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Module 9 - Legal and Ethical Issues in Prevention and Trearment of Alcohol Use Disorders

PARTICIPANT HANDOUT

Introduction

This module delineates the special ethical and legal concerns related to the treatment and prevention of alcohol use disorders. General ethical guidelines established by the National Association of Social Workers (Code of Ethics, 1996) and state licensing laws are relevant to the area of substance abuse practice. It is assumed that social workers graduating from accredited programs are fully aware of, and compliant with, these guidelines. This module focuses on the special issues that pertain to alcohol use disorders:

  • Confidentiality
  • Informed consent
  • The duty to care
  • Respecting client self-determination
  • Credentialing mechanisms

Learning Objectives

By the end of this module, learners should be able to:
A. Recognize the unique confidentiality requirements for alcohol use disorder (AUD) treatment and prevention programs
B. Understand the special requirements pertinent to obtaining informed consent for substance abuse treatment programs
C. Consider the issue of 'duty of care' as it relates to this population and to these programs
D. Become familiar with those aspects of respect for self-determination that frequently arise in this area
E. Become familiar with emerging requirements for documentation by practitioners of specific competencies in the field of substance abuse

Background

Ethical concerns in alcohol treatment are often complex and multidimensional and may or may not be addressed in laws and professional ethics codes (Corey, Corey, & Callanan, 1998). Codes of ethical practice serve to educate and inform professionals about sound ethical behavior. They may mandate a minimal standard of practice, though not necessarily the highest standards or "best practices" to which we aspire. Moral principles form the basis of social work's professional code of ethics: autonomy (including client self-determination), nonmalfeasance (avoiding harm), beneficence (promoting good for others), justice (fair and equitable treatment to all), fidelity (honoring commitments), and veracity (truthfulness).

Confidentiality

The Surgeon General's report on mental health (Office of the Surgeon General, 1999) cites empirical studies showing that a concern about lack of confidentiality may deter individuals from seeking needed treatment for alcohol use disorders. Increasing the self-referral into treatment of those with alcohol use disorders was the impetus for the Drug Abuse Prevention, Treatment, and Rehabilitation Act (21 U.S.C. 1175) and its specific provisions for protecting client confidentiality. The requirements of this legislation have been codified in section 42 of the Code of Federal Regulations, Part 2 (CFR). Other entities that also sanction the imperative of maintaining client confidentiality include: the NASW Code of Ethics (1996), state licensing laws conferring privileged communication, and the Americans with Disabilities Act where provisions are particularly relevant to clients with alcohol use disorders and are referred through EAP programs.

Provisions in the CFR

The Substance Abuse and Mental Health Services Administration (SAMHSA) has issued several technical reports explaining the CFR confidentiality requirements. Some of the major provisions that apply to direct practitioners are set forth here, although those provisions targeting program administrators are not discussed.

Office of the Surgeon General
- Drug Abuse Prevention, Treatment, and Rehabilitation Act (21 U.S.C. 1175)
- Section 42 of the Code of Federal Regulations, Part 2 (CFR)

The Substance Abuse and Mental Health Services Administration (SAMHSA) has issued several technical reports explaining the CFR confidentiality requirements. Some of the major provisions that apply to direct practitioners are set forth here, although those provisions targeting program administrators are not discussed.

Provisions in the CFR that differ from established social work practice in other areas include:

  1. Recommendation of a particular and specific release of information form
  2. A provision that when a primary source releases information to a secondary agency, this secondary agency cannot release information to a third entity. A paragraph explaining this restriction is to accompany all releases of information to the secondary source.
  3. Recommendation to inform clients in writing, upon entry into or application for, treatment as to limitations on confidentiality. A sample statement that might be adopted by the agency is provided in CFR 42.
  4. A list of limitations on absolute confidentiality that includes medical emergencies, compliance with state child abuse reporting laws, contacting criminal justice authorities if a client threatens to commit or commits a crime against the treatment center, and compliance with court orders.
  5. Confidentiality can be extended to minors if the relevant state statute gives the minor the right to consent to substance abuse treatment.
  6. CFR identifies those professionals to whom CFR regulations apply. These entities include drug and alcohol treatment facilities with tax-exempt status, agencies receiving any form of programmatic federal government funding, private practitioners who receive Medicare payments, and federally-supported agencies that refer clients for drug and alcohol treatment.
  7. The type of information that is confidential includes the client's status as a person who has either received or requested an alcohol use disorder diagnosis or treatment for an alcohol use disorder.
  8. Records with personally-identifiable information are to be secured and under lock.

Other Confidentiality Limitations

Additional limitations to confidentiality have emerged since CFR issuance in l987. Issues relevant to alcohol use disorders include:

  • Some states and locales have adopted mandatory reporting statutes for family violence
  • Some states have expanded the definition of child abuse to include intemperate alcohol use or illegal drug use when witnessed by children
  • Some states have pedophile reporting laws and elder abuse reporting laws

The CFR 42 fails to specifically reference these particular situations, although there is a provision (2.20) indicating that, "no State law may either authorize or compel any disclosure prohibited by these regulations."

Issues of confidentiality have emerged with regard to both HIV and TB reporting to Public Health officials. SAMHSA has published guidelines for complying with state public health laws while also complying with CFR 42 (SAMHSA TIP series 18, 1995; SAMHSA TAP series 13, 1994). Basically, they advise that program officials report known cases of TB without indicating that the individual is receiving treatment for an alcohol use disorder.

The Tarasoff v California Board of Regents ruling (l976) established the professional's duty to warn or protect. In this case, a client at the University Counseling Center confessed his intention to murder his girlfriend to a psychologist. The psychologist had the client detained by the campus police, who then released the client. The client subsequently did murder his girlfriend and the parents successfully sued the University as the psychologist's employer. In their ruling, the court indicated a preference for mental health practitioners to directly warn intended victims, as well as attempting to protect victims (e.g., through initiation of commitment proceedings).

Authorities in the field of ethics (Glaser & Warren, l999; Reamer, l999) have pondered if an HIV-positive client who fails to disclose her/his HIV status to an unknowing sexual partner constitutes a 'Tarasoff fact' situation. Some states have statutes that provide specific guidance in these dilemmas. In practice, the ultimate responsibility for deciding on a course of action rests with the social worker who may be confronted by a vast array of information that is not always consistent. Before embarking on a decision, an ethical social worker should be aware of federal, state and local statutes governing HIV confidentiality. Reamer (1999) advises that, in situations where ethical dilemmas arise, social workers should seek counsel from colleagues (including the state licensing board) and record the gist of the discussion in the client record.

When ethical dilemmas arise, seek counsel from colleagues and the state licensing board. Record a summary of the discussion in the client record.

Glaser & Warren (l999) raise the issue of clients whose job responsibilities (e.g., surgeons, nurses, airline pilots, drivers) are such that intoxication or being 'hung over' while on the job might threaten the lives of others. When the social worker knows that such a client is frequently relapsing, is this a situation where the Tarasoff case applies? Reamer's advice to consult with colleagues and possibly one's licensing board once again becomes germane.

For children and adolescents, maintaining confidentiality of information from legal guardians cannot be promised. Minors require parental permission to engage in any form of treatment, although some states do allow minors to contract for alcohol and drug treatment without such permission. As long as parents are not being billed for treatment, CFR 42 allows for maintenance of confidentiality with minors. CRF does allow a program director to notify a parent that a minor has applied for treatment if the program director deems the minor to be incapable of rational judgment or to be in danger.

Whether social workers should notify parents if they obtain information that a child's life is endangered is unclear, particularly if a parent can take action to prevent this endangerment. Examples include:

  • Learning that the minor frequently rides in cars driven by intoxicated friends
  • Learning that the minor is having sexual relations with persons at high risk for HIV infection.

When deciding how to proceed, the social worker should consult the statutes governing parental notification for the entity sponsoring the program.

Outpatient treatment programs often establish rules against allowing clients to participate in group therapy while intoxicated. If intoxicated clients are routinely denied participation, some mechanism for transporting clients home (without driving their vehicles) should be established. Failing to take steps to prevent "drunk driving" might be construed as a Tarasoff situation. Development of a program policy to prevent drunk driving could be developed, and clients should be informed about any such policy at the initiation of treatment.

Many persons receive their health care through Health Maintenance Organizations (HMOs). HMOs generally construe themselves as contracting with a patient to ensure a patient's health. Both parties have obligations in this agreement. Patients who fail to comply with physician recommendations (e.g., to quit drinking) can be construed as violating a contract and this violation may constitute grounds for disenrollment in the plan. Since treatment for alcohol abuse disorders is often provided "in-house" by officials of the HMO, any information that the client provides to the social worker (who is both an HMO employee and a treatment provider) can be used to disenroll the client.

If a client is an immediate danger to self or others, and it is a product of mental illness, the situation becomes grounds for commitment in most states. Failure to take action when reasons exist to believe that the client constitutes a danger to self or others might be construed as malpractice. CFR 42 Part 2 considers medical emergencies to be grounds for breaching confidentiality.

Informing Clients as to the Limits on Confidentiality

Both the NASW Code of Ethics (1996) and the CFR 42 Part 2 recommend that clients be apprised of the limits on client confidentiality before they begin to disclose. This is part of obtaining informed consent, and should occur at the beginning of treatment before any opportunity for disclosure occurs. Some of the confidentiality limitations previously discussed can be clearly delineated for the client. However, unusual circumstances can arise. It is wise practice to anticipate when a social worker will breach confidentiality and to inform the client.

Information That Must Be Conveyed

How much information must be conveyed to comply with restrictions on client confidentiality? State statutes generally specify the information that professionals are required to report. There is no obligation to relinquish an entire record or to disclose all information known about the situation. It is the social worker's duty to defend and protect client confidentiality. Only a judge can issue a court order mandating information that exceeds the requirements of a reporting law. It is unwise to assume such duties on one's own.

Turning the Duty to Disclose into a Therapeutic Opportunity

While a client might feel betrayed by the social worker's breach of confidentiality even though required by law, it might be possible to use the situation to further a therapeutic alliance with the client. An example can be drawn from the child abuse field. It may be possible to reframe the situation in non-adversarial terms with the client and social worker conjointly reporting information to the authorities. Clients who fear losing control in dealing with their children could adopt a view of voluntary disclosure as an act of responsible parenting and a step toward recovery. Similar reframing could occur in confidentiality situations with clients experiencing alcohol use disorders.

Relinquishing Confidentiality under Duress

The types and frequency of mandatory treatment referrals are greatly expanding. Drug courts are employed in the areas of Child Protective Services and criminal justice. Drug courts may provide court-ordered treatment in lieu of criminal sanctions or termination of parental rights, and they often make avoidance of negative outcomes contingent on treatment participation. Similarly, Employee Assistance Programs (EAPs) often mandate that continued employment is contingent upon treatment participation and progress. Further, many 'driving-under-the-influence' (DUI) statutes also require mandatory treatment as a requirement for regaining or maintaining a driver's license. With the advent of welfare reform, participation in substance abuse treatment may become requisite for financial assistance. Most of these programs require clients to waive their confidentiality rights to participate in the various program options.

Generally, clinicians have assumed that successful treatment requires that clients are honest and forthcoming (Kelley, 2000). While this assumption has been questioned (Kelley, 2000), the current practice of free exchange of information between treatment providers and those empowered to impose sanctions, has probably discouraged some clients from disclosing information that might result in negative consequences to them. Data attest to the efficacy of mandatory treatment for alcoholism (Littrell, l99l). However, evaluation of how relinquishing confidentiality impacts treatment outcome has not occurred. With burgeoning numbers of clients being mandated into treatment, more evaluation of this issue is certainly desirable. For now, social workers must ultimately honor the wishes of those who are making referrals, but may be able to negotiate specific areas where information must be shared, and areas where information can remain confidential. Clients can then be informed about specific types of information that will be made available to others. This may be more in keeping with ethical guidelines regarding confidentiality in other practice domains. Remember that a breach of confidentiality can be a malpractice liability (Loewenberg, Dolgoff, & Harrington, 2000).

Informed Consent

All states, with the possible exception of Georgia, have statutes mandating that health professionals obtain informed consent for treatment (Appelbaum, Lidz, & Meisel, l987). A failure to obtain or document informed consent may be a source of malpractice liability, despite the quality of care delivered (Corey et al., 1998). It is likely that these informed consent requirements extend to mental health practitioners, as well as to general health practitioners (Appelbaum et al., l987). Some statutes require that health care providers explain both the risks and benefits of the proposed treatment, as well as the risks and benefits of alternative treatments (including the combination of treatment modalities (Zweben, 2001).

Items to Consider for Informed Consent

- A description of any reasonably foreseeable risks or discomforts
- A description of any benefits to the subject or to others
- A disclosure of appropriate alternative treatments, including medications
- A statement describing the extent to which confidentiality of records identifying the client will be maintained
- An explanation of the limitations on confidentiality
- An explanation of whom to contact for answers to pertinent questions and whom to contact in the event of an emergency
- A statement that participation is voluntary (unless mandated)
- Costs to the client
- Consequences and terms of early withdrawal from treatment


When various treatment modalities are available in a given community, the social worker should be able to explain the differences in orientation of the various approaches and to be able to "bottom-line" differences in efficacy among these treatments. Data on the efficacy of medications for the treatment of alcoholism (e.g., disulfiram, acamprosate, naltrexone, selective serotonin reuptake inhibitors) are emerging, as well (Erickson & Wilcox, 2001; Zweben, 2001). Non-physician mental health practitioners probably have a duty to inform clients of the availability of medications for their particular conditions (Littrell & Ashford, l995). As more data become available, the obligation to discuss the various treatment options will become more binding.

This also obligates the social work professional to gain and maintain familiarity with the empirically-based considerations of the various available approaches. The obligation to explain alternative treatments raises the issue of how much knowledge a social worker must have about medications. If the social worker is poorly informed, a client referral would probably suffice to meet informed consent obligations. Because referring all clients to medical providers may be impractical, it is incumbent upon substance abuse treatment professionals to become knowledgeable about relevant medication treatment options.

Issues have been raised as to whether discussing medications with a client might be construed as 'practicing medicine without a license' (Littrell & Ashford, l995). While there are no court cases addressing this issue, social workers who can document their sources of information and can cite reputable sources, sharing factual information, probably cannot be construed as 'practicing medicine without a license' (Littrell & Ashford l995). However, a non-physician should never advise a client to either take or stop taking any medication.

Informed consent is based on the following presumptions:
Conflicts with presumptions when an alcohol use disorder is present:
Client is competent to make informed decision about self-interests Client with impaired cognitive capacity due to chronic alcohol abuse
Client comprehends information being presented for consent Clients who are young or from other cultures may have difficulty understanding consent form
Consent is voluntary without coercion,
undue influence, or duress (Parsons 2001)
Mandated clients are not voluntarily consenting to service

It is imperative that social work practitioners explore and address these issues of consent.

Duty to Care

Establishing Criteria for Terminating Client Treatment
Alcohol treatment programs often establish policies against continuing to work with clients who continue to relapse, and sobriety may be a criterion for continued treatment. There may also be rules against talking with an intoxicated client. These strategies are based on the philosophy that actively drinking clients should not be given social support that might decrease their level of distress (hitting-bottom) and undermine their motivation for sobriety.

In many settings, clients with other DSM-IV disorders are not discharged for failing to comply with the rules when they continue to need treatment. If a treatment provider has an obligation to treat a disease, then the provider tolerates the unpleasant manifestations of that disease while attempting to decrease them. One perspective views denial as a manifestation of alcoholism (Littrell l99l). If denial and lack of motivation are viewed as part of the disease process, it seems unethical to terminate treatment if a client manifests these symptoms.

Some perspectives (e.g., Motivational Interviewing, Marlatt & Gordon's Relapse Prevention (1985), Scott Miller's Solution Focused treatment) view motivation as a product of the interaction between the therapist and client (Littrell, l991). Both share responsibility for a client's motivation. Abstinence is possible, even for clients who initially embrace a controlled drinking goal or indicate that they have no intention to change. Through the processes of engaging, eliciting, and empowering, clients sometimes modify their goals. In situations where perpetual relapse can be attributed to skill deficits, as opposed to a failure to value the goal of sobriety, skills can be honed during the therapeutic process so the client learns how to sustain sobriety. Thus, a client's motivation can be enhanced through the augmentation of self-efficacy.

Data are available to support the Motivational Interviewing perspective. In Europe, treatment programs with controlled drinking goals are often the vehicle by which clients change their goals and achieve sobriety, although it may take two or three years (Littrell, l99l). Even though some individuals continuously relapse, Valliant's work (1995) suggests that after years of slipping and sliding and 'revolving door treatment', many individuals eventually reach sustained recovery. In light of these findings, it seems inappropriate to seek termination simply on the basis of continued drinking.

As an additional concern, some traditional programs require that clients refrain from using all mood- or mind-altering chemicals while in treatment. Although exceptions are sometimes made for medications treating schizophrenia, bipolar illness, or anxiety disorders, some programs consider these drugs to be mind-altering. Sometimes clients who are patients at pain clinics will apply for alcohol treatment. It is not uncommon for pain patients to be prescribed opiates for pain, and benzodiazepines as muscle relaxants. Often physicians treating pain patients have experimented with many drug combinations to find a regimen that offers some modicum of relief and are reluctant to make alterations. Appropriate medication needs are issues around which professionals disagree. When a client applies for entry into a substance abuse treatment program, is it fair to deny treatment on the basis of medications that are taken under the direction of a licensed medical doctor? Are traditional treatment programs under any obligation to meet the unique needs of chronic-pain patients?

Trend Toward Emerging Standards of Practice

In social work, ATOD (Alcohol, Tobacco and Other Drugs) is an area of specialization. ATOD specialists can screen for alcohol use disorders, treat alcoholism, and recognize an acute need for detoxification. In the mental health area, responsibility for diagnosing within one's area of expertise constitutes a duty of care. What level of diagnostic acumen can the public expect from a non-ATOD specialist social worker in cases of acute detoxification or the presence of an alcohol use disorder?

Specific standards of care are emerging for the practice of medicine. Individual physicians have less latitude in determining the treatments offered to patients. For example, the Agency for Healthcare Research and Quality, an arm of the U.S. Department of Health and Human Services, has issued guidelines for the treatment of major depression. The American Psychiatric Association has guidelines for the treatment of smoking cessation. Medicare specifies the number of compensated in-patient days for each Diagnostic Related Group.

In the area of alcohol use disorders, the American Society of Addiction Medicine (ASAM) has issued standards for levels of care (Mee-Lee, l994). These standards address, for in-patient or out-patient treatment, the number of hours of therapeutic contact per week recommended for clients in various categories (e.g., those with various amounts of social support or manifesting danger to self or others). In malpractice suits, lawyers will undoubtedly refer to these published standards to build a case against social workers who fail to adhere to various guidelines. For the present, social workers should at least be aware of ASAM criteria and other relevant standards of care so that they can justify their actions if they deviate from a standard of care.

The most common reason for failure to comply with an ASAM standard of care is the lack of a payment mechanism for treatment. For example, ASAM recommends in-patient treatment for substance abusers who lack social support. Many homeless individuals fall into this category and the availability of in-patient treatment is dwarfed by the size of the homeless community experiencing need. Managed care clients experience similar limitations on access to recommended levels of care (Galanter, Keller, Dermatis & Egelko, l999). How to be ethical when resource limitations preclude good treatment is an issue that must be addressed by the social work profession.

ASAM Patient Placement Criteria, Second Edition Revised (ASAM PPC-2R)

The American Society of Addiction Medicine (ASAM) Patient Placement Criteria are national guidelines for placement, continued stay and discharge of patients with alcohol and other drug problems.

The ASAM PPC-2R provides two sets of guidelines, one for adults and one for adolescents, and 5 broad levels of care for each group. The levels of care are:
- Level 0.5, Early Intervention
- Level I, Outpatient Treatment
- Level II, Intensive Outpatient/Partial Hospitalization
- Level III, Residential/Inpatient Treatment
- Level IV, Medically-Managed Intensive Inpatient Treatment

Within these broad levels of service is a range of specific levels of care.


Factual Information

According to the American Psychological Association's code of ethics (l992, 3.03a, 6.03a, 7.04), ethical psychologists should have supporting data for factual statements they make. There is no similar provision in the NASW Code of Ethics, but some question if there should be. In l935, only limited data were available to support or refute the theory of alcoholism that was propounded with the advent of AA. In recent years, a great deal of empirical research has tested some theoretical hypotheses (Littrell, l991). Should an ethical social worker be required to stay apprised of data supporting and refuting various perspectives? To what extent should social workers be required to distinguish between facts and opinions when talking with clients? Again, social work guidelines have not been proffered.

Quite apart from the ethical obligation to adhere closely to facts when speaking with clients, there is a practical necessity. The American community has better access to information than in the past, particularly through internet and other media sources. For example, findings from the Rand report indicating that a sizable proportion of individuals who had been treated for alcoholism had achieved a controlled drinking recovery, was widely publicized (see Littrell, l99l). Given a highly informed client community, it is incumbent upon social workers to stay abreast of emerging research in their field in order to maintain credibility.

Client Self-Determination

Mandated Services
There is a modest amount of literature related to social work practice with involuntary and/or nonvoluntary clients (De Jong & Berg, 2001; Rooney, 1988: Rooney, 1992). Mandated treatment conflicts with the social work values of client autonomy and self-determination. Aside from the question of whether treatment can or should be mandated, are questions about the appropriateness of specific types of treatment being mandated. For example, Glaser and Warren (l999) summarize court cases with rulings that AA cannot be mandated as a sole source of treatment. Mandated AA violates the separation of church and state provisions in the First Amendment to the Constitution. Social workers should be cognizant of these rulings and aware of alternative community support groups that particular clients might find more compatible with their religious, spiritual, or existential perspectives.

Respect for Differences in Culture and World Views
Other modules in this curriculum discuss the need to develop effective treatment approaches for specific target populations (e.g., Native American, GLBT, ex-patriot, Hispanic-American, and women). Concern for client self-determination is a practical as well as an ethical issue. The predominating forms of treatment in this country (Littrell, l99l) view education as a critical component. Thus, it is important to recognize when the recommended professional practice literature differs in perspective from that of clients. For example, the concept of the client admitting loss of control and being powerless over alcohol may be perplexing or disturbing to some types of clients. For individuals not raised in a western culture, the notion that an individual might attempt to control anything in the first place may be very foreign. There are also profound gender-related implications surrounding issues of power and control. In another example, a diagnostic item in Jellinek's (1946) progression of alcoholism is "keeping company with individuals below one's social status." For a person raised in a more egalitarian society, this might be difficult to grasp. Taking an inventory and assessing for "character defects" may cause some to wonder how to define "character defect" in a non-culturally biased manner. In some cultures, expected spousal behavior (positive) can also be labeled as the type of enabling behavior (negative) warned against in programs like Alanon.

Respect for cultural diversity is infused throughout the curriculum in social work education. However, it is often difficult to recognize when one's own cultural rearing results in concepts, perspectives, frames of reference, and practices that are not universally shared. Self-critical evaluation, and acknowledgement of discrepancies between the practitioner's and client's perspectives, should be a routine aspect of the social worker's demonstration of respect for cultural diversity.

Controlled Drinking Goals
One of the most controversial issues in the field of alcohol use disorders is if controlled drinking is an achievable objective (Goldsmith, Larimer, & Marlatt, l994). Controversy aside, this issue does fall under the rubric of client self-determination. Who has the right to select the treatment goal -- the client or the treating professional? Respect for client autonomy and self-determination comes into conflict with patterns of paternalism in these situations (Linzer, 1999).

Credentialing for Alcohol Treatment Providers

In some states, authorities have mandated specific qualifications for treatment providers who provide services to clients with alcohol use disorders. Evidence of specific competence in the field of substance abuse, in addition to a generic professional licensure, is usually expected (Institute of Medicine, l990; Moyers & Hester, l999). Generally, states have honored certification through the National Association of Alcohol and Drug Abuse Counselors (NAADAC) or the International Certification Reciprocity Consortium (ICRC). When a human services profession has developed a specific certification procedure for competence in substance abuse (e.g., psychology, social work, medicine), states have honored these certificates, as well.

With the initiation of ATOD (Alcohol Tobacco and Other Drugs) certification, NASW sought to provide a mechanism through which professionals wishing to maintain their identity as social workers, could document competence. Social workers desiring NASW's ATOD certification should be aware that 180 hours of continuing education in substance abuse are required within specifically delineated areas of instruction (see checklist associated with this curriculum). In order to guarantee competent social work practice to the population of individuals with alcohol use disorders, each of us should continue to demand high-level substance abuse training in the social work MSW curriculum. It is probably easiest to obtain the required course work for certification while one is working toward completion of an MSW degree.

RECOMMENDED CLASSROOM ACTIVITIES

  1. Divide the class into 2 groups: those taking the position that treatment programs have a right to discharge clients for drinking while in the program and those taking the position that treatment programs owe a duty of care to those who cannot or will not maintain sobriety during the treatment. Give each side l0 minutes to develop their positions, then allow discussion. [Should members of the audience be totally unfamiliar with the Minnesota Model of treatment philosophy or the Marlatt and/or Motivational Enhancement perspective, then the group facilitator should be prepared to take a stance.]
  2. In small groups, explore the various aspects of technology that have, and are continuing to emerge, around social work practice. As a class, discuss the impact that technology can have on the ethical practice (i.e., how does it affect confidentiality, securing of records, informed consent, inter-agency sharing of information, delivery of services without face-to-face contact, ensuring identity, client access to information via the internet, client access to alternative treatments, etc.)

GROUP DISCUSSIONS

  1. One of the most difficult aspects of professional ethics arises when there is a concern about impairment of a social work colleague. Discuss how you would know that a colleague is experiencing impairment (i.e., due to alcohol involvement, or it may be due to some other mental health concern), what are the ethical issues that are involved and where do they come from, and what are the possible options available when you suspect this is occurring? What are the ethical pros and cons of the various options? [See Code of Ethics, 2.09]
  2. What are the ethical considerations that arise with mandatory reporting policies/laws?
  3. What are the ethical considerations that arise with mandated treatment?
  4. Ethical issues arise with respect to social work practice with aging clients (e.g., autonomy, informed consent, self-determination, and rationing of limited resources/responsibility to care). How do you feel about the following statement: "If an older person has a drinking problem, really, what's the harm? Maybe, in their old age, we should just let them enjoy their drinking with what little time they have left."
  5. Under what conditions do you see possible conflicts between the ethical practice of social work and research into alcohol use disorders and their treatment? What are the roots of these conflicts? What are the possible resolutions? (See Ethics: Research with Subjects, In S. J. Freeman (2000) Ethics: An introduction to philosophy and practice. Belmont, CA: Wadsworth.)

References

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Appelbaum, P. S.; Lidz, C. W., & Meisel, A. (1987). Informed consent: Legal theory and clinical practice. New York: Oxford University Press.

Beahrs, J. O., & Gutheil, T. G. (2001). Informed consent in psychotherapy. American Journal of Psychiatry, 158, 4-10.

Berg, I. K. & Miller, S. D. (1992). Working with the problem drinker: A solution-focused approach. New York: Norton.

Bissell, L. & Royce, J.E. (1994). Ethics for addiction professionals (2nd ed). Center City, MN: Hazelden.

Corey, G.; Corey, M. S. & Callanan, P. (1998). Issues and ethics in the helping professions, 5th edition. Pacific Grove, CA: Brooks/Cole.

Daley, D. C., & Marlatt, G. A. (1997). Managing your drug or alcohol problem: Client workbook. San Antonio, TX: The Psychological Corporation.

De Jong, P., & Berg, I. K. (2001). Co-constructing cooperation with mandated clients. Social Work, 46, 361-374.

Erickson, C. K., & Wilcox, R. E. (2001). Neurobiological causes of addiction. Journal of Social Work Practice in the Addictions, 1, 7-22.

Galanter, M.; Keller, D. S.; Dermatis, H. & Egelko, S. (1999). The impact of managed care on addiction treatment. Working Group of the American Society of Addiction Medicine Managed Care Initiative. Available at (http://www.asam.org/ppol/managedcare.htm)

Glaser, F. B., & Warren, D. G. (1999). Legal and ethical issues. In: B. S. McCrady, & E. E. Epstein, (Eds.) Addictions: A comprehensive guidebook (pp.399-413). New York: Oxford University Press.

Goldsmith, R J.; Larimer, M. E. & Marlatt, G. A. (1994). Abstinence as the goal of treatment: Two views. In: N. S. Miller (Ed.). Principles of addiction medicine (pp.1-8). Chevy Chase, MD: American Society of Addiction Medicine.

Hundert, E.M. (1987). A model for ethical problem solving in medicine, with practical applications. American Journal of Psychiatry, 144, 839-846.

Institute of Medicine. Who provides treatment? In Broadening the base of treatment for alcohol problems, (chapter 4, pp. 98-141). Washington, D.C.: National Academy Press, 1990.

Jellinek, E. M. (1946). Phases in the drinking history of alcoholics. Analysis of a survey conducted by the official organ of Alcoholics Anonymous. Quarterly Journal of Studies on Alcoholism, 7, 1-88.

Kelly, A. E. (2000). Helping construct desirable identities: A self-presentational view of psychotherapy. Psychological Bulletin, 126, 475-494.

Linzer, N. (1999). Resolving ethical dilemmas in social work practice. Boston, MA: Allyn & Bacon.

Littrell, J. L. (1991). Understanding and treating alcoholism: An empirically based clinician's handbook of the treatment of alcoholism: volume 1. Hillsdale, NJ: Lawrence Erlbaum.

Littrell, J. & Ashford, J. B. (1995). Is it proper for psychologists to discuss medication with clients? Professional Psychology: Research and Practice, 26, 238-244.

Loewenberg, F. M.; Dolgoff, R. & Harrington, D. (2000). Ethical decisions for social work practice, 6th edition. Itasca, IL: F. E. Peacock.

Marlatt, G. A. & Gordon, J. R. (1985). Relapse prevention. New York: Guilford Press.

Mee-Lee, D. (1994). Placement criteria and patient-treatment matching. In: Principles of Addiction Medicine, section IX, chapter 3. Chevy Chase, MD: American Society of Addiction Medicine.

Moyers, T. B., & Hester, R. K. (1999). Credentialing, documentation, and evaluation. In: B. S. McCrady, & E. E. Epstein, (Eds.) Addictions: A comprehensive guidebook (pp.414-420). New York: Oxford University Press.

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Updated: March 2005