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The Ethics of Substance-Abuse Issues
5/1/2007
Rhonda Williams, Ed.D., LPC, NCC
Tuesday May 01, 2007
by: Rhonda Williams, Ed.D., LPC, NCC

Section: Inside Insight


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Considering the fact that approximately 19.5 million Americans consider themselves illegal substances users and 22 million Americans are coping with substance-abuse dependency issues, it’s a given that most professional school counselors will work with this issue more than once in their careers. Countless students at all age levels are affected by substance abuse in some form or another – either their own, a family member’s or a friend’s. Arguably, dealing with substance abuse may be one of a school counselor’s most difficult ethical concerns. Its metaphoric equivalent is like walking down the Yellow Brick Road, never knowing for sure if you’re on the right path heading toward the Emerald City or if you’re about to run into the flying monkeys.

Every case is difference, and there aren’t any definitive road maps leading to the best route to take when counseling students with drug or alcohol issues. However, there are standard ethical road blocks to consider in every case. Because dealing with substance use and abuse issues is unpredictable, school counselors must rely on an ethical decision-making model to guide them through the interventions necessary to help the students.

The ethical literature provides many types of decision-making models. One in particular is Solutions To Ethical Problems in Schools (STEPS), outlined in ASCA’s “School Counseling Principles: Ethics and Law,” by Carolyn Stone. This nine-step, school-specific method involves:

1. Defining the problem emotionally and intellectually
2. Applying the ASCA and ACA ethical codes and the legal issues
3. Considering the student’s chronological and developmental levels
4. Considering the setting, parental rights and minor’s rights
5. Applying the moral principle
6. Determining a potential course of action and its consequences
7. Evaluating the selected action
8. Consulting with peers
9. Implementing the selected course of action

As you work through this or other ethical decision-making models, you must take appropriate ethical and legal issues into consideration. These issues include informed consent, confidentiality, parents’ rights, students’ rights, duty to report and danger to others.

Informed consent: The purpose of informed consent is to meet the moral obligation of respect and autonomy for the person with whom your working. By giving the student information about the counseling process and the limitations and purpose of that process, you provide the student with the opportunity to chose whether to continue the counseling or not.

Certainly you must take the student’s developmental and cognitive capacity factors into account when discussing the limitations of confidentiality and informed consent. Obviously the younger the student, the simpler your language must be. Also take into consideration whether the student is intoxicated, has had long-term impact from drug use or any other factor that might impair his or her understanding of the intention of the counseling process. Be sure to provide enough information in an understandable manner, but don’t overwhelm for the student.

Also keep in mind that given the risk-taking behaviors and impulsivity of drug and alcohol abusers, those students might underestimate the risks in self-disclosure.

When should you present informed consent? Most likely, you’ll base this decision on previous interactions with the student, developmental age, need for relationship building or the possibility of imminent danger. You don’t want to scare away the student by introducing informed consent too quickly. On the other hand, you also don’t want to be caught in the middle of a counseling session with a student only to realize the issue may be turning toward the possibility of disclosure.

Confidentiality: Confidentiality when working with minors can be a tricky situation, and the road becomes even rockier when the issue is substance use or abuse. Each state has different laws and regulations regarding confidentiality and privilege, including confidentiality for minors. The ground rules for your state are invaluable and necessary information, including those issues regarding addiction and rehabilitation.

As with informed consent, be sure to explain confidentiality in a manner the student can comprehend. If you want to maintain the student’s trust, you must make every effort to make sure students believe you will keep conversations confidential whenever possible. If you must breach confidentiality, it’s possible students may take their confidences elsewhere, possibly to an unreliable or destructive resource. If you’ve already discussed the boundaries of confidentiality with the student, it will be easier to proceed should you need to breach that confidentiality.

On occasion, critical information may have been shared that leads to mandated reporting to protect the student or others. Again, consider a developmental approach when helping students understand the reason why disclosure is necessary. You may need to them understand the consequences for not reporting the information. If possible, consider involving students in the disclosure process, which may help them feel more empowered. Whatever the reason for the disclosure, you’ll need a well-thought-out plan for disclosure.

Making the decision to disclose confidential information is a difficult professional and personal choice. If the worst were to happen, however, taking action to protect the student would be a more defensible course than to have done nothing at all.

Parents’ rights vs. child’s rights: Nothing can take a faster turn into an ethical dilemma than the debate between parents’ rights and the child’s rights. When dealing with substance use and abuse, there remains controversy over whose rights we should be protecting. In “Ethical and Legal Issues in School Counseling,” Coll says, “When referring a student to outside agencies, the client’s written consent, not parental consent, is needed.” The Office for Substance Abuse Programs, in its “Legal Issues for Alcohol and Other Drug Use Prevention and Treatment Programs Serving High-Risk Youth,” indicates that even students under the age of majority have the right to refuse consent in sharing their substance abuse information including information from a school-based alcohol and drug treatment or after-care program.

However, it wise to understand that the laws are nebulous regarding this topic of confidentiality of minors and the rights of parents where substance abuse is concerned. Generally speaking, confidentiality for a minor is given to the parents or guardians until the child attains majority age. Different states have different laws about age of majority and child’s rights vs. the parents’ rights. Evaluate the parent/child relationship and the relationship between parent and school counselor before making decisions regarding the breach of confidentiality.

Think About This
Consider this scenario: An eight-year-old boy has to call 911 because his mother is passed out and not breathing. She is transported to the hospital due to a prescription drug overdose, leaving the boy alone. Although this isn’t the first time this has happened, the boy doesn’t want his mom to know he shared the information with you. What should you do with this information?

Using the STEPS decision-making model, what would you need to consider in making an ethical decision in this example?

• Define the problem emotionally and intellectually. Things to consider: The danger posed to the child, the relationship between the child and the mother
• Apply the ethical codes. Things to consider: Confidentiality of child, of mom, child in need of care.
• Consider the developmental and chronological factors. Things to consider: Is the eight year old alone, or are there younger or older siblings?
• Consider the parent’s rights vs. the child’s rights. Things to consider: The knowledge of the parent being transported by ambulance is technically covered under the confidentiality of HIPPA.
• Apply the moral principles. Things to consider: nonmaleficence – to do no harm to the student
• Determine the possible courses of action. Things to consider: Should social services be involved or other resources that breach the mom’s confidentiality?
• Evaluate the selected action. Things to consider: What will the relationship between you and the student be like if you report?
• Consult and document. Things to consider: possibly presenting this as a hypothetical situation to Department of Human Services to get some ideas.
• Implement the course of action: Things to consider: Always error on the side of doing what is best for the child.

Duty to report: The majority of all state laws and professional association ethical standards have provisions for breaching confidentiality for a child in imminent danger. One of the few areas in which most agencies, governing bodies and practitioners agree is that confidentiality can’t be maintained when imminent danger exists. While substance use and abuse can be an antecedent to imminent danger, it can also mask level and immediacy of the danger. You’ll need to decide for yourself what actually constitutes imminent danger in the case of substance abuse. Is the student taking meth in imminent danger? Is the student sharing needles for drug use in imminent danger?

It is the school counselor’s ethical duty to report, refer and include family in the safety plan. Although confidentiality is the cornerstone to a counseling relationship, it is by far better to lose the relationship with the student than to lose the student’s life. Family involvement and referral may be the very interventions that will preempt the downward spiral of a child in imminent danger. 

While trying to determine the student’s safety, also consider the safety of the school environment. You can’t risk the school’s safety or that of another individual to maintain confidentiality.

Consider the case of the pregnant teen. She has told you she is planning to keep her baby. However, you are also aware of her use of methamphetamines and alcohol. Would the unborn child be considered in imminent danger? Is the teen in imminent danger? Let’s walk through this case using the STEPS ethical decision-making model.

• Define the problem emotionally and intellectually. Things to consider: The illegal use of drugs and danger to the student and her child.
• Apply the ethical codes: Things to consider: Confidentiality of the student as a minor, her parents’ legal rights.
• Consider the student’s chronological and developmental levels. Things to consider: Have the drugs affected her developmental capacity?
• Consider the setting, parental rights and student’s rights. Things to consider: The rights of the student, the parents and the unborn child.

Apply the moral principles. Things to consider: What beneficence issues arise in promoting the good for others in this scenario?

• Determine a potential course of action. Things to consider: Contacting social services or parents.
• Evaluate the action. Things to consider: The damage to the relationship with the student and/or the parents
• Consult with peers and document. Things to consider: What resources might you reach out to? Document the decision-making process that you went through.
• Implement the plan with the support of your consultant and your ethical decision making.

Danger to others: Students threatening or implying danger to others, whether in a drug-induced state or not, require immediate action despite confidentiality issues. In this arena the expectations are less convoluted. ASCA ethical code A.7. is clear regarding danger to others in that school counselors “inform parents/guardians or appropriate authorities when the student’s condition indicates a clear and imminent danger to the student or others.”

Although immediate disclosure may be necessary, it doesn’t mean you can’t advocate for the student in some capacity. Trying to maintain some type of connection with the student through a referral process may serve the counseling relationship well when the student returns to the school.

Consider this scenario: A high school student, who has missed several days of school, bursts into your office and lies down on the floor. Clearly under the influence, the student describes his past several days on the street taking many types of drugs. His parents kicked him out of the house, and he hasn’t eaten in three days. He is irrational and has threatened to kill you if you tell anyone. Although the threat seems more drug-induced than real, what safety, legal and ethical steps to you take? 

• Define the problem emotionally and intellectually. Things to consider: The safety of student and staff.
• Apply the ethical codes and the legal issues. Things to consider: Level of danger to self or others.
• Consider the student’s chronological and developmental levels. Things to consider: Level of cognitive capacity at the current time.
• Consider the setting, parental rights and minor’s rights. Things to consider: Immediate disclosure to security, administration without further jeopardizing your own safety.
• Apply the moral principle. Things to consider: Loyalty and fidelity to the student, staying connected with the student despite the threats.
• Determine a potential course of action and its consequences.

Things to consider: Is there a possible overdose?

• Evaluate the selected action. Things to consider: Who and how to contact support for you and the student.
• Consult. Things to consider: After safety has been established, with whom do you consult in an effort to help this student?
• Implement the selected course of action.

Over the course of their careers, most school counselors will have some experiences dealing with substance abuse. Therefore, it’s imperative to evaluate your moral compass and get professional development in advance of dealing with this issue.

Students need a trusting relationship, especially when a substance use or abuse situation has made them so vulnerable. How to navigate this ethical and legal road is a difficult challenge for school counselors. The rules of the road aren’t clear and often are left up to the individual school counselor. Following an ethical decision-making model is the key to working through a complex situation. The bottom line is consultation and documentation. Working through each step of the decision-making model and documenting the decisions made will clearly indicate forethought and process-driven decision making.

Unfortunately we don’t always know which road to take for our students or ourselves. As the professionals assigned to guiding students through difficult times, it is up to our professional integrity to make sure we have established a structure for a substance use or abuse situation and have developed a plan that supports students who come to us with their life challenges.

Rhonda Williams, Ed.D., LPC, NCC, is an assistant professor at the University of Colorado in Colorado Springs and chair of ASCA’s Ethics Committee. She can be reached atrwilliams@uccs.edu.