Ethical Issues in Counseling Teenagers with Alcoholism

Introduction

Counselors charged with treating young people who abuse substances in general and alcohol in particular are faced with challenging issues as they seek to formulate timely and effective clinical interventions using evidence-based protocols. These young people are frequently abusing other substances as well, and their involvement with law enforcement and premarital sex further exacerbates their condition. Indeed, treating anyone suffering from alcoholism is a daunting enterprise, but these problems are especially pronounced with teenage alcoholics given their propensity for experimentation and proclivity for impulsive behaviors.

To gain fresh insights in these areas, this paper reviews the relevant literature to identify ethical issues involved in counseling teenagers with alcoholism, including informed consent contents in psychotherapeutic settings, dual relationships, and psychological testing in personnel selection. A discussion concerning the rules governing sexual intimacy with clients and former clients is followed by a discussion of personal psychotherapy as a requirement of a graduate training program, including an examination of deception in research. Next, an assessment of special concerns and particular benefits of an outpatient setting is followed by a description of the relevant minimum HIPAA requirements. Finally, a discussion concerning how psychologists become involved with fraudulent practices is followed by an evaluation of professional responsibilities. A summary of the research and important findings are presented in the conclusion.

Adolescents suffering from substance abuse issues have a right to understand and approve of any treatment in a process known as informed consent. Informed consent is required for all medical and research procedures based on the guiding principle that people who undergo these procedures have a fundamental right to be informed concerning the implications of the treatment and to provide their consent with a complete understanding of those implications (Barnes & Murdin, 2001). According to Barnes and Murdin, "Informed consent means that an individual grants to someone the permission to do something they would not have the right to do without such permission. Need for consent arises from the recognition of the individual's right to autonomy and self-determination" (p. 117). The complete understanding of the treatment involved in a psychotherapeutic setting is regarded as an essential element of informed consent, but this level of understanding is not always attainable depending on the cognitive and emotional capabilities of the clients involved (Barnes & Murdin, 2001). In these cases, therapists should consider alternative methods of obtaining informed consent (Barnes & Murdin, 2001).

Given the universal applicability of informed consent for medical treatment, it is not surprising that a growing number of authorities maintain that informed consent is also recommended for psychotherapy. In this regard, Croarkin and Berg (2003) report that many authorities have concluded that informed consent should include information relevant to the client's decision. According to Croarkin and Berg:

This includes treatment contracting, information about the effectiveness and safety of therapy, as well as alternatives and consequences of no therapy. However, applying this doctrine to psychotherapy is challenging due to the diversity of psychotherapists, the myriad of variables inherent in the process of psychotherapy, and the potential risk of contaminating the process of psychotherapy with this information. (p. 384)

Minimum Contents of Informed Consent for Psychotherapy

Advocates of informed consent for psychotherapeutic settings maintain that this procedure is necessary in order to "protect patients' rights to their best interests, empower them to exercise control in their treatment, and provide a means for legal recourse should their rights be violated" (Croarkin & Berg, 2003, p. 384). In addition, informed consent for psychotherapy can provide significant psychotherapeutic benefits. In this regard, Croarkin and Berg report that:

This interactive educational process may hone patients' self-esteem, encourage autonomy, defend against pernicious regression, and establish their active role in the therapeutic process, setting the groundwork for the therapeutic alliance and for effective psychotherapy. This process may also broaden treatment options for patients and distribute liability more judiciously. Specifically, liability is transferred from the psychotherapist to the therapeutic dyad of patient and therapist. (2003, p. 384)

Notwithstanding these considerations, the minimum contents of an informed consent for psychotherapeutic purposes consist of two elements: (a) disclosure of information the client needs to make an informed decision concerning participation in therapy, and (b) free consent to therapy without experiencing undue influence from others (Charman, 2004). In this regard, Charman advises that "Consent is grounded in the view that adult clients are fully autonomous human beings who deserve the freedom to make decisions about therapy that they exercise in other aspects of their lives" (2004, p. 350). Not only do all clients, including teenagers, have a right to informed consent, they also have a right to undergo therapy without becoming emotionally or romantically involved with their therapists — issues discussed further below.

Dual relationships involving boundary issues have been the source of countless ethical dilemmas for psychotherapists. In this regard, Reamer (2003) reports that "Ethical issues related to professional boundaries are among the most problematic and challenging. Boundary issues involve circumstances in which therapists encounter actual or potential conflicts between their professional duties and their social, sexual, religious, or business relationships" (p. 121). The boundary issues involved extend to others besides clients, and practitioners can become involved in dual relationships with colleagues as well (Reamer, 2003). In this regard, Moleski and Kiselica (2005) note that "Some of the most challenging ethical situations result from dual relationships between counselors and others. A dual relationship is created whenever the role of counselor is combined with another relationship, which could be professional (e.g., professor, supervisor, employer) or personal (e.g., friend, close relative, sexual partner)" (p. 4).

Whatever their nature, dual relationships are considered unethical and potentially threatening to the treatment process. According to Zur and Lazarus (2002), "Dual relationships between psychotherapists and clients have been frowned upon and denounced by the majority of therapists, ethicists, courts, licensing boards, ethics committees and educators" (p. 3). This disapproval of dual relationships is based on the need to protect clients as well as the validity of the treatment process itself — an issue especially important when adolescent patients are involved. Zur and Lazarus add that "The main reasons given for this proscription are that clients must be protected from exploitative and harmful therapists and that dual relationships, according to some, are not only harmful to clients but also compromise the integrity of the therapeutic process" (2002, p. 3).

The research to date shows a divergence of opinion concerning the ethical nature of post-termination non-sexual dual relationships. In this regard, Pritchett and Fall (2001) report that:

Despite evidence that these relationships are harmful to the client, both counselor perception and ethical codes are vague about the ethics surrounding this issue. Although sexual dual relationships have clearly defined characteristics and ethical guidelines that most professionals understand, non-sexual dual relationships do not enjoy the same level of ethical clarity. (p. 73)

As a result, non-sexual relationships between clients and therapists that extend beyond the duration of treatment remain a source of ethical concern (Pritchett & Fall, 2001). Kagle and Giebelhausen (1999) emphasize that "Few would argue that sexual relationships between practitioners and clients are ethical. Such relationships clearly violate the norms of social work and other helping professions" (p. 213). With younger patients, sexual conduct in a dual relationship has been equated to child abuse, and sexual conduct between practitioners and clients is regarded as a felony in seven states (Kagle & Giebelhausen, 1999).

A final important point is that every therapeutic relationship is unique and the boundaries established by the therapist will therefore be individualized to the setting. For example, Harper and Steadman (2003) emphasize that "Many authors agree that maintaining boundaries with clients is basic to the development of an emotionally and physically safe therapeutic environment in which a trusting relationship can be developed. However, because boundaries emerge from the interaction, they are unique to each relationship" (p. 64).

Psychological testing to identify optimal candidates for employment dates back more than 100 years. According to Scroggins, Thomas, and Morris (2008), "Personnel selection in general, and the concomitant use of varied forms of psychological testing in particular, has its origins in the late 19th century" (p. 100). Much of the early focus of personnel selection using psychological testing was on new troops enlisting in the military during the two world wars and the explosive growth of the private sector thereafter (Scroggins et al., 2008). Psychological testing for personnel selection purposes faded into disfavor during the 1960s, but it continues to be used by human resource practitioners today. Scroggins and colleagues advise that "Many HR practitioners, however, have continued to use personality testing with an optimistic and enduring faith in its ability to discriminate between good and poor job candidates" (p. 101).

Dual Relationships and Psychological Testing in Personnel Selection

In cases where cheating is suspected — such as when a teenage applicant may be using a smartphone or consulting notes during testing — psychologists have a professional responsibility to conform to relevant privacy laws with respect to the results of such tests, including following the decision-making model provided by organizations such as the Canadian Psychological Association (CPA). This approach is applied to these issues in Table 1 below.

Table 1: Application of CPA's Decision-Making Model to Personnel Selection Results

Identification of individuals and groups potentially affected by the decision: (1) Applicant; (2) Potential employers; (3) Testing organization.

Identification of the relevant issues and practices: (1) Stakeholders have a reasonable expectation of accuracy in the administration of personnel selection tests. (2) Applicants have a reasonable expectation of privacy in the release of their test results.

Consideration of how personal biases, stresses, or self-interest might influence the development of or choice between courses of action: Testing authorities may be biased against younger applicants and may translate personal anxieties about technology into perceptions of cheating.

Development of alternative courses of action: (1) Reveal suspicion of cheating to stakeholders. (2) Conceal suspicion of cheating from stakeholders.

Analysis of short-term, ongoing, and long-term risks and benefits of each course of action: If the suspicion of cheating is revealed, the likelihood of the applicant receiving a job offer is seriously diminished; conversely, if the results are concealed and the applicant secures employment, it may be through fraudulent methods.

Choice of course of action after conscientious application of existing principles, values, and standards: The ethical issues in this case require the testing authority to reveal the suspicion of cheating.

Action, with a commitment to assume responsibility for the consequences: Reveal the suspected cheating and recommend an alternative testing regimen to confirm or refute the initial testing results.

Evaluation of the results of the action: This step would dictate the steps that follow.

Assumption of responsibility for consequences of the action: If subsequent tests confirmed cheating, the action is substantiated. If not, the suspicions of cheating may have been based on personal biases.

Appropriate action, as warranted and feasible, to prevent future occurrences of the dilemma: Prevent all testing subjects from leaving the testing area during administration of the test and require that all handheld mobile devices be left outside the testing area.

In addition, professional psychologists must conform to the ethics guidelines and codes of conduct in their respective states, as well as in national organizations such as the American Psychological Association (APA). According to the APA, "Membership in the APA commits members and student affiliates to comply with the standards of the APA Ethics Code and to the rules and procedures used to enforce them. Lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct" (Ethical principles of psychologists and code of conduct, 2012, para. 2).

Conclusion

Pritchett, S. & Fall, K.A. (2001, Spring). Post-termination non-sexual dual relationships: Dynamics and assessment. TCA Journal, 29(1), 72–75.

Ross, A.S. & Grant, M.K. (1999). Experimental and nonexperimental designs in social psychology. Boulder, CO: Westview Press.

Scroggins, W.A., Thomas, S.L. & Morris, J.A. (2008, Spring). Psychological testing in personnel selection. Public Personnel Management, 37(1), 99–102.

Shipway, L. (2004). Domestic violence: A handbook for health professionals. London: Routledge.

Sileo, C.C. (1999, August 29). Under fire, therapy faces a backlash. Insight on the News, 10(35), 6–9.

Sonkin, D. (2012). Domestic violence treatment: Legal and ethical issues. Retrieved from

Understanding health information privacy. (2012). U.S. Department of Health & Human Services. Retrieved from

Westman, J.C. (1999). Licensing parents: Can we prevent child abuse and neglect? New York: Insight Books.

Willis, R. (2010, January 1). A fool for a client: Competency standards in pro-se cases. Brigham Young University Law Review, 1, 321–332.

Zirkle, D.S. & Jensen, M.A. (2002, January). Therapeutic practices and ethical beliefs of professionals working with adolescents in residential treatment. Counseling and Values, 46(2), 108–111.