Research indicates that patients with longer stays in alcohol and other drug (AOD) treatment have improved health-related outcomes. Since time in treatment and treatment completion are generally associated with more successful outcomes, identification of factors related to treatment retention is important. The growing list of studies confirm the link between time in treatment and improved outcomes (Basso & Bornstein, 2000; Hubbard, et al., 1996; Moos, 2003; Simpson, 1981; Stark, 1992; Zweben & Zuckoff, 2002). Having established this connection, studies have been conducted to determine or predict what clinical interventions or other variables might impact retention (Patterson, 2008).

With this in mind, a retention study was conducted in an intensive outpatient program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). While the retention intervention being tested did not provide significant findings, there was a significant difference between clients who were entered into SAMHSA’s web-based client follow-up system compared to those not entered. These findings raise an issue of program resource allocation. The question to consider for clinicians is whether they expend similar amounts of energy with clients who they feel will not be available for six-month follow-up.

The consequences of addiction among healthcare professionals (HCPs) are not limited to the usual problems we are well aware of in others with this disease. In the healthcare workplace patient harm is a real, preventable possibility. Addiction in this setting can undermine professional peer morale, and healthcare systems, clinics and hospitals can be at risk for legal retribution (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). The nature of the healthcare workplace is unfamiliar to most counselors and treatment programs. Addiction among HCPs can result in great harm to the practitioner and to others, requiring programs and counselors that specialize in this area of addiction treatment. Counselors working with HCPs face unique challenges, but they also play a tremendous role in the remarkable outcomes of physicians with addiction.

The Seattle Post Intelligencer reported the case of an anesthesiologist who was “diverting drugs from my patients” and described him as intoxicated with Demerol during surgery (Smith, C., 2003). A female patient was left in a “persistent vegetative state” (essentially a lasting coma) after the routine surgical procedure. The anesthesiologist stopped her oxygen while she was still paralyzed and could not breathe on her own. Both he and the hospital were sued and he entered addiction treatment. A surgical technician in Colorado was indicted last year after it was found that she had likely infected up to 5,700 people with Hepatitis C (Denver Post, 2009). At least 35 people have tested positive for Hepatitis C as a result of her actions. The surgical technician, who was addicted to heroin, stole and injected herself with syringes of fentanyl, refilled them with saline and replaced the contaminated syringes to be used on patients, resulting in patients being subjected to inadequate anesthesia, excess pain and exposure to Hepatitis C.

While some claim these are sensational examples of rare events, the actual number of such events is undetermined. These horrific situations usually only get discussed when exposed by the patient, the family or the legal system, after the healthcare professional gets caught. Counselors cannot expect HCPs to admit to these indiscretions, and certainly not in a typical group setting.

Addiction is a significant problem among HCPs. Accurate numbers are difficult to come by, but data from physician populations reveals that the rate of addiction during a physician’s career is estimated to be the same or somewhat higher than in the general population—10 to 12 percent (Hughes, P.H., Brandenburg, N., Baldwin, D.C. Jr., et al., 1992; McLellan, A.T., Skipper, G.S., Campbell, M. & DuPont, R.L., 2008). It is unknown whether the rate of addiction among nurses is any different than the general population (Maher-Brison, 2007).

Compared to the general public, physicians are more likely to use prescribed medications, but the primary problem remains alcohol (50.3 percent) (McLellan, A.T., Skipper, G.S., Campbell, M. & DuPont, R.L., 2008). Anesthesiologists are the exception to this, in that the most common drug of abuse among this group is highly potent injected opioids, such as fentanyl/sufentanil, which are at least 100 times more powerful than heroin (Kintz, P., Villain, M., Dumestre, V. & Cirimele, V., 2005). In a study of 16 state physician health programs that examined 904 consecutive physicians placed under monitoring, five medical specialties comprised greater than half of the physicians: family medicine (20 percent), internal medicine (13.1 percent), anesthesiology (10.9 percent), emergency medicine (7.1 percent) and psychiatry (6.9 percent) (McLellan, A.T., Skipper, G.S., Campbell, M. & DuPont, R.L., 2008). Anesthesiologists comprise 5.2 percent of physicians nationwide; therefore, they are remarkably over-represented in physician health programs (American Medical Association, 2007). All HCPs need specialty treatment, but anesthesiologists, nurse anesthetists and other operating room personnel require special attention due to the dangers associated with diversion and use of the most powerful substances known.

A university hospital referred one of its physicians to the state HCP program for evaluation after she was caught stealing opioids. Although the physician did not admit to having a problem, she agreed to enter a residential treatment program for evaluation. She drove from the office of the HCP program to her home in disgrace. There she gathered a large syringe of morphine with plans to kill herself rather than enter treatment. She sat in her car in the treatment program parking lot for an hour trying to decide whether or not to take her life. Fortunately, she chose to undergo the evaluation and save the morphine for later. Once involved in the program she divulged her plan, provided the morphine to staff and fully engaged in the recovery process.

Most states have HCP programs for addicted physicians that are affiliated with the state medical board or the state medical association. However, many states do not provide the same level of intervention and monitoring for other HCPs, including nurses. Nurse anesthetists—with the same access to opioids as anesthesiologists—have no monitoring programs in many states. As a result, they are often undertreated, and many die as a result of their addictions. State physician programs emerged in the 1970s after the American Medical Association (AMA) recognized the extent of the addiction problem (AMA, 1973).

Rapid confirmation that a substance-use problem may exist, with immediate intervention, prevent the potential for harm to patients, workplace complications and harm to the addicted healthcare worker. The hospital does not need evidence “beyond a reasonable doubt” to intervene, as personnel are not being accused of a crime (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). Instead, they are undergoing a work-fitness evaluation seeking evidence of an illness, one the individual may be the last to fully recognize. Once confronted about the possibility of addiction the HCP may act desperately; thus, great care must be taken to prevent suicide or other adverse outcomes (Myers, M.F. & Gabbard, G.O., 2008).
Many states, like Minnesota, have laws that require reporting of impaired physicians and allows for discipline of physicians who do not report such situations. Reporting to state HCP programs is an alternative to licensing board discipline, which usually provides evaluation and treatment with a rehabilitative model. These state HCP programs provide supportive, non-disciplinary assistance to physicians, and sometimes other HCPs with an illness that may impair the ­ability to practice with reasonable skill and safety. State HCP programs may subsequently report physicians to the medical board should they fail to comply with the required monitoring and aftercare plan. Minnesota law includes reporting immunity, which protects those reporting and those cooperating with an investigation about a physician from civil liability or criminal prosecution (MN Statute 1996, 214.34). State laws and the reporting processes in some states minimize the resistance associated with reporting a colleague and protect those who do so. It is crucial that treatment programs know the laws of each state they deal with.

Addiction is a disease of the brain’s reward circuitry where the dysfunction is primarily in the limbic system and the pre-frontal cortex. Advances in the neurobiology of addiction have revealed supraphysiologic release of dopamine, establishing an excessive signal of reward by addictive substances (Kalivas, P.W. & Volkow, N.D., 2005). Pre-frontal inhibition of drug use secondary to conscious recognition of mounting consequences would be a normal response, but is undermined as limbic drives prevail. Survival itself is reprioritized and becomes secondary to the ongoing use of the drug (Hyman, S.E., 2005).

This reprioritization explains how the addicted HCP can continue to use drugs while the potential adverse consequences mount. The use of the drug becomes paramount, and the damaged brain does not recognize consequences; it only strives for more of the drug. The addicted typically do not fully recognize their plight or the risks they are taking to continue drug use. The prominence of the new limbic drive for the drug recruits higher cortical centers, using the healthcare professional’s intelligence against themselves to preserve continued drug access and use. It should not be surprising that the addicted will deny use; bargain for situations that facilitate continued use; and even give up careers, family and sometimes life itself in the pursuit of the addictive substance. Treatment for addiction is rarely sought spontaneously.

HCPs often resistant to treatment
Addiction counselors who work with HCPs must be seasoned veterans with the confidence, skills and tact to deal with very intelligent, often intimidating and sometimes manipulative individuals. HCPs rarely admit to having addiction upon initial intervention and evaluation (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009) even with remarkable evidence to the contrary. They resist treatment and use their intelligence to deny and hide the problem, often using their credentials to intimidate addiction counselors, who must be ready and able to mitigate such situations. They pose challenges to the standard means of history taking and diagnosis. This author worked with a physician that emptied his bladder, catheterized himself and filled his bladder with clean urine prior to urine drug screening to avoid detection of drug use. Another physician had been doing a medical procedure and was noted by several nurses to have alcohol on his breath. He denied this, and tried to intimidate the nurses and his colleagues as they sought help from the state health professional program, who were well aware of him due to a history of alcohol dependence. Later, upon threat of loss of license, he admitted to regular alcohol use occurring over a several month period. Qualified, experienced counselors have little difficulty with such situations, and they need a treatment team with similar experience with this population in order to provide appropriate, effective treatment services.

Unfortunately for the physician and other HCPs with addiction who are unable to recognize the problem, there are many reasons that peers and family do not identify or intervene early in the course of addiction. Medical schools provide few, if any, days of training in addiction, and the vast majority of primary care physicians have been shown to be unable to recognize and appropriately treat alcoholism (CASA, 2000; McGlynn, E.A., Asch, S.M., Adams, J., et al., 2003). Colleagues are hesitant to engage in another’s private affairs and will resist acting on a disease they have very little knowledge about Farber, N.J., Gilbert, S.G., Aboff, B.M., et al., 2005).

Addiction can be misunderstood as a choice, not an illness, inhibiting action by others. There may be a “conspiracy of silence” in the workplace and the home, limiting any involvement on the part of friends, family and colleagues. If the practice is small, or the physician is in a position of power in a hospital or large clinic, other employees may fear for their jobs and careers if they mention the possibility of addiction. Family members may know of the addiction earlier than those in the workplace, but they could be hesitant to act for fear of financial consequences, loss of job, loss of prestige and loss of licensure. Fear of litigation can limit appropriate attention to this disease. Stigma and bias also interfere, as people often cannot believe a physician could have addiction or only believe addiction occurs in the lower socioeconomic classes (Talbott, G.D., 1982).

Limited discussion of patient morbidity and mortality by HCPs in treatment programs is commonplace and may be legitimate, due to legally protected information that cannot be shared; but the culture of medicine also contributes to the lack of attention to clinical ­mistakes and adverse events in the healthcare workplace. Among physicians (especially surgeons) and other healthcare personnel there may be a credo that prevents emotional expression related to negative clinical outcomes. Such a culture also prevents discussion of personal problems and recognition and attention to addiction among colleagues. As a result, self doubt, guilt and shame are addressed only in isolation. These factors must be recognized by counseling staff, and addressed within the course of addiction treatment, which requires a safe, healing environment that fosters appropriate disclosure.
The healthcare professional peer group process is ideal for such therapeutic activities, when facilitated by experienced counselors. Such groups model a healthy, new and different way of expressing thoughts and emotions related to workplace problems that would not be appropriate for groups with non-HCPs. HCPs also find it hard to fool each other. When an orthopedic surgeon denied he had workplace access to Propofol—a hypnotic anesthetic that was named in the Michael Jackson case—his peers immediately responded in disbelief and listed multiple ways he could readily find and use this drug. Addiction counselors must be well aware of issues specific to healthcare professionals and properly ­distinguish when and how to therapeutically address events related to the healthcare workplace.

HCP treatment programs must provide extensive, professional evaluations to establish an accurate diagnosis, determine potential co-occurring psychiatric problems, provide information for treatment planning, satisfy state HCP program requirements and establish a record for return to work decision making. Proper evaluation includes a physical examination, psychological and psychometric testing, an assessment of ­family functioning and a psychiatric evaluation. Physi­cians seldom enter treatment without coercion and will initially only rarely describe the history in an accurate manner secondary to both denial and conscious decision making. They recognize little incentive to admit to a drug problem and are afraid and anxious secondary to potential job loss and licensure issues (Talbott, G.D., 1982). They also are driven by the continued pursuit of powerfully reinforcing drugs that limit objective self-examination. Collateral information is essential to the diagnostic evaluation and may be the only way to obtain a history adequate to making an accurate initial diagnosis (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). Most treatment programs specializing in HCPs require signed release of information forms or they will not complete these specialized evaluations or initiate treatment. Evaluation and treatment requires a multidisciplinary team with experience working with HCPs (Graham, A.W., Schultz, T.K., Mayo-Smith, M.F. Ries, R.K., Wilford, B.B., 2007).
Addiction professionals working with this population need to understand the language of medicine, the medical workplace, access to prescribed medi­cations, some of the unique stressors associated with medical practice, the potential for co-morbid psychiatric illness and the personality traits and disorders common to physicians and other healthcare personnel. They also need knowledge of numerous, prescribed, addicting medications, workplace access to these medications, the unique stressors of the healthcare workplace and the risks associated with return to work, especially related to relapse. Psychiatric illness and cognitive impairment can complicate treatment, recovery and successful return to work. As a result these issues are specifically screened and evaluated. The diagnosis of addiction is ade by history and relies on behavioral descriptions. It often requires gathering a history of substance use related behavioral changes from multiple sources to make a diagnosis in a healthcare professional. Addiction counselors must clearly and correctly document information supporting the addiction diagnosis and treatment planning decisions, knowing that the medical record will often be used in legal proceedings.

HCP treatment programs include group and individual psychotherapy, education about addiction, and skills training to prevent a return to drug and alcohol use (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). They also emphasize fellowship and encourage physicians to learn from one another and re-establish positive relationships with a level of intimacy that helps with acceptance and healing. These programs require complete abstinence from alcohol and drugs, and the vast majority use a 12 Step model based on the principles of Alcoholics Anonymous. A recent study revealed that 95 percent of physicians were treated using a 12 Step model and 78 percent entered residential treatment for a mean of 72 days (range 30 to 90 days) (Kintz, P., Villain, M., Dumestre, V. & Cirimele, V., 2005). It is necessary to provide a milieu that establishes a safe place for physicians and other HCPs to become patients and to express themselves in a manner that allows for acceptance of addiction and pursuit of recovery. Group therapy with other HCPs breaks through some of the defenses that can limit self-examination and supports recognition of cues and triggers unique to the health-care ­setting. They have the opportunity to discuss the stressors associated with medical practice and their predicaments, including medical board involvement, legal issues and potential problems with the Drug Enforcement Adminis­tration. Most HCPs are tremendously ashamed of taking drugs from the workplace and injecting themselves and have great difficulty admitting to this. They often think of themselves as the only person who has ever diverted drugs for self-use. Group therapy with other addicted HCPs often results in admission of addictive behaviors and enhances acceptance. Addiction treatment is arranged to help people break the cycle of addictive behaviors and address associated problems that have usually gone unnoticed secondary to the numbing power of addictive drug use. Participants examine their relationships, their use of money, their families, their decision-making and other major life areas. Addiction can alter perspective so significantly that physicians often enter treatment convinced that their work or other stressors have caused drug use, only to realize, once sober and in recovery, they are very happy and proud to be doctors.

Prior to completing treatment physicians and other HCPs should undergo a practice assessment to examine their ability to return to work. This assessment provides the opportunity to establish the risks of returning to practice, to determine a treatment plan supportive of abstinence in the workplace, to address relapse prevention and to initiate the decision-making about timing of return to practice (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). Some physicians and other HCPs can go right back to the workplace, whereas others require further treatment or a period of abstinence prior to returning to work. Some will have to consider a different type of practice or another specialty. A very small group will not return to the practice of medicine. Return to work decisions are difficult and require the expertise of a treatment team well-versed in healthcare professional treatment and decision-making, the staff of the state HCP program, and the help of others in the medical workplace. Several factors predict relapse in HCPs, including: a positive family history for addiction/alcoholism; a psychiatric illness in addition to addiction; use of a major opioid and a psychiatric illness; and use of a major opioid, a psychiatric illness and a positive family history (Domino, K.B., Hornbein, T.F., Polissar, N.L., et al., 2005). This information is being used in treatment, monitoring and return-to-work decisions for addicted physicians.

Anesthesiologists, nurse anesthetists and other operating room personnel who return to their prior workplace will be handling the very drugs they were addicted to, which is unlike almost all other addicted patients, and specifically includes the risks of cues and triggers associated with prior drug use. As a result, recommendations have been made to prevent their return to the operating room (Berge, K.H., Seppala, M.D. & Lanier, W.L., 2008). Currently a group, including the author, is working on a return-to-work decision making tool for ­anesthesiologists and nurse anesthetists that will help define expectations of the individual and the state monitoring program to standardize the decision-making and reduce relapse risk.
A primary role of state HCP programs is monitoring recovery activities after successful treatment completion, and requires communication and collaboration with the treatment program. Most physicians can return to practice with a solid recovery program and monitoring in place. Recovery rates of physicians rank alongside those of commercial airline pilots, which are the highest measured at 74 to 90 percent. As a result, a rehabilitation model and support for return to practice is appropriate. How­ever, without appropriate monitoring, the risk would be formidable and return to the medical workplace should not be considered. State HCP programs contract with recovering individuals and require compliance with activities known to support ongoing abstinence and recovery from addiction. These activities include: group therapy with other healthcare professionals, individual therapy, mutual help meetings (AA, NA, etc.), oversight meetings, drug screening—both random and for cause—and workplace monitoring. Require­ments can also include psychiatric care, family therapy and limitations on work place, work hours and prescribing (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). Ex­tensive high-quality specialized treatment; motivation to maintain licensure; and return to practice and long-term monitoring all are driving factors that result in positive outcomes for physicians. This is not well established or studied among other HCPs, but similar programs exist for non-physician healthcare professionals in some states, with outcomes supporting this approach.  

Addiction is a relatively common illness and affects physicians at the same or slightly higher levels than the general population. Unfortunately, other HCPs do not receive the same treatment and monitoring in many states. Treatment in specialty programs designed for HCPs is necessary to address the issues unique to physicians and other healthcare personnel. Physicians have remarkable recovery rates when involved in appropriate treatment and monitoring programs. All medical personnel with exposure to powerfully addictive medications in the workplace should have access to HCP programs and monitoring systems to ensure appropriate treatment and the highest likelihood of successful abstinence and recovery. We can learn from the remarkable positive outcomes of physicians to improve the recovery rates of other HCPs as well as anyone with addiction.

Marvin D. Seppala, MD, Chief Medical Officer, Hazelden Foundation and Hazelden Springbrook, in Newberg, Oregon, has specialized in treating healthcare professionals since its inception in 1988. Hazelden’s main campus in Center City, Minnesota will be re-establishing a healthcare professionals program in early 2010.

References
American Medical Association (2007). Physician Characteristics and Distribution in the U.S.
AMA Report (1973). The sick physician: impairment by psychiatric disorders including alcoholism and drug dependencies. Journal of the American Medical Association, 223(6):684–687.
Berge K.H., Seppala M.D. & Schipper A.M. (2009). Chemical dependency and the physician. Mayo Clinic Proc. 84(7):625–631.
Berge K.H., Seppala M.D. & Lanier, W.L. (2008). The anesthesiology community’s approach to
opioid- and anesthetic-abusing personnel. Anes­the­siology, 109(5):762–764.
CASA (2000). Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse.
Denver Post (2009). Multiple articles.
Domino, K.B., Hornbein T.F., Polissar N.L., et al. (2005). Risk factors for relapse in health care professionals with substance use disorders. Journal of the American Medical Association, 293(12):1453–1460.
Farber N.J., Gilbert S.G., Aboff B.M., et al. (2005). Physicians’ willingness to report impaired colleagues. Social Science & Medicine, 61:1772–1775.
Graham A.W., Schultz T.K., Mayo-Smith M.F., Ries R.K. & Wilford B.B. (2007). Principles of Addiction Medicine. 3rd ed. Chevy Chase, MD: American Society of Addiction Medicine.
Hughes P.H., Brandenburg N. & Baldwin D.C. Jr, et al. (1992). Prevalence of substance use among US physicians [published correction appears in Journal of the American Medical Association, 268(18):2518; Journal of the American Medical Association, 267(17):2333–2339.
Hyman, S.E. (2005). Addiction: a disease of learning and memory. American Journal of Psychiatry, 162(8):1414–1422 .
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Kintz P., Villain M., Dumestre V. & Cirimele V. (2005). Evidence of addiction by anesthesiologists as documented by hair analysis. Forensic Science International, 153:81–84.
Maher-Brison. (2007). Addiction: An Occupational Hazard in Nursing. American Journal of Nursing, 107(8):78–79
McGlynn E.A, Asch S.M, Adams J., et al. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348(26):2635–2645.
McLellan A.T, Skipper G.S., Campbell M. & DuPont R.L. (2008). Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ, 337:a2038.
Myers M.F., Gabbard G.O. (2008). The Physician as Patient: A Clinical Handbook for Mental Health Professionals. Washington, DC: American Psychiatric Publishing.
Smith, C. (2003). System of secrecy potentially puts patients at risk. Seattle Post Intelligencer, Nov. 25, 2003.
Talbott G.D. (1982). The impaired physician and intervention: a key to recovery. Journal of the Florida Medical Association, 69(9):793–797.

Editor’s Note: This article is based on interviews with several addiction treatment professionals who also act as consultants,providing their addiction treatment expertise to treatment programs in several countries through C4 Recovery Solutions.  

It is a known fact that of the many individuals in the United States who suffer from substance use disorders and addiction are not receiving treatment for their ­addictions.

There are those who believe that this is the result of a flawed health care system, in which health insurance in unavailable to a large number of individuals. Some believe that the stigma addiction carries is keeping many individuals from seeking and receiving treatment for their addictions. Still, others believe that too much energy is expended debating whether addiction is indeed a disease—worthy of the same level of care and attention to treatment that is given to other chronic diseases, such as cancer or diabetes—and not enough resources are directed toward ensuring that addiction is better understood, by providing training to physicians and other clinicians.

According to the many treatment professionals, like Dr. Bob Lynn, all of these are barriers that prevent the United States from providing effective treatment to every addicted person. While this may sound like an impossible task, Dr. Lynn explains that this is already being done in other countries. Lynn is part of a group of consultants from around the world who work with C4 Recovery Solutions, a non-profit corporation that is dedicated to improving the effectiveness of substance use disorder prevention and recovery services worldwide. According to Rick Ohrstrom, the chairman and a founding member of C4 Recovery Solutions, the group remains committed to creating an international credentialing system that sets global professional standards for the addiction treatment workforce in an effort to improve upon the quality of addiction treatment worldwide.
Like many in his field, Ohrstrom is concerned that with the generational shift occurring in the addiction treatment field, there is reluctance on the part of both the retiring addiction professionals and the newcomers to the field, and as a result, vital information is not being passed on appropriately.

“In addition to bringing together people from different cultures that are doing the same types of treatment, C4 is convening people from both generations to enhance what’s good about both generations,” Ohrstrom said. “There is real value in that.”

Dr. Lynn, who brings more than 38 years of experience with addiction treatment, employee assistance programs and state government, has played a significant role in developing new assessment methods and coordinated treatment centers in the United States, Europe and the Middle East. Like his colleagues, who are working with C4 Recovery Solutions in more than 20 countries, Dr. Lynn takes an approach to addiction treatment that is based on a client’s individual needs. From there, treatment is provided through a continuum of care that allows treatment professionals to determine what is working or not working, in order to provide treatment that is based on positive outcomes.

Since the United States operates under a very bureaucratic system, many treatment centers are not invested in this type of outcomes-based treatment, Dr. Lynn said. For example, he explains that with the exception of a few sporadic programs, there is very limited outreach to drug and alcohol addicts in the United States. In other countries, such as Denmark, Amsterdam, the United Kingdom and Canada, addiction professionals are working to engage people in treatment at an earlier stage by going out on the streets and into prisons to identify individuals who are in need of addiction treatment services. According to Lynn, in many overseas programs, there are more groups that are willing to provide treatment to everyone, whereas in the United States, many people are literally being “screened out” of addiction treatment, most often because of their inability to pay for treatment.

The Middle East Project
There is much to be learned from the way addiction treatment is being provided in other countries, Dr. Lynn said. For instance, one would not expect that in the West Bank and Jerusalem, themain inpatient program would have a full continuum of care better than anything ever seen in the United States, despite deplorable political circumstances and living conditions, Lynn said.

According to Lynn, the staff in the Middle East program not only demonstrated a passion for their work, but also, were more credentialed and educated than staff in many other programs around the world. They had higher levels of training and held advanced degrees, Lynn said. The staff went to drug-infested areas and recruited people off the street to come to treatment. Each person was given care based upon his or her needs, for as long as necessary. The aftercare program included helping these people get jobs, and in some cases, even setting them up with their own businesses.

Majed Alloush is the General Director of the Al-Sadiq Al-Taieb Association, a charitable, non-profit organization that has been working in Palestine since 1986 to provide assistance and treatment for addicts and their families.  The inpatient treatment and rehabilitation center, built in 1991, today is a 40-bed facility that offers a holistically-based program with wellness, prevention, intervention, treatment and rehabilitation services.
According to Mr. Alloush, the more than 36-year occupation of Palestine has resulted in residual feelings of oppression, despair and depression among many of the Palestinian people. About 65 percent of the population lives below the poverty line, and about 37 percent are jobless, creating a hopeless feeling among many, who turn to violence and drug use, Alloush said. In the past five years, alcohol has become a bigger problem in Palestine, and heroin, cannabis and prescription drug abuse also is on the rise, as is suicide.

This is pretty significant, according to Alloush, since the use of alcohol and suicide goes against the norms and way of life for the Palestinian people. There also is a significant amount of shame associated with these addictions and their consequences, Alloush explained, noting that the program run by Al-Sadiq Al-Taieb is designed to treat the entire family, not just the addict. The people in this region are a very tight-knit group, and everyone in the community knows one another, Alloush said.
Realizing that the youth in Palestine are at risk of drug use and violence, Alloush explained that the program also has a large prevention component. The program encourages children to play on the playgrounds that have been built, and strives to get youth involved in volunteer work around the community, Alloush said.

The RISE Project
An example of another project that focuses heavily on prevention efforts, particularly for its youth population, as well as assisting with education and skills development, is the Reaching Individuals Through Skills and Education (RISE) project. The program, which is part of C4 Recovery Solutions, has provided education, life and social skills training parenting training, youth leadership, adult literacy courses and peer drug prevention training to several communities in Kingston, Jamaica for more than 15 years.

According to RISE Executive Director Sonita Abrahams, many of the youth who have been involved in the program during childhood and/or adolescence, have gone on to get their education and return to work with RISE. The program, which recognizes addiction as a “family disease,” provides counseling services to the entire family.

Much of the program focuses on services that meet the needs of young people, particularly those living in the inner-city communities. Many of the youth programs under RISE have helped to unify members of the community and discourage gang violence, which is a major problem in parts of Jamaica. In addition to educational training and counseling, some of these programs engage adolescents by encouraging them to participate in activities such as dance, music and drama.

In addition to its work designing, implementing and monitoring projects to improve outcomes-based prevention, treatment and recovery services for substance use disorders worldwide, C4 Recovery Solutions also hosts annual conferences in the United States and Europe—the Cape Cod Symposium on Addictive Disorders (CCSAD) and the UK/European Symposium on Addictive Disorders (UKESAD).  Also, to further the implementation of utcomes-based treatment systems, C4 Recovery Solution.

C4 Recovery Solutions operates on a variety of funding streams. The two main sources of revenue are the Ohrstrom Foundation and the time and work that is so generously donated by C4 board members. In addition, C4 makes a slight surplus by operating the Cape Cod Symposium on Addiction Disorders, which is applied to other projects. 

C4 Recovery Solutions currently has other exciting projects in the works C4 also attempts to generate revenue from ongoing projects and applications. This year, C4 is launching a new innovative outcome management software, which aims to provide useful real-time analytics to the field, as well as a modest cash flow for other less financially-sustainable projects, like its Middle Eastern efforts.

C4 is always looking for partners to fund innovative new initiatives and welcomes any approaches from interested parties.  To find out more about C4 Recovery Solutions, visit their website at www.c4recoverysolutions.org.

This article is published in Counselor, The Magazine for Addiction Professionals, February 2010, v.11, n.1, pp.10-13. 

In the field of alcohol and substance abuse counseling there are many counselors and therapists who are, themselves, recovering addicts or alcoholics. There is a professional and ethical dilemma that occurs when the urge arises for the counselor to disclose that he can relate to his client’s struggle on a personal level , as he too is in recovery. Would doing so shift the focus on to the counselor and away from the client? This dilemma could place the counselor in conflict with personal and professional ethics not to self-disclose. What are the clinical and therapeutic advantages or disadvantages of self-disclosure in the field of alcohol and substance abuse ­counseling?

This article explains the importance of professional and ethical decision making with regard to counselor self-disclosure in the field of substance abuse counseling. There is a process whereby the counselor can make a responsible ethical decision based on criteria that will be the most advantageous to the client. Also, included in this article is an analysis of the implementation of a decision-making process on the specific dilemma, as defined above. Specifically, we will examine the clinical effects of self-disclosure as it relates to alcohol and substance abuse counselors, who are themselves in recovery, treating clients who are addicts and or alcoholics. Is self-disclosure in this scenario a professional and effective therapeutic technique? To tell or not to tell; that is the question that will be answered.

There are several published ethical decision-making formats that could be used to answer most professional and ethical dilemmas. To resolve this question this writer will use a generic format. The first step is to identify the situation that requires consideration and decision making. As mentioned, in the field of alcohol and substance abuse treatment there are many therapists and counselors who are, themselves, recovering addicts and alcoholics. Often, when working with addicts and alcoholics, a counselor will hear this statement from the client—“What do you know about addiction? How can you help me? Everything you have learned is from a book.” If the counselor is in recovery—perhaps for many years and doing well—that would make the client’s statement false. The counselor will know full well and firsthand the insanity of active addiction. The dilemma that requires a clinical decision is: should the counselor  inform the client that his perception of the situation is false and untrue? Would the counselor’s self-disclosure clinically and therapeutically help the client move forward in his treatment? Or, would it be detrimental to the client to share this information with him? Who would be affected by the decision of the counselor to self-disclose?

In the example being analyzed here, both the client and counselor will be affected by this decision in several areas. The level of trust in the relationship could go either up or down. The client will definitely view the counselor differently. Also, the counselor will surely lose some level of professionalism. The resulting shift in differentiation will affect the therapeutic anonymity for both the client and the counselor. If the primary goal of therapy is to aid the client, then the counselor must first establish who the actual client is. A good starting point would be to establish that the counselor is not the client. The client is clearly the client, as identified under the American Psychological Association Diagnostic Statistical Manual of Mental Disorders—IV-TR (2000) for alcohol dependence and or drug dependence. It has now been established that under therapeutic protocol, the client’s needs must come first. The next step is for the counselor to assess his or her relevant areas of competence and of missing knowledge, skills, experience or expertise in regard to the relevant aspects of the situation (Pope & Vasquez, 2007).

In this step, counselors need to be open-minded and able to assess their own areas of competence, whether they are personally in recovery, or not. In this scenario, to be an alcohol and substance abuse counselor, an individual would need specific training, state certification, and in some states, an appropriate university degree in human service for credentialing. With the proper training, education and credentialing, an effective counselor should be able to professionally facilitate and assist the client to advance in his treatment without shifting the focus onto himself and away from the primary objective (i.e. the client’s recovery not his own).   

Training in this specific area of alcohol and substance abuse counseling is available at both the state and national level. The National Institute on Drug Abuse (NIDA) position is that counselors in recovery should use their own judgment, preferably in consultation with a supervisor, about when, how and whether to reveal their own personal recovery experiences. This self-disclosure should be made only with a clear understanding of the potential benefits to the client. At no time should a counselor use the group [or individual] sessions to discuss or resolve his or her own personal problems (NIDA, 2000). In regard to this issue of self-disclosure of recovering counselors in the field of alcohol and substance abuse, there is no relevant legal standard. The decision remains in the hands of clinical directors or as a component of the policies and procedures of the treatment provider. Again, the primary objective is to keep the focus on the client’s recovery.

Since Freud, psychodynamic theorists have generally regarded therapist self-disclosure as detrimental to treatment because it might interfere with the therapeutic process, shifting the focus of therapy away from the client. According to this perspective, the counselor is thought to act as a mirror on which the client’s emotional reactions can be projected. If a counselor discloses personal information during therapy, this therapeutic anonymity could be disrupted. Further, it is argued that counselor self-disclosure may adversely affect treatment outcome by exposing weaknesses or vulnerabilities, thereby undermining client trust (Barrett & Berman, 2001).

It was reported by White (2006) that self-disclosure has become increasingly discouraged in the addictions counselor role. To paraphrase, the use of self—using one’s own personal and cultural experiences to enhance the quality of service—has changed dramatically over the past four decades. In the “paraprofessional” era of addiction counseling in the 1950s to early 1970s, disclosing one’s status as a recovering person and using selected details of one’s personal addiction and recovery history as a teaching intervention were among the most prominent counselor interventions. This dimension of the counselor role was based in great part on the role these dimensions played in successful sponsorship within Alcoholics Anonymous through the 1980s and 1990s. In present day professional alcohol and substance counseling such self-disclosure has come to be seen as unprofessional and a sign of poor boundary management (White, 2006).

The next step in the decision-making process is for a counselor to consider how, if at all, their personal feelings, biases or self-interest might affect their ethical judgment and reasoning (Pope & Vasquez, 2007). Herein may lie the most difficult step in the decision-making process for a counselor who is in recovery and treating a newly recovering addict, either individually or in a group setting. Therapists and counselors are human beings, and as such, have feelings. These feelings might affect clinical judgment and reasoning with regard to setting boundaries, so as to avoid a dual relationship. This is not to say that therapists and counselors cannot be genuine. Genuineness is the ability to be oneself and feel comfortable in the context of a professional relationship with a client. It does not imply a high degree of self-disclosure, but a genuine presence in the therapeutic relationship (OASAS, 2008).  

The primary reason that professional relationships and boundary setting are so difficult for individuals in the fields of psychology, social work and counseling, is that treatment takes place in a healthcare and or mental health setting. In this setting it will be necessary for the therapist to place the needs and care of the client above his or her own needs. This could mean that the counselor may have to listen more than talk. This practice allows the client, through guidance by the counselor, to discover his own solutions. The counselor should not disclose his recovery. In some cases individual counselors like to talk more than listen, and may end up using clients for their own self gratification. Having said that, the field of psychotherapy is not for everyone. Good listeners make good counselors.

If a counselor has even the slightest oncern surrounding the question of elf-disclosure, he should seek consultation from supervision. Is there anyone who would likely provide useful consultation in making the decision to self-disclose? Marsia Booker, LMSW, CASAC (personal interview, Jan. 30, 2009) is the Executive Clinical Director of Interline Outpatient Services, Queens, NY, and was able to be succinct in her consultation for this specific situation being discussed in this article. Ms. Booker explained that when a counselor discloses that he or she is also in recovery from addiction, the client will relate to this shared experience rather than the professional ability of the counselor to treat them. Ms. Booker went on to explain that the client will start to relate to his counselor as a peer. In this process, the counselor loses his or her professional status and lessens his or her ability to effectively treat the client. There is a loss of differentiation that can damage the therapeutic relationship. Therefore, Ms. Booker’s clinical position is that her counselors and social workers, who are also in recovery, not self-disclose to their clients who are in treatment at Interline Outpatient Services.

One might ask at this point–what could be an alternative? The answer to this question is a challenging one. The alternative course of action is for the counselors not to broadcast that they are also in recovery. When a counselor hears a statement from the client like: “What do you know about addiction? How can you help me? Everything you have learned is from a book.” A client my simply ask; “Are you in recovery, too?” The counselor must invoke an alternative response other than self disclosure. A possible alternative could be: “This is not about me—it is about you. How can I help you to develop a recovery plan that works for you?” This strategy will get the focus back on the client. Or possibly: “How I got here is not important. What is important is how you got here and how I can help you move forward in your personal recovery.” What is most important is how the client came to be in that seat not how the counselor came to be in his or her seat. Again, this strategy will turn the focus back onto the client and make his or her recovery the primary objective of treatment.

As an additional decision-making strategy, try to adopt the perspective of your clients. From the client’s perspective this writer would rather have his counselor in the role of a highly trained and highly educated professional. The client needs to see his counselor as a professional individual who has the knowledge and ability to help him recover. As the client, this writer would not wish to relate to his counselor as a peer and thereby damage the therapeutic relationship. Upon careful review of this decision-making process, this writer would be very comfortable with making the decision not to self-disclose.

Counselor self-disclosure exists and will continue to exist in the field of psychology and counseling. Bridges (2001) points out that while most counselors engage in some form of disclosure, intentional decisions to share feelings and personal views with patients remain a complex area of clinical practice. This article can report that not all self disclosure is inappropriate. There are  times when self-disclosure works, if it relates to information that the client may be stalled in understanding, or it relates to what is taking place right in that moment. For example, if a client is revealing parenting issues, a counselor may admit that he or she is also a parent, and offer professional therapeutic insight as a counselor/parent. This is not to be confused with the argument that counselor self-disclosure aids in client self-disclosure. Barrett and Berman (2001) state that “although our evidence indicates that therapist self-disclosure can be helpful for treatment, it does not confirm the argument that therapist self-disclosure exerts its impact by encouraging client self-disclosure.” Self- disclosure is not an effective technique for aiding the client in being more open and forthcoming.

Clinicians repeatedly encounter dilemmas for which a clear professional clinical response can be elusive. Standards and procedures cannot take the place of an active, deliberative and creative approach to fulfilling clinical responsibilities. Being prepared in advance and having a decision-making process in place is important because in the human services and healthcare industry, these situations may arise without warning and may need to be addressed fairly quickly. Therefore, know in advance that you are going to be challenged by your clients in regard to this question. It may come as a form of deflection whereby the client is deflecting the attention away from himself. Do not be fooled!  Be prepared in advance with your answer, as suggested above, and return the focus where it belongs; back onto the client.

Continuing training and counselor wellness are key components to the operation of an effective treatment program. Counselor wellness and client wellness are intrinsically and proportionally related.  It is the recommendation of this writer that clinical supervisors provide adequate and ongoing training to counselors and social workers who are themselves in recovery and working with newly recovering addicts in treatment, particularly adolescents. Thera­pists and counselors may self-disclose in other areas, when therapeutically advantageous for the client. However, the disadvantages, as analyzed herein—even the perceived disadvantages to the homeostasis of the therapeutic relationship—far outweigh any possible advantage that self-disclosure might offer. Therapists and counselors who are also recovering addicts and alcoholics and who wish to be considered professional and effective should not, under any circumstances, self-disclose to his or her clients that they are also in recovery. The new question you now need to ask yourself is—are you up to the challenge?

William A. Rule, MS/Psy, CASAC holds a degree in psychology and is a certified substance abuse counselor for the state of New York. He has more than 20 years experience in the field of recovery from addiction, has authored the No Matter What! Relapse Prevention Workshop © which is available free online at www.imustnotuse.com, and is a co-founder and VP of Development for the first nationwide satellite television show based on addiction recovery. He also serves as coordinator of the special needs (MICA) program at an outpatient clinic, and does volunteer educational and prevention work within his community in Long Island.

References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: Author
Bridges, N. A. (2001). Therapist’s self-disclosure: Expanding the comfort zone. Psychotherapy 38;1.  January 23, 2009 from: http://search.ebscohost.com.ezproxy.apollolibrary.com
Barrett, M. S., & Berman J. S., (2001). Is psychotherapy more effective when therapists disclose information about themselves? Journal of Counseling and Clinical Psychology. Retrieved January 23, 2009 from: http://search.ebscohost.com.ezproxy.apollolibrary.com
Pope, K.S., & Vasquez, M.J.T. (2007). Ethics in psychotherapy and counseling. San Francisco, CA: Josey Bass. Retrieved January 12, 2009 from: https://ecampus.phoenix.edu
Office of Alcoholism and Substance Abuse Services, NYS (2008). Motivational interviewing in a chemical dependency treatment setting. Retrieved January 23, 2009 from: http://www.oasas.state.ny.us/AdMed/documents/motinter06.pdf
White, W. L., (2006). Sponsor, recovery coach, addiction counselor: The importance of role clarity and role integrity. Philadelphia, PA: Philadelphia Department of Behavioral Health and Mental Retardation. Retrieved January 23, 2009 from: http://www.oasas.state.ny.us/recovery/documents/WhiteSponsorEssay06.pdf

Dual relationships dominate the ethical landscape of counseling. They are the leading cause of malpractice lawsuits (Corey, Corey & Callanan, 1993); they are a frequent cause of professional sanction (Carr, 2001; Robinson, 2001) and they have earned the attention of state legislatures who enact laws to protect clients from abuse (General Assembly of North Carolina, 1998). In much of the discourse, “dual relationships” are treated as synonymous with “sex with clients.” Sex with clients is clearly unethical. However, there is a wide variety of more ambiguous multiple relationships the counselor can have with clients. During the last 10 years, these other types of dual relationships have earned increasing interest (Corey, Corey & Callanan, 1993) as recently exemplified by the expansion of the American Psychological Association’s Code of Conduct (American Psychological Association, 2002). This article will articulate the damaging aspects of these dual relationships, present a method for placing the relationships on a continuum of potential for harm, and suggest steps to prevent violations of the boundaries that protect clients and the public.