“Ethical Violations: A Quantitative Study Comparing Human Service Professions”
by John Gallagher, MSW, LSW, CAC, LCDC (Texas)

 As the substance abuse treatment profession continues to gain momentum with the development of new evidenced-based practices and better medical knowledge, ethical practices also need to be revisited to assure that the best quality of care is being provided.  The topic of ethics needs to be examined further than just the basic terminology, laws, and ethical standards.  This does not imply that these areas of ethics are not important; rather it emphasizes the idea that educating professionals on ethics is not our only solution to reducing ethical violations.  “Ethical Violations: A Quantitative Study Comparing Human Service Professions” studies this need to gain a better understanding of ethical practice, specifically focusing on identifying personal and professional risk factors that place a professional at risk for an ethical violation.     

In 2007, the research project began by comparing the number of ethical violations in the substance abuse treatment profession to other human service professions.  The research project began in Pennsylvania and is scheduled to be completed nationally within a five year period.  The total number of ethical violations from 2003-2007 were examined for Certified Addiction Counselors (CAC and CAC Diplomate).  This information was then compared to the total number of ethical violations, from the same time period, of the comparison groups.  The compare groups consist of licensed professionals in Pennsylvania and include Licensed Psychologists, Licensed Social Workers (LSW and LCSW), Licensed Professional Counselors (LPC), and Licensed Marriage and Family Therapists (LMFT).    

This quantitative comparison concluded with several significant facts, two of which are highlighted below.  First, substance abuse treatment professionals have the highest rate of ethical violations among all other human service professionals.  Certified Addiction Counselors had a 12.4% higher rate of ethical violations compared to Licensed Social Workers, a 17.1% higher rate than Licensed Psychologists, an 18.8% higher rate than Licensed Professional Counselors, and a 26.3% higher rate than Licensed Marriage and Family Therapists.  Second, 84.6% of all ethical violations for substance abuse treatment professionals were for dual relationships and exploitation of patients, including sexual relationships with a current or former patient.  46.2% of the ethical violations for Certified Addiction Counselors from 2003-2007 were for dual relationships and 38.4% were for exploitation of patients.  As mentioned previously, this research is being completed nationally and the states that I am currently studying (Colorado, Maryland, and Texas) are showing similar statistics.  These similarities include dual relationships and sexual relationships with current or former patients as the highest violated ethical standard.

It is important to mention that the statistics presented are only preliminary outcomes and the research is an ongoing process.  At this time, there are many limitations to the research which include a limited understanding of the gender, age, educational level, and recovery status of the professionals who violated an ethical standard.  Also, this study provides a challenge to producing qualitative research, as it can be assumed that the professionals who committed the ethical violations of dual relationships and exploitation of patients are not willing to be interviewed on their view of the factors that contributed to the violation.  This can lead to the speculated interpretation of the statistics presented.  A final note to mention is that the total number of ethical violations for Certified Addiction Counselors from 2003-2007 was minimal compared to the total number of CAC’s and CAC Diplomate’s in Pennsylvania, which as of July 2008 was 1641.  Therefore, the statistics indicating an increased risk for ethical violations in the substance abuse treatment profession is targeted towards a small portion of professionals and not the profession as a whole. 

Upon examination of the data and the collective clinical experiences in the profession, it is suspected that one factor that contributes to this high-rate of ethical violations and boundary breaches with patients is the clash between two cultures - the 12-Step Culture and the Treatment Culture.  Although using the word clash to describe two cultures that have been working together since the rise of the profession may seem bizarre, it seems that there are differences in the philosophies of each culture that may contribute to increasing a professional’s risk for an ethical violation.    

It appears that substance abuse treatment professionals who practice a 12-Step program face unique challenges to providing ethical practice.  This does not imply that professionals who are in “recovery” do not or can not practice ethically, just that there are challenges he or she may face.  For example, the use of self-disclosure in 12-Step programs is highly encouraged, if not a core function of the program.  An example of this is Speaker Meetings in which a member of the 12-Step program self-discloses his or her “story” to the other members.  This is very appropriate in the 12-Step setting, but if a counselor would share his or her “story” during group therapy in a treatment setting this is considered poor practice and the non-therapeutic use of self-disclosure according to current best practices.    

Additionally, the 12-Step philosophy is formatted in dual relationships by getting a sponsor, showing signs of affection through hugging, and exchanging phone numbers.  Our ethics have taught us that exchanging phone numbers with a patient for the purpose of a dual relationship is a violation and sponsorship of a current or former patient is not appropriate.  Many substance abuse treatment agencies have embraced the use of hugging in their culture and the use of this technique can be appropriate at times; however, there is a risk for abuse of this technique.  Hugging is a sign of affection and if this behavior is initiated by the counselor and used frequently, this could be a sign of the counselor getting his or her own needs met and this may increase the risk for boundary breaches.  For members of the recovering community who work in the substance abuse profession, this can be a challenge to find balance between their role in recovery and their role as a professional. 

Outside consultation by two leaders in the area of ethics provides additional interpretation of the statistics.  Dr. Randall Basham, Ph.D., Professor of Social Work at The University of Texas at Arlington, and Dr. Michael Daley, Ph.D., Professor of Social Work at The University of South Alabama, shared their expertise on personal and professional risk factors that increase a professional’s risk for violating ethical standards.  This shared knowledge is provided to help develop a better understanding as to why the ethical violations for Certified Addiction Counselors are violations of patient boundaries and the long term theme of our profession, “Do No Harm.”  Listed below are the personal and professional risk factors that increase a professional’s risk for violating ethical standards:

1)       Limited knowledge of the code of ethics and why adhering to ethical guidelines are best practice

2)       Isolation

3)       Life crisis

4)       Limited social connectedness

5)       Non-therapeutic use of self-disclosure

6)       Limited availability or use of supervision

7)       Limited availability or use of case consultation

These seven identified risk factors highlight several needs for all substance abuse treatment professionals.  One of the primary needs is to have a solid support system, both personally and professionally.  Professionally, the use of supervision helps provide education, guidance, accountability, and support.  What is important is that agencies staff supervisors who are qualified and trained in the use of supervisory skills.  Personally, the use of an Employee Assistance Program (EAP) can support professionals as they manage the risk factors of isolation, life crisis, and limited social connectedness.  Agencies that provide EAP services to their staff and encourage the use of clinical and peer supervision provide a culture that is conducive to reducing ethical violations.  A final recommendation focuses on the need to thoroughly educate professionals on ethics.  It is essential that ethics trainings and supervision not just merely present the code of ethics, but also provide explanation as to why it is in the best interest of the patient population to adhere to the standards. 

Gathering the data for the research and facilitating the research has enabled me to consult nationally with many helpful professionals in our field and I welcome the opportunity to meet others by receiving your feedback on the research presented and your thoughts on the article.  I can be contacted at   jrgallagher@tarrantcounty.com.