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Ethical and Professional Responsibilities Back to Course Index

 

 

 As a substance abuse professional, it is your professional conduct that gets patients safely through their day. You are responsible for a myriad of tasks, from charting to the mood in a particular group. Your conduct and choices have much to do with the success of the therapeutic atmosphere.

It is crucial for you to have an excellent understanding of patient’s rights, cultural diversity, and how a client’s cultural background affects their treatment, confidentiality requirements, and mandatory abuse reporting issues.  This course will explore these topics.

Professional Conduct and Ethics

As a result of increased litigation and ethics complaints against mental health practitioners — a significant portion of which alleges some kind of ethics violation — many professional education programs, social service agencies, licensing boards, and professional associations are sponsoring special training and education on ethics-related risk management, especially related to such issues as confidential and privileged information, informed consent, conflicts of interest, dual relationships and boundary issues, termination of services, and documentation.  This training and education typically focus on common ethical mistakes, procedures for handling complex ethical issues and dilemmas, forms of ethical misconduct, and prevailing ethical standards.

The professional’s mantra is do no harm. Sometimes with legal stipulations requiring one thing and a code of ethics stating the opposite, as a practitioner, you can be left asking, which action is less harmful.

Ethical decisions made during treatment can be challenging, but the effort of keeping the client’s best interest at heart remains primary.

The working definition of ethics includes the study of standards of conduct and moral judgment; this is the system or code of morals of a particular person, religion, group, or profession. To be ethical means, as a professional, you are conforming to the standards of conduct agreed upon by a given profession or association. Morals refer to the principles of rightness or wrongness that individuals or groups adhere to. We can differentiate between morals and ethics. To be moral implies conformity with the generally accepted standards of goodness or rightfulness of conduct or character. To be ethical implies conformity with an elaborated, ideal code of moral principles, sometimes with the code of a particular profession. It takes honesty and courage to use introspection and recognize how our morals and values affect how we behave in a professional situation. A mental health technician who was molested at the age of 6 will undoubtedly be affected by this experience, particularly when a convicted child molester is the client. As objective as we want to be, we all see through our own filters. What is most important is rather than insisting we see every client as a blank slate, admit and continually check ourselves for the filters that are part of who we are. To be aware of them and act accordingly is far more ethical than to deny they exist.

The Florida Certification Board provides certification for professionals in the State of Florida.  The FCB is dedicated to the principle that certified professionals must conform their behavior to the highest standards of ethical practice.  To that end, the FCB has adopted the Certified Professional Code of Ethics (the Code) to be applied to all professionals, certified or seeking certification.

The FCB may refuse to issue a credential to any applicant, may issue a reprimand, or suspend or revoke the credential of any certified individual who has been convicted of a felony, is found to have been in violation of the Code, or falsifies any information on the application or in the Application Portfolio. 

All applications for certification require applicants to indicate whether or not the applicant has ever been convicted of a felony.  If the applicant indicates “yes” in this section of the application, he/she must provide the FCB with any and all information concerning any arrest(s), convictions, indictments, suspensions, or revocations.

The FCB is committed to investigate and sanction those certified professionals or those seeking certification who breach the Code.  Certified professionals or those seeking certification are therefore encouraged to thoroughly familiarize him/herself with the Code and to guide their behavior according to the rules set forth within the Code.

Substance abuse treatment professionals who hold other licenses, such as a licensed clinical social worker (LCSW) or a mental health counselor (LMHC), for example, should be familiar with their board’s code of ethics.  They then have to reconcile the board’s code of ethics with the Florida Certification Board’s code, the National Association of Addiction Counselors (NAADAC) code, and so forth.  There also may be agency standards that conflict with an individual’s personal beliefs, as well. In either case, there is a constant need to weigh what may “feel right” personally with the standards and policies of the environment and profession.

These codes of ethics are documents created by professional organizations to provide their members with values and standards of behavior for their discipline.  These codes are based on the seven ethical principles discussed in The Terminology of Health Care Ethics. Each professional should make themselves knowledgeable of the codes pertaining to their profession. 

 

Confidentiality and Regulations on Privacy

The primary regulations that effect substance abuse treatment confidentiality are title 42 of the Code of Federal Regulations (CFR) and HIPAA.  There are individual Codes of Ethics for certified and licensed practitioners, as well.  This course will primarily focus on appropriate documentation, HIPAA, and 42 CFR.

Title 42 of the Code of Federal Regulations (CFR) part 2

The purpose of the regulations at title 42 of the Code of Federal Regulations (CFR) part 2 (42 CFR part 2) is to ensure that a patient receiving treatment for a substance use disorder in a part 2 program is not made more vulnerable by reason of the availability of their patient record than an individual with a substance use disorder who does not seek treatment. Now, more than 29 years since the part 2 regulations were last substantively amended, this final rule makes policy changes to the regulations to better align them with advances in the U.S. health care delivery system while retaining important privacy protections.

The privacy provisions in 42 CFR Part 2 were motivated by the understanding that stigma and fear of prosecution might dissuade persons with substance use disorders from seeking treatment. To add an extra layer of protection on these records, the regulations outline under what limited circumstances information about a patient’s treatment may be disclosed with and without the patient’s consent. Who and what is covered can be confusing, though.

42 CFR Part 2 applies to any individual or entity that is federally assisted and holds itself out as providing and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment. Most drug and alcohol treatment programs are federally assisted. For-profit programs and private practitioners that do not receive federal assistance of any kind would not be subject to the requirements of 42 CFR Part 2 unless the State licensing or certification agency requires them to comply. However, any clinician who uses a controlled substance for detoxification or maintenance treatment of a substance use disorder requires a federal DEA registration and becomes subject to the regulations through the DEA license.

A program is “federally-assisted” if it:

(a) Receives federal funds in any form, whether or not the funds directly pay for alcohol or drug abuse services; or

(b) Is being carried out under a license, certification, registration, or other authorization granted by the federal government (e.g., licensed to provide methadone, certified as a Medicare provider); or

(c) Is assisted by the IRS through a grant of tax-exempt status or allowance of tax deductions for contributions; or

(d) It is conducted directly by the federal government or by a state or local government that receives federal funds, which could be (but are not necessarily) spent for alcohol or drug abuse programs.

The Federal Drug and Alcohol Confidentiality Law – 42 CFR Part 2 states that any information that would identify a patient as having an alcohol or drug problem, either directly or indirectly, is protected.  

The Federal Drug and Alcohol Confidentiality Law – 42 CFR Part 2 42 CFR Part 2’s prohibition on disclosing patient-identifying information has very few exceptions. The following are the general categories of exceptions:

  • written consent
  • internal program communications
  • removal of all patient-identifying information
  • medical emergency
  • court order
  • crime on program premises or against program personnel
  • research
  • audits and evaluations
  • child abuse

The best way to ensure communications are permissible under 42 CFR Part 2 is to have the individual sign a consent/authorization form that complies with the requirements of both HIPAA and 42 CFR Part 2.  

The elements of a consent/authorization form that must be included are listed below.  In addition, it also includes applicable state law as well.

  • Name or general designation of the program or person permitted to make the disclosure
  • Name or title of the individual or name of the organization to which disclosure is to be made
  • Name of the patient
  • Purpose of the disclosure
  • How much and what kind of information is to be disclosed
  • Signature of the patient (and, in some states, a parent or guardian)
  • Date on which consent is signed revocation at any time except to the extent that the program has already acted on it
  • Date, event, or condition upon which consent will expire if not previously revoked

 

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA was enacted in 1996, and its legislation addresses insurance portability, fraud enforcement, and administrative simplification. 

Portability is primarily concerned with controlling the continuity of health coverage when an individual changes jobs.  It also addresses under what situations pre-existing medical conditions will be covered.

Fraud enforcement addresses the federal government’s fraud enforcement authority in various situations.

We will focus most intently on Administrative Simplification. A significant challenge for most health care providers is to determine the most efficient and cost-effective method to protect a patient’s privacy and the confidentiality of protected health information.

HIPAA privacy and security regulations include provisions for the punishment of individuals and/or organizations that fail to protect the confidentiality of patient information.  Prior to HIPAA, no federal law protected patient information; consequently, it was sometimes exploited for personal gain.

The HIPAA Act requires that covered entities comply with the regulations.  Most health care providers, clearinghouses, and health plans are covered entities.  Whether your work setting falls under the regulations or not, you should be committed to protecting patient privacy and confidentiality.  When an employee compromises patient information and/or records by not adhering to the policies regarding privacy, there is a potential impact on both the hospital or practice and, when appropriate, their license to practice.  It is the employee’s responsibility to carefully review and become knowledgeable of the privacy policy and to comply with the requirements.

The guiding principle for communication with or about patient information should be based on the concept of the need to know or who needs the information for treatment and/or health care operations.

Activities such as medical record review, training, and evaluation of staff performance are essential functions and must be supported.  However, only those with a need to know will have access to protected information. 

There are numerous ways medical information may be used by others. The following are three examples:

  • Early termination of an employee because his medical condition could lead to future medical problems.
  • Unauthorized release of potentially damaging medical history which could limit career opportunities
  • Refusal to hire based on certain medical risks.

HIPAA requires covered entities to implement comprehensive policies and procedures to protect the privacy and security of health information. These requirements are contained in regulations published by the US Department of Health and Human Services.

Covered entities are:

  • Providers who use electronic transactions
  • Health plans
  • Health care clearinghouses

The privacy rule protects individually identifiable health information in the hands of covered entities and their contractors.

This information is also called protected health information or PHI. The privacy rule protects individually identifiable health information, whatever the form of the information (written, electronic, or spoken).

Examples of protected health information include:

  • A providers patients medical record
  • A health plan’s claims information
  • A provider’s billing information
  • A provider’s quality assurance files, if they contain information about identifiable individuals
  • A conversation between a doctor’s receptionist and a patient about the patient’s insurance coverage.

Any information that could potentially identify the patient is considered individually identifiable information under HIPAA.

Examples include, but are not limited to:

  • Name
  • Address
  • Social Security Number
  • Relatives Name
  • Date of Birth
  • Telephone Number
  • Medical Records Number
  • Fingerprints
  • Photos

Releasing any of this information without establishing that the recipient has a need to know and/or a signed authorization to release is a violation of the HIPAA privacy regulation.

A significant departure from the standard practice is the handling of psychotherapy notes.  These notes have more stringent protection as they generally contain the personal notes of the treating psychotherapist, which may be damaging to the individual should the information become available to the general public.

HIPAA requires specific authorization for the release of psychotherapy notes.

The minimum necessary standard for protection of confidentiality is that a reasonable effort is made by health care workers to use or disclose only the protected health information needed to do their job. Experienced health care workers can make these reasonable effort decisions more professionally as they are more awareness of good business practices and the HIPAA regulations. Needless to say, it is an ongoing challenge to maintain the proper balance between patient privacy and comprehensive and timely patient treatment. One should always ask, “Is this needed to do my job” and if the answer is no, act accordingly.

The clinical staff is allowed to review the entire patient record and to share information with other attending clinicians. This broad approach to record availability for treatment may occasionally expose a clinician to confidential information that is not needed for treatment. An example would be a patient is in isolation, and you become aware of why he or she is there. This information is confidential and should not be communicated to others. It is also possible to view patient information at other locations in the hospital. This information is generally posted in areas that are not readily available to the public. Again, this information is confidential and should not be disclosed to anyone, including co-workers, other patients, visitors, or anyone else who may ask.

Protect privacy by:

  • Hold private conversations with patients—close room doors when possible.
  • Speak softly in semi-private or ward areas and close curtains or other privacy items when possible.
  • Avoid discussions of patient information in public places such as the cafeteria, elevators, restrooms, etc.
  • Restrict the use of answering machines to non-confidential information and when appropriate get approval to leave a message
  • Limit paging information to non-confidential information

Every patient has a right to privacy.  It is essential to the success of any practice or facility to adhere to the privacy rules and to also encourage co-workers to follow the rules.

Protect electronic date by:

  • Block patient information when not in use with screen savers or by logging off.
  • Place screens in locations and positions so as to minimize exposure to others.
  • Do not make passwords obvious, such as your name. Commit the password to memory. Do not write it down and place it on or near the computer.
  • Never share your password with anyone.

The transmission of health information by fax is not covered by the security standards. However, good business practices mandate that an entity should only fax to a secure location and to coordinate with the recipient to ensure their awareness that you are sending a fax and that it contains sensitive information. If you are to receive a fax, the process is reversed. Never send a fax to an unattended machine.

If information is obtained appropriately from an entity by an authorized person and subsequently transmitted by fax to an entity that is not authorized to receive that information, this could constitute a violation of both the privacy and security standards.

Providers sometimes are required to release patient information even if the patient does not agree with the transaction.  In most cases, the courts authorize the release.  Examples of circumstances that may arise are:

  • Communicable diseases that the law required to be reported to health agencies
  • Certain information regarding the failure of medical devices is required to be reported by the Food and Drug Administration.
  • Suspected child abuse or domestic violence is required to be reported to the police in some states.
  • The court has a right to certain information about patients when conducting a criminal investigation.
  • Providers are required to report suspicious death or certain injuries.
  • Providers are required to report deaths to the coroner.

The primary purpose of confidentiality is to protect the client’s right to privacy by ensuring that matters discussed with a professional are not disclosed to others without the expressed consent of the client. Clients need to be well informed on what is held confidential and what is required by law to be reported. This will help to build trust, and through this trust, the client will be more willing to be open and honest and participate in treatment more fully.

There are limits to Confidentiality. For example, a counselor can request a group keep each other’s information private, but it needs to be understood that a lack of privacy is an inherent risk with group counseling. There are other limits of confidentiality, including concerns of safety.

Typical Limits to Confidentiality:

This list is not inclusive, but rather a guide to typical situations where confidentiality often gets limited. Always, always, always inform the client in writing with their signature of any limitations of confidentiality before beginning treatment.

Before releasing ANY client information without written authorization from the client, consult a supervisor or attorney, and document this consultation.

  •         Subpoena
  •         Child abuse or Neglect
  •         A client is deemed a danger to themselves or others
  •         During a medical emergency, information relevant to the emergency.
  •         Under defined circumstances, providers are required to reveal
  •         information on minors to parents, guardians, or surrogate decision-makers.
  •         Third-party payers and state oversight agencies.

 A consent to release information should follow these guidelines:

It should be in writing and include:

  • The name or general designation of the program(s) making the disclosure.
  • The name of the individual or organization who will receive the disclosure.
  • How much and what type of information is to be disclosed.
  • A statement that the client may revoke the consent at any time, except to the extent that the program has already acted on the basis of the consent (already released information).
  • The date, event, or condition upon which the consent expires, if not previously revoked.
  • The date upon which the consent is signed.

 

Mandatory Abuse Reporting

The lengths to which a community goes to protect its most vulnerable members help define it as a civil society. Different states around the U.S. have varying laws that impose requirements on the reporting of abuse to the proper authorities, with the aim of putting an end to violence and emotional harm. Florida’s legislature has enacted mandatory reporting laws for the abuse of children, the elderly, and individuals with disabilities.

Who Must Report?

Unlike many states where only specified legal and health care professionals must report abuse and criminal mistreatment of elders and other vulnerable adults, in Florida, any person who knows or suspects abuse must report it. However, in the case of children, the list of mandatory reporters is limited. The list includes health care professionals–including doctors, nurses and dentists; educators–including teachers, school administrators, guidance counselors, and school mental health professionals; child welfare agency personnel; childcare providers and their employees; law enforcement officers and staff; and people who process or produce printed or visual materials, such as photo processors. Of course, anyone else aware of child abuse may report it, although not legally obligated to do so.

Under Florida’s mandatory reporting laws, knowledge or reasonable suspicion of abuse, neglect, or abandonment are applied as the standards for reporting. The actions that must be reported include physical abuse, sexual abuse, neglect by parties responsible for care, words, or behaviors that could cause psychological damage, and exploitation.

The laws prohibit false reporting of abuse for the purpose of harassing the accused abuser, financial gain of the reporter, obtaining legal custody of the child or a vulnerable adult, or any personal benefit. Moreover, legal privileges that normally apply between spouses or between physician and patient are eliminated for abuse reporting, although attorney-client and clergy-penitent privileges do apply.

Mandatory reporters must provide their names, addresses, and contact information in their reports. However, their identities will be kept confidential by the investigating agencies. Individuals who comply with the law and report abuse in good faith are protected from civil or criminal liability. On the other hand, those who do not fulfill their mandatory duty to report are committing a second-degree misdemeanor.  

 

Solving Ethical Problems 

The first step in analyzing moral issues is obvious but not always easy: get the facts. Some moral issues create controversies simply because we do not bother to check the facts. This first step, although obvious, is also among the most important and the most frequently overlooked.  However, having the facts is not enough. Facts by themselves only tell us what is; they do not tell us what ought to be. In addition to getting the facts, resolving an ethical issue also requires an appeal to values.

Ethical issues are both personal (micro) and societal (macro) in nature. There is an ongoing struggle between legislating morality for the “public good” and fighting to retain an individual’s right to autonomy. It is the intense emotional nature of such concerns that takes an issue from a personal level to a societal level.

Syringe exchange programs are a good example of such ethical dilemmas. While the Secretary of the U.S. Department of Health and Human Services announced that a review of scientific reports indicated that SEPs could be an effective component of a comprehensive strategy to prevent HIV, many argued whether giving out clean syringes may sanction or encourage illegal drug use.  The good of many avoiding HIV weighted against the bad of the individual encouraged to use drugs.

Alcohol and drug counselors may find that their time is spent not only sorting out client-level ethical dilemmas but also dealing with societal-level dilemmas. This could involve advocating for legislation that protects the rights of clients or adapting to the impacts of a policy that will further restrict a provider’s ability to intervene effectively with a client group.

Perhaps the most difficult dilemma occurs when there are conflicts between the clinicians’ values and the client’s behaviors. Professionals know that if a client threatens suicide or homicide, there is a duty to report. But most of the daily concerns that arise are not so simple. Ethical issues come up in numerous, seemingly insignificant ways. Did the client understand what the release of information stated, or did she rush so that the provider could make the next appointment? Did the clinician listen to what the client said about her culture, and how the treatment plan would not work because it was not created in a culturally competent manner? Was information about the client shared with another helping agency, even though she did not give a release to that particular agency? These are the kinds of issues that arise every day, affecting client care and reflecting on one’s status as a clinician, as well as on the agency’s reputation.

All professionals should have a process for dealing with ethical concerns. Although ethical issues are usually complex enough to require a case-by-case evaluation, supervision, and agency practices should provide for a routine process for approaching an ethical issue. For example, an agency might have, as a policy and procedure, a practice where the employee consults with a supervisor or an ethics consultation team within the agency, within a specified timeframe, and guidelines are provided for how to document such discussions. There could also be agency protocols for situations that have arisen in the past, such as a client’s admission that she is suicidal or homicidal, clients who come to the facility intoxicated and insist on driving home, or clients who admit to illegal activity. Given the ambiguous nature of ethical dilemmas, it is helpful to clarify the process for resolving dilemmas, even if the resolution may differ from case to case.

The following steps,  suggested by the NASW, provide a structured process for ethical decision making:

  • Identify clinical issues. When an ethical issue arises, the provider should review the larger picture in her work with the client or system. Identifying clinical issues is the first step. What are the clinical needs of the client? How does the ethical dilemma relate to what the client presented with initially? It is important to assess the clinical issues so that pertinent information is not missed. For example, if a client with advanced AIDS is asking for help in ending his life, the provider would review the client’s previous mental health history and current emotional issues, look for any significant changes in the client’s support system, and determine if the client is experiencing social or psychological issues that might influence his decision. Until this is done, it is impossible for the clinician to address the ethical issue regarding the end of life.
  • Identify legal issues. There can be significant legal issues to consider. Has the clinician reviewed the State and local laws regarding the issue? If necessary, has the clinician checked with an attorney for consultation or informed his supervisor of possible liability questions?
  • Identify system issues. What are the policies and procedures of the clinician’s agency regarding the ethical question? In some agencies, the answers may be hard to find, but they can shed light on any restrictions the clinician may face or make the choices clear. For example, if it is against policy to accept a gift from a client, the clinician can avoid a personal rejection by referring to the policy. Agency policy also can help a clinician in a legal challenge. For example, if the clinician followed agency policy, it is less likely that the clinician can be challenged legally for actions pertaining to that policy (although the agency can still be challenged).
  • Identify cultural issues. Cultural issues often are glossed over in the midst of a dilemma or crisis. Yet cultural issues are significant for understanding the client’s motivation and whether or not the client will act according to the proposed treatment plan. For example, a gay, African American client may have difficulty dealing with his homosexuality and, as a result, may be having anonymous unprotected sex impulsively. In African American culture, it can be especially difficult for men to acknowledge their homosexuality. If the client is HIV positive, there is an ethical need to educate him about protecting others. If the clinician does not acknowledge the client’s discomfort on a cultural level, the education process will be limited, and the clinician will miss the “larger picture.”
  • Identify ethical issues. What is the clinician’s reaction to the situation? Ethical issues often are revealed when there is a “gut instinct” that something is not right. Confusion, anxiety, or uncertainty about what to do next with the client are indicators that an ethical issue is at stake. If basic principles seem to be compromised, the clinician should stop and evaluate further. A significant step is for the clinician to examine her own feelings about the situation. The clinician needs to identify any counter-transference issues regarding the situation to ensure that the issue can be viewed objectively.
  • Review what principles are at stake. What is the true dilemma? Is there a dilemma at all? So much can be occurring with a client that it is difficult to see the real issue, or whether the issue is significant. Is harm being done either by the client or to the client? Can the client make her own decisions, and is she not being allowed to do so? Is the client being treated fairly regardless of race, culture, or lifestyle? Is there a threat to the client’s confidentiality? These are the questions relating to basic ethical principles.
  • What are the possible options? By this point, the clinician’s next step may be clear already. Or, there may be choices of possible options. It is useful to simply list all of the possible options and then examine them.
  • Review the pros and cons of each option. List the pros and cons of each possible option, noting the impact of the options on the welfare of the client, the clinician, the agency, and others involved in the situation, such as the client’s support system.
  • Act. At this point, the clinician should be ready to make a decision. Sometimes the decision may not be one that everyone is comfortable with, but it may be the least objectionable plan. The client should understand the rationale for the clinician’s decision, and there should be evidence of the clinician’s thought process in the documentation of consultations, discussions with the client, and supervisory meetings.
  • Follow up and evaluate. An ethical decision should be evaluated, and the impact on the client monitored. For example, if the clinician decided to breach confidentiality for the protection of the client, how has this affected the clinical work with the client? These issues should be considered once an initial crisis has passed.

 

Achieving and Maintaining Competence

Questions to consider:

  • What is professional competence?
  • Why is competence so critical for substance abuse professionals?
  • Are there ever times when it is okay to practice outside the scope of one’s competence?

Attaining and maintaining professional competence is an important ethical concern. 

Counselors need to be aware of personal problems that may interfere with their ability to provide care.  These problems could include issues such as a divorce, a medical or psychological illness. 

Maintaining competence is also related to continuing education. Most states are quite specific to continuing education hours and requirements. Providers are urged to review the specific requirements listed in their state.

An area of competence that merits special attention is self-monitoring for the possible effects of compassion fatigue. While there are a number of definitions of this phenomenon, all share the idea that helping professionals can be affected by their work with clients, and that these effects can sometimes be negative. Other terms for compassion fatigue are secondary traumatic stress and burnout. While those of us in the helping professions may not directly experience trauma, we care for patients in emotional pain or distress.  Symptoms of compassion fatigue include impairments to the ability to be therapeutically effective, as well as physical and effects on the clinician. Many of these are symptoms that are similar to the symptoms of primary post-traumatic stress disorder.

  • Avoidance or dread of working with certain patients
  • Boundary issues, such as over-involvement with patients
  • Reduced ability to feel empathy towards patients or families
  • Frequent use of sick days
  • Lack of joyfulness/Irritability
  • Poor concentration, focus, and judgment
  • Sleep disturbances
  • Excessive use of substances
  • Anxiety

It is important for treating clinicians to understand the concept of compassion fatigue, and to practice self-assessment. 

In addition to maintaining professional competence through appropriate training, supervision, and education, it is also ethically important that clinicians appropriately identify their licensure status — a key indicator of professional ethics — to potential clients.  

 

Examples of Situations Posing Ethical Dilemmas

Susan has been a client of James for three months.  She really enjoys the warm feeling of being in his office.  She has appreciated the wonderful smelling candles he burns.  She brings James a present of her personal favorite aroma, scented candles.

Professional ethics codes typically caution therapists from giving or receiving gifts within a therapy relationship. For example, the American Counseling Association Code of Ethics (2014) advises counselors to consider the therapeutic relationship, the monetary value of gifts, and the motivation for accepting or declining gifts from people they serve, and the American Psychological Association Code of Ethics (2010) requires that psychologists avoid personal and financial situations that could create a conflict of interest.

John has started seeing Jennifer, a new client, but finds himself very attracted to her.  She can sense this attraction and seems to be reciprocating.  She figures if she leads the way, he will feel as though he hasn’t stepped out of his professional boundaries, so she kisses him when saying goodbye at the end of the session.

 

Never engage in romantic or sexual behaviors with a client.  Most codes of ethics have strict guidelines for the relationship after counseling has ended.  A sexual relationship with a current client is illegal and unethical.  There is an imbalance of power at the core of the helping relationship.

 

The Ethics of E-Therapy

E-therapy is a new form of counseling that is arising in the last years. E-therapy, cybertherapy, web-counseling, and Internet counseling are often used interchangeably. Because e-therapy does not involve real-world interactions with clients, some ethical and legal concerns become more complicated.

The ethical dimensions of e-therapy include competence, credentialing, informed consent, exceptions to confidentiality, as well as privacy and security limits. The informed consent (written and verbal) including the potential risks, consequences, and benefits of telemedicine, or competence to practice, confidentiality, doing no harm, and on how terminations, interruption of service, and payment arrangements need to be discussed. Other factors to consider include provided adequate emergency contact information in case your distance client faces a crisis and ensuring that your patient’s privacy and confidentiality are adequately protected by encrypting electronic transmissions and records.

While substance abuse counselors can treat clients from all over the globe, they should adhere to the laws and ethical guidelines of the state or country where they are licensed to practice. Unfortunately, the global nature of the Internet can make codes of conduct difficult to enforce.

Be aware of security issues, such as the potential for emails to be read or video conversations to be hacked into. Because of these potential violations of privacy and confidentiality, substance abuse counselors need to be very aware of the technology they are using and any potential limitations it may have and should also use software and applications that reduce the risk of a privacy breach. They should also work to be on top of new technology that may better assist them in this endeavor.

 

The Ethics of Recovering Addicts as Professionals in the Field

How many times has a client asked you if you “understood”?  “Have you ever used heroin?  If not, how could you possibly know?”  When someone becomes immersed in the industry that has saved them, they are more successful in their own lives, as well as can serve as an excellent model for success. However, this is not without some potential pitfalls.

In the 1940s, due to a shortage of professional counselors, combined with the hope of rehabilitation for the addict, there grew a belief that the recovered alcoholic could enter the field of addiction treatment as a paraprofessional. These early stages of addiction treatment and the emergence of the recovered substance abuser as a counselor fostered a discussion in the role played by the paraprofessional. This discussion subsequently encouraged an accumulation of literature during the early stages of substance abuse treatment in North America, which later began to diminish as the field moved forward towards the twenty-first century.

The concept of the paraprofessional has grown into the primary therapist over the years.  The belief that having come through the fire lends an experience that someone who has never faced the issue cannot relate to. The upside is that people that believe addiction is a disease that has to be worked on every day are more likely to reach out and help people going through the same process.

There is a perceived potential risk for relapse associated with recovered addicts working in the addictions field to consider. Potential risks for relapse discussed are the ex-addict’s motivation for entering the addiction field, personal help from self-help groups may be lost once in the field, over-involvement with clients, over-involvement with work, over-identification with clients and the repercussions of relapse. 

Professional Responsibilities

Addiction counselors, as professionals, have an obligation to go further than attempting to do the right thing.  What might be ok for the person sitting in the office next to you might not be the same as what is right for you.   The codes that we have discussed and will explore help provide the structure we need to follow through on our professional responsibilities. It is your responsibility to:

  • Maintain knowledge regarding the addiction field.
    • Federal, State, agency, and professional codes of ethics.
    • Client rights and responsibilities.
    • Professional standards and scope of practice.
    • Boundary issues between client and counselor.
    • Difference between the role of the professional counselor and that of a peer counselor or sponsor.
    • Consequences of violating codes of ethics.
    • Means for addressing alleged ethical violations.
    • Non-discriminatory practices.
    • Mandatory reporting requirements.
  • Adhere to Federal and State laws and agency regulations regarding the treatment of substance use disorders.
    • Federal, State, and agency regulations that apply to addiction counseling.
    • Confidentiality regulations.
    • Client rights and responsibilities.
    • Legal ramifications of non-compliance with confidentiality regulations.
    • Legal ramifications of violating client rights.
    • Grievance processes.
        •  
  • Recognize the importance of individual differences that influence client behavior and apply this understanding to clinical practice.
    • Differences found in diverse populations.
    • How individual differences impact assessment and response to treatment.
    • Personality, culture, lifestyle, and other factors influencing client behavior.
    • Culturally sensitive counseling methods.
    • Dynamics of family systems in diverse cultures and lifestyles.
    • Client advocacy needs specific to diverse cultures and lifestyles.
    • Signs, symptoms, and patterns of violence against persons.
    • Risk factors that relate to potential harm to self or others.
    • Hierarchy of needs and motivation.
  • Utilize a range of supervisory options to process personal feelings and concerns about clients.
    • Know your limits
  • Develop and utilize strategies to maintain one’s own physical and mental health.
    • Relationship between physical and mental health.
    • Using prevention measures to guard against burnout.
    • Employing stress reduction strategies.
    • Locating and accessing resources to achieve physical and mental health.
    • Modeling self-care as an effective treatment tool.

So, what is the answer to solving ethical problems in the substance abuse counseling field? There is no definitive answer, but if we use the knowledge we have acquired from studying medical ethics, and mix that knowledge with a little experience, we should have a good recipe for making the best ethical decisions in difficult situations.  Seek supervision.  Always keep in mind; if you wouldn’t want all of your friends, neighbors, and colleagues to read about you doing whatever action you are contemplating doing on the front page of tomorrow’s newspaper, it is likely that you shouldn’t do the behavior.

 

Cultural Diversity

Historical documents often refer to the United States as the great cultural experiment or a melting pot as diverse peoples are molded and shaped into the American Way of Life. This undertaking has yielded various shades of success as new citizens adapt to a common language, habits, and values. The final outcome of the great culture experiment will be determined over the next several generations. A common view is that we the people have made a lot of progress toward accepting people based on their individual merits but we have a long way to go to overcome all of the cultural barriers.   Recent trends appear to be toward cultural pluralism and diversity as concepts being advanced to promote the co-existence of various cultural groups, all of who may simultaneously maintain some of their distinctive characteristics. However, there are other conflicts between ethnic and cultural groups, and there is inequality in the social and economic resources available to different groups. There are also different general acceptances, power, and prestige issues between ethnic and cultural groups, as well as differences with the majority cultures.   These have a significant impact on minority persons who may also have a social or community need. It is often difficult to separate socioeconomic, ethnic, gender, age, and other variables that influence the behavior and attitude of members of these sub-populations.   Consequently, they often experience multiple jeopardizes, including minority statutes, parenting problems, physical and mental challenges, age, lifestyles, and other factors.

Individuals who are disadvantaged and sometimes disenfranchised are sometimes labeled as hidden populations and include individuals such as the homeless, chronically mentally ill, criminal and juvenile offenders, prostitutes, runaways, and others. It follows that less personal and research data are available on these groups due in part to their migratory lifestyles and loss of identity. They are generally omitted from surveys because they are not living in typical homes, are not attending school, and choose not to cooperate with interviewers.   However, many members of these groups have a greater need for social services, medical, food, shelter, and other services than the general population.

The United States remains a nation in which ethnic minorities and other disadvantaged groups (elderly, females, etc.) are often subjected to prejudicial treatment, as well as having to continuously deal with negative life experiences, including language, religion, family relationships, value system, and community norms. Minority groups and other special sub-populations are disproportionately represented among the economically disadvantaged. They are more likely to live in urban centers that have higher crime rates, poorer schools, substandard housing, and fewer employment opportunities.  

Ethnic populations are set apart from the mainstream culture by differences in language (whether a foreign language or an English dialect) and create communication difficulties. The language barrier (includes reading, writing, and verbalizing) increases stress, interferes with psychosocial functioning, and increases the difficulty associated with getting the help they need to successfully integrate themselves into the mainstream of society.   Consequently, additional services are often needed to overcome previous deficiencies and also to accelerate the interventions needed for complex social problems.

It should be noted that many ethnic group members, and other special populations, often demonstrate remarkable strengths despite many obstacles and hardships. In some cases, powerful religious beliefs help sustain members through difficult situations. Although family relationships and values may be different, supportive bonds may be formed through extended family members (may include non-related individuals) that are not typically found in the mainstream culture.

 

General Barriers to Social Services

Racial and ethnic populations may face a number of problems (language, transportation, etc.) that may impede their access to social services. Individuals from racial/ethnic groups tend to under-utilize healthcare, prenatal care, mental healthcare, and substance abuse treatment, or they seek them as a last resort. Treatment may be sought only when the resources of the traditional family support network have been exhausted. At this point, problems may be so chronic and severe that treatment outcomes may be poor.

The individual’s economic status may be a deterrent to the purchase of services. Racial/ethnic populations are not only more likely to have lower incomes than those of the mainstream population but to be less insured.   For example, the US Bureau of Census (1997) indicated Hispanics were the most likely group to have no health insurance.   In 1997, approximately 30% of the total US population received health insurance via Medicare or Medicaid.

Those needing social services may live in areas where access to providers is limited because of distance or transportation problems. Also, those with access may often find services that are inadequate or inconveniently scheduled. Others may not realize they are eligible or may not be aware of what services a local program offers.   Many social services providers are not able to address the specific needs of individuals from cultural backgrounds different from their own, even when they speak the client’s language of origin. This is further compounded when trying to develop written material for linguistic and culturally diverse populations.   Issues such as literacy levels and regional differences (different dialects) need to be taken into account when developing written program material.

Beliefs and attitudes regarding health and illness may act as obstacles keeping racial and ethnic populations from seeking treatment for social problems.   The literature on health and mental health has identified a number of factors that contribute to the underutilization of services. For example, reliance on folk remedies may cause some underutilization of medical services. Cultural stigmas attached to psychiatric care, psychotherapy, counseling may invoke fear of losing status and of being judged a failure by the family and the community, and, thereby, contribute to underutilization.   Cultures differ in their characterization and acceptance of abnormal behaviors. For example, what is considered abnormal behavior in one culture may be accepted or encouraged in another.   For example, the practice of voodoo may be accepted in one group and scorned in other groups. Abnormal behaviors may be attributed to physical or psychological causes, or they may be viewed as the direct result of supernatural or spiritual factors.

Emergency rooms often serve as primary care providers for members of racial and ethnic minority groups in urban areas. Individuals with long-standing social problems are more susceptible to serious medical problems and are more likely to use emergency rooms. However, emergency rooms often are unable to provide appropriate referrals to social services or to provide the follow-up to assure appropriate care is provided.

Regardless of the services required, racism on an institutional or individual level can be a significant barrier to effective treatment. Institutional racism within a service organization is evident when the program design is oblivious to the racial, cultural, or ethnic backgrounds, values, and mores of its client population. Latent prejudices on the part of the staff, as well as language and cultural differences,  undermine efforts to help patients achieve recovery.

A community in social and economic turmoil may reject social service providers who are outsiders. Negative experiences with providers who may have lacked respect, awareness, or concern for cultural differences often reinforce unfavorable attitudes and distrust. For example, some treatment programs may be rendered ineffective if the community has not been involved in their planning and implementation.

 

Cultural Competence

The importance of culture increases in individuals living in a socio-cultural setting other than the one they came from. Also, for those who have not experienced socio-cultural change, cultural issues may come to the forefront in interactions with individuals who do not share the same culture of origin. Such encounters prompt the realization that different cultures view the world in different ways. A way to help bridge those differences is through the acquisition of knowledge about other cultures. Cultural knowledge enhances the understanding of different views and also helps to develop more effective problem-solving strategies.

A cultural competency program is one that demonstrates sensitivity and understanding of cultural differences. It is a fundamental ingredient that helps to develop trust, as well as an understanding of the way members of different cultural groups,  define health, illness, and health care. Consequently, culture is a set of academic and interpersonal skills that allow individuals to increase their understanding and an appreciation of cultural differences and similarities within, among, and between cultural/ethnic groups.

A culturally competent social service provider recognizes and utilizes the client’s strengths, values, and experiences while encouraging behavioral and attitudinal change. Culturally responsive services generally focus on the following:

  • Knowledge of the client’s native language
  • Sensitivity to the cultural mores of the client population
  • Staff background similar to clients
  • Treatment/services modalities that include values of the client population
  • Representation of the client population in decision-making and policy implementation.

It has been recommended that cultural competency programs need to implement cultural competence at all levels: Policy, structure, attitude, staff, and policy. Stated slightly differently, culturally competent systems include professional behavioral norms that are built into the organization’s mission, structure, personnel, and program design and treatment modalities.

Cultural competence also infers the willingness of professionals and the programs they operate to conduct self-appraisals to develop an understanding of how they may differ from the clients they serve. Cultural competence also entails the acknowledgment of existing inherent cultural biases on one’s attitude and behavior. A provider’s discomfort in relating to individuals who are different can be communicated in many non-verbal ways. Common factors that influence comfort include ethnic and racial characteristics, socioeconomic background, religion, and physical and mental handicaps. However, cultural competence requires communication that goes beyond language proficiency to focus on meanings and interpretations. Consequently, within a culturally competent framework, knowledge of cultural beliefs and expectations are necessary for effective communication.

The conceptualization of a continuum of cultural competence was developed by Georgetown University. It can be used to assess the level of cultural competence. It includes:  

  • CULTURAL DESTRUCTIVENESS: Attitudes, policies, and practices that are destructive to other cultures.
  • CULTURAL INCAPACITY: Lacks the capacity to help, but is not intentionally destructive.
  •  CULTURAL BLINDNESS: Attempts to treat all people as though they are alike. It infers that one’s color or culture does not matter.  Services are so culturally neutral; they are not relevant to anyone.
  • CULTURAL PRE-COMPETENCE: Individuals or agencies realize they have weaknesses in their cultural competence and attempts to improve. The risk at this stage is that token change may be accepted as sufficient.
  • CULTURAL COMPETENCE: Others are accepted and respected for their differences, and cultural knowledge is continually expanded. In program settings, staff who are committed to their particular culture are hired; staff is encouraged to become comfortable working in cross-cultural situations.
  • CULTURAL PROFICIENCY: Different cultures are held in high esteem: agencies and staff advocate and work to improve relationships among cultures throughout society.

The melting pot continues to blend people from all cultures into one people. I think the great American experiment has proven successful, as we have adopted the strengths of each culture into the mainstream culture. Again, we have made a lot of progress, but there remains a lot of work to be done.

 

Language Considerations

One of the greatest barriers to the acculturation of racial/ethnic groups into the American way of life is language. Most early immigrants that came to the U.S. did not speak, read, write, or understand spoken English. Fortunately, some of the more recent immigrants have a better command of the English language, but problems still exist, especially with low socioeconomic individuals who migrate to the US to avoid poverty and unemployment in their native country.  

The language barrier also extends into the workplace. For example, over half of US companies provide limited training material in languages other than English. It appears some progress is being made in this area in recent years and more written materials are becoming available in Spanish but seldom in other languages. There are also additional risks to the workforce due to the language barrier.

  • Non-English speaking (and reading) workers are at greater risk due to their inability to recognize hazardous operations.
  • Verbal commands or warnings often are misunderstood or not acted upon because of uncertainty.

Due to these factors and other considerations, OSHA requires that employers establish effective communication with non-English speaking workers. Again, some progress is being made, but there is a long way to go. One way an employer can bridge the gap is to recognize the need for the language interpreting and translation services. Employers may also hire and train bi-lingual staff and translate safety-sensitive documents into native languages. The employer may also provide cultural diversity training for all staff.

 

Professional Ethics and Boundary Issues

Boundaries are the framework within which the counseling relationship occurs.  Boundaries keep the relationship professional.  They set the parameters within which the client remains safe, and the treatment can be effective.  They also help to protect the clinician both emotionally and legally.

Having a strong ethical compass is critical to being a good counselor.  Are your boundaries consistent?  Do they waiver based on how you feel about the client or the situation?  Do they establish healthy relationships, enabling the client to experience personal growth?

Professional issues typically include personal disclosure, limits regarding the use of touch, the tone of the professional relationship both in treatment and with the chance meeting in public, fee setting, the projected length of sessions, the limits of the relationship, and ultimately end “all things ethical.” 

The primary concern in establishing and managing boundaries with each individual client must be the best interests of the client. Except for behaviors of a sexual nature or obvious conflict of interest activities, boundary considerations often are not clear-cut matters of right and wrong. Rather, they are dependent upon many factors and require careful thinking through all the issues, always keeping in mind the best interests of the client.

Many questions arise when navigating the counseling relationship.  Should a counselor date a former client? If they can date, how long should they wait after counseling has been terminated to have a relationship? Should the counselor terminate counseling if they begin to become interested in the client privately? Should a therapist accept a client’s gift?

The relationship outside of counseling, the acceptance of gifts, and the recognition of a previous or current client in public are examples of areas that could pose problems for both the therapist and the client.

Boundary issues also involve counselors and supervisors, both during academic years and post-graduation on into the workforce, as well as colleague situations. Should my aunt, as a licensed professional, be able to supervise my practicum as an intern? If my husband is a psychologist speaking for an association offering continuing education, should I be able to earn contact hours if I attend?

Most state boards and all national associations have bi-laws and regulations concerning the relationships between a counselor and a client, as well as a supervisor and a counselor. It is good counsel to make yourself aware of the regulations and then to steer clear of any inappropriate situations. It is also a best practice to make your clients aware of the general boundaries and why they exist such as, “please understand to protect your privacy, if I see you in public I will not acknowledge you in any way. This is not intended to offend you, but only to protect you.” This way, the client will not feel slighted should the event occur.

 

Dual Relationships with Clients

 In most friendships or marriages, the relationship bears some resemblance to a seesaw. I tell you my thoughts, and in turn, you tell me your thoughts. You know my faults, and I learn yours. There is a give and take of information that creates a balance. A therapist/client relationship is not balanced. By the nature of the relationship, one person is telling intimate details, feelings, and fears, and the other is not. This intimate knowledge creates the power that has to be handled professionally.  

A dual relationship exists when a therapist serves in the capacity of both the therapist and at least one other role with the same client. Most commonly, the second relationship is social, financial, or professional and maybe concurrent or subsequent to the therapeutic relationship. The American Psychological Association reports research citing that dilemmas arising from “blurred, dual, or conflicting relationships” were the second most frequent ethical dilemma noted. Dual relationships can also be a major basis for licensing disciplinary actions and ethics complaints against mental health professionals.

The Code of Ethics for the American Counseling Association (ACA) strongly advises avoidance of harmful dual relationships whenever possible:

Counselors are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of clients. Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. When a dual relationship cannot be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired, and no exploitation occurs. (ACA, 1995, Standard A. 6.a.)

The ethics code for the American Psychological Association states that multiple relationships may be unavoidable and recommends that therapists remain aware of the potentially harmful consequences. They recommend refraining from multiple relationships if harm may occur.

The ethics codes of the American Association of Marriage and Family Therapists, National Association of Social Workers, and the American Association of Pastoral Counselors recommend avoidance of multiple relationships that exploit or harm clients. All of the above codes strictly prohibit sexual activity between therapist and client. All but the AAPT code warns against superior/subordinate dual relationships, such as when a therapist has an administrative, supervisory, or evaluative role with a client.

A window into any relationship is only as clear as the participant’s insight. Most people see things from their point of view. Is it wise, with one participant in a more powerful position to enter into multiple types of relationships with someone?

Therapists can and should be concerned about any behavior on their part that may interfere with their ability to maintain a professional and therapeutic relationship with their clients. When roles get blurred as when the therapist and patient become personal friends, business partners, or become involved sexually, it often becomes impossible for the therapist to maintain professional objectivity. Dual relationships can erode and distort the professional nature of the therapeutic relationship. They may create conflicts of interest that compromise professional judgment or create situations where the therapist is engaged in meeting his or her own social, financial, or personal needs, rather than putting the welfare of the client foremost. Dual relationships can affect the current and future benefits of therapy.

Some of the clearest cut dual and boundary problems are therapists engaging in business ventures with patients or having sexual relationships with patients or former patients. It is clearly unethical, and in most states, therapists who have sexual relationships with clients violate the law, as well as ethical standards. But these overt situations are not the only type of dual relationships. Friendships, dating a client’s brother, or even being neighbors are also potentially hazardous situations.

The reality of potentially overlapping relationships and the effects of overlapping relationships make for a complicated decision-making process.  To determine if a relationship outside of the therapeutic realm is hazardous, a professional must explore several areas.

Circumstantial roles, those that occur by pure coincidence, such as running into a client at their sales job in the mall, are difficult to avoid. They are bound to occur, and this potential and how it is to be handled should be discussed in advance. As noted earlier: “If I see you in public, please do not be offended, but I will not approach or acknowledge you in any way to protect your confidentiality.”

Shifts in professional roles include difficulties that arise when a teacher or supervisor counsels a student. There is a clear potential for difficulty with this type of dual relationship. Personal and professional role conflicts include sexual or romantic, social, and peer-like relationships.   These personal and professional situations are fraught with danger.

Some professionals use their own comfort level to gauge whether they could successfully manage the overlapping relationship. The type and severity of the clients’ presenting problems are also used as an indicator when deciding to enter a dual relationship. Therapists are more likely to enter a dual relationship if the client is seeking problem-solving and would likely avoid a dual relationship with a client if they suspected a complex issue such as a personality disorder. Other therapists involve prospective clients in the decision-making process to decide if the benefits of entering into a dual relationship outweigh the risk. Keith Brownlee (1996) expresses that “Pivotal to any decision making based on the codes, are the two central principles, impaired objectivity, and risk of exploitation.

When a dual relationship exists, it is important to minimize the risks by engaging in ongoing consultation, setting clear expectations and boundaries, informed consent, documentation.

Physical Contact and Sexual Relationships with Clients

The achievement of trust is possible in a therapeutic relationship because there is no fear of losing “self” in establishing a connection with a therapist. Most clients come to the situation with a vulnerable self.   Intimacy for these individuals can easily lead to abuse if those with whom they relate prove untrustworthy.

Many therapeutic styles involve the healing touch. Hugging a client when they enter the office, holding their hand through difficult sessions or placing a hand on their shoulder when they are crying can all be ways of expressing interest and concern. They can connect and solidify the helping relationship. They can also be abused, misunderstood, and damaging. This issue forces counselors to examine the heart of the therapeutic process: the counseling relationship.

It is doubtful that most therapists set out to exploit their clients. When a counseling relationship turns into a romantic relationship, the professional will often say, I can’t help whom I fell in love with. This type of violation is more of a process than a single event.  Yet when professionals deny or remain unaware of their personal significance, power, or authority, they will begin the process of boundary violation. Any time a professional exploits a relationship to meet personal needs rather than the needs of the client, even if not consciously done, the boundaries have been crossed, and the professional is responsible.

There is a clear consensus among the professional associations that concurrent sexual and professional relationships are unethical and, in many states, also illegal. Many of the associations agree that a sexual relationship cannot later be converted into a therapeutic relationship.

Ethical codes vary in their requirements about the length of time that must pass for another “significantly different” relationship, especially a sexual one, to be permissible (Herlihy & Corey, 1992). Although most codes prohibit the counselor from having a sexual relationship with a current client, variation occurs in the prohibition of such a relationship with former clients and the length of time that must pass for such a relationship to be permissible (American Counseling Association, 1995; National Association of Alcoholism and Drug Abuse Counselors, 1995).

All the major professional associations agree that sexual contact less than two years after termination of the professional relationship is unethical. If a sexual relationship occurs after a two-year interval, the burden rests with the therapist to demonstrate that there has been no exploitation. Considerations include the amount of time that has passed since termination; nature and duration of therapy; circumstances surrounding termination; client’s personal history; client’s mental status, and any statements or actions by the therapist suggesting a romantic relationship after terminating the professional relationship.

There is disagreement among practitioners about whether a sexual relationship initiated after termination is ever ethical. Some maintain that “once a client, always a client.” The transference elements of the therapeutic relationship persist forever, and therefore, many professionals consider romantic relationships with former clients unethical.

After having various standards for a number of years, the American Psychiatric Association went from a “nearly never OK” standard to an absolute “never OK” standard.

The National Association of Social Workers code prohibits sex with former clients in section 1.09, but states that if a social worker claims an exception, the full burden is on them to demonstrate “…that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.” The codes also ban sexual contact with clients’ relatives or close personal friends where there is a potential to harm the client, but it is not clear whether this extends to a former clients’ relatives and friends.

The American Association for Marriage & Family Therapy has forbidden sex for 2 years after termination. This applies to either spouse or any family member who is seen in even a single session of marital or family therapy.

The American. Association for Pastoral Counseling has a prohibition of no sex for two years following termination of the counseling.

The American Psychological Association created an absolute prohibition for two years following termination of therapy. Even in relationships which begin after 2 years, the psychologist has the burden of showing there has been no exploitation, in light of “relevant factors, including (1) the amount of time that has passed since therapy terminated, (2) the nature and duration of the therapy, (3) the circumstances of the termination, (4) the patient’s or client’s personal history, (5) the patient’s or client’s current mental status, (6) the likelihood of adverse impact on the patient or client and others, and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the patient or client.”. A few standards are provided for terminating: unless precluded by the client’s conduct, “…the psychologist discusses the patient’s or client’s views and needs, provides appropriate pre-termination counseling, suggests alternative service providers as appropriate, and takes other reasonable steps to facilitate the transfer of responsibility to another provider if the patient or client needs one immediately.

The above-mentioned associations are not meant to be finite standards. It is recommended that each professional explore their association’s codes. State licensure laws or certification laws in each state may also include codes of conduct, which define the post-termination relationship with a former client or patient. Most codes adopt the ethical standards of the major national professional organization for that profession. However, in some states such as Florida, the standards may be more stringent. For example, the Board of Licensure of Psychologists in Florida has a rule that for the purpose of evaluating a case of therapist-client sex, the therapeutic relationship “…is deemed to exist in perpetuity.” This was the first “never OK” rule.

Although sexual relationships are clearly defined, there are many other forms of physical contact that many professionals utilize in their therapeutic modalities. Professionals have argued that the increased sensitivity to physical contact with clients inhibits counseling. In Neuro-Linguistic Programming, anchoring is done by applying gentle pressure to a part of the client’s body, such as the top of the knee. Reaching out to touch someone on the hand is a common gesture showing concern and support. It is difficult and sad to think an innocent gesture of support could be misunderstood or potentially hazardous.

Transference and countertransference can lead to harmful situations. Intense friendships that confuse the counseling or make the client unnecessarily dependent on the helper can be very damaging to a client.  Even romantic “game-playing” can be quite distracting and harmful. Even without overt sexual contact, boundary breakdowns can lead to damages similar to those seen when the relationship becomes sexual (Schoener et al., 1989, pp. 133-147; Simon, 1991) These damages can include:

  • The failure to render needed therapy — undermining what good work may have been done;
  •  Failure to refer for other services — the psychotherapist “hanging on” to the client and trying to provide for all of his or her needs;
  • Creation of unhealthy dependency which is difficult to resolve;
  • Confusing the client about what is therapy and what is personal;
  • Breach of trust — client distrusting professionals as a result of the corruption of the therapy;
  • In some instances, interference in family relationships, friendships, etc.
  • Anger, loss of self-esteem, depression, and other psychological distress.

 

To Prevent and Avoid Sexual Misconduct:

  1. Respect cultural differences and be aware of the sensitivities of individual clients.
  2. Do not use gestures, tone of voice, expressions, or any other behaviors which clients may interpret as seductive, sexually demeaning, or as sexually abusive.
  3. Do not make sexualized comments about a client’s body or clothing.
  4. Do not make sexualized or sexually demeaning comments to a client.
  5. Do not criticize a client’s sexual preference.
  6. Do not ask details of sexual history or sexual likes/dislikes unless directly related to the purpose of the consultation.
  7. Do not request a date with a client.
  8. Do not engage in inappropriate ‘affectionate’ behavior with a client such as hugging or kissing. Do offer appropriate supportive contact when warranted.
  9. Do not engage in any contact that is sexual, from touching to intercourse.
  10. Do not talk about your own sexual preferences, fantasies, problems, activities, or performance.
  11. Learn to detect and deflect seductive clients and to control the therapeutic setting.
  12. Maintain good records that reflect any intimate questions of a sexual nature and document any and all comments or concerns made by a client relative to alleged sexual abuse, and any other unusual incident that may occur during the course of, or after an appointment.

Self-Disclosure 

 

How much of themselves, if anything, should effective counselors reveal to clients? Does self-disclosure by the therapist help the therapeutic process or interfere with clients’ needs? Self-Disclosure, to some degree, is almost a universal behavior for counselors to use with the clients. Up to 70% of therapists have used some degree of self-disclosure in their practice. 

Even therapists who are uncomfortable with the idea of talking about themselves during sessions often believe that it is impossible for a therapist to be completely anonymous to their clients. After all, everything the psychologist says or does is revealing in some way to the patient. Further, an over-emphasis on this can be troubling or even damaging to the client. The client may begin to feel self-conscious about his or her own revelations or feel judged or disliked by the therapist.

A research study reported in The Journal of Consulting and Clinical Psychology supports appropriate self-disclosure. Researchers from the University of Pennsylvania’s Center for Psychotherapy Research studied clients and therapists-in-training who had randomly been asked to make revelations about themselves during the course of therapy or not. The study authors found that the clients whose therapists were willing to talk about themselves or offer opinions felt more secure in the counseling process and liked their therapists better than participants whose therapists were not offering any information about themselves. The therapist’s use of self-disclosure demystifies both the therapist and the client. It allows more of the client’s essence to come out and allows the interaction to become more of a dialogue.

In a group setting, group leaders can use self-disclosure, just like other members of the group, to become part of the genuine flow of communication. They openly share their thoughts and feelings in a thoughtful and accountable manner, respond to others authentically, and acknowledge or refute motives and feelings attributed to them. They can demonstrate respect for the feedback group members offer them.

Appropriate Self-disclosure is done for the purpose of helping the client.  Some common situations in which a therapist would be justified in making a self-disclosure include:

  •         The disclosure is made for the purposes of the patient, not the therapist.
  •         The disclosure is that type that should be made to a patient with a certain type of disorder.  For example, if a patient is suffering from depression, the disclosure that the therapist had suffered from depression in the past might help the patient by giving him insight into the fact that a person suffering from depression can get past it. 

Ultimately, the appropriateness of a therapist’s self-disclosure comes down to the question of whether it was made with the patient’s best interests at heart.

Excessive therapist self-disclosure, however, is the most common boundary violation. Although it does not always lead to, it is also a frequent precursor to sexual involvement with clients, as well as a number of other therapeutic mistakes. 

Disclosing personal information can seem very natural and, as noted, can be helpful to the client and the therapeutic process. It can be done with the intent to show that the client is not alone in their specific situation or to encourage positive behaviors.

Therapist self-disclosure is problematic when it involves:

  • Disclosing current personal needs or problems
  • Disclosure as a common, rather than a rare event, during sessions
  • Disclosing things not clearly connected to the client’s problems or experiences, or not clearly things which would be likely to encourage or support client
  • Self-disclosure is not only frequent but uses up more than a few minutes in a session.
  • Self-disclosure occurs despite apparent client confusion or romantization

Sound Decision Making With Boundaries

One of the easiest gauges to use to determine if you are making good boundary decisions is to ask yourself, how would I feel if I woke up tomorrow morning, and this was broadcast on the front page of the Newspaper in my hometown? David, A Therapist in Walnut Cove, Was Supervised During His Practicum For Licensure By His Aunt Who Is Also In The Industry. If the thought of this headline being read by your colleagues, neighbors, friends, and family doesn’t leave you with a confident feeling, then it probably is not a secure boundary decision. Don’t do anything that you would not want to see on the front page of the newspaper.

A second way to explore the relationship is to look for ways that this could jeopardize the counseling and the client. For example, you are seeing Jessica, who is nine years old and very upset over her parents pending divorce. Her mother has brought her in for regular sessions for 4 months. On one afternoon, her father comes to pick her up after her session, and sparks ignite between the two of you. It is likely not in the best interest of Jessica for the counselor with whom she has been trusting with her broken family to begin dating her father, who is divorcing her mother. Ask yourself, can I potentially see how this could negatively affect my client?

As seen the decision-making process is at times set in place by associations and state laws, always should be in agreement with our morals and by who we want to be and be seen as, and many times a gray area that each professional must navigate by how they feel about the situation. Many professionals feel differently based on the circumstances. In a national survey of psychologists, psychiatrists, and social workers, Borys (1988) found how the comfort levels break down in the following areas:

The professionals were asked if they would:

                                                           Never     Few     Several     Many       All

Accept a gift under $10:

19.5%

 

53%

 

10.4%

Accept an invitation to the client’s special event:

50%

22%

3.4%

 

 

Becoming friends after termination:

65%

23%

3.3%

 

 

Treating an employee:

57%

12.8%

3%

 

 

Disclose their own stresses to the client:

59%

26.8%

9.7%

1.3%

 

Invite to open house:

50%

5.7%

6.7%

2.7%

3.4%

 

Beyond the specifics set forth in an association code or state licensing law, the counselor is left to navigate the waters. Ultimately though, make no mistake; it is the counselor’s responsibility to cause no harm to the client. The counselor is the sound, stable, professional in the scenario.

Emotional and Dependency Needs

It is crucial for a counselor to maintain a good awareness of their own emotional and dependency needs so as to not reverse the therapeutic process for their own gain.

Using excessive self-disclosure, romantic encounters-whether brought to fruition or just perpetuating a client’s flirtation out of your own desire to be flattered, or financial dealings that can be seen as exploitations is in opposition to the true goals of therapy.

It is a very dangerous power position to be in if the therapist cannot see
how he is getting his own needs met by using his position. The use of ongoing supervision can be effective here. 

Professional Distance

To be a successful counselor, an individual needs good personal boundaries, as well. This means allowing clients to be responsible for their own decisions and actions and allowing them to experience the consequences. Professional distance does not mean that a counselor should be cold and uninvolved, but it is important the client works as hard as the counselor and the client own the issue. Burn out in the mental health field is a major issue. Over involvement on an emotional level can cause therapists to lose their objectivity. They cannot exercise proper judgment in their dealings with those with whom they are seeking to help. There are many steps in establishing health professional distance to explore a few:

  • Allow clients to participate in identifying the goals of treatment.
  • Identify resources in the community that meets specific needs for the clients so that the client can benefit from several support systems such as community projects and church groups with similar interests.
  • Help clients to accurately evaluate their options and to see progress-establish benchmarks for measuring growth.
  • Help clients develop strategies for handling problems outside of and between sessions.
Therapeutic Styles  

People who grow up in dysfunctional families tend to believe they are not allowed to have personal boundaries. This personal boundary, essentially the line that divides me from you, has been debated for decades by the different treatment modalities. Freud, although he thought that a therapist should be a blank slate and should refrain from any self-disclosure, was known to take patients on vacation to analyze them.  D. W. Winnicott had patients living with him as part of their treatment.

Research has failed to show that practice style is the major issue in boundary breakdowns. Some who practice modalities that frown upon self-disclosure end up having sexual relations with their clients, and some who use touch techniques never have issues.

Dynamics Which Make Psychotherapy a Potential Setting for Boundary Violations and Exploitation        

Many clients come into therapy, vulnerable, confused, and in need. Without clear boundaries, I can’t tell what is your stuff and what is mine. Maintaining this line is essential to effective work. However, keeping a clear line between the client and the counselor is not easy.

Some of the reasons for the difficulty include:

  • Therapy involves a fiduciary relationship with unequal power, especially early in the relationship. The therapist sets all the rules, and the therapy is conducted in private, so there is little accountability.
  • Transference
  • Wishes for nurturance can emerge and be quite powerful
  •  Rescue fantasies — the countertransference trap of doing a better job than someone’s parents or previous therapist/counselor;
  • Fantasy that love, or sex, is curative in and of themselves
  • Repression or disavowal of anger at client’s persistent thwarting of your therapeutic efforts
  • It is a fertile ground for acting out anger at the organization, supervisor, etc.
  • Defense against grief and mourning at termination;
  • It is an unreal world — the “exception” fantasy
  • Cultural myth that the “right woman” can fix the most disordered man

Supervisory Oversight 

Some areas which require self-awareness and watchfulness by ones’ supervisors or consultants include:

  • Obvious therapist distress or upset
  • Therapeutic drift — shifting style and approach to a given client
  • Lack of goals and reflection on progress in therapy
  • Therapy which exceeds normal length for a client of that type in the particular therapist’s practice.
  • Exceeding areas of competence, reluctance or unwillingness to refer for other types of therapy, assessment, etc.
  • Unwise techniques:
  • Routine hugs
  • Face to face, intimate hugs
  • Excessive touch
  • Sessions in a non-traditional setting when this isn’t necessary
  • Adult clients on lap
  • Routine or common socializing with clients
  • Excessive self-disclosure by the therapist
  • Direct intervention in the client’s life
  • Becoming enmeshed in a client’s life — treating close friends or family members
  • Unique vulnerabilities:
    • Attraction
    • Over-identification with client
    • Uniquely similar family dynamics
    • Divorce or loss in the therapist’s life
    • Identity disturbance in the therapist

Public opinion and courts have to lead the way. Therapists can and have been sued for malpractice when their treatment leads to harming their patients, and one of the most common causes of malpractice is therapists having sexual relations with patients and former patients.

Nowadays, virtually every professional discipline has ethical codes, which cover boundary issues and most expressly prohibit sexual relations with patients.  

In order to establish a helping relationship, the individual in need must relinquish some level of control to create trust.  The client or patient’s trust rests on the assumption that the professional will operate within the context of the client’s need.   When the client expects this and projects an aura of sanctity onto the professional, the client’s vulnerability becomes a key factor in the relationship.   This is the reason that a client (adult or teen, male or female) is not considered morally and legally culpable if an illicit relationship develops between the two.  It remains incumbent upon the professional to set the limits of the relationship.

The key to dealing with these issues? Know who you are; know your strengths and weaknesses, and commit to using your strengths (power) in service to others.  Find ways outside of the therapeutic process of having your personal needs for intimacy met appropriately.  No spouse or best friend can meet all your needs, but perhaps a cluster of persons with whom you share a reciprocal relationship can.  No one seeking your help in a professional role should be meeting your needs for receiving care.

 

Laws and Rules Specific to Florida

FLORIDA CHAPTER 397

SUBSTANCE ABUSE SERVICES

Problem use or abuse of alcohol or other drugs have a profound effect both on the individual, as well as the community Substance abuse impairment is a disease that affects the whole family and the whole society and requires a system of care that includes prevention, intervention, clinical treatment, and recovery support services that support and strengthen the family unit. Further, it is the intent of the Legislature to require the collaboration of state agencies, service systems, and program offices to achieve the goals of this chapter and address the needs of the public; to establish a comprehensive system of care for substance abuse, and to reduce duplicative requirements across state agencies. Chapter 397 is designed to provide for abuse services.                                                                                                                                                                                                                                                                The recovery business is a highly regulated one. We will explore an overview of Chapter 397 and the Marchmen Act in this course; however, if you are operating a program or work regularly at this end of the industry, we recommend you read the statutes with care and in their totality. Staffing requirements, levels of care, marketing services, and client rights are very clearly defined in the statutes, as well as on a national level, and they can be confusing.

It is the goal of the Legislature to discourage substance abuse by promoting healthy lifestyles; healthy families; and drug-free schools, workplaces, and communities. With regard to those in the mental health field, chapter 397 strives for a comprehensive continuum of accessible and quality substance abuse prevention, intervention, clinical treatment, and recovery support services in the least restrictive environment which promotes long-term recovery while protecting and respecting the rights of individuals, primarily through community-based private, not-for-profit providers working with local governmental programs involving a wide range of agencies from both the public and private sectors.

These regulations are written to address identified needs, delivered without discrimination, and with adequate provision for specialized needs. It is the intent of the Legislature to provide an alternative to criminal imprisonment for substance abuse impaired adults and juvenile offenders by encouraging the referral of such offenders to service providers not generally available within the juvenile justice and correctional systems, instead of or in addition to criminal penalties.

Having an extra bedroom or two and a degree does not make you able to receive and treat those in need of services.  Chapter 397 states that the Department has the responsibility to designate addictions receiving facilities for the purpose of ensuring that only qualified service providers render services within the context of a secure facility setting.

To move forward, let’s establish some definitions, particularly focusing on those related to treatment and levels of care.

Addictions receiving facility is a secure, acute care facility that provides, at a minimum, detoxification, and stabilization services; is operated 24 hours per day, 7 days per week; and is designated by the department to serve individuals found to be substance use impaired as described in s. 397.675, who meet the placement criteria for this component.

Authorized agent of the department means a person designated by the department to conduct any audit, inspection, monitoring, evaluation, or other duty imposed upon the department pursuant to this chapter. An authorized agent must be qualified by expertise and experience to perform these functions.

Beyond the safe management capabilities of the service provider refers to an individual who is in need of:

(a) Supervision;

(b) Medical care; or

(c) Services,

beyond that which the service provider or service component can deliver.

Clinical assessment means the collection of detailed information concerning an individual’s substance use, emotional and physical health, social roles, and other areas that may reflect the severity of the individual’s abuse of alcohol or drugs. The collection of information serves as a basis for identifying an appropriate treatment regimen.

Day or night treatment is a service provided in a nonresidential environment with a structured schedule of treatment and rehabilitative services.

Day or night treatment with community housing means a program intended for individuals who can benefit from living independently in peer community housing while participating in treatment services for a minimum of 5 hours a day for a minimum of 25 hours per week.

Detoxification is a service involving subacute care that is provided on an inpatient or an outpatient basis to assist individuals to withdraw from the physiological and psychological effects of substance abuse and who meet the placement criteria for this component.

Intensive inpatient treatment includes a planned regimen of evaluation, observation, medical monitoring, and clinical protocols delivered through an interdisciplinary team approach provided 24 hours per day, 7 days per week, in a highly structured, live-in environment.

Intensive outpatient treatment is a service that provides individual or group counseling in a more structured environment, is of higher intensity and duration than outpatient treatment, and is provided to individuals who meet the placement criteria for this component.

Medication-assisted treatment for opiate addiction is a service that uses methadone or other medication as authorized by state and federal law, in combination with medical, rehabilitative, and counseling services in the treatment of individuals who are dependent on opioid drugs. 

Outpatient treatment is a service that provides individual, group, or family counseling by appointment during scheduled operating hours for individuals who meet the placement criteria for this component.

Residential treatment is a service provided in a structured live-in environment within a non-hospital setting on a 24-hours-per-day, 7-days-per-week basis, and is intended for individuals who meet the placement criteria for this component.

Medication-assisted treatment (MAT) is the use of medications approved by the United States Food and Drug Administration, in combination with counseling and behavioral therapies, to provide a holistic approach to the treatment of substance abuse.

Medical monitoring means oversight and treatment, 24 hours per day by medical personnel who are licensed under chapter 458, chapter 459, or chapter 464, of individuals whose sub-acute problems are so severe that the individuals require intensive inpatient treatment by an interdisciplinary team.

Qualified professional means a physician or a physician assistant licensed under chapter 458 or chapter 459; a professional licensed under chapter 490 or chapter 491; an advanced registered nurse practitioner having a specialty in psychiatry licensed under part I of chapter 464; or a person who is certified through a department-recognized certification process for substance abuse treatment services and who holds, at a minimum, a bachelors degree. A person who is certified in substance abuse treatment services by a state-recognized certification process in another state at the time of employment with a licensed substance abuse provider in this state may perform the functions of a qualified professional as defined in this chapter but must meet certification requirements contained in this subsection no later than 1 year after his or her date of employment.

Screening means the gathering of initial information to be used in determining a persons need for assessment, services, or referral.

Secure facility except where the context indicates a correctional system facility, means a provider that has the authority to deter the premature departure of involuntary individuals whose leaving constitutes a violation of a court order or community-based supervision as provided by law. The term secure facility includes addictions receiving facilities and facilities authorized by local ordinance for the treatment of habitual abusers.

Service provider or provider means a public agency, a private for-profit or not-for-profit agency, a person who is a private practitioner, or a hospital licensed under this chapter or exempt from licensure under this chapter.

Substance abuse programs and services or drug control applies generally to the broad continuum of prevention, intervention, clinical treatment, recovery support initiatives, efforts to limit substance abuse, and initiatives and efforts by law enforcement agencies to limit substance abuse.

 

STATEWIDE DRUG POLICY COUNCIL

The Statewide Drug Policy Advisory Council was created to establish and institutionalize a rational process for long-range planning, information gathering, strategic decision-making, and funding for the purpose of limiting substance abuse. The council endeavors to combat substance abuse with a comprehensive, integrated, and multidisciplinary approach.

The advisory council determines the most effective means of establishing clear and meaningful lines of communication between the advisory council and the public and private sectors. They review and make recommendations to the Governor and Legislature substance abuse laws, funding, research, programs, and services. They assist communities and families in pooling their knowledge and experiences with respect to the problem of substance abuse.

 

TREATMENT BASED DRUG COURT PROGRAMS

Each county may fund a treatment-based drug court program under which persons in the justice system assessed with a substance abuse problem will be processed in such a manner as to appropriately address the severity of the identified substance abuse problem through treatment services tailored to the individual needs of the participant.

Drug court programs integrate alcohol and other drug treatment services with justice system case processing. Using a non-adversarial approach, prosecution and defense counsel promote public safety while protecting participants due process rights. Entry into any pretrial treatment-based drug court program must be voluntary. Entry into any post adjudicatory treatment-based drug court program as a condition of probation or community control must be based upon the sentencing courts assessment of the defendants criminal history, substance abuse screening outcome, amenability to the services of the program, total sentence points, the recommendation of the state attorney and the victim, if any, and the defendants agreement to enter the program.

Eligible participants are identified early and promptly placed in the drug court program. Drug court programs provide access to a continuum of alcohol, drug, and other related treatment and rehabilitation services. Abstinence is monitored by frequent testing for alcohol and other drugs.

The treatment-based drug court programs must include therapeutic jurisprudence principles and adhere to the following 10 key components:

  • Drug court programs integrate alcohol and other drug treatment services with justice system case processing.
  • Using a non-adversarial approach, prosecution and defense counsel promote public safety while protecting participants due process rights.
  • Eligible participants are identified early and promptly placed in the drug court program.
  • Drug court programs provide access to a continuum of alcohol, drug, and other related treatment and rehabilitation services.
  • Abstinence is monitored by frequent testing for alcohol and other drugs.
  • A coordinated strategy governs drug court program responses to participants’ compliance.
  • Ongoing judicial interaction with each drug court program participant is essential.
  • Monitoring and evaluation measure the achievement of program goals and gauge program effectiveness.
  • Continuing interdisciplinary education promotes effective drug court program planning, implementation, and operations.
  • Forging partnerships among drug court programs, public agencies, and community-based organizations generates local support and enhances drug court program effectiveness.

ADDICTION PROFESSIONALS

Certification for addiction professionals in the state of Florida is offered through the Florida Certification Board.  The board has a Code of Ethics for its certified members, and the first principle is that Addiction Professionals will conform to applicable local, state, and federal laws. It is unlawful for any person or agency to act as a substance abuse service provider unless it is licensed or exempt from licensure under Chapter 397 of the Florida Statutes.

397.403 begins the directives for anyone or agency that would like to make an application as a provider.

Substance abuse programs operated directly or under contract by the department, the Department of Corrections, the Department of Juvenile Justice, any other state agency, or any local correctional agency or authority, which programs constitute any service provider licensable components as defined in this chapter, are subject to licensure and regulation in accordance with rules jointly developed by the department and the state or local agency operating the program unless otherwise exempt.

 

COST OF SUBSTANCE ABUSE SERVICES

In an effort to protect the client, the following directives cover the issue of costs of substance abuse services:

(1) Before accepting an individual for admission and in accordance with confidentiality guidelines, both the full charge for services and the fee charged to the individual for such services under the provider’s fee system or payment policy must be disclosed to each individual or his or her authorized personal representative, or parent or legal guardian if the individual is a minor who did not seek treatment voluntarily and without parental consent.

(2) An individual or his or her authorized personal representative, or parent or legal guardian if the individual is a minor, is required to contribute toward the cost of substance abuse services in accordance with his or her ability to pay unless otherwise provided by law.

(3) The parent, legal guardian, or legal custodian of a minor is not liable for payment for any substance abuse services provided to the minor without parental consent pursuant to s. 397.601, unless the parent, legal guardian, or legal custodian participates or is ordered to participate in the services, and only for the substance abuse services rendered. If the minor is receiving services as a juvenile offender, the obligation to pay is governed by the law relating to juvenile offenders.

(4) Service providers that do not contract for state funds to provide substance abuse services, as defined in this chapter, may establish their own admission policies regarding provisions for payment for services. Such policies must comply with other statutory and regulatory requirements governing state or federal reimbursements to a provider for services delivered to individuals. As used in this subsection, the term contract for state funds does not include Medicaid funds.

(5) Service providers that contract for state funds to provide substance abuse services as defined in this chapter must establish a fee system based upon an individuals ability to pay and, if space and sufficient state resources are available, may not deny an individual access to services solely on the basis of the individual’s inability to pay.

All owners, directors, and chief financial officers of service providers are subject to level 2 background screening, as provided under chapter 435. Inmate substance abuse programs operated directly or under contract with the Department of Corrections are exempt from this requirement.

All service provider personnel who have direct contact with children receiving services or with adults who are developmentally disabled receiving services are subject to level 2 background screening as provided under chapter 435.

Each service provider must ensure:

(a) Sufficient numbers and types of qualified personnel on duty and available to provide necessary and adequate safety and care.

(b) Adequate space for each individual served within a residential facility.

(c) Adequate infection control, housekeeping, and sanitation.

(d) Adequate disaster planning policies and procedures.

(2) The State Fire Marshal shall, in cooperation with the department, establish and enforce minimum fire safety standards, which standards must be included in the rules adopted by the department.

CLIENT RIGHTS

As treatment providers, it is our responsibility to ensure that clients know and understand their rights.  Clients receiving substance abuse services from any service provider are guaranteed protection of the following rights taken verbatim from the Florida Legislature:

(1)  RIGHT TO INDIVIDUAL DIGNITY.–The The individual dignity of the client must be respected at all times and upon all occasions, including any occasion when the client is admitted, retained, or transported. Substance abuse clients who are not accused of a crime or delinquent act may not be detained or incarcerated in jails, detention centers, or training schools of the state, except for purposes of protective custody in strict accordance with this chapter. A client may not be deprived of any constitutional rights.

(2)  RIGHT TO NONDISCRIMINATORY SERVICES.–

(a)  Service providers may not deny a client access to substance abuse services solely on the basis of race, gender, ethnicity, age, sexual preference, human immunodeficiency virus status, prior service departures against medical advice, disability, or number of relapse episodes. Service providers may not deny a client who takes medication prescribed by a physician access to substance abuse services solely on that basis. Service providers who receive state funds to provide substance abuse services may not provided space and sufficient state resources are available, deny a client access to services based solely on the inability to pay.

(b)  Each client in treatment must be afforded the opportunity to participate in the formulation and periodic review of his or her individualized treatment or service plan to the extent of his or her ability to so participate.

(c)  It is the policy of the state to use the least restrictive and most appropriate services available, based on the needs and the best interests of the client and consistent with optimum care of the client.

(d)  Each client must be afforded the opportunity to participate in activities designed to enhance self-image.

(3)  RIGHT TO QUALITY SERVICES.–

(a)  Each client must be delivered services suited to his or her needs, administered skillfully, safely, humanely, with full respect for his or her dignity and personal integrity, and in accordance with all statutory and

regulatory requirements.

(b)  These services must include the use of methods and techniques to control aggressive client behavior that poses an immediate threat to the client or to other persons. Such methods and techniques include the use of restraints, the use of seclusion, the use of time-out, and other behavior management techniques. When authorized, these methods and techniques may be applied only by persons who are employed by service providers and trained in the application and use of these methods and techniques. The department must specify by rule the methods that may be used and the techniques that may be applied by service providers to control aggressive client behavior and must specify by rule the physical facility requirements for seclusion rooms, including dimensions, safety features, methods of observation, and contents.

(4)  RIGHT TO COMMUNICATION.–

(a)  Each client has the right to communicate freely and privately with other persons within the limitations imposed by service provider policy.

(b)  Because the delivery of services can only be effective in a substance abuse free environment, close supervision of each client’s communications and correspondence is necessary, particularly in the initial stages of treatment, and the service provider must therefore set reasonable rules for telephone, mail, and visitation rights, giving primary consideration to the well-being and safety of clients, staff, and the community. It is the duty of the service provider to inform the client and his or her family if the family is involved at the time of admission about the provider’s rules relating to communications and correspondence.

(5)  RIGHT TO CARE AND CUSTODY OF PERSONAL EFFECTS OF CLIENTS.–A client has the right to possess clothing and other personal effects. The service provider may take temporary custody of the client’s personal effects only when required for medical or safety reasons, with the reason for taking custody and a list of the personal effects recorded in the client’s clinical record.

(6)  RIGHT TO EDUCATION OF MINORS.–Each minor client in a residential service component is guaranteed education and training appropriate to his or her needs. The service provider shall coordinate with local education agencies to ensure that education and training is provided to each minor client in accordance with other applicable laws and regulations and that parental responsibilities related to such education and training are established within the provisions of such applicable laws and regulations. Nothing in this chapter may be construed to relieve any local education authority of its obligation under law to provide a free and appropriate education to every child.

(7)  RIGHT TO CONFIDENTIALITY OF CLIENT RECORDS.–

(a)  The records of service providers which pertain to the identity, diagnosis, and prognosis of and service provision to any individual client are confidential in accordance with this chapter and with applicable federal confidentiality regulations and are exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution. Such records may not be disclosed without the written consent of the client to whom they pertain except that appropriate disclosure may be made without such consent:

  1. To medical personnel in a medical emergency.

  2. To service provider personnel if such personnel need to know the information in order to carry out duties relating to the provision of services to a client.

  3. To the secretary of the department or the secretary’s designee, for purposes of scientific research, in accordance with federal confidentiality regulations, but only upon agreement in writing that the client’s name and other identifying information will not be disclosed.

  4. In the course of review of records on service provider premises by persons who are performing an audit or evaluation on behalf of any federal, state, or local government agency, or third-party payor providing financial assistance or reimbursement to the service provider; however, reports produced as a result of such audit or evaluation may not disclose client names or other identifying information and must be in accord with federal confidentiality regulations.

  5. Upon court order based on application showing good cause for disclosure. In determining whether there is good cause for disclosure, the court shall examine whether the public interest and the need for disclosure outweigh the potential injury to the client, to the service provider-client relationship, and to the service provider itself.

(b)  The restrictions on disclosure and use in this section do not apply to communications from provider personnel to law enforcement officers which:

  1. Are directly related to a client’s commission of a crime on the premises of the provider or against provider personnel or to a threat to commit such a crime; and

  2. Are limited to the circumstances of the incident, including the client status of the individual committing or threatening to commit the crime, that individual’s name and address, and that individual’s last known whereabouts.

(c)  The restrictions on disclosure and use in this section do not apply to the reporting of incidents of suspected child abuse and neglect to the appropriate state or local authorities as required by law. However, such restrictions continue to apply to the original substance abuse client records maintained by the provider, including their disclosure and use for civil or criminal proceedings which may arise out of the report of suspected child abuse and neglect.

(d)  Any answer to a request for a disclosure of client records which is not permissible under this section or under the appropriate federal regulations must be made in a way that will not affirmatively reveal that an identified individual has been, or is being diagnosed or treated for substance abuse. The regulations do not restrict a disclosure that an identified individual is not and never has been a client.

(e)1.  Since a minor acting alone has the legal capacity to voluntarily apply for and obtain substance abuse treatment, any written consent for disclosure may be given only by the minor client. This restriction includes, but is not limited to, any disclosure of client identifying information to the parent, legal guardian, or custodian of a minor client for the purpose of obtaining financial reimbursement.

  1. When the consent of a parent, legal guardian, or custodian is required under this chapter in order for a minor to obtain substance abuse treatment, any written consent for disclosure must be given by both the minor and the parent, legal guardian, or custodian.

(f)  An order of a court of competent jurisdiction authorizing the disclosure and use of confidential information is a unique kind of court order. Its only purpose is to authorize a disclosure or use of client identifying information which would otherwise be prohibited by this section. Such an order does not compel disclosure. A subpoena or a similar legal mandate must be issued in order to compel disclosure. This mandate may be entered at the same time as, and accompany, an authorizing court order entered under this section.

(g)  An order authorizing the disclosure of client records may be applied for by any person having a legally recognized interest in the disclosure which is sought. The application may be filed separately or as part of a pending civil action in which it appears that the client records are needed to provide evidence. An application must use a fictitious name, such as John Doe or Jane Doe, to refer to any client and may not contain or otherwise disclose any client identifying information unless the client is the applicant or has given a written consent to disclosure or the court has ordered the record of the proceeding sealed from public scrutiny.

(h)  The client and the person holding the records from whom disclosure is sought must be given adequate notice in a manner which will not disclose client identifying information to other persons, and an opportunity to file a written response to the application, or to appear in person, for the limited purpose of providing evidence on the statutory and regulatory criteria for the issuance of the court order.

(i)  Any oral argument, review of evidence, or hearing on the application must be held in the judge’s chambers or in some manner which ensures that client identifying information is not disclosed to anyone other than a party to the proceeding, the client, or the person holding the record, unless the client requests an open hearing. The proceeding may include an examination by the judge of the client records referred to in the application.

(j)  A court may authorize the disclosure and use of client records for the purpose of conducting a criminal investigation or prosecution of a client only if the court finds that all of the following criteria are met:

  1. The crime involved is extremely serious, such as one which causes or directly threatens the loss of life or serious bodily injury, including but not limited to homicide, sexual assault, sexual battery, kidnapping, armed robbery, assault with a deadly weapon, and child abuse and neglect.

  2. There is a reasonable likelihood that the records will disclose information of substantial value in the investigation or prosecution.

  3. Other ways of obtaining the information are not available or would not be effective.

  4. The potential injury to the client, to the physician-client relationship and to the ability of the program to provide services to other clients is outweighed by the public interest and the need for the disclosure.

(8)  RIGHT TO COUNSEL.–Each client must be informed that he or she has the right to be represented by counsel in any involuntary proceeding for assessment, stabilization, or treatment and that he or she, or if the client is a minor, his or her parent, legal guardian, or legal custodian, may apply immediately to the court to have an attorney appointed if he or she cannot afford one.

(9)  RIGHT TO HABEAS CORPUS.–At any time, and without notice, a client involuntarily retained by a provider, or the client’s parent, guardian, custodian, or attorney on behalf of the client, may petition for a writ of habeas corpus to question the cause and legality of such retention and request that the court issue a writ for the client’s release.

(10)  LIABILITY AND IMMUNITY.–

(a)  Service provider personnel who violate or abuse any right or privilege of a client under this chapter are liable for damages as determined by law.

(b)  All persons acting in good faith, reasonably, and without negligence in connection with the preparation or execution of petitions, applications, certificates, or other documents or the apprehension, detention, discharge, examination, transportation, or treatment of a person under the provisions of this chapter shall be free from all liability, civil or criminal, by reason of such acts.

In addition to these rights, it is also required that prior to accepting a client for admission both the full charge for services and the fee charged to the client for such services under the provider’s fee system or payment policy must be disclosed to each client or his or her authorized personal representative, or parent or legal guardian if the client is a minor who did not seek treatment voluntarily and without parental consent. It is also noted that a client or his or her authorized personal representative, or parent or legal guardian, if the client is a minor, is required to contribute toward the cost of substance abuse services in accordance with his or her ability to pay unless otherwise provided by law. The parents of a minor are not responsible for payment of services if the minor presents for treatment without parental consent unless required by law, or the parent or guardian takes part in treatment.

 

VOLUNTARY ADMISSION FOR SUBSTANCE ABUSE TREATMENT

A person who wishes to enter treatment for substance abuse may apply to a service provider for voluntary admission.

Within the financial and space capabilities of the service provider, a person must be admitted to treatment when sufficient evidence exists that the person is impaired by substance abuse, and the medical and behavioral conditions of the person are not beyond the safe management capabilities of the service provider.

The service provider must emphasize admission to the service component that represents the least restrictive setting that is appropriate to the person’s treatment needs.

The disability of minority for persons under 18 years of age is removed solely for the purpose of obtaining voluntary substance abuse impairment services from a licensed service provider, and consent to such services by a minor has the same force and effect as if executed by an individual who has reached the age of majority. Such consent is not subject to later disaffirmance based on the minority.

Except for purposes of law enforcement activities in connection with protective custody, the disability of minority is not removed if there is an involuntary admission for substance abuse services, in which case parental participation may be required as the court finds appropriate.

 

INVOLUNTARY ADMISSION FOR SUBSTANCE ABUSE TREATMENT

What can someone do when a person doesn’t see what he or she is in need of?  Involuntary admission to a treatment program is appropriate when  there is good faith reason to believe the person is substance abuse impaired and, because of such impairment:

1) Has lost the power of self-control with respect to substance use; and either

(2)(a) Has inflicted, or threatened or attempted to inflict, or unless admitted is likely to inflict, physical harm on himself or herself or another; or

(b) Is in need of substance abuse services and, by reason of substance abuse impairment, his or her judgment has been so impaired that the person is incapable of appreciating his or her need for such services and of making a rational decision in regard thereto; however, mere refusal to receive such services does not constitute evidence of lack of judgment with respect to his or her need for such services.

Service providers have certain responsibilities regarding involuntary admissions.

It is the responsibility of the service provider to ensure that a person who is admitted to a licensed service component meets the admission criteria specified in s. 397.675. They must ensure that the medical and behavioral conditions of the person, as presented, are not beyond their safe management capabilities. They must provide the least restrictive available setting that is responsive to the person’s treatment needs.

They have restrictions on the census, and they must verify that this admission will not result in excess of their licensed service capacity. The service provider must determine whether the cost of services is within the financial means of the person or those who are financially responsible for the persons care, They must take all necessary measures to ensure that each individual in treatment is provided with a safe environment, and to ensure that each individual whose medical condition or behavioral problem becomes such that he or she cannot be safely managed by the service component is discharged and referred to a more appropriate setting for care.

When, in the judgment of the service provider, the person who is being presented for involuntary admission should not be admitted because of his or her failure to meet admission criteria, because his or her medical or behavioral conditions are beyond the safe management capabilities of the service provider, or because of a lack of available space, services, or financial resources to pay for his or her care, the service provider must attempt to contact the referral source, which may be a law enforcement officer, physician, parent, legal guardian if applicable, court and petitioner, or other referring party, to discuss the circumstances and assist in arranging for alternative interventions.

When the service provider is unable to reach the referral source, the service provider must refuse admission and attempt to assist the person in gaining access to other appropriate services, if indicated.

Upon completing these efforts, the service provider must, within one workday, report in writing to the referral sources, in compliance with federal confidentiality regulations:

1. The basis for the refusal to admit the person, and

2. Documentation of the service provider’s efforts to contact the referral source and assist the person, when indicated, in gaining access to more appropriate services.

When, in the judgment of the service provider, the medical conditions or behavioral problems of an involuntary individual become such that they cannot be safely managed by the service component, the service provider must discharge the individual and attempt to assist him or her in securing more appropriate services in a setting more responsive to his or her needs. Upon completing these efforts, the service provider must, within 72 hours, report in writing to the referral source, in compliance with federal confidentiality regulations:

(a) The basis for the individual’s discharge; and

(b) Documentation of the service provider’s efforts to assist the person in gaining access to appropriate services.

Upon giving his or her written informed consent, an involuntarily admitted individual may be referred to a service provider for voluntary admission when the service provider determines that the individual no longer meets involuntary criteria.

A client involuntarily admitted to a licensed service provider may only be released by a qualified professional. Notice of the release must be provided to the applicant in the case of an emergency admission or an alternative involuntary assessment for a minor, or to the petitioner and the court if the involuntary assessment or treatment was court-ordered.

In the case of a minor, the release must be:

(1) To the individual’s parent, legal guardian, or legal custodian or the authorized designee thereof;

(2) To the Department of Children and Family Services pursuant to s. 39.401; or

(3) To the Department of Juvenile Justice pursuant to s. 984.13.

A parent, legal guardian, or legal custodian who seeks involuntary admission of a minor is required to participate in all aspects of treatment as determined appropriate by the director of the licensed service provider.

 

PROTECTIVE CUSTODY WITHOUT CONSENT

Avery is enjoying spring break! Laying on the beach drinking beer all day, then hanging out at the motel’s bar all evening. Staggering down the sidewalk and in and out of traffic, Avery meets Officer Notonmywatch. The Officer suggests to Avery that he drive him to a detox facility. Avery refuses and yells at the officer. Officer Notonmywatch takes Avery into protective custody. How long can the officer keep Avery in protective custody?

 

Answer: 72 hours.

Frequently, a person under the influence is not in the best frame of mind to protect themselves or others.  In a circumstance such as this, an officer may need to place the person in a safe environment with or without their consent.

A person in circumstances which justify protective custody may consent to be assisted by a law enforcement officer to his or her home, to a hospital, or to a licensed detoxification or addictions receiving facility, whichever the officer determines is most appropriate.

 If a person in circumstances which justify protective custody fails or refuses to consent to assistance and a law enforcement officer has determined that a hospital or a licensed detoxification or addictions receiving facility is the most appropriate place for the person, the officer may, after giving due consideration to the expressed wishes of the person:

(a)  Take the person to a hospital or to a licensed detoxification or addictions receiving facility against the person’s will but without using unreasonable force; or

(b)  In the case of an adult, detain the person for his or her own protection in any municipal or county jail or other appropriate detention facility. 

Such detention is not to be considered an arrest for any purpose, and no entry or other record may be made to indicate that the person has been detained or charged with any crime. The officer in charge of the detention facility must notify the nearest appropriate licensed service provider within the first 8 hours after detention that the person has been detained. It is the duty of the detention facility to arrange, as necessary, for transportation of the person to an appropriately licensed service provider with an available bed. Persons taken into protective custody must be assessed by the attending physician within the 72-hour period and without unnecessary delay, to determine the need for further services.

The nearest relative of a minor in protective custody must be notified by the law enforcement officer, as must the nearest relative of an adult unless the adult requests that there be no notification.

Once a client no longer meets the involuntary admission criteria or a 72 hour period has elapsed the client must be released by a qualified professional.  The client may also consent to remain voluntarily in treatment.  A client may only be retained in protective custody beyond the 72-hour period when a petition for involuntary assessment or treatment has been initiated.

EMERGENCY ADMISSION FOR SUBSTANCE ABUSE ISSUES

In the event a person meets the criteria for involuntary admission in s.397.675 they can be admitted to a hospital or to a licensed detoxification facility or addictions receiving facility for emergency assessment and stabilization, or to a less intensive component of a licensed service provider for assessment only.  Once at the facility it is necessary to obtain a  physician’s certificate and the completion of an application for emergency admission.

The following persons may request an emergency admission:

(1)  In the case of an adult, the certifying physician, the person’s spouse or guardian, any relative of the person, or any other responsible adult who has personal knowledge of the person’s substance abuse impairment.

(2)  In the case of a minor, the minor’s parent, legal guardian, or legal custodian.

Time Frames for Emergency Admissions:

Within 72 hours after an emergency admission to a hospital or licensed detoxification or addictions receiving facility, the client must be assessed by the attending physician to determine the need for further services. Within 5 days after an emergency admission to a nonresidential component of a licensed service provider, the client must be assessed by a qualified professional to determine the need for further services. Based upon that assessment, a qualified professional of the hospital, detoxification facility, or addictions receiving facility, or a qualified professional if a less restrictive component was used, must either:

(1)  Release the client and, where appropriate, refer the client to other needed services;

       or

(2)  Retain the client when:

(a)  The client has consented to remain voluntarily at the licensed provider; or

(b)  A petition for involuntary assessment or treatment has been initiated, the timely filing of which authorizes the service provider to retain physical custody of the client pending further order of the court.

An addiction receiving facility may also admit a minor for involuntary assessment and stabilization when requested by the minor’s parent, guardian, or legal custodian. The minor must meet the criteria for involuntary admission in s. 397.675. Within 72 hours after the involuntary admission of a minor, the minor must be assessed to determine the need for further services. Assessments must be performed by a qualified professional. If, after the 72-hour period, it is determined by the attending physician that further services are necessary, the minor may be kept for a period of up to 5 days, inclusive of the 72-hour period.

 

ASSESSMENT OF MINORS

In addition to protective custody, emergency admission, and involuntary assessment and stabilization, an addictions receiving facility may admit a minor for involuntary assessment and stabilization upon the filing of an application to an addiction receiving facility by the minors parent, guardian, or legal custodian. Within 72 hours after the involuntary admission of a minor, the minor must be assessed to determine the need for further services. Assessments must be performed by a qualified professional. If, after the 72-hour period, it is determined by the attending physician that further services are necessary, the minor may be kept for a period of up to 5 days, inclusive of the 72-hour period.

An application for alternative involuntary assessment for a minor must establish the need for immediate involuntary admission and contain the name of the minor to be admitted, the name and signature of the applicant, the relationship between the minor to be admitted and the applicant, and factual allegations with respect to:

  • The reason for the applicant’s belief that the minor is substance abuse impaired; and

  • The reason for the applicant’s belief that because of such impairment, the minor has lost the power of self-control with respect to substance abuse; and either:

  • The reason the applicant believes that the minor has inflicted or is likely to inflict physical harm on himself or herself or others unless admitted; or

  • The reason the applicant believes that the minor’s refusal to voluntarily receive substance abuse services is based on judgment so impaired by reason of substance abuse that he or she is incapable of appreciating his or her need for such services and of making a rational decision regarding his or her need for services.

A minor who has been assessed must, within the time specified, be released or referred for further voluntary or involuntary treatment, whichever is most appropriate to the needs of the minor.

 

INVOLUNTARY ASSESSMENT AND STABILIZATION FOR SUBSTANCE ABUSE

Ruth’s husband would not initiate an emergency admission for Ruth’s alcohol and heroin addiction. As her therapist, you want her to undergo an assessment and stabilization in a detoxification facility or hospital. Although Ruth refused your suggestion, you filed a petition with the court. If the petition is granted, how long may Ruth be detained at the detoxification facility or hospital under involuntary assessment and stabilization?

Answer: 5 days

A person determined by the court to appear to meet the criteria for involuntary admission under s. 397.675 may be admitted for a period of 5 days to a hospital or to a licensed detoxification facility or addictions receiving facility, for involuntary assessment and stabilization or to a less restrictive component of a licensed service provider for assessment only upon entry of a court order or upon receipt by the licensed service provider of a petition.

Involuntary assessment and stabilization may be initiated by the submission of a petition to the court.

(1)  If the person upon whose behalf the petition is being filed is an adult, a petition for involuntary assessment and stabilization may be filed by the respondent’s spouse or guardian, any relative, a private practitioner, the director of a licensed service provider or the director’s designee, or any three adults who have personal knowledge of the respondent’s substance abuse impairment.

(2)  If the person upon whose behalf the petition is being filed is a minor, a petition for involuntary assessment and stabilization may be filed by a parent, legal guardian, legal custodian, or licensed service provider.

A licensed service provider may admit a client for involuntary assessment and stabilization for a period not to exceed 5 days. The client must be assessed without unnecessary delay by a qualified professional. If an assessment is performed by a qualified professional who is not a physician, the assessment must be reviewed by a physician prior to the end of the assessment period.

 

Extension of time for completion of involuntary assessment and stabilization:

If the involuntary assessment and, if necessary, stabilization is not completed within 5 days a written request for an extension of time may be requested.  The additional time is not to exceed 7 days after the date of renewal.  This can be accomplished through the court system with or without a hearing depending upon circumstances. The original court order authorizing the involuntary assessment and stabilization, or a request for an extension of time to complete the assessment and stabilization that is timely filed pursuant to this section, constitutes legal authority to involuntarily hold the client for a period not to exceed 10 days in the absence of a court order to the contrary.

 

DISPOSITION AFTER INVOLUNTARY ASSESSMENT 

When it is appropriate based upon the involuntary assessment the qualified professional or facility must:

 (1)  Release the client and, where appropriate, refer the client to another treatment facility or service provider, or to community  services;

(2)  Allow the client, if the client has consented, to remain voluntarily at the licensed provider; or

(3)  Retain the client when a petition for involuntary treatment has been initiated, the timely filing of which authorizes the service provider to retain physical custody of the client pending further order of the court. 

The disposition of the client who was assessed involuntarily must be provided to the petitioner and to the court within the regulations of confidentiality.

 

INVOLUNTARY TREATMENT FOR SUBSTANCE ABUSE ISSUES

In the event an individual meets the criteria for involuntary admission provided in s. 397.675 and:

(1)  Has been placed under protective custody pursuant to s. 397.677 within the previous 10 days;

(2)  Has been subject to an emergency admission pursuant to s. 397.679 within the previous 10 days;

(3)  Has been assessed by a qualified professional within 5 days;

(4)  Has been subject to involuntary assessment and stabilization pursuant to s. 397.6818 within the previous 12 days; or

(5)  Has been subject to alternative involuntary admission pursuant to s. 397.6822 within the previous 12 days.

Involuntary treatment is not to exceed 60 days.  When the conditions justifying involuntary treatment no longer exist, the client must be released as provided in s. 397.6971. This includes when a client no longer meets the criteria for involuntary treatment and has given their informed consent to be transferred to a voluntary status or if the client was admitted on the belief that they were a danger to themselves or others and this threat no longer exists.  When the conditions justifying involuntary treatment are expected to exist after 60 days of treatment, a renewal of the involuntary treatment order may be requested pursuant to s. 397.6975 prior to the end of the 60-day period. The court may renew the involuntary treatment order, however, the period is not to exceed 90 days.