Tag Archives: Adolescents

Substance Abuse Grab-bag

On the subject of terminology, I thought it was rather odd that NHW made the statement that “the phrases ‘chemical dependency, addiction, and habit’ are still in use but less so than ‘substance abuse, use, or misuse;’” and then later citing “changes in the thinking in the field of chemical dependency.”  (Netherton, Holmes, & Walker, 1999, p. 241)  Perhaps that’s an indication that old habits are not easily broken.

The text again acknowledges that “the use of substances to cope, alter moods, or reach another level of consciousness has been an acceptable form of communication and expression for most of humankind.”  (Netherton et al., 1999, p. 242)  This statement alone suffices to encapsulate the difficulty of the task at hand.  Quite simply, there is a significant portion of the population that doesn’t recognize there is a problem.  “Substance use has become less stigmatizing among adolescents and is fiend less as a problem among their peers.”  (Netherton et al., 1999, p. 242)  Check and checkmate.

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I have trouble “getting behind” the disease model for substance use and abuse.  To my eyes, substance use appears more like a behavior than a disease.  In my experience, alcoholism is typically a secondary symptom stemming from another underlying physical cause or emotional disorder.  The degree and the prevalence of comorbidity would appear to support this position.  While I don’t disagree that the behavior needs to be recognized and addressed, I believe that addressing the underlying emotional disorder is critical to the long term success of these individuals.

Other substance-related models include the developmental model, the gateway model, problem behavior theory, cognitive models, the social learning model, and finally… the addictive behavior model.  I believe that social learning weighs heavily on the adolescent mind, and I wholly support the statement that “adolescents place great value on peer opinions and struggle to fit in.”  (Netherton et al., 1999, p. 247)  This serves as an entry point for the behavior, which then sets the tone for the addictive behavior model, which subsequently suggests that behaviors are a series of bad habits that have been over-conditioned to the extent that they become detrimental.

“Long-term substance use is related to psychiatric conditions such as suicide and depression, affective disorders, eating disorders, and personality disorders.”  (Netherton et al., 1999, p. 248)  This is only the second time in this class where we have listed entire categories as being comorbid with a specific disorder.  Is this the first mention of dual diagnosis in this class, or have we previously addressed that?

Addressing treatment, the treatment options range from pretreatment services, through outpatient treatment, to intensive inpatient treatment and/or residential care.  “Some of the fundamental treatment services include structure, dual diagnosis capabilities, pharmacological interventions, arrangements with medical care, role modeling, client participation in the therapeutic milieu, family groups, individual and group therapy, school/vocational training, recreational programs, relapse prevention, and 12-step support.”  (Netherton et al., 1999, p. 255)

Of the specific treatment approaches and interventions, I most identified with the harm reduction approach.  “Harm reduction, harm minimization, and risk reduction are terms that describe methods based on the assumption that habits can be placed along a continuum ranging from lowest risk to highest amount of risk.”  (Netherton et al., 1999, p. 258)  The object, or the goal, is the transition the individual along the continuum to a behavior that is less harmful.  It seems to be more progressive in its approach, with its intent to “normalize rather than marginalize substance abusers.”  I don’t think this is necessarily the ideal treatment for all people who suffer from alcohol-related problems, but I think it would be a less invasive and potentially better received option than some of the more stringent measures.

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Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Ethical Issues to Consider When Counseling Minors

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Four ethical issues consistently emerge when one considers children as clients outside the school setting; counselor competence, informed consent and a minor’s ability to enter into a contractual relationship, confidentiality, and child abuse reporting.  (Lawrence & Robinson-Kirpius, 2000)  Although no plan of action can completely remove the possibility of a malpractice lawsuit, there are strategies that would allow us to minimize that risk.

On the subject of competence, there are specific skills and knowledge required when one intends to counsel children. Aside from familiarity with the disorders that are specific to and primary found among children (i.e., ADHD, Separation Anxiety Disorder, and RAD), being an effective counselor for children requires a foundation in theoretical models that are generally applied to children and their needs.  Examples might include theories of ego identity, moral, psychosexual, and cognitive development specific to the context of serving children.  All levels of the clinical experience need to be modified to be developmentally appropriate, including assessment, diagnosis, and treatment.  “Because minors are a special, diverse client population, ethical practice mandates distinct education, training, and supervised practice before commencing independent practice that includes minors.”  (Lawrence & Robinson-Kirpius, 2000, expression ETHICAL ISSUES)

“Informed consent involves the right of clients to be informed about their therapy and to make autonomous decisions pertaining to it.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 160)  Typically, a minor can enter into a contractual agreement in one of three ways; with parental consent, involuntarily at a parent’s insistence, or by court order.  The most common scenarios involve getting parents or caregivers involved with the process.  Without that involvement, we risk being sued for failure to gain consent.  Although court ordered treatment does not typically require parental consent, it is considered best practice to inform parents as soon as it is reasonably possible.  Similarly, in the case of emergency, minors can typically provide informed consent when delay of treatment would endanger their life or health, but again, parental consent should be obtained when possible.  (Lawrence & Robinson-Kirpius, 2000)

Confidentiality is of primary concern when working with minors, primarily because inconsistencies exist where what is legally required may not coincide with what is ethically desired.  “The basic dilemma with respect to confidentiality is who is the client, the parent or the child.”  (Lawrence & Robinson-Kirpius, 2000, expression Confidentiality)  Ideally, counselors should involve parents and create a “three-way bond of trust.”  When that is not possible, or otherwise resisted by the minor in question, it is suggested that we encourage disclosure by underscoring possible benefits.  Once parental consent is obtained, it is critical that we strive to maintain balance and clearly define limits to our ability to disclose information.

Child abuse, and the reporting of that situation, is one of the most common breaches of legal and ethical standards.  “This may be because reporting abuse can disrupt not only the therapeutic relationships but also disrupt and irrevocably destabilize the family in which the abuse occurs.”  (Lawrence & Robinson-Kirpius, 2000, expression Child Abuse Reporting)  Nonetheless, reporting child abuse is mandatory in all 50 states, and should be considered as one of our primary responsibilities as practicing clinicians.

As one can surmise, there are a number of possible scenarios where ethics and legal obligations collide.  Because I am going to be entering the profession as a novice counselor, I am most concerned with the definition of “competence.”  If at that time I have any withholdings regarding working with the minor population, I would certainly seek out supervision or continuing education.  Furthermore, I can minimize the risk of working with this population by familiarizing myself with state law that pertains to informed consent with minors.  Although it is not exclusive to practicing with this population, I would attempt to keep accurate and objective records of all interactions with both the parents and the child client.

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Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Lawrence, G., & Robinson-Kirpius, S. E. (2000, Spring). Legal and ethical issues involved when counseling minors in nonschool settings. Journal of Counseling and Development : JCD, 78(2), 130-137. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=52748628&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD