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    * Ethics Ethical Considerations for the Use of Family Therapy in Substance Abuse Treatment David Whittinghill University of Alabama-Birmingham ‘This article examines the wrique ethical consideration forthe pro vieion of family therapy as substance abuse treatment. Use of frity ‘erapy as substance abuse reanment has gown rapidly, but the eth ‘cal codes tha guide clinical practice have not kept pace. Ethical plfalle specific to family counseling within alcohol and drug treat iment programs are identified and guiding ethical principles are presented. ubstance abuse disorders in the United States are wide spread, and the need for treatment excceds demand (Mejita & Bokos, 1997). Subsequently, researchers and clini cians persistently experiment find more effctive methods Of treatment to further reduce the incidence of substance abuse. One of the most promising adjuncis toaddictionstreat- ‘ment inzecent years has been family therapy. Substance abuse treatment researchers have found that family therapy, when appropriately applied, significantly reduces episodes of hharmful drug usc (Longbaugh, Beattie, Noel, Stout, & Malloy, 1993; Montietal., 1990) and improvesthe likelihood ‘of long-tenn abstinence from drug abuse (Bressi eta, 1999; (O'Farrell, Choquette, Cuter, Brown, & McCourt, 1993). Asa resultof these and similar findings, che use of family eounsel- ing as substance abuse treatment has grown rapidly However, the practice of family counseling within substance abuse treatment has advanced more rapidly than the ethical codes that guide clinical practice, This is most unfortunate, as the ethical principles associated with substance abuse counseling, and family therapy are different from those used to guide the practice of individaal counseling (Bissell & Royce, 1994; Coney, Corey, & Callahan, 1993; Kaplan & Culkin, 1995; Lawson, Lawson, & Rivers, 2000; Marsh, 1997; Welfel, ‘Author's note: Correspondence regarding this ticle shouldbe d- rected to David Whitinghill, PD, University of Alabama-Bir- rmingham, 901 S.13th Sueet, Binmnghan, AL 35294; work phone: (205) 975-9612; cell phone: (205) 837-2607; or email: wawhie@ beds 1998), Thus, many practitioners providing family therapy to substance abusers and their families are inadequately pre- pered and thereby are putting themselves at preater risk for ehaving unethicaly. ‘The purpose of this article, therefore, is to discuss the spe- ial ethical concerns encountered when family therapy is used in substance abuse treatment. In general, the ethical ‘lemmas family practitioners face most oftea when working im alcohol and drug settings can be classified using ethical principles set forth in the model by Kitchener (1984), with particular attention given to the philosophical constructs of Justice, beneficence, and nonmaleficence, JUSTICE, ‘The principle of justice embraces the notion that all help- ing professionals, including family therapists, are obliged 10 act fairly and to avoid bias or stereotypes that might affect provision of treatment (Kitchener, 1984). For example, coun- selors following this principle would make every effort 10 ensure that cqual accesso services was afford ro all who need lnelp. Although most family counselors providing sub- stance abuse treatment adhere to this principle, some who practice within inpatient treatment programs, especially ‘those programs that mandate partiipation in family therapy, are at increased risk for acting unjustly. Many substance- abusing individuals are homeless (Usdan et al, 2001), and of those, many are single with either no living family members ‘or no familial contact in recent years (Rahav eta. 1995). Eah- ical problems arise when these individuals are denied admis- sion in treatment programe because the drug abuser lucks a family member who ean conjointly participate in treatment. ‘Those at greatest risk for violating this ethical guidetine are those that translate the term faily member literally and rule ‘out significant others who may play 2 role in the client life ‘This is mos ikely due toa cursory understanding of systems theory and thereby fails to recognize that other relationships, albeit not the clients family of origin or significant other like THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES, Vo. 10No. Janus 2002.78.78 (© 1002 Sage Pbetions ® ett pny ARES DE ae 4 76 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES January 2002 spouse or lover, can alsoaffect the client’ substance-abusing. behaviors Justas itis unethical tedeny help to those who can- not pay for services, so Is it unethical to deny treatment to those who do not fit particular counseling paradigm, BENEFICENCR Beneficence in counseling is defined asthe cornmitment to do good or what s best forthe client or group (Hill, Glaser, & Harden, 1995). Whereas many factors have & bearing on Deneficence related tothe provision of mental health services, Welfel (1998) asserted that the counselor's commitment to ‘work within his or her level of competence is atthe heart of| “doing good,” because providing services without proper training deprives the client ofthe professional help that has been promised and thatthe clienthas aright toreceive. Unfor- tunately, the practice of family therapy in many substance abuse treatment programs runs counter to this principle, because those providing services to ubstence-abusing fami- lies ate insufficiently trained and ate therefore at increased risk for committing ethical violations. For example, 40% to 55% of substance abuse services, including family therapy, are provided by paraprofessional counselors who lack formal ‘counselor preparation (Banken & McGovern, 1992; Mulli- ‘gan, MeCanty, Potter, & Krakow, 1989) and instead learned about family counseling from participation in scholastically unregulated workshops or on-site training provided by col- Teagues who may or may not be adequately trained in family therapy (Kimmel, 1994). Suissequently, the competence of these counselors varies greatly and thereby increases the isk that those who participate in substance abuse family therapy provided by paraprofessional practitioners will be seated inoptly and will likely experience litle, if any, meaningful improvement ‘Bthical isks also exist for graduates of marriage and farn- ily preparation programs who are employed at substance ‘abuse teatment centers, Although these individuals arguably receive a more comprehensive and in-depth education cam- ppared to their paraprofessional counterparts, they too can fll far short of doing whats best for these families, For example, the literature reveals that many degreed family counsclors provide substance abuse services based solely on the empiri- cally unsupported “family disease” model (O' Farrell, 1994), ‘The primary aim ofthis approach sto educate and encourage family members to recognize and accept that they, lke the substance abuser, are victims of the “disease of addiction” and as a result ar “enabling” or perpetuating the substance abuse by playing out stereatypic familial zoles assumed to be ‘maladaptive and counterproductive (Goodwin & Wamock, 1991). Although the family disease model of substance abuse tweatmentinand ofitselfis not necessarily unethical, coursel- ing limited exclusively to the disease model without giving proper consideration and attention to more critical fa ‘issues is not beneiicial. Although families of alcoholies and addicts are well-suited for family therapy, many are in the midst of one or more substance-related crises, which require the complete attention and energy of the family. Crises expe- rienced by these families include threat of divorce or other legal proceedings, real or impending job and home loss, and potential for violence (aston, Swan, & Sinha, 2000; Menees & Segtin, 2000). Therefore, to do the most good, heneficent family therapists know that they must first help their elients| handle pressing crises, prior to provision of counseling based ‘on the disease or other systemic model NONMALEFICENCE, ‘Theethical principle ofnonmaleficenceis broadly defined asa counselor's duty tozvoid doing harmo the client, (i210 avoid negative treatment effets). Folowing this principle, counselors are obliged to become aware of and avoid poten. tially hamnful interventions and instead to se those that have been shown tohave litle to norisk for psychologically injur- ing the client (Welfl, 1998). Consideration of tis ethical principles particularly important when using the Family ds- ‘ease model of substance abuse textmont. As noted previ ‘ously, the family disease theory of addiction is loosely based ‘on eybmetics or systems theory and asserts that problematic dug use is not solely caused by the actions of the addict bat instead contonds that each family members equally rspoa- sible forthe pathological drug use a each adopts maladaptive behaviors that reinforce the drug use (George, 1950). Although studies indicate that this partealsr approach has potential forreducing excessive druguseandimproving over- ll familial functioning in families in which members exter ralize and assign blame for family problems tothe substance abuser, itisriskytouse when working with feniies that inter- neliz familial difficulties, Reseach indicates a majority of| thespouses andchildrenofadgicts and alcobolies wrongfully assume personal responsibility for problems common to those fanlies, including the addicts excessive use of drugs, ‘nd seis of emotional, pica, andor sexual abuse perpc- (cated bythe substance abuse: Furthermore, they irationelly believe that if they were a “beter person.” (eg. made better ses, nagged less, or kept a cleaner hous), the addicted family member would not findit necessary to misuse drugs oF perpetate cis of physical or emotional abuse on them o fh crs (Banister & Peavey, 1994; Weissherg, 1983). Therefore, use ofthe family disse approach can behave in that it conceptually einfores the selFaccassory belies ofthese individuals and constitutes a set of behaviors known as “blaming the viesm.” which have been shown to exacerbate the mental anguish of these aloady expericacing paychologi- cal cistress (Collins, 1993, p. 471). With this i mind, itis incumbent on family practitioners to consider carefully the Innefits und risks of using a family disease approach with substance-abusing families. Specifically, the fiily coun- selor must weigh the potential benefits the intervention may have for reducing the excessive drug use of the lone addict against the possible psychological injury of multiple family members. CONCLUSION ‘There arc unique ethical problems associated withthe rap- idly growing use of family therapy as substance abuse treat- ‘ment. Several ethical puidefines have been suggested for fam- ily practitioners working with families of alcoholics and addicts, Fist, family counselors aze obligated to make certain thatall who need help are provided equal access to substance abuse treatment and that none are discriminated against because their circumstances do not fit the guiding conceptual model ‘Inpparticalar, family counselors providing substance abuse {reatment should not refuse help to those without family and should instead learn to define family nontraditionally (e.g coworkers, acquaintances with whom the client shares

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