's Child Protective Services Agency, who has placed her children into foster care pending the outcome of the case.
(Note: It may be helpful to make a photocopy of one profile form, female side, and draw in the following scores:
FVA=5, FVOD=7, SYM=2, OAT=5, SAT=5, DEF=9, SAM=12, FAM=10, COR=6, RAP=1;
Rule 8=yes, for a "High Probability" at the bottom.
An initial review of Sally's scores indicates that, although she apparently understood the SASSI items and most likely responded in a meaningful way (RAP=1), there is evidence of significant defensive responding (DEF=9). Despite her defensiveness, the results indicate that she has a high probability of having a substance dependence disorder based on Decision Rule 8 (OAT 5 or more, DEF 8 or more and SAM 8 or more). To put it another way, there is a 93% chance that Sally will meet the DSM-IV diagnostic criteria for having a substance dependence disorder once a more comprehensive evaluation is completed.
For now, however, the SASSI has provided us with important information concerning Sally's illegal act; her behavior is likely to be related to a serious addiction problem. In this light, we can now shift to looking for additional features on her profile that might help us to understand Sally better and develop a more empathic point of view. Learning more about her perspective and how she is dealing with this entire process, including the new information from the SASSI, certainly is one way to provide supportive and effective care to her during a mandated process of evaluation.
A prominent aspect of Sally's SASSI results reflects her similarity to substance dependent individuals who were instructed to conceal and minimize any evidence of their substance abuse problems (DEF=9, SAM=12). One inference that can be drawn from this is that she is likely to have significant difficulty in disclosing personal information about her misuse of substances, as well as other problematic behaviors. Other SASSI scales scores may be reflecting this mind set. For example, she does acknowledge some misuse of alcohol and other drugs but no more so than the average person in the general population (FVA=5, FVOD=7). Her SYM score of 2 is also average, indicating no significant similarity to substance dependent individuals who report experiencing many of the behaviors correlated with addictions. However, given that each of these scales are derived from highly face valid items that can be easily manipulated, it would be reasonable to suspect that Sally may be under-reporting or misrepresenting problems in each of these areas.
We can now apply some of Dr. Frank Miller's suggested guidelines in helping us better understand Sally's perspective. It is easy to imagine that she may harbor some resentment towards the evaluation process and the practitioners involved. After all, she stands to lose not only her freedom but her two children as well. Underlying the overt anger and resistance may be an extreme sense of fear, apprehension and powerlessness in the face of feeling completely helpless to influence decisions that will undoubtedly affect the rest of Sally's life. When viewed from her standpoint, it then becomes easy to see Sally's defensiveness as a somewhat natural response to the threat she must be feeling. It's no wonder that she is having difficulty acknowledging her substance abuse problems.
Despite Sally's lack of ability and willingness to recognize the impact of her substance abuse on her life, it is our ethical responsibility as counselors to use our knowledge, skills and experience to lead her to an accurate understanding of the nature of her substance dependence problems. This should be accomplished in a climate of respect and acknowledgement of the pressures that she is currently facing. As Frank points out, an attitude of respect is particularly important when attempting to build a therapeutic alliance with clients like Sally that are mandated for assessment and treatment.
One way to engender open communication in a respectful way is to invite Sally to join you in a process of reviewing her responses on the SASSI face valid items. Acknowledging that it is important for you to understand her point of view, perhaps asking for further clarification or details as you actively listen is one way to cultivate trust and rapport. This communicates genuine concern and interest that may help Sally feel supported and empowered as she describes her experiences. Empathic responses that demonstrate a good understanding of the difficulties she is facing while helping her to gain insight regarding the nature of her substance dependence problems would be useful in making her an active partner in creating a treatment plan that she can accept.
Another effective way to increase Sally's awareness of her substance abuse problems while maintaining a respectful relationship is to provide cognitively based educational programming. Didactic presentations of alcohol and drug information generally are viewed by clients as less threatening and often tend to elicit a more favorable response. Sally may particularly benefit from content that describes the impact of substance abuse on families and how, with proper treatment and aftercare, recovering individuals are often able to be reunited with their children and other family members.