Short answer? No.

Long answer: Perhaps in time!

Co-occurring disorders are just one of the dynamics that make substance abuse counseling a challenging profession. We know that the most effective intervention integrates treatment for both the addictive disorder and the other mental illness (NCCBH, 2003). That is why advanced-practice substance abuse counselors are asked to develop skills in dual diagnosis treatment. In fact, some of the U.S. states that credential advanced-practice counselors require competency in dual diagnosis treatment for licensure.

Your desire to try an alternative treatment technique (especially one that this particular client presumably has not yet tried) is on target. You want to provide the most effective treatment. The ethical conflict, though, rests on the issue of competence.

The mandate that counselors only practice within our areas of competence is so key that state laws, scopes of practice for licensure, and professional codes of conduct almost unanimously require that we avoid practicing outside of that space. Practicing outside of our areas of competence risks doing harm, violating one of the fundamental principles of behavioral health care.

But we have other ethical mandates too — to provide the best interventions, to continue to learn new, promising techniques, and to seize opportunities to help our clients become healthier.

What brings us to competence?
Books on new treatments intrigue us. At continuing education events, we are motivated, encouraged, and inspired by success stories of our colleagues. So whether it is hypnotherapy, multi-family group work, or EMDR, I can see why you would want to try a new technique with a client whose needs are pressing.

But regardless of the intervention in question, the requirement for competence trumps the desire to try a new therapy. And reading a book, or attending a short seminar, rarely brings one to the level of competence. But what does? What do we do to continuously grow our skills?

The answer depends on the point from which you start. Competence can be described as a triangle with three sides: virtues (such as integrity and caring), our basic counseling abilities (such as listening, reframing, and directing), and specific “competencies” (in this case they might include the skills of conceptualizing PTSD, sequencing EMDR steps, and integrating the technique into the counseling process, etc.). To become competent, find out what you already bring and develop what you need. Easily said, difficult to do.

Six steps for developing competence
The basic process of developing competence looks very much like this:

1. Gain knowledge.

2. Practice new skills under the guidance of an expert.

3. Use the constructive criticism of others to make corrections and identify areas that need improvement.

4. Practice with increasing independence. (For example, the EMDR Institute recommends 20-30 sessions with clients before taking “Part 2” of their training.)

5. Receive ongoing supervision and problem-solving as you integrate new techniques into your counseling process. (Local supervisors are not always available. But with telephone-based supervision, Listservs, and online real-time chat, you can make it happen.)

6. Document your efforts to grow new areas of competence. Keep records of the training you receive, record supervision sessions, use tape and video documentation of counseling sessions, and keep notes from supervisors.

What can you do?
So what are your options? If EMDR (or any technique new to you) seems to be the way to go, you can refer your client to an experienced provider. She can take the case, or serve as an adjunct to your ongoing work with the client. To make that happen, you might have to shift from counselor role to case manager role for a time. And with readings on PTSD treatment, you might find other promising ways to lessen the effects of PTSD while staying within your current areas of competence. Still interested in a particular therapeutic technique? Plan out how you’ll develop your competence, and then go for it.

Adam Robinson, MA, CSAPC ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is associate director of Program Services at Wake AHEC in Raleigh, NC, and former chair of the NC Substance Abuse Prefessional Certification Board Ethics Committee.

References
EMDR Institute, Inc. Training Programs. (Online). Accessed via Internet at http://www.emdr.com/ on May 24, 2004.
Johnson, B. (2003). Framework for Conceptualizing Competence to Mentor. Ethics & Behavior, 13(2).
Lee, C., Gavriel, H., Drummond, P., Richards, J., & Greenwald, R. (2002). Treatment of PTSD: Stress Inoculation Training with Prolonged Exposure Compared to EMDR. Journal of Clinical Psychology, 58(9).
National Council for Community and Behavioral Healthcare (NCCBH). (2003). “Collaborative care” (Online). Accessed via Internet at http://www.nccbh.org/
40th/CollabCare.doc on July 1, 2004.

This article is published in Counselor,The Magazine for Addiction Professionals, October 2004, v.5, n.5, pp. 19-20.

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