Ethics in psychosocial interventions.

It is important for health professionals to have an ethical framework to help take decisions regarding psychosocial interventions in patients with addictive disorders. As patients with addictive disorders are vulnerable to unethical actions in the name of treatment, therapists need to aware of their role in delivering ethical care - not just in their own clinical practice but in the setting in which they deliver the interventions. This article aims to sensitize the health professional to the various arenas in which ethical challenges may arise.

INTRODUCTION

Ethical challenges arise when a health care intervention intended to help a patient is also associated with a possible negative fallout. This makes it important for health care professionals to have some kind of a framework to help balance the advantages versus disadvantages of an action, (or not taking an action), to enable ethical decision making. This article will focus on ethical issues in psychosocial interventions in addictive disorders. While some of these issues pertain to health care interventions in general- there are some ethical issues of particular relevance in interventions in addictive disorders- whether it is substance use- licit (like alcohol) or illicit (like cannabis) substance use or behavioural addictions (like gambling disorder).

Terminology

As this supplement is intended for health professionals from varied backgrounds, the term therapist will be used to denote the health professional. The term patient will be used, rather than client, as that better captures the nuances of the fiduciary nature of the therapist patient relationship (one in which the patient places trust in the therapist), and the intrinsic power imbalance in this relationship. And while addictions occur in all genders, for ease of reference ‘he’ will be used to denote the patient. Along the same line, the therapist will be denoted as 'she’.

Fundamental principles of medical ethics

The four principles which have been the bedrock of ethical decision making are listed below.1

1. Non maleficence- do no harm

While therapists may be alert to the risks or side effects of pharmacological interventions, it may be hard to imagine that psychosocial interventions could harm. An example of this would be if an untrained therapist tries to deal with domestic violence in a person with alcohol use. It needs training and great sensitivity to deal with this issue safely- while protecting the spouse from further violence, addressing the violence and attempting to change the behavior and attending to legal aspects.

2. Beneficence- to do good

Patients and family members are generally very vulnerable when they access help- especially if they do so in a crisis situation or after getting into legal problems. Any psychosocial intervention should be ‘evidence based’. A well trained therapist should be able to evaluate whether things are truly on track and the patient truly benefiting from the intervention. Objective evidence of better socio occupational functioning is a useful outcome measure. For example, in students an improvement in attendance would be a useful indirect marker.

3. Autonomy

The patient has a right to decide whether or not they will engage in a particular form of intervention, and when they want to stop. While one of greatest strengths in our culture is the role and support of family members, it should not mean that family members can override patient autonomy. Respecting the patient's autonomy is not just important from a human rights view, but from the reality that unless the patient truly wants to change behavior/stop or reduce use of substance- no psychosocial intervention can work.

4. Justice

Patients with addictive behaviour especially in certain settings like prison are vulnerable to abuse. If as a therapist one gets to know that this is happening, it would be important to counsel the patient on their right to make a complaint and facilitate additional support or legal help.

In another vein, when a patient with substance use in involved in a crime- it is important to support patient and family to face the consequences of the behaviour. If family members resort to ‘corrupt’ methods to ‘protect’ the patient- that would not only be unethical and illegal but a failed opportunity to motivate the patient to change behaviour.

The two additional principles which have been also highlighted by health workers are:

Dignity- respecting the dignity of both the patient and the therapist.

Honesty- Though may be uncomfortable at times, truthful communication to the patient is important, as trust is the cornerstone of an effective therapist patient relationship.

Some ethical challenges in addictive disorders

If one bears the ethical principles listed above in mind- it would be easier to understand the ethical issues which can arise in several contexts in psychosocial interventions in addictive disorders. Table 1.

Table 1

Contexts of ethical challenges in psychosocial interventions

a. Around the intervention

i. Evidence based

The document published in 2016 for field testing by the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO), emphasizes the need to ensure interventions in substance use be evidence based, especially in countries with limited resources2. This is an ethical and financial need, as patients and family members are vulnerable when they access help- especially when they come in a crisis situation. The document suggests that three criteria be met:

Evidence that the intervention leads to a reduction of substance use or risk of relapse

Evidence that the intervention leads to an improvement in physical, psychological and social wellbeing and functioning.

Evidence that there is reduction in the risks to health and social consequences from substance use.2

ii. Subject to audit and research

Unless interventions are subjected to scientific audit- it would be difficult to generate reliable evidence beyond anecdotal impressions. Any research done, should follow the Indian Council of Medical Research (ICMR) guidelines and subject to approval by the local Institutional Ethics Committee (IEC). Like with other research, issues like informed consent and confidentiality are important.

iii. Culturally relevant, acceptable and gender sensitive

As India is so culturally diverse, any intervention should be appropriate and acceptable to the local population, as well as gender sensitive. If group work is done, particular care should be taken to ensure that it is gender sensitive.

iv. Ethical referral process

Any psychosocial intervention should be part of an ethical and transparent referral process. No intervention should be sought as a result of obtaining or offering inducements or kickbacks.

v. Opportunity for ethics discussion and supervision

However, experienced the therapist may be, there should be an opportunity available to confidentially discuss ethical challenges in handling a given patient and to obtain further professional guidance.

b. Around the patient

i. Autonomy

The patient's informed consent should be obtained before any intervention and the patient should be made aware of the fact that they can withdraw from the intervention at any point. As mentioned earlier, while it may be appropriate for family to be able to persuade and influence a patient to take help, coercion would not only be unethical3– but futile in the long run as patient engagement and a good therapist patient relationship is important for success in treatment.

ii. Confidentiality

There is a no doubt that confidentiality is important to ensure an effective therapeutic alliance. The choice of which family member or friend, the patient would want to involve in their care should remain with the patient. However, it is very important to set the limits of confidentiality before embarking on the intervention i.e. under in which circumstances would confidentiality be broken, to whom and to what extent. This is not just where there is a risk of self- harm or risk of harm to others- but where there is a legal requirement for mandatory reporting as in child sexual abuse or a request for a report. With adolescents, it is good if the parents also understand this, as sometimes they request that information from the adolescent be told 'secretly’ to them, which is obviously not acceptable.

iii. Vulnerable groups

The special concerns of groups like children, adolescents, women, migrants and LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual and ally), will also have to be addressed in any psychosocial intervention in these groups, if relevant. Sometimes, information on help that can be obtained from an advocacy group or legal support would need to be given.

iv. Dual diagnosis

If the patient has any medical, psychiatric or behavioural comorbidities, the intervention should also take that into account. Where there is high risk sexual behaviour- the ethical need for confidentiality should be balanced with the duty to warn if there is risk of sexually transmitted diseases like HIV. It would be important to follow the law of the land. If there is an ethical dilemma, a senior or a colleague should be consulted with a documentation of the discussion and rationale for decision taken.4

c. Around the therapist

i. Proper qualification

It is imperative that the therapist be appropriately qualified for the job description and delivery of the intervention. As it is possible that some colleagues may offer a qualification without the required training, it is important that the therapist has had supervised experience before taking on patients for therapy or intervention. It is always important to check the references prior to any appointment.

ii. Attributes of an effective therapist

Like therapists working in any field, the effective therapist must have good communication skills and respect diversity in patient populations. It is especially important to guard against therapeutic nihilism or pessimism.56 The therapist should also be an advocate for patient rights regarding treatment and effective rehabilitation. Working with patients with addictive behaviours can be emotionally challenging. The therapist has an ethical duty to take care of self, so that they can be at their effective best when dealing with patients and avoid burnout. The recent amendment to the Declaration of Geneva/Hippocratic Oath adopted by the World Medical Association states ““I will attend to my own health, well-being, and abilities in order to provide care of the highest standard” (7). If burnout occurs, the therapist should be able to recognize early signs and get help for him/herself quickly.

iii. Respect boundaries

The therapist should maintain boundaries in the therapist patient relationship and not exploit the patient for social, business, romantic or sexual gain. If the patient reports a boundary violation by a colleague, it should be reported.8

iv. Awareness or referral and handover process

The therapist should be aware of one's limitations, when and how to refer the patient for further medical or psychiatric help. If for whatever reason a therapist is unable to continue the care of a particular patient, the therapist should take steps to hand over the care of the patient safely to someone else. This should be explained to the patient beforehand.

v. Persons in recovery as therapists

If a person in recovery is working as a therapist, it is just as important to ensure he or she is trained appropriately for the job. Supervision is important for all therapists and a therapist in recovery should not be involved in patient care if there is a relapse. There should be particular awareness and care taken about maintaining boundaries and if 'self disclosure’ is done, it should be done in a manner that is addressing the needs of the patient, not that of the therapist.9

d. Around the setting where the intervention is delivered

It is difficult for a therapist to deliver ethical interventions, if she is not working in an environment which actively supports ethical care. The reason the following are listed as part of the ethics of psychosocial intervention is that is the ethical duty of the therapist to ensure the facility where she delivers the care is also keeping to an ethical and legal standard.

i. Compliance with government regulations

The setting where the intervention is delivered should follow the law of the land and have the appropriate government licenses.10 Where there are rules about ensuring standards in health care delivery- not just in terms of the quality of care, but also that of numbers of personnel, confidential storage of patient documentation, logistic requirements of space and facilities, compliance with inspections- sometimes it would be ethical duty of the therapist to it point out deficiencies to the administration and ensure they are rectified. These are invariably minimum standards- so the setting might warrant a higher requirement depending on the work load.

ii. Appropriate redressal mechanisms

Wherever the therapist delivers the intervention, there should be a transparent system in place for patients to given feedback or even make complaints. While it is understandable that therapists feel upset when patients threaten to make a complaint- telling them that they have the option to do so, can sometimes paradoxically defuse the situation. Sometimes the complaint may not be about the therapist, but systemic issues like waiting time or charges- where a complaint/feedback can actually rectify a genuine problem.

iii. Antisexual harassment policy

In compliance with the Supreme Court ruling regarding protection of women from sexual harassment in the workplace, every setting should have a functioning antisexual harassment committee. Some hospitals in India have made it gender neutral- i.e. protect workers of all genders and have extended its ambit to take complaints from patients too. The Indian Psychiatric Society has published Guidelines for doctors on Sexual boundaries in the doctor patient relationship, and this is freely available on its website.811 Its principles stand true for all health professionals and not just doctors.

iv. Opportunities for staff growth, support and safety

The setting where the intervention is delivered should provide for opportunities for staff growth like attending conferences and workshops. Adequate security and access to legal advice is important. Infrastructural support like a secretary to handle appointments or even the telephone helps the professional to concentrate on efficient and ethical delivery of the intervention.

v. Safe whistleblowing

Sometimes unethical actions by therapists do happen. If the therapist is senior, it might be difficult to address it. Unless there is a system for safe whistleblowing- ideally in a spirit of effective 360 degree feedback (multi-level feedback), unethical actions by senior therapists may not come to light for several years. Of course, one needs to be aware of the limitations of individual reports in a multisystem feedback, as sometimes juniors may not raise issues for fear of reprisals, yet flag a problem where none exists in view of own biases and motivations.

vi. Support advocacy

Unethical actions can sometimes occur within ‘wrong rules’, and one is reminded of Martin Luther King's sobering line, “Never forget that everything Hitler did in Germany was legal”. In such situations, the therapist with the support of the administration of the setting in which she works should advocate for the rights of patients (and sometimes of therapists) through appropriate legal channels.

CONCLUSION

This article has highlighted some the arenas where ethical challenges can occur. Sometimes it is difficult to make black and white statements about the ethics of an action. In these situations, it is the context that can help delineate an ethical action from an unethical one. Despite experience, they will be times when a therapist may face difficult ethical dilemmas. In these situations, the therapist should reach out to a senior, a colleague or a member of the health fraternity for help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.