Role Reversal for Former Patients Results in Ethical Challenges

The possible ethical dilemmas around former patients coming to work at the agencies where they once received treatment came fast and furious at an NCAD East breakout session on Thursday:

• Can a clinician accept a former client's friend request on social media?

• What if a former client relapses while working at the program and wants to keep that hidden for fear of dismissal?

• What if a former client is assigned to case manage a new patient with a very similar trauma history, which could lead to a dangerous trigger?

Easy answers were in shorter supply, though the session's co-presenters (a clinical social worker and a peer support specialist) emphasized the importance of open communication and careful, consistent documentation when addressing potential ethical conflicts.

Also, “We have to examine our own personal biases,” said Lauren Quick-Graham, MSW, who currently serves as a crisis line worker for a managed care organization. “We all have personal biases, whether we are in recovery or not.”

Quick-Graham shared the podium with Wendy Isbell, CSAC, a peer support specialist at the University of North Carolina Horizons Program, a treatment program where women can reside with their young children while in treatment. The two have been colleagues and recalled sharing several uncomfortable experiences, such as when the theft of a stored controlled substance at a facility led to false accusations against an employee in recovery who had used that drug in the past (it turns out that a manager was to blame for the missing medication).

Quick-Graham and Isbell agreed that the growth of the peer support workforce will bring more potential ethical challenges to the fore, and that organizations need to be talking more about how to handle issues such as employee slips or what to do when a former client invites the now-colleague to her wedding.

Being trauma-informed

Another breakout session on the opening day of NCAD East offered guidance on achieving trauma-integrated addiction treatment. Michael Barnes, PhD, chief clinical officer at Foundry Treatment Center in Steamboat Springs, Colo., said that when he arrived at the facility, it had a good focus on trauma but a relatively nonsupportive physical environment.

Barnes explained that men and women were receiving treatment in the same building at the time, and issues began to ensue during recreation time in the evenings. Ultimately, “We made a decision to be a men's-only program,” Barnes said.

He emphasized that in a largely traumatized society, focusing on developmental trauma should be at the core of efforts to bring about trauma-integrated care in an organization.

Foundry Treatment Center uses the Neuro Affective Relational Model (NARM) as the organizing theory of its trauma-focused efforts. It emphasizes helping clients to meet needs for connection, attunement, trust, autonomy and love/sexuality.

Both patient and staff education in this model are critical, said Barnes, who cited research such as a 2009 study of addiction counselors that found secondary traumatic stress highly prevalent in these helping professionals. Fifty-six percent of those surveyed met one criterion for post-traumatic stress disorder (PTSD), with 19% meeting all criteria for the diagnosis.

Progress within hospital

Leaders at Gateway Foundation in Illinois discussed in an afternoon breakout session the progress they have made at four Illinois hospitals in engaging patients with opioid use disorders and connecting them to follow-up care—whether at Gateway or otherwise.

Project Warm Handoff uses a Screening, Brief Intervention and Referral to Treatment (SBIRT) approach and a team concept combining the efforts of credentialed engagement specialists and recovery coaches with lived experience. Gateway has been pleased that virtually all patients, whether hospitalized originally for an opioid overdose or another problem, are willing to accept a handoff appointment, although the organization has found that only about half of the patients eventually make it to that initial appointment.

These Gateway leaders are strong supporters of specialty-care professionals' efforts in nontraditional service environments. “We have to be open to new approaches—customary practices won't save lives,” said Sally Thoren, executive director.