Ethical Issues in RecoveryOriented Programs and Practices

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Ethical Issues in Recovery-Oriented Programs and
Practices

• Rethinking Boundaries and Dimensions in
  Constructing Mutually Respectful Relationships

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Seminar Objectives

• Identify ones own issues in recovery-oriented
  ethical practice
• Define classical ethical principles and current
  applicability to supporting recovery
• Explore means of negotiating ethical boundaries
  with peer support specialists
• Use principles in ones own practice setting.

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PA OMHSAS Definition

• Recovery is a self-determined and holistic
  journey that people undertake to heal and grow.
  Recovery is facilitated by relationships and
  environments that provide hope, empowerment,
  choices and opportunities that promote people
  reaching their full potential as individuals and
  community members.

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Components of Recovery

• People need
• Hope
• Connectedness
• Support
• Education and knowledge
• Personal responsibility
• Self-advocacy
• Value, purpose and meaning in life
• (OMHSAS Recovery Curriculum Workgroup 2005)

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Recovery Involves More Than Traditional Service
Provision

• Essential components to promote recovery
• Access to recovery oriented services
• Peer and consumer support/self-help groups
• Family and friend supports and relationships
• Work and meaningful activity
• Self-determination
• Management of discrimination
• Community involvement
• Educational opportunities
• Access to training and technologies that foster
  recovery

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Clinical Communication in Recovery-Oriented
Practice

• Some suggestions for how to think and behave
  under different circumstances with different
  levels of risk to the person receiving services

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Suggestions for Recovery-Oriented Practice

• Pat Deegan spells out nine principles and subsets
  of these principles in her Common Ground
  approach to supporting choice. She discusses
  both neglect and toxic help and pays
  considerable attention to examining three areas
• The comfort zone
• The conflicted zone
• The non-negotiable zone (risk management)
• Her analysis is very useful for practitioners and
  supervisors.

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The Conflicted Zone

• When choices appear to be self defeating or
  diminish quality of life.

Let the person do what he/she wants (NEGLECT)
Get person to do what I want (POWER/CONTROL)
Response Continuum
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When Conflicted

• Dont abandon the person (their choice) and
  neglect rather than empower
• Do remain engaged and supportive
• Brainstorm other options discuss pros/cons
• Educate about alternatives
• Talk situation over with supervisor peers
• Dont move to control and out of relationship

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When Risk Management is Needed

• Dont develop a plan on your own and assume the
  person will always need such a plan and rely on
  it to solve the problem
• Consult with others to develop a RM plan
• Remain engaged and openly communicating your
  concern and intent, inviting involvement
• Include specific criteria in plan that person
  needs to demonstrate in order to have a less
  restrictive plan restoring more freedom/choice
• Problem-solve in advance prevent crises

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Forced Choice vs. Real Choice

• Choosing between only A B forced
• Validating feelings, empathizing with perspective
  and preference, and searching for alternatives
  with others are necessary
• Giving choices even when first one is limited
• Advocacy for preferences may include seeking
  legal and/or human rights advice, support from
  others who have been affected, forcing creation
  of alternatives, looking for out-of-system
  alternatives be creative

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Influencing Choice

• Reinforces
• Support choice and goal realization
• Planned and understood
• Informed with accurate information

• Threats, Coercion, Bribes
• Ignores choice
• Focus on workers agenda
• Rely on misinformation and/or inadequate
  information

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Thinking about Ethics and Boundaries in
Recovery-Oriented Programs and Practice

• Possible similarities and differences in clinical
  practice and in peer support services in terms of
  ethical practices and boundary conditions

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BASIC ETHICAL PRINCIPLES

• BENEFICENCE
• NONMALFEASANCE
• AUTONOMY
• FIDELITY
• JUSTICE
• CONFIDENTIALITY
• VERACITY

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BASIC STEPS IN ETHICAL DECISION-MAKING

• Determine the facts (which? whose?)
• Analyze ethical aspects (rights? duties?)
• Outline the options (moral justification for
  each?)
• Make a decision (results desired process/means
  to end)
• Take action (reflecting above values/principles)
• Evaluate the decision (from 5 back to 1)

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Definitions Boundary

• Boundaries define space
• Treatment boundary is a psychological containment
  field (Bridges,1999)
• Boundary is the edge of appropriate behavior in a
  given situation (Gutheil,1999)
• Shaped by theoretical perspective

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Relationship of Boundaries to Ethical Principles
and Values

• Proper boundary maintenance imparts the
  behavioral message that honesty, integrity, and
  respect for the worth of the individual are the
  most adaptive ways of coping with human problems
• Boundaries provide a sense of safety within which
  helping and healing can occur
• Attention to boundaries provides clarity about
  mutual rights and responsibilities

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Breaches of Boundary(Gutheil, 1999)

• Boundary crossing
• Action does not harm
• May advance treatment
• Boundary violation
• Exploitative or harmful

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Changing Boundaries in Recovery-Oriented Practice

• Considerations
• focus on the person, not the program
• partnership rather than professional expert
• choice and self-management rather than
  prescription and compliance
• shared process rather than dictated goals
• focus on relationship and trust as central

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Peer Supports Recovery Coach

• Legitimized by dual credentials
• experiential knowledge about recovery acquired by
  the process of recovery (ones/others)
• Experiential expertise ability to transform this
  knowledge into skills for helping others achieve
  and sustain recovery
• Wounded healers in a long tradition
• those who have suffered and survived and
  illness or experience who use their own
  vulnerability and the lessons drawn from that
  process to minister to others seeking to heal
  from this same condition. (p. 5)

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Peer-Based Recovery Supports Provide

• Emotional support empathy, love, caring
  concern
• Informational support health wellness,
  educational assistance, new skills
• Instrumental support concrete assistance in task
  accomplishment, e.g., applications, help with
  child care, transportation, clothing
• Companionship connection in recreation, recovery
  supports, meeting others

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Possible Roles Defined

• Monitor
• Tour guide
• Advocate
• Educator
• Community organizer
• Lifestyle consultant/ guide
• Friend

• Outreach worker
• Motivator cheerleader
• Ally and confidant
• Truth-teller
• Role model mentor
• Planner
• Problem-solver
• Resource broker

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Outside of the Role

• Sponsor do not provide steps/principles of a
  particular recovery program in this role
• Therapist/counselor do not diagnose or focus on
  problems/issues/trauma
• Nurse/physician do not suggest or disagree with
  medical advice or prescribed drugs beyond bounds
  of your training experience
• Priest/clergy do not promote a particular
  religion/doctrine/church, interpret, offer
  forgiveness or provide pastoral counseling

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Differences in Recovery Support

• Spans periods of pre-recovery engagement,
  recovery initiation, stabilization maintenance
• Relationships are less hierarchical, involve
  different core functions and are governed by
  different accountabilities
• Consumers of peer-based recovery support services
  differ in kinds of non-clinical supports needed
  and may need different types of services at
  different stages of illness recovery
• Services may be adjunctive to treatment or an
  alternative to treatment depending on needs

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Dangerous Assumptions 1-7

• People who have a long, and by all appearances,
  quality sobriety, can be counted on to act
  ethically as recovery coaches.
• People hired as recovery coaches will have common
  sense.
• Breaches in ethical conduct are made by bad
  people. If we hire good people, we should be
  okay.
• Adhering to existing laws and regulations will
  assure a high level of ethical conduct.

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Dangerous Assumptions 1-7(continued)

• Ethical standards governing clinical roles
  (e.g., psychiatrists, psychologists, social
  workers, nurses, addiction counselors) can be
  indiscriminantely applied to the role of recovery
  coach.
• Formal ethical guidelines are needed for
  recovery coaches in full-time paid roles, but are
  not needed for recovery coaches who work as
  volunteers for only a few hours each week.

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Dangerous Assumptions 1-7(continued)

• If a recovery coach gets into vulnerable ethical
  territory, he or she will let us know. If the
  supervisor isnt hearing anything about ethical
  issues, everything must be okay.

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4 Ethical Terms for Recovery Coaches

• Iatrogenic unintended, treatment-caused harm or
  injury
• Fiduciary one person has a special duty and
  obligation for the care of another
• Boundary Management decisions that increase or
  decrease intimacy within a relationship (involves
  behaviors disclosures)
• Multi-party Vulnerability how multiple parties
  can be injured by what the recovery coach does or
  fails to do

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A Peer-based Model of Ethical Decision-making
(White et al, 2007)

• Question 1 Potential for harm for whom and
  magnitude of risk?
• Question 2 Are any core recovery values
  applicable to the situation and, if so, what
  course of action do they suggest?
• Question 3 What laws, organizational policies or
  ethical standards apply to this situation and
  what actions would they suggest or dictate?

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A Peer-based Model of Ethical Decision-making
(White et al, 2007)
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A Peer-based Model of Ethical Decision-making
(White et al, 2007)

• Gratitude Service
• Recovery
• Use of Self
• Capability
• Honesty
• Authenticity of Voice
• Credibility
• Fidelity
• Humility

• Loyalty
• Hope
• Dignity and Respect
• Tolerance
• Autonomy Choice
• Discretion
• Protection
• Advocacy
• Stewardship

Suggested Course of Action for each Core Recovery
Value
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To Download the Complete Document for your use

• Just google Ethical Guidelines for the Delivery
  of Peer-based Recovery Support Services
• The paper by William L. White, MA, will come up
  for download as a pdf file

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To reach the presenter

• Call Taylor Anderson at 215-831-3574 (or
  toll-free at 1-877-243-3033)
• e-mail Taylor.Anderson_at_Drexelmed.edu
• Mail Taylor B. Anderson, MSW, LSW, CPRP
• Department of Psychiatry
• Drexel University College of Medicine/BHE
• c/o Friends Hospital, 202W
• PO Box 45357 (4641 Roosevelt Blvd.)
• Philadelphia PA 19124