Principles of Effective Treatment and Ethical Considerations

Question 1

Principles of effective treatment

Answer 1

1. No single treatment is appropriate for all individuals
2. Treatment needs to be readily available
3. Effective treatment attends to multiple needs of the individual, not just his or her drug use
4. An individuals treatment plan must be assessed continually & modified as necessary to ensure the plan meets the person’s changing needs
5. Remaining in treatment for an adequate period of time is crucial for treatment effectiveness
6. Counselling (individual or group) & other behavioural therapies are critical components of effective treatment for addiction
7. Medications are an important element of treatment, especially when combined with counselling & other behavioural therapies
8. Clients presenting with coexisting mental health & substance abuse should have both disorders treated in an integrated way.
9. Medical detoxification is only the first stage of treatment & by itself does little to change long-term drug use
10. Treatment does not need to be voluntary to be effective
11. Possible drug use during treatment must be monitored continuously
12. Treatment programs should provide assessment for blood borne viruses & other infectious diseases, & counselling to help modify or change behaviours that place the person or others at risk of infection.
13. Recovery can be a long term process & frequently requires multiple episodes of treatment

Question 2

Highlighted Principles of effective treatment

Answer 2

1. No single treatment is appropriate for all individuals
2. Effective treatment attends to multiple needs of the individual, not just his or her drug use
3. Remaining in treatment for an adequate period of time is crucial for treatment effectiveness
4. Treatment does not need to be voluntary to be effective

Question 3

Percentages of patients who relapse

Answer 3

Type 1 diabetes: 20-50% 
Drug Addiction: 40 to 60% 
Hypertension: 
50 to 70% 
Asthma: 50 to 70%

Question 4

Effectiveness of TreatmentComparison of Treatment approaches & matching

Answer 4

Are some treatments more effective than others?

Project MATCH (1997)
eight year period; 30 locations; 130 clinical professionals
12 step programs; CBT; MET (Motivational Interviewing)
few outcome differences, apart from the effect of Psychiatric Severity
without Dual Diagnosis more abstinent days following 12-step rather than CBT
but for those with DD this effect disappeared

Question 5

Criticisms of Project Match

Answer 5

Criticisms of Project Match (e.g. Glasser 1999; Heather 1999)
Eligibility criteria
Polydrug users excluded (except THC)
Too much focus on assessment and follow-up for research
interrupted usual therapy
All participants attended AA groups
the 12-step group just went to more
Abstinence was the determinant of success
No control group

Question 6

Major conclusions from Project Match:

Answer 6

Major conclusions from Project Match:
No superior treatment model exists
Therapist and therapeutic relationship (Bambling & King 2001)
No single treatment intervention is effective for all people
Matching treatments to clients is a complex but important process

Question 7

Glasser on Project Match

Answer 7

“Project MATCH… the Titanic of treatment outcome studies.

Like Project MATCH, the great ship was large, the largest man-made object to that point in history. It was complex; it generated enormous enthusiasm;

and it sank like a stone on its maiden voyage with great loss of life…”

Question 8

Miller & HesterInformed Eclecticism

Answer 8

“…future progress and practice should be directed to an informed eclecticism, an openness to a variety of approaches that is guided by scientific evidence.”

Question 9

Miller & Hester Informed Eclecticism 4 assumptions:

Answer 9

There is no single superior approach to Treatment (Rx) for all individuals
Rx programs/systems should be constructed with a variety of approaches that have been shown to be effective
Different individuals respond best to different Rx approaches, and
It is possible to match clients to optimal Rx, therefore increasing Rx effectiveness and efficiency

Question 10

Australian Treatment Outcomes Study (ATOS)

Answer 10

Australian Treatment Outcomes Study (ATOS)
Heroin users
Replacement; withdrawal; residential rehabilitation; non-Treatment control
3 and 12 month post entry follow-up

Treatment sample differed from general population
More PTSD, Depression, Borderline PD, and disability.
High suicide and overdose rate; criminality (Holt, Ritter, Swan and Pahoki, 2002)

Question 11

ATOS Outcomes

Answer 11

General functioning improved (Ross et al 2004)

Majority of participants abstinent for the 1 month prior to 12 month follow-up
65% Replacement
63% residential rehabilitation
52% withdrawal
25% non-Treatment control

Noticeable reduction in criminal behaviours, improved injection related health, decline in Depression

Question 12

Future directions

Answer 12

Research indicates a need to:

Improve understanding of dependence & withdrawal

Greater attention to the use of psychosocial interventions as primary & adjunct treatment

Consider significance of lifetime treatment history & how individual treatment episodes fit together to achieve recovery

Assess effectiveness & efficiency under typical circumstances

Assess effectiveness of treatment interventions with subgroups

Question 13

Ethics

Answer 13

To be a utilitarian means that you judge actions as right or wrong in accordance with whether they have good consequences. So you try to do what will have the best consequences for all of those affected.
Peter Singer

In the real world, 90% of the money spent on medical research is focused on conditions that are responsible for just 10% of the deaths and disability caused by diseases globally.
Peter Singer

Question 14

Ethics in AOD practice

Answer 14

Consider the many difficult decisions you may be faced with when working in the alcohol and drug field…
How might the illegality of drug use impact on your work?
What about working with drug using parents?
Or clients under 18?
When do you terminate treatment?

Question 15

Quote

Answer 15

“Addiction affects the lives of all human kind, either directly or indirectly. The cost to individuals and societies is immense and tackling the problem is as much one for policy makers as clinicians, counsellors and scientists. Ethical issues permeate much of the work of all these groups.”

Question 16

Levels of ethics?

Answer 16

Macro ethics (theory) Frameworks / theory

Meso ethics (applied) Procedural / guidelines

Micro ethics (applied) In practice

Question 17

Impact of ethics & values

Answer 17

Unique moral, ethical and legal issues
Unique risks to user and community balanced with therapeutic goals
Potential impact on the therapeutic relationship, clinician and clients reactions, and services offered
Who should have access to treatment? (esp. public)
Consent (intoxication, third party pressures)
Illegal behaviours and confidentiality limits
Minors
Harm reduction vs No Tolerance/Abstinence approaches
New horizons / challenges (e.g. EPS)

Question 18

Impact of ethics and values

Answer 18

Values and beliefs:
Different beliefs associated with different drugs
Differences between personal beliefs and evidence of harm
Based on personal experiences?
Stigmatisation of drug use often means clients have often experienced judgemental approaches and rejection in the past
Stigma is a barrier to accessing treatment

Question 19

Barriers for mental health professionals

Answer 19

Lack of familiarity with AOD issues
Belief that referral is most appropriate way to manage
Stereotyped beliefs of clients
difficult and chaotic (media influence)
focus on intoxication, non-compliance, likelihood of relapse, potential violence, and criminality
Views on how to manage relapse vary greatly
From supportive to judgemental
Concerns about lack of skills / providing ill informed service

Question 20

Ethical guidelines

Answer 20

No one code to guide decision making in the AOD field…
ADCA Code of ethics
Only a discussion paper… and appears to be unavailable now that ADCA has been “defunded” (http://www.atoda.org.au/policy/adca-defunded/)
APS Code of Ethics and Substance Use Position Paper (2009)
Unique to Psychology?
Individual services Code of Conduct, policy and procedures
Are these always based on ethical principles?
Legislation – eg Child Protection Act, Health Services Act, Drug Misuse Act
Is legislation always based on ethical principles?

Question 21

ADCA – Code of ethics Guiding principles

Answer 21

Equity and access
The client/worker relationship
Privacy and confidentiality
Training & professional development
Responsive services
Effective and efficient services
Reducing stress and workload issues
Community consultation and involvement
Ethics committee approval for research
Advocacy in public policy and public health outcomes

Question 22

When does it fall down?

Answer 22

Breaches in professional practice are most likely to occur:
When workloads are high
When staff are under significant stress
When client and clinician’s values are in conflict
Lack of defined policies, procedures and guidelines
Lack of supervision / support
Lack of professional development opportunities

Question 23

Case example

Answer 23

Ryan is a 15 year old male, presenting at a NSP.

He asks for a injecting equipment, saying he is going to be injecting amphetamines.

He said that he has been injecting himself for about 2 months and that he “always uses clean fits, cause I don’t want to get hep c”

Question 24

Ethical issues with ryan case

Answer 24

What are the ethical issues?

How do we decide what to do here?

Now imagine that you are at the end of an 8 hour night shift, and you’ve been having trouble sleeping for the last few nights
How might this affect your decision making?

Question 25

What do Psychologists do?

Answer 25

Duncan, Williams, and Knowles (2013)
Explored views of 264 Australian Psychologists
Case of a fifteen year old client using drugs and alcohol, and a number of other concerns
Asked when they would breach confidentiality for different drug types and use frequencies

Question 26

Application Benaroya (2004)

Answer 26

An applied ethics process, the goal of which is to reach consensus decisions on ethical challenges, through structured open discussion in a series of steps:

1) identify the practical ethical problem
2) identify the client’s individual context
3) identify the duty of care responsibilities of each staff member
4) identify the values staff consider essential to responding to the problem
5) identify any conflicting values
6) identify alternative solutions to the ethical conflicts identified
7) choose the consensus option best suited to the program objectives; and
8) provide justification for the choice.

Question 27

APS Guidelines on Confidentiality

Answer 27

1.Understand the legal context and the organisational requirements associated with confidentiality and limitations
e.g. Child safety requirements
2.Informed Consent
Prior to treatment, ensure clients are aware of the limitations of confidentiality
Consider the capacity of the person to provide consent (e.g. minors, intoxication, mandated clients etc…)
3.Only breach confidentiality when:
Consent exists to do so
There is a legal obligation to do so
There is an immediate and specified risk to an identified person that can be averted by the disclosure of confidential information
4.When disclosing information, only disclose what is needed to achieve the purpose of the disclosure and only to individuals who require the information
5.Where safety permits, psychologists inform clients:
if their information is to be disclosed;
about what information is to be disclosed;
of the circumstances and the reasons for the intended disclosure of information; and
to whom and when the disclosure is to be made.

Question 28

Case example

Answer 28

A 22 year old female client drives to the service you are working in for her second counselling appointment.
During the session you smell alcohol on her breath and she seems forgetful and clumsy.
Her BAL reading is 0.09. She is intending to drive home “I’m fine I do this all the time”; “I have the right to do what I want to do”; “let me go or I am never coming back here”

What would you do?

Question 29

Summary

Answer 29

There are well researched principles of effective treatment
No stand alone superior treatment option exists
Implement evidence based best practice
Treatment matched to client
Treatment should be maintained for 3 months or longer
Range of options (e.g. Counselling, medications)

A&D treatment services and the use of substances raise significant ethical issues that significantly impact on individuals, help seeking and treatment being offered
Several codes exist, however ethical decisions will still always be guided by individual circumstances and there are no ‘black or white’ answers
Ethical issues impact on clinician’s well being and conversely this affects decision making
Decision making processes and training/supervision is essential