Louise Stanger (pictured right) is a renowned speaker, educator, licensed clinician, social worker, certified Daring Way facilitator and interventionist who uses an invitational intervention approach to work with complicated mental health, substance abuse, chronic pain and process addiction clients.
Louise collaborated with Heather Hayes (pictured left) on this article. Heather is the Founder and CEO of Heather R. Hayes & Associates, Inc. She specializes in the treatment of adolescents/young adults, trauma, brain disorders, complex mental health issues and the full spectrum of addictive disorders.
Yes, In Many Ways, Addiction Treatment Providers and Professionals Are Responsible For The Opioid Epidemic And Its Seemingly Inescapable Grasp.
In the wake of the addiction treatment industry's lowest moment and the opiate epidemic's highest surge, we need to take a deeper look at what got us here and why the industry itself is very much to blame. The investigation begins and ends with ethics.
Recent, high profile FBI raids at “reputable” Florida and Southern California treatment centers, coupled with the terrifying patient brokering cases that have come under scrutiny by Massachusetts Attorney General Maura Healy (May, 2017) are just a glimpse into the cannibalistic treatment industry and the ethics problem that led to the worst addiction problem our wonderful nation has ever known. Closer to home, the OC Register (May 30, 2017) reports that in Southern California alone, there are over 1,117 licensed rehab centers and thousands of unlicensed sober living homes that require little to no regulation regarding the ownership. "No degree, Medical or otherwise is required to get a license," and "on average, somebody dies every two weeks while being in a licensed rehab care." With incidents like these being reported across the country on a daily basis and the grim reality that there are 105 people dying every day from opioid addiction, the need for ethical behaviors and strict standards of care are not just a necessity, but truly a life or death situation for the countless addicts fighting for their lives.
When we think about ethics it is important to note, we have a national crisis in Ethics. On July 6, 2017 Walter M. Shaub Jr. resigned as head of the United States office of Ethics leaving us and the rest of the country wondering where have our ethics gone as a nation in general and as behavioral health care professionals in particular. As licensed clinicians and interventionists who hail from different parts of the country (Los Angeles and Atlanta) we are, as many of our colleagues, gravely concerned about the behavioral health care industry and the important role ethics play. In this brief article, we have joined together to share our knowledge, underscore the importance of Ethics and revisit the basics of Ethics 101.
With the stories of addiction treatment insurance fraud and patient brokering running rampant (notably in places like South Florida), we must turn a sharp and unrelenting eye toward the ethics of everyone who provides – or professes to provide – drug and alcohol treatment.
Ethics may be defined as the shared, written beliefs (individual at the micro level, group at the mezzo level, and organization/societal at the macro level) a group or individual maintains about what constitutes correct and proper behavior. Think of ethics as standards of conduct that guide the choices behavioral health care experts make, moment to moment, as they organize and provide care for clients.
With a clear definition in mind, we can begin to unravel the more innovative and relatively recent types of ethical abuses. One such type includes billing insurance companies for services that were never received, and reaping tens to hundreds of thousands of dollars in the process. Sadly, the legislation created to improve access to mental health treatment has made anyone with an insurance policy a prime target for the ethically bankrupt, who see clients as nothing more than a massive payday.
Yet another violation targets well-known treatment providers, fraudulently using their names to attract potential clients and then rerouting them to other treatment centers where the recruiters get kickbacks.
In an era where truth seems to be contingent upon what you already believe to be so – and anyone who says differently is “fake news” – it is increasingly difficult to parse out fact from fiction. For example, in recent years, budget constraints and a stubborn economy have led some treatment centers and other facilities to adopt the “heads in beds” approach, whereby leaders of these organizations adopt misleading websites and advertisements, overpromising and under-delivering on services, and fake money-back-guarantees to fill their centers. Moreover, some organizations pressure staff to fill quotas and meet deadlines – all at the expense of quality of care. With such murky information, clients and patients may face life-or- death situations in the addiction treatment industry.
So what can we do, as those on the front lines of this battle – both against drug and alcohol addiction and the ones who would seek to exploit them?
I think we need to get back to basics. Ethics 101. For any of us who have earned a professional license or certification in the field (such as LCSW, LPC, BRN, MD, Psych D, and CADAC licenses), the fundamental principles of providing ethical care were drilled into us throughout our professional education and our licensing processes. This is what our code of ethics looks like:
- Working within your scope of practice
- Not engaging in dual relationships
- Not conducting treatment strictly for financial gain
- Proper therapist/Interventionist disclosure (of personal beliefs and values)
- Proper payment procedures
- No wrongful termination or abandonment of clients
In our training and licensure requirements, we were quizzed over and over about specific hypothetical situations and asked how to respond with the most impeccable integrity in each case. These things were – and are – important because without them, we lose our credibility as treatment providers and, more tragically, our clients suffer. For most of us, we continue to receive training in ethics so as to maintain the integrity of our licensing and certification boards.
Let’s take a closer look at some of these ethical guidelines:
This is one of the hallmarks of an ethical provider-client relationship because it establishes trust between the two parties. It ensures a client that you have their best interest at heart and that you will vigorously protect their identity, personal information, the details of their addiction and everything they’ve said or done. Aside from the caveats of a client revealing to you a specific intent and means to harm themselves or others (in which case you are bound to report this for the safety of all involved), you promise them that everything they share with you is safe and will not be shared indiscriminately.
Before you begin treatment, you provide a written statement of this ethical standard and verbally explain it to your client, ensuring they understand what it means. They sign the statement if they agree to treatment given these conditions, and only then can you begin working together.
If you need to see a client’s medical records or would like to communicate with any previous therapists with whom they’ve worked, you receive a signed consent to release information from your client and then use that information only for and in your confidential treatment together. At no time do you release one piece of your client’s information to anyone for whom they have not given you expressed written consent to do so.
This seems like something of a no-brainer in terms of best practices, yet if treatment providers followed confidentiality guidelines to the letter, many of the client abuses we see would not exist. So, it bears returning to this cornerstone of ethical treatment.
Lastly, health professionals are under a duty to warn, which requires them to report to officials and law enforcement when clients and patients become violent and/or threaten violence toward themselves or others. Or, if one suspects, child, spousal or elder abuse. Laws related to duty to warn have ramped up in recent years due to mass shootings and other violent behavior. And these laws protect health professionals from civil and criminal liability for failure to report so long as they act “in good faith.”
Scope of Practice
Another principle we learn in our professional studies is only to treat clients within the scope of our practice. This means that if you are not trained to treat co-occurring mental health and substance abuse disorders, then you should never advertise that you do, nor should you actually conduct this type of treatment – ever. The end.
It’s quite simple, really, yet countless ethically unmoored treatment providers do just this – all the time.
Perhaps they purport to be an Interventionist, having never been trained as one or certified through any sort of Interventionist or addictions counseling program. Some people might have been involved with an intervention as a loved one or as the addicted person, and therefore determine they can just as easily do it and pocket a tidy payment in the process. Or perhaps they purport in being trained in co-occurring disorders and yet they do not have the necessary training.
If you are a family member looking for an Interventionist or a therapist, ask to see their licenses and or certifications (and then verify them with the certifying entity) and request to speak with others who can confirm their qualifications. If you come up short in any of these areas, run for the hills.
A licensed professional is bound by their certifying agency to only provide treatment in the areas in which they have been adequately trained. It can be a slippery slope to push the limits of our clinical scope of competence, so it is even more important to adhere rigorously to this ethical standard.
Yet another ethical standard that would seem to be rather black and white, dual relationships nonetheless have tripped up many otherwise competent and honest clinicians. In the simplest terms, dual relationships are when you have an additional or multiple relationships with your client outside of your therapeutic relationships. Examples of dual relationships are when the client is also a student, family member, employee, business associate of the clinician or fellow 12-Step or peer support group member or acquaintance such as another parent at your child’s school. In many respects, dual relationships are similar to a Rubik's Cube - multifaceted and rarely do all the sides line up correctly. The reason we need to be concerned about dual relationships is they can hurt the client and behavioral health care professional relationship.
This ethical guideline exists is to protect the trust a client has in you and your therapeutic relationship, and to not exploit that for any reason – be it for financial gain or undue personal influence. You want to preserve the integrity of the relationship, protecting it from outside forces.
For some reason, this issue gets muddied more often than you would think. It’s not uncommon when an acquaintance finds out your occupation for them to say, “I’ve been looking for a good therapist! Can I see you?” It’s happened to us more times than I can count. Or when a friend or relative is going through a rough patch personally, and they call you asking for your professional help. Or you go to an AA meeting and you see your client there.
Your personal inclination toward empathy may cause your initial reaction to be, “Sure! How can I help?” The ethical implications of that response can be quite damaging – to you professionally and, ironically, to the person you want to help – because you can’t maintain an ethical and strictly professional relationship with someone you know. It inevitably leads to all kinds of complications.
Some dual relationships are unavoidable SUCH AS being a business associate or a parent in the same class but the majority are voluntary. Such is the case when a clinician and client are friends, become business partners, or engage in social activities outside the therapy relationship. Dual relationships that raise the greatest ethical, and possibly legal concerns, are those of a sexual nature. While such relationships may appear to be occurring between two consenting adults, the nature of the therapy relationship itself creates a situation where the client is in a vulnerable position. A sexual relationship enhances this vulnerability and may even exacerbate a client’s mental health concerns and symptoms.
As an example, the social work Code of Ethics stipulates that if a dual relationship is exploitative, whether it begins before, during, or after a professional relationship, it should be avoided. There is room for interpretation, and many of the dual relationships social workers encounter are much more subtle than the egregious exploitation of a sexual relationship. Examples include developing a friendship with a client, participating in social activities with clients, belonging to the same social advocacy group as a client, accepting goods instead of money, sharing religious beliefs, and counseling a friend.
What’s Right or Wrong With Dual Relationships? The potential for exploitation or harm to a client is what makes dual relationships insidious. Dating, bartering, and entering into business arrangements with clients represent examples of situations that are best avoided. As such, it’s important to establish boundaries because they serve three purposes:
- Protect the therapeutic process. According to law, a client and health care professional share a fiduciary relationship. Having a boundary here shows that there is only a professional relationship exchanged.
- Protect clients from exploitation. Clients may be vulnerable and a proper boundary here protects them from further harm.
- Protect clinicians from liability. Malpractice lawsuits run rampant in health care.
In order to fully support the needs of a client, dual relationships must be avoided and nonsexual dual relationships must be thoughtfully evaluated. Clinicians should carefully consider how a dual relationship will impact a client’s ability to be honest and face difficult issues or feelings. In addition, it is important to consider if a change in boundaries will support the client’s health and wellbeing.
No Payment for Referrals
Another important ethical standard is not accepting payments for referrals – something that is woefully abused within the addiction treatment world. Even principled clinicians may fall prey to this violation when it falls under the guise of a marketing agreement with a treatment center.
Because the current landscape of drug and alcohol treatment is largely the wild west of unregulated practices, it falls on individual practitioners to observe basic ethical standards to ensure the best interests of clients are protected and served.
As a result of kickbacks and other unethical practices (such as the ones bulleted above), Congress passed the Stark Law, a series of provisions that ban referrals and kickbacks in the healthcare field. Furthermore, this law has inspired many organizations to examine and enhance their code of ethics to deter individuals and organizations from slipping into these types of ethical dilemmas. When communities come together to bolster our collective social conscience, it challenges everyone to uphold the values we hold dear in our homes and workplaces.
In addition to professional development on the topic of ethics, let’s take a moment to investigate an ethical model that is easy to teach and implement, and can help shape the way we work in the behavioral health community. Elaine Congress, a professor and social worker, developed the “Congress Model,” which uses an acronym to employ a collection of guideposts for groups and individuals in the behavioral health field to consider when faced with ethical dilemmas:
E - examine relevant personal, societal, agency, client and professional values.
T - think about what ethical standard of the NASW (National Association of Social Workers)
code of ethics applies, as well as relevant laws and case decision.
H - hypothesize about possible consequences of different decisions.
I - identify who will benefit/be harmed
C - consult with supervisors and colleagues about the most ethical choice.
As more and more principled treatment professionals actively take a stand against ethical abuses in our industry, we can shrink the market for those who wish to make a quick buck at the expense of the addicted, and hurting people’s lives.
In spite of the unchecked charlatans among us, far more excellent, experienced and ethical clinicians are tirelessly working to provide quality treatment. Let’s work hard to be them, support them, and protect them and those they serve. A number of treatment industry professionals from across the United States and beyond have come together with the goal of promoting the highest ethical behavioral health treatment standards for the benefit of consumers, family members and providers of mental health and substance use disorder treatment. This Coalition aims to use advocacy, education and legislative action to assist all consumers in need with accessing providers that are transparent, qualified, and whose primary motivation is the transformative power of recovery.
To learn more about Louise Stanger and her interventions and other resources, visit her website.