Frequently Asked Questions

What are the requirements for license renewal? Licenses Expire CE Hours Required Mandatory Courses 3 hours of Ethics (each renewal) 2 hours of Medical Errors (each renewal) Clinical Social Worker, Marriage and Family 30 3 hours of Laws and Rules Therapists, and Mental Health Counselor (All hours are allowed through home-study) (every third biennium) licenses expire on March 31, 2017. 2 hours of Domestic Violence (every third biennium) How do I complete this course and receive my certificate of completion? Online Go to SocialWork.EliteCME.com and follow the prompts. Print your certificate immediately. How much will it cost? Cost of Courses Course Title CE Hours Price Ethics and Boundaries (Required for renewal) 3 $15.00 Medical Errors in the Mental Health Profession (Required for renewal) 2 $10.00 Domestic Violence (Required every third biennium) 2 $10.00 Florida Law for the Social Worker, Mental Health Counselor and Marriage and Family Therapist 3 $15.00 (Required every third biennium) Cultural Competence in Mental Health Practice Part I: Principles, Preparation and Priorities for 3 $15.00 Practice The Heroin Abuse Epidemic in America: Identification, Treatment and Prevention 4 $20.00 Medication Management of Opioid Dependence 5 $25.00 Understanding Neurotransmission and the Disease of Addiction 4 $20.00 The Use of the Internet in Therapy: Guidelines and Best Practices 4 $20.00  BEST VALUE  Entire 30-Hour Course  SAVE $103 30 $47.00 Are you a Florida board approved provider? Yes. Elite is approved by the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health counselors to provide continuing education for licensees. Provider number 50-4007. Additionally, our courses are nationally approved by the National Association of Social Workers (NASW); provider number 886463821. Are my credit hours reported to the Florida board? Yes, we report your hours electronically to the board through CEBroker within one business day. You keep your certificate of completion for your records. Is my information secure? Yes! Our website is secured by Thawte, we use SSL encryption, and we never share your information with third-parties. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online – at SocialWork.EliteCME.com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or Email us at [email protected] or call us toll free at 1-866- 653-2119, Monday - Friday 9:00 am - 6:00 pm EST. Important information for licensees. Always check your state’s board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. See Customer Information (last page) for the board’s contact information.

SocialWork.EliteCME.com Page i Table of Contents

CE for Florida Social Work All 30 Hrs Professionals ONLY CHAPTER 1: ETHICS AND BOUNDARIES Page 1 $ Ethical issues are common in any profession. But mental health work, which relies heavily on 47 relationship building and which can directly impact the health and welfare of its clients, poses even greater responsibilities and challenges. Ethical decision-making is a complex process, requiring mental health practitioners to look at not just the immediate impact, but also the long-term and future consequences of their actions. Ethics and Boundaries Final Exam Page 14 What if I Still Have CHAPTER 2: Medical Errors in the mental health Questions? profession Page 15 No problem, we have several options for you to choose from! Medical errors are defined and governed by various entities, such as state legislatures, mental health associations and best practice institutions, to help preserve the health, safety and welfare Online at SocialWork.EliteCME. of the public. As members of a health care prevention, intervention and oversight team, mental com you will see our robust FAQ health professionals have a responsibility to be aware of medical errors, as well as learn strategies section that answers many of to minimize them. your questions, simply click FAQ Medical Errors in the Mental Health Profession Final Exam Page 20 in the upper right hand corner or Email us at [email protected] CHAPTER 3: domestic violence Page 22 or call us toll free at 1-866-653- 2119, Monday - Friday 9:00 am Domestic violence is an urgent public health problem with devastating consequences for women, - 6:00 pm, EST. men, children, youth, and the elderly. Domestic violence has no age, gender, social, ethnic, geographic, education, economic, or race boundaries. There is no typical victim, yet it affects the Visit health and well being of all persons involved in the crime; in particular, contributing to children in SocialWork.EliteCME.com care. Mental health practitioners have an obligation to screen clients for domestic violence as part to view our entire course library of their information gathering. and get your CE today! Domestic Violence Final Exam Page 27

CHAPTER 4: florida law for the social worker, PLUS... mental health counselor, and marriage and Lowest Price Guaranteed family therapist Page 28 Serving Professionals Since 1999

The Florida Statutes are state laws that are arranged by titles, chapters, parts, and sections. They are considered permanent, but are reviewed and updated annually and may be amended, altered, or repealed. Social workers, mental health counselors and marriage and family therapists practice in their area of competency, and in some cases there are a number of statutes that apply to their work. Multiple statutes govern the practice of these professions and their agency supervisors who direct staff as they carry out their duties in administration, education, and support. The statutes inform the way the administrators manage funds and resources for the agency, and their work as advocates and community health team members.

Florida Law for the Social Worker, Mental Health Counselor, and Marriage and Family Therapist Final Exam Page 60

Elite Continuing Education

©2016: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.

Page ii SocialWork.EliteCME.com CHAPTER 5: CULTURAL COMPETENCE IN MENTAL HEALTH PRACTICE Part i: principles, preparation and priorities for practice Page 61

Demonstrating cultural competence is an integral part of mental health service delivery. On the national level this issue has received greater support as the United States government recognizes the influence and impact of converging nationalities and cultures. Because divisions of race, ethnicity and culture exist in the United States, there is an increasing awareness of cultural competence and how it can eliminate disparities in care for people of diverse racial, ethnic and cultural backgrounds. Cultural Competence in Mental Health Practice Part I: Principles Preparation and Priorities for Practice Final Exam Page 75

CHAPTER 6: THE HEROIN abuse EPIDEMIC IN AMERICA: IDENTIFICATION, TREATMENT AND PREVENTION Page 76

The purpose of this course is to familiarize professionals with basic information concerning heroin addiction, which has reached epidemic proportions in the United States and around the globe. This includes facts about heroin and addiction, effects on the brain, progression of the disease, psychological and physical effects of short-term and chronic use, screening, treatment, and prevention. The Heroin Abuse Epidemic in America: Identification, Treatment and Prevention Final Exam Page 92

CHAPTER 7: MEDICATION MANAGEMENT OF OPIOID DEPENDENCE Page 93 In recent years, opiate dependence has become a catastrophic problem in the United States, causing thousands, especially younger people, to lose their lives, and leaving loved ones behind to question these senseless losses. People included in this grave epidemic come from the full spectrum of socio-economic backgrounds. It is an addiction, where, truly, no one gets left behind. Medication Management of Opioid Dependence Final Exam Page 114

CHAPTER 8: UNDERSTANDING NEUROTRANSMISSION AND THE DISEASE OF ADDICTION Page 116

In this course, learners will gain further understanding about the interaction between neurotransmitters and addictive substances, as well as how they alter neurotransmission, subsequent thinking and behaviors. Learners will also gain a deeper awareness about research methodologies about neurotransmission and drug interaction, as well as recent scientific findings. Abused drugs affect the way people think, feel, and behave. The long-term effects ultimately interface with our overall society as well at great emotional and financial cost to those affected. Understanding Neurotransmission and the Disease of Addiction Final Exam Page 132

CHAPTER 9: THE USE OF the INTERNET in THERAPY: GUIDELINES AND BEST PRACTICES Page 133

The field of online therapy is likely to continue to grow as the Internet and other forms of electronic communication become part of our daily lives. A therapist should stay abreast of the constantly changing regulatory and ethical issues with online therapy. Certainly, the advantages are there: Flexible schedules, low overhead, and the ability to reach more clients in a larger geographical area. The potential of online therapy cannot be ignored and providers should be aware of the growing trend in this area. The Use of the Internet in Therapy: Guidelines and Best Practices Final Exam Page 144

SocialWork.EliteCME.com Page iii Chapter 1: Ethics and Boundaries

3 CE Hours

By: Rene’ Ledford, MSW, LCSW, BCBA and Kathryn Brohl, MA, LMFT

Learning objectives ŠŠ Understand the importance of professional values and ethics in ŠŠ Identify elements and conditions of informed consent. mental health practice. ŠŠ Understand the basic requirement of HIPAA and the Privacy Rule ŠŠ Identify the role and the impact of law in mental health practice. as it relates to practice. ŠŠ Recognize and distinguish between problematic and non- ŠŠ Understand the impact of technology on mental health practice and problematic boundary issues in mental health practice. the unique responsibilities that are included. ŠŠ Describe ways mental health practitioners can prevent unethical or ŠŠ Identify a protocol for ethical decision-making. illegal behaviors in daily practice.

Introduction Ethics and mental health practice Ethical issues are common in any profession. But mental health Given her strong belief in client self-determination, the client’s work, which relies heavily on relationship building and which can belief in her ability to assist, and her willingness to read the directly impact the health and welfare of its clients, poses even greater literature and consult the Internet on protocol, Mary agreed to responsibilities and challenges. revise their plan of treatment and proceed. Mental health practitioners must rely on internal guides of character ●● Joaquin, a licensed clinical social worker, and his client, a young and integrity and external guides such as laws and ethical codes of man with schizophrenia, have successfully worked together to conduct. Consider these two examples: achieve stability in symptom management and independent living. ●● Mary, a mental health counselor, provided counseling services Joaquin and his client are close in age, have many interests in at a community mental health center. Most of her clients did not common and consequently have achieved a strong rapport and have insurance nor could afford to pay privately anywhere else. mutual trust. Now Joaquin is transferring to a supervisory position, After several years of postgraduate full-time practice, Mary felt which will effectively end his professional relationship with the competent providing services for most issues. client. His client wishes to continue their relationship as friends, and Joaquin is tempted to do so. After three sessions with one of her clients, her client confessed that he wanted a sex-change operation and would need Mary’s In these two examples, each mental health practitioner demonstrates support through the process. Mary had taken few graduate level both a compassion for and commitment to their respective clients. They courses in human sexuality and had no other specialized training in are at a crossroads in their relationship with their clients. What they this specialized area. If there was another clinician available who decide to do next must consider various issues that include what is in the specialized in gender reassignment issues, her client could not afford it. best interest of the client and the client’s right to self-determination.

The primary reason for action What is easiest, most comfortable, and/or desired by these mental If Mary makes the wrong decision, she might either violate ethical health practitioners should never be the primary reason for action. If guidelines or the law, or both. She may be committing a medical error the needs of the client versus mental health therapist were the only and putting her client at risk of harm. Her actions may also result in considerations, decision-making would be easy. However, the mental Mary being sued and/or censured. health worker must also consider the ethical guidelines established by Joaquin must ask himself the question, “Am I considering crossing various government agencies and national mental health professional the boundaries of our professional relationship for my own needs or associations, as well as the law. for those of my client?” Clearly both Joaquin and his client value a In the first scenario, Mary must balance both her and her client’s desire friendship but what potential harmful impact could this have on one or to continue what appears to be a comfortable and trusting therapeutic both of them? relationship, with the need to provide the most effective service for the Ethical decision-making is a complex process, requiring mental health client. Clearly Mary is not qualified to provide the service this client practitioners to look at not just the immediate impact, but also the needs. Is her plan for a crash course in transgendered treatment adequate? long-term and future consequences of their actions. Should she make a referral to a more competent therapist? Should she work with the client to overcome the financial barriers he is facing?

Page 1 SocialWork.EliteCME.com Defining ethics The word “ethics” is derived from both the Greek word “ethos,” which For example, documenting that a service has occurred when it hasn’t means character, and the Latin word “mores,” meaning customs. may be unethical, but not subject to prosecution. Unfortunately, it Ethics defines what is good for both society and the individual. Though may take high-profile adverse consequences of unethical behavior, closely related, law and ethics do not necessarily have a reciprocal such as the discovery that a child under protective custody has been relationship. While the origins of law can often be based upon ethical missing for months, to create new laws that support ethical standards principles, law does not prohibit many unethical behaviors. Likewise, of behavior. For instance, in a well-publicized case, the state of Florida adherence to certain ethical principles may challenge a mental health made the falsification of documentation, e.g., visitations that never practitioner’s ability to uphold the law. took place, illegal for people employed as child welfare workers.

Implications for practice Ethical standards are, according to Reamer (Ethical Standards in enforced by its own ethics committee. The American Counseling Social Work, 1998), “created to help professionals identify ethical Association “promotes ethical counseling practice in service to the issues in practice and provide guidelines to determine what is ethically public.” The primary mission of the National Association for Social acceptable and unacceptable behavior.” What makes mental health Workers is to “enhance human well-being and help meet the basic work unique is its focus on the person as well as its commitment to the human needs of all people, with particular attention to the needs and well-being of society as a whole. empowerment of people who are vulnerable, oppressed, and living in The social work profession adopted the first code of ethics for the poverty.” profession in 1947. In 1960, following the formation of the National Being part of a professional association not only brings a wealth of Association of Social Work, another code of ethics was drafted, with knowledge and expertise but also certain rights and privileges for its multiple revisions in the following years. Ethics have been developed members. But those benefits must not overshadow the professional’s for other national mental health licensing associations and boards commitment to promote ethical behavior on behalf of clients. that include among others, The American Association for Marriage When an individual identifies with a mental health profession, he or and Family Therapy, The American Counseling Association, and The she is pledging to practice in an ethical and responsible manner. In American Mental Health Association. addition to allegiance to the professional ethics and standards of practice The American Association for Marriage and Family Therapy “strives it promotes, the individual also has a duty to support the values, rules, to honor the public trust in marriage and family therapists by setting laws, and customs of the society with which they remain a part. standards for ethical practice as professional expectations” that are

The law and mental health Here is one scenario that illustrates how law can interface with mental legal responsibility to learn and follow any and all regulations in the health practice: jurisdiction within which they practice. A licensed mental health practitioner believes a foster teen’s In the case described above, federal and state laws about mandatory allegations of abuse toward her foster father merely represent reporting leave little choice for a professional but to report the countercoercive behavior related to her adjustment within a more allegations of abuse. Sometimes we can be too sure of our abilities or stable, rule-enforced environment and chooses not to report it. He too fearful (in this case, potentially losing a foster parent), and in doing rationalized that this family had successfully helped many children so ignore the very real consequences of violating the law. Or, in less before without incident. obvious circumstances, we may just not know. As pointed out earlier, criminal law and professional and ethical With the advent of technology-based practice, such as e-therapy, the guidelines are not one and the same – they may complement each mental health practitioner’s scope of responsibility is even larger; some other or be in opposition of one another depending on the issue and on jurisdictions identify the location of practice, and thus the applicable the state. For example, a minor legal offense may result in a small fine laws and rules, as that of the client’s. We will explore more about but could then lead to loss of a professional license. Licensed mental technology-based and other practice implications later in this course. health practitioners have not just an ethical responsibility but also a

Impact of law on practice Currently the United States, including all 50 states, the District of policy if they were not practicing legally at the time of a questionable Columbia, Puerto Rico, the U.S. Virgin Islands, and other countries ethical occurrence; i.e., were not licensed as required by law. regulate some form of mental health practice. Many typically regulate There are also laws that impose legal obligations to abide by practices practice through statutes, i.e., practice acts that stipulate who may that further serve to protect the consumer, such as federal and state practice and/or call themselves mental health practitioners (Saltzman statutes requiring mandatory child abuse reporting, practices that ensure and Furman, 1998). State oversight boards give authority to practice to client confidentiality, or competence to perform certain services. qualified individuals, typically defined by three competencies: ●● Education. Unlike regulation under the law, adherence to regulations set forth by ●● Experience. private credentialing bodies is voluntary. However, the regulations and ●● Passing score on an examination. codes of ethics are universally respected. Mental health professionals also practice in accordance to the professional standards of care Failure to abide by these regulations can have serious and negative legal established by private professional association organizations such as and financial consequences. For example, mental health professionals ACA, NASW, or AAMFT. need to understand that they may not be covered by their insurance

SocialWork.EliteCME.com Page 2 Establishing ethical codes of conduct In addition to professional affiliation code of ethics, (such as 8. Collegial actions. established within national professional associations), state licensing 9. Reimbursement. laws and licensing board regulations identify basic competencies for 10. Conflicts of interest. mental health practice. Failure to follow the ethical codes of one’s Of the 267 individuals found to have violated ethical standards, 26 percent profession may result in expulsion from the profession, sanctions, were found to have violated only one ethics category, while 74 percent fines, and can result, if sued, in a judgment against the practitioner. had violated more than one. Most of the cases (55 percent) involved For example, Strom-Gottfried (2000) reviewed 894 ethics cases filed with boundary violations, such as those involving sexual relationships and NASW between July 1, 1986, and December 31, 1997. About 48 percent dual relationships. Given the frequency that these violations occur, (and of the cases resulted in hearings and of those, 62 percent concluded remember, this study only examined reported violations) we will be that violations had occurred for a total of 781 different violations. exploring these two violation types in more depth later. The findings The study clustered those violations into 10 categories: reflected a variety of inappropriate behaviors that blurred the helping 1. Violating boundaries. process and exploited clients including: 2. Poor practice. ●● The use of physical contact in treatment. 3. Competence. ●● The pursuit of sexual activity with clients, either during or 4. Record keeping. immediately after treatment. 5. Honesty. ●● Social relationships. 6. Confidentiality. ●● Business relationships. 7. Informed consent. ●● Bartering.

Unintended actions Some mental health professionals may argue that an action is ethical as Literalization long as you are not intending harm and/or are not knowingly violating The principle (or rationalization) of literalization states that if we an ethical standard or law. Or, what about those unique situations cannot find a specific mention of a particular incident anywhere in that don’t readily lend themselves to a reference in law or codes of legal, ethical, or professional standards, it must be ethical. conduct? What defines prudent practice? Grappling with questions Assisting mental health practitioners in resolving ethical dilemmas that about what is unethical and what isn’t ethical is a situation faced by may arise in practice is just one of several purposes for establishing any person in the helping professions. ethical codes of conduct. Pope and Vasquez (1998) discuss the tendency to rationalize that an Ethical standards of practice for mental health generally benefit both action is acceptable, as it relates to the practice of psychotherapy and the practitioner and the public and include: counseling. 1. Identifying core values. This rationalization encompasses two principles: 2. Establishing a set of specific ethical standards that should be used 1. Specific ignorance. to guide mental health practice. 2. Specific literalization. 3. Identifying relevant considerations when professional obligations Specific ignorance conflict or ethical uncertainties arise. The principle (or rationalization) of specific ignorance states that even 4. Providing ethical standards to which the general public can hold if there is a law prohibiting an action, what you do is not illegal as long mental health professionals accountable. as you are unaware of the law. 5. Providing mental health ethical practice and standards orientation to practitioners new to the mental health field. 6. Articulating formal procedures to adjudicate ethics complaints filed against mental health practitioners.

Core values and ethical principles The core values espoused by mental health ethics codes incorporate a ●● Financial arrangements conform to accepted professional practices. wide range of overlapping morals, values, and ethical principles that lay Depending on a particular professional association’s Code of Ethics, the foundation for the profession’s unique duties. They generally include: ethical professional practice can include: ●● Service. ●● Helping people in need. ●● Autonomy – Allowing for freedom of choice and action. ●● Challenging social injustice. ●● Responsibility to clients. ●● Respecting the inherent dignity and worth of the person. ●● Responsibility to the profession. ●● Recognizing the central importance of human relationships. ●● Responsibility to social justice. ●● Behaving in a trustworthy manner. ●● Responsibility for doing no harm. ●● Practicing within areas of competence and developing and ●● Dignity and worth of the person. enhancing professional expertise. ●● Confidentiality. ●● Importance of human relationships. The intent of some of the principles, such as responsibility to students ●● Do good and be proactive. and supervisees, are what mental health practitioners can aspire ●● Professional competence. to, while others are much more prescriptive, clearly identifying ●● Integrity. enforceable standards of conduct (Reamer, 1998). ●● Engagement with appropriate informational activities. Most ethics codes describe specific ethical standards relevant to six ●● Treating people in accordance with their relevant differences. areas of professional functioning. These standards provide accepted ●● Responsibility to students and supervisees. standards of behavior for all mental health clinicians concerning ●● Fidelity. ethical responsibilities: ●● Responsibility to research participants. 1. To clients.

Page 3 SocialWork.EliteCME.com 2. To colleagues. 5. To a particular mental health profession focus. 3. To practice settings. 6. To the broader society. 4. As professionals. This course will continue to look at issues around each of those areas.

Ethical responsibilities to clients This illustration highlights the complexity of ethical responsibility to that he only needs help downloading information from the Internet clients: and then it is his right to weigh the options of proceeding. Rene Example: A depressed, 80-year-old client, suffering from the believes the client’s depression is directly related to the pain, painful, debilitating effects of arthritis, asks Rene, his mental because the client is otherwise of sound mind, and therefore has a health therapist, for information on assisted suicide. He tells her right to determine his future. Commitment Client interests are primary. The example above epitomizes the each other. The professional is then faced with a conundrum that difficulties often faced by mental health practitioners when the offers a multitude of potential decisions, actions, and consequences. principles of law, personal belief, professional codes of ethics, client We will discuss more about how the worker can best weigh all these need, and cultural and societal norms intersect and at times contradict considerations to make the most ethical decision later in this course.

Self-determination Another standard that strongly reflects the mental health practitioner’s client or to others. Other client choices, such as staying in an abusive commitment to a client is that of self-determination. Professionals relationship or living in squalor or on the streets, may challenge a have an obligation to support and assist clients in accomplishing their professional’s personal values and sincere desire to protect, also known goals, only deviating from this when a client’s goal puts them or others as “professional paternalism” (Reamer, 1998). In the absence of clear imminently at risk. and present harm, the client has a right to choose his or her own path and Defining risk can be difficult – most mental health professionals make his or her own decisions, whether we agree or disagree. cannot argue that suicide or homicide do not present a clear risk to the

Suicide: The right to choose versus duty to protect Sometimes a mental health practitioner may be faced with a choice protect. It also raises the issue of client autonomy versus the professional between a client’s right to choose suicide and the duty to protect his or obligation to prevent discrimination. Thus, it is essential that mental her life. The request by the emotionally stable and rational terminally ill health practitioners establish clear procedures that ensure impartial client is a good example of a situation that is not as “cut and dried” as that assessment while valuing client autonomy and individual treatment. involving a severely depressed young woman contemplating suicide. Since laws and professional codes of ethics are not always clear and Would one client deserve individual consideration and thus not be do not always spell out our specific duties and responsibilities, it is assessed for possible hospitalization over the other? Most workers recommended that workers not only do everything to assist clients in choose this profession because it supports respect for the strengths and taking advantage of any options to alleviate their distress, but also rely abilities of clients, and thus their ability to learn, make good decisions, on practice guidelines that call for: and be self-sufficient. But aside from laws prohibiting assisted suicides, ●● Careful evaluation, such as the client’s ability to make rational workers also rely on intuition and judgment in determining whether choices based on the mental state and social situation. to take action to protect a client from harm. This scenario blurs the ●● A good therapeutic alliance. line between respect for the client’s wishes and society’s obligation to ●● Consultation.

Informed consent Informed consent services should only be provided when valid informed participate. This concept of informed consent is closely linked with consent can be obtained. Therefore, clients must know the exceptions to the value of self-determination. self-determination before consenting to treatment or other services. Mental Generally, potential threats and factors to be considered in ensuring the health professionals working in child welfare or forensic practice settings validity of informed consent are: are faced with additional challenges. In their article about informed ●● Language and comprehension. consent in court-ordered practice, Regehr and Antle (1997) state: ●● Capacity for decision making. Informed consent is a legal construct that is intended to ensure ●● Limits of service refusal by involuntary clients (including court- that individuals entering a process of investigation or treatment mandated clients). have adequate information to fully assess whether they wish to ●● Limitations and risks associated with electronic media services. ●● Audio and videotaping.

Competence (or professional and ethical competence) Another section that relates to informed consent, competence, is The study also revealed findings of incompetence, in conjunction mental health professionals’ responsibility to represent themselves and with other forms of unethical behavior, in 21 percent of the cases. In to practice only within the boundaries of their education, experience, these cases, reasons why a social worker was not competent to deliver training, license or certification, and level of supervisory or consultant services included: support. For example, poor practice, or the failure of a worker to ●● Personal impairments. provide services within accepted standards, was the second most ●● Lack of adequate knowledge or preparation. common form of violation found in Strom-Gottfried’s study of code ●● Lack of needed supervision. violation allegations resulting in social work practice (2000).

SocialWork.EliteCME.com Page 4 Conflicts of interest One of the most difficult areas of responsibility to clients is conflict of The issue of informed consent should include both prescribing the interest. Workers need to avoid conflicts of interest that interfere with need to inform clients of potential or actual conflicts, and taking the exercise of: reasonable steps to resolve the conflict in a way that protects the ●● Professional discretion. client’s needs and interests. ●● Impartial judgment.

Dual or multiple relationships Dual or multiple relationships occur when mental health professionals clients and are responsible for setting clear, appropriate, and culturally relate to clients in more than one relationship, whether professional, sensitive boundaries. social, or business. Dual or multiple relationships can occur Recognizing that there are many contexts within which mental health simultaneously or consecutively. work is practiced, dual relationships are not always entirely banned by Dual or multiple relationships with current or former clients should be different professional association ethical codes. The word “should” in avoided whenever possible, and the exploitation of clients for personal, sections where dual or multiple roles are outlined within various codes religious, political, or business interests should never occur. of ethics, implies there is room for exceptions. However, what they Further, workers should not engage in dual or multiple relationships are usually distinguishing is that dual relationships are not permitted with clients or former clients where there is a risk of exploitation when there is risk of exploitation or harm. In not banning all dual or potential harm to the client. In instances when dual or multiple relationships, each worker bears the responsibility for both determining, relationships are unavoidable, workers should take steps to protect and if needed, proving that the relationship was not harmful to the client.

Boundary violations Conflicts of interest relate closely to other types of unprofessional relationship that is exploitive, manipulative, deceptive, or coercive in behavior such as boundary violations, which more specifically identifies nature. harmful dual relationships. Most mental health professionals can easily ●● Buying property from a disaster client at far below its market level. recognize and identify common boundary issues presented by their clients. ●● Falsely testifying to support fraudulent actions of clients. Likewise, most can identify examples of boundary violations around ●● Imposing religious beliefs on a client. professional behavior, for example, sexual misconduct. While not ●● Suggesting that a hospice client make you executor of his/her will. exclusive to the clinical role, there are certain situations that are ●● Referring a client to your brother-in-law, the stockbroker. more challenging than others, especially for workers vulnerable to ●● Friendship with the spouse of a client you are treating for marital committing boundary violations. issues. Boundary issues involve circumstances in which there are actual or Five conceptual categories with regard to boundary violations potential conflicts between their professional duties and their social, generally occur around five central themes: sexual, religious or business relationships. These are some of the most 1. Intimate relationships – These relationships include physical challenging issues faced in the mental health profession and typically contact, sexual relations, and gestures such as gift giving, involve conflicts of interest that occur when a worker assumes a friendship, and affectionate communication. second role with one or more clients. Such conflicts of interest may 2. Pursuit of personal benefit – The various forms this may take involve relationships with: include monetary gain, receiving goods and services, useful ●● Current clients. information. ●● Former clients. 3. Emotional and dependency needs – The continuum of boundary ●● Colleagues. violations ranges from subtle to glaring and arise from social ●● Supervisees and students. workers’ need to satisfy their emotional needs. 4. Altruistically motivated gestures – These arise out of a mental With that in mind, the following would be examples of inappropriate health practitioner’s desire to be helpful. boundary violations, and thus unethical, in that they involved a dual 5. Responses to unanticipated circumstances – Unplanned situations over which the social worker has little to no control.

Intimate relationships As discussed earlier, boundary issues involving intimate relationships and leads on jobs) is another matter. It is important to remember that are the most common violations. Those involving sexual misconduct this can apply both ways, i.e., the mental health professional needs to are clearly prohibited and will be further explored. avoid offering assistance in areas outside his or her role. While most professionals might agree that having other nonsexual “Your usefulness to your patients lies in your clinical skills and relationships, such as a friendship, with a current clinical client is separation of your professional role from other roles which would inappropriate, the rules are not as clear regarding ex-clients and even be better filled elsewhere in their lives. Do not suggest, recommend, less so for those clients in case management, community action, or or even inform the patient about such things as investments, and be other non-clinical relationships. cautious about giving direct advice on such topics as employment and When a dual relationship results in personal benefit to the practitioner it relationships. There is a difference between eliciting thoughts and also undermines the trusting relationship. Some of the scenarios mentioned feelings to encouraging good decision making and inappropriately earlier (getting property below market value, becoming the executor of the influencing those decisions” (Reid, W. 1999). client’s will, and referring clients to a relative) are all examples. Another tricky area involves bartering arrangements, particularly There are very respectful, sound and appropriate reasons for involving the exchange of services. These should be considered encouraging clients to share what they know and to listen to their carefully, and according to Reamer (2003), be limited to the following strengths. Benefiting from information the client has (e.g., stock tips circumstances when they are:

Page 5 SocialWork.EliteCME.com ●● An accepted practice among community professionals. worker, for example, may work in a small, isolated community that ●● Essential to service provision. would expect its community members to share in social customs such ●● Negotiated without coercion. as family meals and weddings. ●● Entered into at the client’s initiative. Ethical guidelines recommend giving students a copy of supervisees’ ●● Done with the client’s informed consent. guidelines to guarantee client protection instead of blanket advice to Again, the professional is in the unenviable position of determining avoid dual relationships altogether (Boland-Prom and Anderson, 2005). whether an action presents the possibility of psychological harm to the Freud and Krug (2002) also feel that “over-correcting a problem, as client. Kissing on the cheek, for example, may be perfectly correct and is a frequent tendency in our society, sometimes escalates the very clearly nonsexual in certain cultures and contexts, but may confuse or transgressions against which the new rules are to protect us.” While intimidate a client in other contexts. necessary and healthy debate continues, practitioners need to, no Another area fraught with peril is when workers engage in behavior matter what their scope of practice, seek guidance and input from a arising from their own emotional needs. Most mental health practitioners variety of sources to make good decisions around boundary issues. are more familiar with examples of intentional and even more egregious There are some areas where clear rules about dual relationships are examples, such as the practitioner who uses undo influence to “convert” essential and include: the client or takes sides in a custody case in order to foster a relationship 1. Protection of the therapeutic process – In the context of current with one of the spouses. Many times the boundaries are crossed clinical practice, “even minor boundary trespasses can create unintentionally, as in a practitioner who becomes overly involved in a case unwarranted expectations.” Transference and countertransference with which she personally identifies. Or the worker may be experiencing issues are present and cannot be underestimated. According to Freud life issues that make him or her more vulnerable to the attention of a client. and King (2002), “The mystique of the tightly boundaried, hierarchical Mental health professionals have a responsibility to maintain competence therapeutic relationship heightens transference phenomena.” in both the professional and emotional arenas. Regardless of the 2. Client protection from exploitation – A clinician may be tempted circumstances, the worker’s first responsibility is always to the client. to meet personal sexual, financial, or social needs with persons There are also times when the intent of the professional is truly out of who may be particularly vulnerable to exploitation. Ethical a desire to be helpful, such as buying merchandise from a client whose guidelines serve to protect clients from exploitation. business is struggling or inviting a divorce recovery group client to a 3. Protection from potential legal liability – Workers are concerned community function in order to help her broaden her social network. about legal liability, and “careful adherence to the boundary While some types of situations may not be considered unethical or specifications may protect clinicians from malpractice suits.” illegal, the worker needs to carefully review his or her motivation and Ultimately, it is the mental health professional’s responsibility to the potential consequences of each decision. Some helpful questions to establish culturally appropriate and clear boundaries for clients ask are: because doing so often prevents issues from surfacing in the first place. ●● Would I do this for all my clients? The worker cannot underestimate the importance of expectations – ●● Am I doing this because I feel uncomfortable (e.g., saying no)? respecting the client means together creating a safe relationship where ●● Am I feeling at a loss to help the client any other way and thus boundaries and expectations are unambiguous and openly discussed. feeling, “I must do something” to feel competent? To further minimize possible harm to all parties – the client, the ●● How might the client interpret my gesture? worker, the employer, and so on – the following risk management ●● Am I doing this just for the client’s interest or also for my own interest? protocols to address boundary issues are suggested: ●● What are all the potential negative outcomes? 1. Be alert to potential or actual conflicts of interest. There will be occasions when you incidentally come into contact with a 2. Inform clients and colleagues about potential or actual conflicts of client, such as finding your client’s daughter is on the same soccer team interest; explore reasonable remedies. as your child. Some practitioners go out of their way to live in a different 3. Consult colleagues and supervisors, and relevant professional community so the chances are minimal that this could happen. Others literature, regulations, policies, and ethical standards to identify see that as over-managing a potential situation that is unlikely to lead to pertinent boundary issues and constructive options. harm for the client or colleague (as in the case of supervisees). 4. Design a plan of action that addresses the boundary issues and The appropriateness of relationships with clients is often debated protects the parties involved to the greatest extent possible. across the profession. The unique service settings and roles assumed 5. Document all discussions, consultation, supervision, and other by workers often contrast with the traditional clinical approach to steps taken to address boundary issues. human service. Applying strict rules around relationships can appear 6. Develop a strategy to monitor implementation of your action plan excessive and/or contradictory with sound mental health practice. A (clients, colleagues, supervisors, and lawyers).

Sexual relationships, physical contact, sexual harassment, and derogatory language Ethical mental health practice limits sexual relationships with clients, Sexual harassment former clients, and others close to the client, physical contact where there In 1980, the EEOC (Equal Employment Opportunity Commission), the is risk of harm to the client, sexual harassment, and the use of derogatory agency that enforces Title VII, first defined sexual harassment as a language in written and verbal communication to or about clients. form of sex-based discrimination and issued guidelines interpreting the law. These guidelines define unlawful sexual harassment as: ●● Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature, when: ○○ Submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment. ○○ Submission to, or rejection of, such conduct by an individual is used as the basis for employment decisions affecting such individual.

SocialWork.EliteCME.com Page 6 ○○ Such conduct has the purpose or effect of unreasonably ●● The alleged “power differential” between any patient and his or interfering with an individual’s work performance or creating her clinician. an intimidating, hostile or offensive working environment. Anyone working in mental health practice has experienced different In mental health practice, sexual harassment can take many forms relationships with clients. Sometimes it is nearly impossible not to form including offensive or derogatory comments, sexually oriented respect and even affection for clients. However, practitioners must work jokes, requests or demands for sexual favors, leering, visual displays diligently to avoid problems, i.e., either crossing the boundaries of the depicting sexual imagery, innuendos, pinching, fondling, impeding professional relationship or even appearing to do so. In addition to other someone’s egress, etc. Workers should not sexually harass supervisees, previously discussed actions designed to prevent harm to the client, students, trainees or colleagues. workers can proactively address this issue by doing the following: Sexual misconduct ●● Limit practice to those populations that do not cause your own Some states also have laws making sexual misconduct subject to needs to surface. lawsuits and even arrest. Practitioners need to be sure about the rules ●● Seek clinical supervision to effectively deal with personal feelings. that apply to them, as well as be aware of how their behavior may ●● Document surroundings and who was present during sessions and be perceived by others. For example, Reid points out that in most visits. situations, consent will not be an effective defense against sexual ●● Avoid seeing the client at late hours or in locations that are atypical misconduct allegations. The reasons Reid (1999) gives for a client’s for routine practice. ability to consent being called into question are: Reporting sexual misconduct by a colleague is an ethical responsibility ●● The fiduciary trust between clinician and patient. of mental health practitioners. Many states have laws that require ●● Exploitation of transference feelings. licensed professionals to report such misconduct as well as other ●● The right of the patient to expect clinical needs to be the overriding ethical violations to their state boards. It is the responsibility of every priority. professional to protect clients by reporting a reasonable knowledge or ●● Exploitation of the patient’s purported inability to resist the suspicion of misconduct between the client and colleague. therapist’s influence.

Professional boundaries self-assessment Below are red flags that professional boundaries may be compromised. 8. Have you ever given a client a gift? Some relate to you and some to clients. As you honestly answer the 9. Have you ever visited a client after case termination? following questions yes or no, reflect on the potential for harm to your 10. Have you ever called a client when “off duty?” client. 11. Have you ever felt sexually attracted to a client? 1. Have you ever spent time with a client “off duty?” 12. Have you ever reported only the positive or only the negative 2. Have you ever kept a secret with a client? aspects of a client? 3. Have you ever adjusted your dress for a client? 13. Have you ever felt that colleagues/family members are jealous of 4. Has a client ever changed a style of dress for you? your client relationship? 5. Have you ever received a gift from a client? 14. Do you think you could ever become overinvolved with a client? 6. Have you shared personal information with a client? 15. Have you ever felt possessive about a client? 7. Have you ever bent the rules for a client?

Clients who lack decision-making capacity The practitioner’s responsibility is to safeguard the rights and interests of clients who lack decision-making capacity.

Payment of services With regard to payment of services, it is most helpful to refer to your bonuses, or other remuneration for referrals. Clear disclosure and particular professional association’s financial arrangement ethical explanation of financial arrangements, reasonable notice to clients for standards. Professional association ethical guidelines, in general, call intention to seek payment collection, third-party pay or fact disclosure, for fair and reasonable fees for services, prohibition or no prohibition and no withholding of records because payment has not been received of solicitation of fees for services entitled and rendered through the for past services, except otherwise provided by law, are also examples workers’ employer, and avoidance of bartering arrangements. Other of ethical financial guidelines. guidelines include no acceptance or offering of kickbacks, rebates,

Ethics in practice settings

Administration Mental health administrators should advocate within and outside their and a work environment that is not only consistent with, but agencies for adequate resources, open and fair allocation procedures, encourages compliance with ethical standards of practice.

Billing Practitioners need to establish and maintain accurate billing practices associations and boards include these expectations in their own values that clearly identify the provider of services. Many agencies, and codes of ethics, commonly under the category of stewardship.

Page 7 SocialWork.EliteCME.com Client transfer Mental health practitioners should consider the needs and best Informed consent is an important aspect of this issue, in that a interests of clients being served by other professionals or agencies practitioner must discuss all implications, including possible benefits before agreeing to provide services, and discuss with the client the and risks, of entering into a relationship with a new provider. appropriateness of consulting with the previous service provider.

Client records Maintaining records of service and storing them is not always easy. To facilitate the delivery and continuity of services, the practitioner, Aside from the potential negative legal fallout of not doing so, there with respect to documentation and client records, must ensure that: are good reasons for keeping records including: ●● Records are accurate and reflect the services provided. ●● Assisting both the practitioner and client in monitoring service ●● Documentation is sufficient and completed in a timely manner. progress and effectiveness. ●● Documentation reflects only information relevant to service delivery. ●● Ensuring continuity of care should the client transfer to another ●● Client privacy is maintained to the extent possible and appropriate. worker or service. ●● Records are stored for a sufficient period after termination. ●● Assisting clients in qualifying for benefits and other services. ●● Ensuring continuity of care should the client return.

Recordkeeping State statutes, contracts with state agencies, accreditation bodies and Again, professionals who are primary custodians of client records other relevant stakeholders prescribe the minimum number of years should refer to additional legal requirements, such as those established records should be kept. For example, HIPAA has a requirement of six by state licensing boards, regarding care for client records in the event years for electronic records. The Council on Accreditation requires they retire and/or close their business or practice. records be kept a minimum of seven years. The NASW Insurance Trust actually strongly recommends retaining clinical records indefinitely.

The Privacy Rule (HIPAA) In 1996, the 104th Congress amended the Internal Revenue Code with them are confidential. For example, a patient may want to be of 1986, and created Public Law 104-191, the Health Insurance called on a work phone rather than home telephone. Portability and Accountability Act. This established the first-ever ●● Complaints – Patients may file a formal complaint regarding national standards for the protection of certain health information. privacy practices directly to the provider, health plan, or to the These standards, developed by the Department of Health and Human HHS Office for Civil Rights. Consumers can find out more Services, took effect April 14, 2003. The Privacy Rule standards information about filing a complaint athttp://www.hhs.gov/ocr/ address who can use, look at, and receive individuals’ health hipaa or by calling 866-627-7748. information (protected health information or PHI) by organizations It is very important to know that professionals who work in the mental (covered entities) subject to the rule. These organizations include: health field are responsible for following and enforcing the HIPAA ●● Most doctors, nurses, pharmacies, hospitals, clinics, nursing Privacy Rule. homes, and other health care providers. ●● Health insurance companies, HMOs, and most employer group The American Recovery and Reinvestment Act of 2009 put new teeth health plans. into the laws and penalties for HIPAA violations when it implemented ●● Certain government programs that pay for health care, such as tiered penalties reflecting the circumstances surrounding the violation. Medicare and Medicaid. These acknowledged whether the violator did not know about the violation, had reasonable cause, allowed the violation because of Key provisions of the standards include: willful neglect but subsequently corrected it or allowed the violation ●● Access to medical records – Patients may ask to see and get a because of willful neglect and did not correct it. copy of their health records and have corrections added to their ●● For violations that the entity did not know about, minimum fines health information. are $100 per violation; up to $50,000 may be imposed, with an ●● Notice of privacy practices – Patients must be given a notice that annual maximum of $1.5 million. tells them how a covered entity may use and share their health ●● For violations that had reasonable cause and were not due to information and how they can exercise their rights. willful neglect, a minimum fine of $1,000 and up to $50,000 may ●● Limits on use of personal medical information – The privacy be imposed, with an annual maximum of $1.5 million. rule sets limits on how health plans and covered providers may ●● For violations due to willful neglect that were corrected within the use individually identifiable health information. Generally, health required time period, a minimum fine of $10,000 and up to $50,000 information cannot be given to the patient’s employer or shared for may be imposed, with an annual maximum of $1.5 million. any other purpose unless the patient signs an authorization form. ●● For violations due to willful neglect that were not corrected, a ●● Prohibition of marketing – Pharmacies, health plans and other minimum fine of $50,000 per violation may be imposed, with an covered entities must first obtain an individual’s specific authorization annual maximum of $1.5 million. before disclosing their patient information for marketing. ●● Stronger state laws – As stated earlier, confidentiality protections However, courts in some cases have treated multiple violations as are cumulative; any state law providing additional protections separate cases, allowing the maximum fines to be much higher that would continue to apply. However, should state law require a certain $1.5 million. disclosure – such as reporting an infectious disease outbreak – the In addition, criminal penalties may apply in some cases. A person who federal privacy regulations would not pre-empt the state law. knowingly obtains or discloses individually identifiable health information ●● Confidential communications – Patients have the right to expect in violation of HIPAA faces a fine of $50,000 and up to one year of covered entities to take reasonable steps to ensure communications imprisonment. The criminal penalties increase to $100,000 and up to five years imprisonment if the wrongful conduct involves false pretenses,

SocialWork.EliteCME.com Page 8 and up to $250,000 and up to 10 years imprisonment if the wrongful It may seem that the law only places limits on the sharing of information; conduct involves the sale, transfer or use of individually identifiable health however, it does allow the sharing of protected health information as information for commercial advantage, personal gain or malicious harm. long the mental health worker takes reasonable safeguards with the Criminal sanctions are enforced by the Department of Justice. information. Some steps professionals can follow include: This rule ensures protection for clients by limiting the way covered ●● Ensure that protected health information is kept out of sight. entities can use personal medical information. The regulations protect This could mean keeping it in separate, locked files, covering or medical records and other individually identifiable health information turning over any material on your desk, or setting your computer (identifiers) whether it is transmitted in electronic, written, or verbal to “go blank” after a minute or two in case you walk away. format. This, then, would include faxes, e-mail, online databases, ●● If you must discuss protected health information in a public voice mail, and video recordings, as well as conversations among area, such as a waiting room, hospital hallway, or courtroom, practitioners. Examples of identifiable health information include: make sure you speak quietly so others cannot overhear your ●● Name or address – including city, state, or ZIP code. conversation. If this cannot be assured, move to another area or ●● Social Security numbers. schedule another time to discuss the information. ●● Dates related to birth, death, admission, discharge. ●● Use e-mail carefully. Make sure you send the information only to ●● Telephone and fax numbers. the appropriate people. Watch the “CC” lines to make sure your ●● E-mail or URL addresses. e-mail is not copied to unauthorized parties. Use passwords and ●● Medical record numbers, account numbers, health plan beneficiary other security measures on computers. numbers. ●● If you send a fax, don’t leave the material unattended. Make sure ●● Vehicle identifiers such as driver’s license numbers and license that all of the pages go through and check the fax numbers carefully plate numbers. to make sure it is sent to the correct person. You should also add a ●● Full face photographs distributed by the agency. disclaimer stating that the information in your fax is confidential. ●● Any other unique identifier, code, or characteristic used to identify ●● Avoid using client names in hallways, elevators, restaurants, clients is protected under HIPAA. etc., unless absolutely necessary. ●● Post signs and routinely review standards to remind employees In addition to reasonable safeguards, covered entities are required to protect client privacy. to develop and implement policies and procedures that limit the ●● Secure documents in locked offices and file cabinets. sharing of protected health information and to implement them as appropriate for their practices. The policies must limit who has access Note that there is another law that provides additional protections for to protected health information, specify the conditions under which it clients receiving alcohol and drug treatment. Information is available can be accessed and designate someone to be responsible for ensuring at the Substance Abuse and Mental Health Services Agency website at procedures are followed (privacy officer). www.samhsa.gov.

Supervision and consultation Mental health supervision and management generally include three ●● They should not engage in dual or multiple relationships with primary aspects of the supervisory role: supervisees when there is risk of exploitation or potential harm. 1. Administration. ●● They should fairly and respectfully evaluate supervisee performance. 2. Support. ●● They should avoid accepting supervisees when there has been 3. Education (Kadushin, 1992). a prior or an existing relationship that might compromise the While the supervisor of mental health work is increasingly involved supervisor’s objectivity. in the administrative and political realm, to get the work done, ●● They should take measures to assure that the supervisee’s work is supervision, coaching, mentoring, and consultation remain key roles. professional. Mental health practitioners need to be keenly aware of the role of ●● They should not provide therapy to current students or supervisees. a supervisor, because he/she is responsible for both the actions and Supervisors should consult their particular professional association omissions by a supervisee, aka, vicarious liability. guidelines regarding supervision, human resource policy, and other To provide competent supervision, supervisors, particularly those in applicable resources. Effective and ethical supervisory practices not clinical settings, should remember the following: only benefit the supervisees and their clients but the supervisor as well. ●● They need to possess the necessary knowledge and skill, and do so Supervisors can manage their vicarious liability in several ways through: only within their area of competence. ●● Clearly defined policies and expectations. ●● They must set clear, appropriate, and culturally sensitive ●● Awareness of high-risk areas. boundaries that would include confidentiality, sexual ●● Provision of appropriate training and supervision. appropriateness and others outlined earlier in this training. ●● Understanding supervisee strengths and weaknesses as practitioners. ●● Developing an adequate feedback system. ●● Supervisors knowing their own responsibilities.

Commitment to employers Several standards that address issues around loyalty and ethical ●● Ensure that the employing organization’s practices do not interfere responsibilities in one’s capacity as an employee are formally or with one’s ability to practice consistent with one’s mental health informally discussed in professional association ethical guidelines. association professional ethical guidelines. Generally, mental health practitioners should: ●● Act to prevent and eliminate discrimination. ●● Adhere to commitments made to employers. ●● Accept employment, or refer others to only organizations that ●● Work to improve employing agencies’ policies, procedures and exercise fair personnel practices. effectiveness of service delivery. ●● Be diligent stewards of agency resources. ●● Take reasonable steps to educate employers about mental health In general, mental health practitioners should support their agency’s workers’ ethical obligations. mission, vision, and values and also its policies and practices; in essence, maintain loyalty to the organization or agency they are

Page 9 SocialWork.EliteCME.com committed to. That is not to say one should disregard the profession’s justifiable on ethical grounds. Most social workers acknowledge that standards and ethical codes of conduct. certain extraordinary circumstances require social disobedience.” When an employer engages in unethical practices, whether knowingly He believes that it is possible to provide clear guidelines about when or not, the worker still has an obligation to voice those concerns it is acceptable to break one’s commitment to an employer. He poses through proper channels and advocate for needed change while several questions that must be explored before taking action: conducting oneself in a manner that minimizes disruption. But ●● Is the cause a just one? Is the issue so unjust that civil what does the worker do when faced with an ethical dilemma in the disobedience is necessary? workplace that is not easily solved? ●● Is the civil disobedience the last resort? This issue has been discussed with regard to the practice of social ●● Does the act of civil disobedience have a reasonable expectation of work when Reamer (1998), in his review of the NASW Code of success? Ethics, discussed the challenge a social worker may have in deciding ●● Do the benefits likely to result clearly outweigh negative whether or not to continue honoring a commitment to the employer: outcomes, such as intraorganizational discord and erosion of staff “This broaches the broader subject of civil disobedience, that is, respect for authority? determining when active violation of laws, policies and regulations is ●● If warranted, does civil disobedience entail the least required to rectify the targeted injustice?

Labor-management disputes Mental health practitioners are generally allowed to engage in When involved in a dispute, job action, or strike, workers should organized action, including the formation and participation in labor carefully weigh the possible impact on clients and be guided by their unions, to improve services to clients and working conditions. profession’s ethical values and principles prior to taking action.

Professional competence The following guidelines discuss professional competence in mental In addition to education and experience, mental health practitioners health practice: need to be cognizant of their personal behavior and functioning and its ●● Accept responsibilities or employment only if competent or there effects on practice: is a plan to acquire necessary skills. ●● Refrain from private conduct that interferes with one’s ability to ●● Routinely review emerging changes, trends, best practices in the practice professionally. mental health field and seek ongoing training and educational ●● Do not allow personal problems (e.g., emotional, legal, substance opportunities. abuse) to impact one’s ability to practice professionally, nor ●● Use empirically validated knowledge to guide practice/ jeopardize the best interests of clients. interventions. ●● Seek appropriate professional assistance for personal problems or ●● Disclose potential conflicts of interest. conflicts that may impair work performance or critical judgment. ●● Do not provide services that create a conflict of interest that may ●● Take responsible actions when personal problems interfere with impair work performance or clinical judgment. professional judgment and performance.

Burnout and compassion fatigue An area receiving increasing attention is that of burnout and Compassion fatigue compassion fatigue. The consequences of burnout and compassion A newer definition of worker fatigue was introduced late in the fatigue (or any other form of professional impairment) include the last century by social researchers who studied workers who helped risk of malpractice action. Results from the effects of day-to-day trauma survivors. This type of worker fatigue became known as annoyances, overburdened workloads, crisis, and other stressors in compassion fatigue or secondary traumatic stress (STS.) Mental health the work place, burnout and compassion fatigue can be serious and practitioners acquire compassion fatigue or STS as a result of helping considered similar in many ways to acute stress and post-traumatic or wanting to help a suffering person in crisis. As a result, they often stress disorder. feel worthless and their thinking can become irrational. For example, Burnout they may begin to irrationally believe that they could have prevented Burnout is a “breakdown of psychological defenses that workers use someone from dying from a drug overdose. to adapt and cope with intense job-related stressors and syndrome in Burnout is gradually acquired over time and recovery can be which a worker feels emotionally exhausted or fatigued, withdrawn somewhat gradual. Compassion fatigue surfaces rapidly and emotionally from clients, and where there is a perception of diminishes more quickly. Both conditions can share symptoms such as diminishment of achievements or accomplishments.” Burnout occurs emotional exhaustion, sleep disturbance, or irritability. when gradual exposure to job strain leads to an erosion of idealism Dealing with burnout and compassion fatigue with little hope of resolving a situation. In other words, when mental A professional mental health practitioner can take steps to increase her health practitioners experience burnout: or his ability to cope and achieve balance in life. Maintaining a healthy ●● Their coping skills are weakened. lifestyle balance and recognizing the signs of burnout and compassion ●● They are emotionally and physically drained. fatigue are one thing: the responsible mental health clinician will also ●● They feel that what they do does not matter anymore. take action, such as a vacation break or change in schedule or job ●● They feel a loss of control. duties. Practitioners also need to not only be aware of the signs and ●● They are overwhelmed. symptoms of burnout and compassion fatigue, but more importantly, the situations that may set the stage for their occurrence. Ongoing supervision is the mental health practitioner’s best defense. In addition, ongoing supervision and regular supportive contact with other practitioners to prevent isolation is recommended. Houston-

SocialWork.EliteCME.com Page 10 Vega, Nuehring, and Daguio (1997), recommend the following ●● Take needed “mental health days” and use stress-reduction techniques. measures to help prevent burnout or compassion fatigue: ●● Arrange for reassignment at work, take leave, and seek appropriate ●● Listen to the concerns of colleagues, family, and friends. professional help as needed. ●● Conduct periodic self-assessments.

Related personal and professional integrity issues Misrepresentation occurs when mental health professionals present opinions, claims, and statements that are either false or lead the listener to believe facts that are not accurate. Three actions must be taken to ensure that clients and the public receive accurate information: 1. Clearly distinguish between private statements and actions, and those as representative of an organization, employer, etc. 2. Accurately present the official and authorized positions of the Mental health practitioners must also address issues related to personal organization they are representing and/or speaking on behalf of. and professional integrity. They are: 3. Ensure accurate information about, and correct any inaccuracies ●● Dishonesty, fraud, and deception. regarding professional qualifications/credentials, services offered ●● Misrepresentation. and outcomes/results. ●● Solicitations. Client solicitation stems from a concern for clients who, due to their ●● Acknowledging credit. situation, may be vulnerable to exploitation or undue influence. Practitioners have an obligation to avoid actions that are dishonest, Because of their circumstances, there is also the potential for fraudulent, or deceptive. Such actions, or in some cases, lack of action, manipulation and coercion. As such, mental health practitioners should put the continued integrity of both the individual mental health worker refrain from doing the following: and the profession at risk. Some examples include: 1. Engage in uninvited solicitation. ●● Falsifying records, forging signatures, or documenting services not 2. Solicit testimonial endorsements from current clients or other rendered. potentially vulnerable persons. ●● Embellishing one’s education and experience history or Mental health practitioners also have an ethical responsibility to the qualifications (refer also to “misrepresentation”). contributions of others by acknowledging credit. They should: ●● Lying to a client or their family to “protect” them from unpleasant 1. Take responsibility and credit only for work they have actually information. performed and contributed to. ●● Not sharing legitimate options to a client because they violate the 2. Honestly acknowledge the work and/or contributions of others. professional’s beliefs. ●● Misleading potential donors or current funders with false outcome data.

Ethical responsibilities to colleagues Licensed mental health practitioners should not only take responsibility ●● Seeking advice and counsel of colleagues who have demonstrated for their own actions, but also take actions that ensure the safety knowledge, expertise and competence so as to benefit the interests and well-being of any clients served by others in the mental health of clients. profession. Thus, their responsibilities include: ●● Referring clients, without payment for such, to qualified ●● Duty to clients. professionals and transferring responsibilities in an orderly fashion. ●● Duty to colleagues. ●● Consulting and assisting impaired and/or incompetent colleagues; ●● Indirectly, duty to the mental health profession. and addressing impairments through proper channels when they In addition, they demonstrate further ethical responsibility by: are unable to practice effectively (e.g., reporting to professional ●● Respecting and fairly representing the qualifications, views and associations or licensing and regulatory bodies). obligations of colleagues. ●● Discouraging unethical conduct of colleagues; being ●● Respecting shared, confidential information. knowledgeable about established procedures, and taking action as ●● Promoting interdisciplinary collaboration. necessary through appropriate formal channels. ●● Not taking advantage of disputes between colleagues and ●● Defending and assisting colleagues who are unjustly charged with employers or exploiting clients in disputes with colleagues. unethical conduct.

Ethical responsibilities to the mental health profession In general, national mental health professional associations discuss the ●● Maintain and promote high standards of practice. responsibility to help maintain the integrity of their particular mental ●● Uphold and advance the values, ethics, knowledge, and mission health focus, as well as issues related to mental health work evaluation of the profession through study, research, active discussion and and research. Maintaining the integrity of the profession is a responsibility reasonable criticism. of every licensed mental health professional and requires the active ●● Contribute time and professional expertise to activities that promote participation of each person whether it be collaborating on the creation respect for the value, integrity and competence of the profession. of new standards, continuing to challenge mediocrity or complacency, or ●● Contribute to the knowledge base and share with colleagues their taking advantage of educational opportunities. Mental health professionals knowledge related to practice, ethics, and research. should demonstrate the following integrity safeguards: ●● Act to prevent unauthorized/unqualified practice of mental health work.

Page 11 SocialWork.EliteCME.com More about informed consent The issue of informed consent relates closely to one of the most 1. Anonymity on the Internet makes it more difficult to determine the important values of ethical mental health practice: Self-determination. client’s mental capacity and/or legal age. In order for informed consent to be valid, the following must be met: 2. Potential conditions, such as suicidal behaviors and eating 1. Consent must be given voluntarily by a person of legal age. disorders, may not be suitable for online therapy. 2. The individual must be competent to refuse or to consent to 3. There is limited empirical research available, thus limiting both the treatment. practitioner and clients’ understanding of the efficacy and the risks 3. The client must be given thorough, accurate information about the associated with e-therapy. service so she or he may weigh the benefits and risks of treatment. 4. Internet identity issues place more burden on the practitioner to determine whether the client is legally and ethically able to consent. One of the newest challenges for mental health practitioners is the issue of informed consent in e-therapy. Kanani and Regehr (2003) point out the following reasons for this:

Ethics for specialized practice areas Responsible mental health practice can be found in a variety of settings abuse, health care, marriage and family issues, couples work, clinical and address multiple issues. As the world changes, practitioners are social work, child welfare, palliative/end of life care, work with increasingly challenged to broaden their knowledge and adopt adolescents, and long-term care. They also publish standards that practices that meet the unique needs of their service populations and address issues such as technology. settings. Currently, most mental health associations provide additional It is helpful to review the relevant issue of technology and the impact guides or standards of practice that address areas including: substance on mental health practice.

Technology While there are many individuals who are hesitant to embrace new ●● Have access to, and ensure their clients have access to, technology technology that can enhance best practice, one cannot ignore its many and appropriate support systems. benefits. Currently, mental health professionals can use technology, ●● Select and develop culturally competent methods and ensure that particularly the Internet, to conduct research, provide e-therapy when they have the skills to work with persons considered vulnerable permitted, advertise their services, and communicate on a global scale (e.g., persons with disabilities, for whom English is not their with both clients and other professionals. primary language). E-mail, though fraught with potential for security violations and ●● Increase their proficiency in using technology and tools that miscommunication, has certainly increased the efficiency and speed enhance practice. with which people can communicate in another region. For example, ●● Abide by all regulations in all jurisdictions in which they practice. a mental health researcher can conduct a search on the Internet to ●● Represent themselves accurately and make attempts to confirm the inquire about and then contact another professional in anther region to identity of the client and their contact information. investigate innovative approaches to service delivery. ●● Protect client information in the electronic record. ●● Provide services consistent with accepted standards of care, Software applications (e.g., basic word processing, financial regardless of the medium used. management systems and documentation templates) assist practitioners ●● Use available technology to both inform clients and mobilize with service planning, delivery, evaluation and reporting. And wireless individuals in communities so they may advocate for their interests. technology allows better utilization of their time away from the office. ●● Advocate for technologies that are culturally sensitive, community Cell phones have greatly increased accessibility as well. Mental health specific, and available for all who can benefit from it. practice would be different without technology. ●● For those in administrative practice, keep themselves informed about National mental health associations, along with others, are continuing to technology that can advance quality practice and operations, invest in develop and publish guidelines to assist practitioners in the appropriate systems, and establish policies that ensure security and privacy. use of technology, including those who provide virtual therapy services. ●● Conduct a thorough assessment, including evaluation of the Technology and practice are generally defined as any electronically appropriateness of potential clients for e-therapy. This includes mediated activity used in the conduct of competent and ethical delivery the need for the social worker to fully understand the dynamics of services. involved and the risks and benefits for the client. ●● Evaluate the validity and reliability of research collected through For example, a copy of the standards as developed by NASW and ASWB electronic means and ensure the client is likewise informed. is available for both review and print at: http://www.socialworkers.org/ ●● Continue to follow applicable standards and laws regarding practice/default.asp and is summarized as follows. Social workers shall: supervision and consultation. ●● Act ethically, ensure professional competence, and uphold the ●● Adhere to NASW standards for continuing professional education values of the profession. and applicable licensing laws regarding continuing education.

Virtual or e-therapy Depending on their mental health focus and where they practice, many living in remote locations, or those concerned about the stigma of mental health practitioners offer online therapy services through real- counseling). time chats, e-mail, videoconferencing, telephone conferencing, and ●● Decrease inhibitions clients may have about fully disclosing instant messaging. The benefits touted by supporters of online therapy, relevant information. as described by Kanani and Regehr (2003), include the ability to: ●● Increase the thoughtfulness and clarity of communication as an ●● Serve millions of people who would otherwise not participate unintended byproduct of written communication. (e.g., people with certain conditions, such as agoraphobia, persons

SocialWork.EliteCME.com Page 12 ●● Produce a permanent record that can be easily referred to and This is clearly an ambiguous area that will undoubtedly continue to be forwarded to clients or colleagues for review and consultation debated. purposes. Kanani and Regehr (2003) have summarized some of the other ●● Substantially reduce overhead costs, thus reducing costs for the concerns raised by others regarding the use of e-therapy: consumer. ●● E-therapy does not allow practitioners to observe and interpret As discussed earlier in this training, one of the major areas still under facial expressions and body language. debate as a result of this new technology is that of jurisdiction. Here ●● The Internet poses a serious risk to security, and thus, to are some thought-provoking considerations. confidentiality. ●● When the client lives in a different state, it is difficult to avoid ●● Inappropriate counseling may occur due to therapist ignorance violating licensure laws because it is still unclear as to which about location-specific factors related to the client (e.g., living state’s laws would be applicable. conditions, culture). ●● Is the origin or location of counseling in the client’s community, ●● Clients cannot be sure as to the credentials, experience, or even the therapist’s, or is it somewhere in cyberspace? identity of the person they are trusting to provide services. ●● What defines location, if a busy executive is involved in an online ●● Clients may not have any legal recourse for malpractice, given session while flying from Tucson to Bangkok? unresolved questions about jurisdiction and standards of care.

Limiting risk in the practice of e-therapy Matthew Robb recommends these points for those practicing e-therapy: ●● Consult your association’s code of ethics – Review standards ●● Full disclosure – This relates to informed consent and the regarding informed consent, confidentiality, conflict of interest, need to fully disclose the possible benefits and risks of distance misrepresentation, etc. counseling, including informing the client that this is a new area of ●● Consult state licensing provisions – Research both the statutory practice, which has not had the benefit of long-term study. regulations of your board, as well as those in the client’s home state. ●● Comprehensive assessment – Provide clients with detailed and ●● Consult a malpractice/risk management attorney – Consider complete assessment tools and encourage full disclosure by client. asking a legal specialist to review website materials to determine ●● Confidentiality and disclosure of safeguards – Take all compliance with standards of care and potential malpractice issues. precautions to safeguard the confidentiality of information and ●● Provide communication tips – If communicating solely by avoid misdirected e-mails, eavesdropping, hacking, etc. Alert the text-based messaging, provide client with clear tips regarding client to these potential risks as well. communication. ●● Emergency contact – Obtain information for an emergency contact and together develop a clear emergency plan.

Conclusion Ethical dilemmas are varied, common and complex. Ethical decision- presentation also does not constitute legal advice. If there is any making can be difficult, as well as time-consuming, while sometimes, discrepancy between the provisions of the HIPAA Privacy Rule, other mental health practitioners are still left with a little ambivalence and laws or regulations, and the material in this presentation, the terms of uncertainty following their decision. Typically, there will be more the laws, rules, professional guidelines and regulations will govern in than one person involved with the ethical decision-making process. all cases. This information is not intended to describe all of the national It is always important to keep in mind the power of supervision and mental health associations’ guidelines, but to ensure that learners are consultation regarding any mental health practice. With an ethical guided by their particular association’s code of ethics and state licensing dilemma, this cannot be overstated. regulations in order to make the most appropriate ethical decisions. This information is not intended to provide all of the details of Any case examples used within this course do not reflect actual individuals. the HIPAA Privacy Rule, or of any other laws or guidelines. This

Page 13 SocialWork.EliteCME.com Ethics And Boundaries Final Examination Questions Select the best answer for each question and proceed to SocialWork.EliteCME.com to complete your final examination.

1. The word ethics means: 7. Specific Ignorance includes which of the following? a. The word “ethics” is derived from both the Greek word a. The principle (or rationalization) of specific ignorance states “ethos,” which means character, and the Latin word “mores,” that even if there is a law prohibiting an action, what you do is meaning customs. not illegal as long as you are unaware of the law. b. Ethics defines what is good for both society and the individual. b. The rationalization that if you can get away with it is OK. c. Though closely related, law and ethics do not necessarily have c. No one will believe the patient over the therapist anyway. a reciprocal relationship. d. All of the above. d. All of the above. 8. The principle (or rationalization) of literalization states: 2. Which of the following are ACCURATE? a. Since it is not found in any legal, ethical, or professional a. The origins of law can often be based upon ethical principles. standards it must be an original work or clinical break through. b. Laws prohibit many unethical behaviors. b. That if we cannot find a specific mention of a particular c. Adherence to certain ethical principles may challenge a mental incident anywhere in legal, ethical, or professional standards, it health practitioner’s ability to uphold the law. must be ethical. d. All of the above. c. No one will know what happens in a confidential setting. d. None of the above. 3. State oversight boards give authority to practice to qualified individuals, typically defined by three competencies: 9. The core values espoused by mental health ethics codes a. Education, experience, passing score on an examination. incorporate a wide range of overlapping morals, values, and ethical b. Empathy, ethics, evaluation. principles that lay the foundation for the profession’s unique c. Education, empathy, enlightenment. duties. They generally include: d. None of the above. a. Service. b. Autonomy, allowing for freedom of choice and action. 4. Failure to abide by these regulations can: c. Responsibility to clients, responsibility to the profession, a. Have serious and negative legal and financial consequences. responsibility to social justice, responsibility for doing no b. Mental health professionals need to understand that they harm. may not be covered by their insurance policy if they were d. All of the above. not practicing legally at the time of a questionable ethical occurrence. 10. Actions designed to prevent harm to the client include the c. There are also laws that impose legal obligations to abide by following: practices that further serve to protect the consumer. a. Limit practice to those populations that do not cause your own d. All of the above. needs to surface. b. Seek clinical supervision to effectively deal with personal 5. State statutes require: feelings. a. Mandatory child abuse reporting, practices that ensure client c. Document surroundings and who was present during sessions confidentiality, or competence to perform certain services. and visits. b. Unlike regulation under the law, adherence to regulations set d. All of the above. forth by private credentialing bodies is voluntary. c. The regulations and codes of ethics are universally respected but do not have to be followed to remain in professional practice. d. Mental health professionals also practice in accordance to the professional standards of care established by private professional association organizations such as ACA, NASW, or AAMFT.

6. Failure to follow the ethical codes of one’s profession may result which of the following? a. Expulsion from the profession, sanctions, fines. b. If sued, in a judgment against the practitioner. c. All of the above. d. None of the above.

SWFL03ET17

SocialWork.EliteCME.com Page 14 Chapter 2: Medical Errors in the Mental Health Profession 2 CE Hours

By: Kathryn Brohl, MA, LMFT and Rene’ Ledford

Learning objectives ŠŠ Define medical error as it pertains to the practice of licensed ŠŠ Describe how medical errors impact mental health clients. mental health practitioner psychotherapy. ŠŠ Inform licensed mental health practitioners about their legal ŠŠ Describe medical error responsibility for mental health practitioners. responsibility in reporting medical errors. ŠŠ List causal factors behind medical errors.

Medical error – Definition Medical errors are defined and governed by various entities, such as state Medical errors occur anywhere in the health care system, including: legislatures, mental health associations and best practice institutions, to ●● Hospitals. help preserve the health, safety and welfare of the public. ●● Clinics. As members of a health care prevention, intervention and oversight ●● Nursing homes. team, mental health professionals have a responsibility to be aware of ●● Physician and mental health offices. medical errors, as well as learn strategies to minimize risk for them. ●● Pharmacies. ●● Patient’s homes. ●● Outpatient surgery centers. Remember: Medical errors can occur at any point in treatment, even in preventive care, and are not limited to Increasingly, mental health professionals have clients who are patient injury or death. following medication protocols and other medical therapies, many of which are potentially lethal when taken improperly. In some states, a medical errors CE course is required to meet professional continuing education standards for licensed mental health Consequently, mental health professionals are often in contact with professionals. In many states, medical errors are governed not through doctors and other licensed medical personnel, and in a position to CE requirement, but by ongoing professional conduct as required by communicate concerns to both providers and clients. Mental health mental health associations and licensing boards. professionals are susceptible to making medical errors as well, and are obligated to report any medical errors by others. As more and more mental health clients are being treated for complex physical and mental co-occurring conditions, mental health Health care personnel and institutions are held accountable for professionals often work with teams of intervention specialists. Any of establishing a safe health care environment for clients/patients. Careful these professionals or work roles can create and contribute to medical review and analysis of sentinel events and near-misses (situations in error for mental health clients. They are part of the hierarchical which medical error occurred but did not cause harm to the client/ medical community and include: patient), suggests examination of sentinel events can be essential to ●● Psychiatrists. determining whether adverse events, such as client/patient injury or ●● Psychologists. death, were caused by the client/patient’s diagnosed condition, a medical ●● Physician’s assistants. intervention, or inaction on the part of the mental health or medical ●● Nurse practitioners. personnel. Sentinel events signal the need for immediate attention and ●● Mental health professionals: investigation in order to reduce occurrence of medical error. ○○ Clinical social worker. The Joint Commission on Accreditation of Healthcare Organizations ○○ Marriage and family therapist. (JCAHO) requires health care organizations to establish internal ○○ Mental health counselor. processes to recognize sentinel events, conduct cause analyses, identify Other medical community members include: and document areas of risk, and implement a risk reduction plan that ●● General medical practitioners. outlines risk reduction measures. Usually, all personnel involved in the ●● Surgeons. systems and processes under review must participate. ●● Medical specialists such as gynecologists, pediatricians, internists, Whether working as a mental health practitioner within a health care and others. organization such as a hospital and subject to JCAHO rules and regulations ●● Nutritionists. or working in private practice, medical error is defined similarly as: ●● Physical and occupational therapists. An event over which health care personnel could exercise control ●● Pain management specialists. and which is associated in whole or in part with medical intervention, Other treatment team members may not be medical personnel but are rather than just the condition for which such intervention occurred, involved with mental health clients. They include: and includes intentional or unintentional mistake of practice and ●● Certified addiction professionals. judgment that creates harm to a patient/client. The intervention could ●● Pastor/ religion/faith leaders. be medical or specialized medical procedures such as diagnosis and ●● Relatives. treatment of a mental health illness.

Page 15 SocialWork.EliteCME.com In summary, a medical error is a failure of a planned intervention or ●● Loss of funds by client/patient or client/patient’s family the use of a wrong plan or inadequate oversight of ethical protocols Mental health clients may become financially negatively impacted that causes an adverse event or near-miss that is preventable under the if mental health professionals demonstrate insensitivity to, or take current state of knowledge. advantage of their clients’ inherent vulnerability to suggestions or recommendations. For example, they may: Examples of medical error harm include: ○○ Seek unnecessary treatment protocols that have neither best ●● Permanent loss of trust by client/patient practice nor scientific merit. As a result of medical error, mental health clients can: ○○ Continue treatments long after they are needed due to a ○○ Lose trust that their personal information will be properly shared. medical error in billing or profit-minded-only practitioners. ○○ Lose trust in the psychological or medical community due to ○○ Pay exaggerated fees for service due to an overexaggerated the medical team’s inability to share information pertinent only sense of importance by the mental health practitioner. to specific team members. ●● Loss of client/patient’s necessary support systems ○○ In 1996, the U.S. Supreme Court decision in Jaffee v. As a result of medical errors by mental health professionals mental Redmond established the psychotherapist/patient privilege health clients can: in the federal courts, on grounds that only the trust that a ○○ Lose important wraparound services due to poor guarantee of confidentiality could provide would foster communication among the intervention team or through lack effective psychotherapeutic treatment. of necessary paperwork that could be explained by staff. ○○ The passage of the federal Health Insurance Portability and ○○ Lose family support if psychological and financial assistance is Accountability Act (HIPAA) has placed significant responsibility withdrawn or reduced through lack of follow-up with insurance on health care providers with regard to preserving patient privacy or completed recommendations by any team member(s). and confidentiality. HIPAA provides special protections for ○○ Follow improper advice and sabotage healthy relationships if psychotherapy notes. For example, in order for them to qualify as support team members are not fully informed regarding client “therapy notes,” they must meet certain conditions that include: background. ■■ Being maintained separately from the patient’s other health ●● Loss of client/patient safety care records. Safety systems extended to mental health clients must encompass ■■ Not being the only source of information for treatment or all elements of practice, including personnel, operational payment. processes, technologies, environment and materials. ■■ Being solely for the use of provider that created them. ●● As a result of medical errors, mental health clients can lose the ■■ Outside of very limited exceptions explicit within ability to feel psychologically or physically safe. They can: the statute, they may not be disclosed under virtually ○○ Experience anxiety or apprehension about new or particular any circumstances without the patient’s expressed environmental settings, and/or the introduction of new authorization. or other medical/mental health professionals, as well as ○○ Loss of trust to the extent that they drop out of medical treatment protocols when proper referrals are not completed or and psychological treatment and consequently relapse or appropriate information shared. exacerbate their conditions. ○○ Place themselves in unnecessary physical or emotional ○○ Loss of trust that accurate information will be passed to them danger because of their inability to use sound judgment and and other support services or that information will not be be exposed to toxic substances, become over-medicated, and withheld from them. continue to be involved with dangerous individuals such as an Family, friends, co-workers or other supportive caregivers can abusive spouse or partner. also lose trust and subsequently impact a mental health client’s ●● Worsen existing or create new physical or mental health psychological, financial, and physical conditions. conditions ●● Reversal or relapse of mental health and other physical Experiencing trauma as a result of medical error can cause mental conditions in client/patient health clients to develop acute stress or post-traumatic stress disorder. Mental health clients can experience a reversal in their mental or As a result of trauma incurred through medical error, a client’s physical conditions. As a result of medical error, a client may: medical condition can worsen or he/she can acquire a new mental ○○ Choose to discontinue medication when medications are not health diagnosis such as post-traumatic stress disorder or other reviewed or renewed, or when clients are not able to finance anxiety disorder that includes acute stress disorder, panic disorder, their health and well-being. phobias, or generalized anxiety disorder. Clients are susceptible as ○○ Take the wrong medication and cause overdose or other physical well to acquiring mood disorders such as depression. or mental harm when the medical team works at cross purposes Panic disorders can result from trauma created by medical errors because of poor communication or separate diagnosis. as well as mood, behavior, other anxiety conditions and regressed ○○ Halt necessary medical visits, causing mental illness relapse or mental health conditions. reversal in their physical and mental functions when they are under the impression that they are not in need of continuing Trauma caused by medical error can substantially affect the quality medical or mental health supervision, or when a mental health of life for clients. Mary Ann is an example of how someone can be practitioner or medical staff fail to schedule necessary sessions traumatized by a medical error made by a physician. or appointments. Case: Mary Ann had been seen by John, a licensed social worker ○○ Abuse medications to the extent that multiple and/or for her depression, for two years. At age 15, Mary Ann’s mother inappropriate medications are taken when mental health took her for her first gynecological appointment. During her practitioners are not in communication with other team appointment, her doctor took her aside and stated that she was members, or medical practitioners fail to document or properly very pretty. He also stated that if she ever needed his help in communicate with one another. understanding how to reach orgasm, he would be happy to spend ○○ Seek unnecessary additional treatment when a mental health time explaining the process. practitioner recommends unconventional medical or mental health practices or practices that do not have significant data to Mary Ann was confused and upset by her doctor’s behavior. She back them up. began to awaken with nightmares and found herself crying more than usual. During one session she tentatively approached John,

SocialWork.EliteCME.com Page 16 trying to understand why she would be so shaken by her medical Due to medical errors mental health clients may: visit. John reported the incident to the doctor’s state licensing board. ○○ Take unnecessary personal risk, engage in passive suicide Mental health clients may experience weakened nervous, autonomic, behaviors. immune, and endocrine system function, in addition to a decline ○○ Lose their lives due to consuming excessive medication or the in their general physical well-being because of trauma created by wrong type of medication. medical error. In Mary Ann’s case, her trauma reactions were reduced ○○ Overdose on drugs or alcohol. by her disclosure to her therapist and her subsequent reprocessing and ○○ Commit suicide. integration of her experience with her gynecologist. ○○ Cause harm to others. ●● Loss of client/patient’s life or permanent physical or mental damage or disfigurement Remember – Relatives and friends of mental health clients can be Death or limitation of neurological, physical or sensory function traumatized by client loss of life or harm to others. can occur as a result of medical error.

Medical error categories and occurrences Medical errors generally occur when there is direct, (active) client ●● Negligence involvement, or indirect, (latent) client involvement through contact Mental health professionals make mistakes when they are: with other professionals, family, agencies, hospitals, etc. ○○ Overly fatigued. Whether the errors occur through direct or indirect client involvement, ○○ In a hurry. they can happen as a result of omission or commission acts. Omission ○○ Inattentive and distracted. acts represent negligence or omission of information. Commission acts ○○ Negligent in not accessing and/or thoroughly reviewing client are overt/covert actions that cause medical error. records. ○○ Negligent in not writing, recording, reading or sharing critical Mental health professionals have serious responsibilities to their reports, reviews or correspondence. clients, colleagues and to the mental health profession. The focal point ○○ Not paying attention to laws and regulations regarding of these interrelated responsibilities is a fiduciary relationship in which confidentiality and consent. the client places trust in the practitioner with the expectation that the ○○ Physically or mentally ill. practitioner is working in the client’s best interest. This expectation is ○○ Not providing an adequate physical professional environment. the foundation of a therapeutic relationship. ○○ Imposing religious or spiritual beliefs onto clients. Through the therapeutic relationship each party assumes separate ○○ Lacking in follow-up. and distinct roles. The practitioner bears the burden of accountability ○○ Negligent in gaining correct medication information. within the relationship because she/he assumes an expert role. This ●● Habituated behavior role impacts the client/practitioner interpersonal dynamic, and creates When mental health professionals fall into habits of poor a power differential within the relationship. professional behavior or continuously take work shortcuts, it can be exhibited through the following behavior: By virtue of expertise through education, degree, license, skills and ○○ Slow response and follow-up with regard to client or calls or experience, mental health professionals generally acquire an authoritative crisis. advantage over clients, thus, setting the stage for potential misuse of ○○ A lack of concern for the client’s well-being. power. With any position of power comes the risk for abuse that can range ○○ Inattention to, or minimization of client concerns and self- from minor improprieties to egregious misconduct and crime. reporting. Licensed practitioners are bound by their professional affiliation ○○ Poor communication with clients, their families or other to act responsibly, even when the client does not. treatment team members. ○○ Disregard for professional boundaries. Greatest risk for committing medical error occurs through: ○○ Continued disregard for physical environment that would ●● Multiple professional involvement. cause safety hazard to clients, such as unsafe or toxic exposure ●● Misdiagnosis. to fumes, cigarette smoke, dangerous structure, or crime. ●● Intimidation. ●● Lack of knowledge ●● Over-treatment. Mental health professionals can demonstrate ignorance or lack of ●● Lack of involvement. skill when they fail to understand or demonstrate the following: Mental health professionals are responsible for maintaining protective ○○ Best practice knowledge – It is important that licensed mental boundaries that ensure their clients’ physical and emotional safety. health practitioners, through various ways, stay current in their When this does not happen, the following common medical errors can psychotherapy practice. occur when mental health professionals: ○○ Professional development – It includes but is not limited to ●● Omit professional background information. ongoing consultation and supervision, peer review, course ●● Relay false client/patient or their own personal information. work, certification training, seeking additional schooling ●● Inappropriately share or distort information. through graduate degree work or academic participation, ●● Are inappropriately assigned to a client. professional membership and periodical reading. ●● Attempt to treat out of the realm of expertise. ○○ Current laws and regulations – Regulations regarding the ●● Do not consult with medical professionals. practice of psychotherapy change. It is best to keep abreast of ●● Do not thoroughly collect background histories. these changes through legislation and association participation. ●● Do not thoroughly complete assessments. Every state has a state website that provides information on ●● Provide inadequate safety or security of physical environment. proposed laws. ●● Assign false diagnosis. ○○ Necessary certification training – Certification is usually ●● Recommend inappropriate or dangerous treatment protocol. required before practicing a new psychotherapeutic technique. While most medical errors are unintentional, some are intentional. It is always best to affiliate with other practitioners who are Most fall under the following categories: participating in the same type of protocol.

Page 17 SocialWork.EliteCME.com ○○ Thorough client/patient social histories or background to strict professional guidelines and ethics. Intentional harm information – Medical error occurs when medical or mental can be considered a crime when mental health professionals health practitioners do not diagnose and treat from the same mindfully: background information. Obtaining releases of information is ■■ Become romantically and/or sexually involved with essential when providing and coordinating appropriate client clients. Romantic or sexual innuendo are medical errors. service. Physical touch does not need to occur for wrong action. ○○ Consultation with experts – Experts are fundamental reality ■■ Falsely bill and/or charge fees to clients or insurance. checks for mental health practitioners. ■■ Administer inappropriate or grossly wrong methods of ○○ Understand personal and professional capabilities and treatment. limitations. ■■ Fail to contact medical personnel or law enforcement when ○○ Obtain sufficient experience to justify decision making or clients threaten to or actually harm themselves or others. behavior. ■■ Fail to report child abuse or make other appropriate reports ○○ Wrong referral or inappropriate referral. to monitoring agencies or personnel. ○○ Missed diagnosis, no diagnosis, or wrong Axis II diagnosis. ■■ Prescribe medications without sufficient licensing or ●● Intentional harm expertise. Intentional harm by mental health professionals is reflected Case: Sam was briefly hospitalized for suicidal ideation and through medical error when they: severe depression. Because he’d not seen a psychiatrist prior to ○○ Unnecessarily or inappropriately assign diagnoses in order to his admission, he was assigned a very busy doctor who supervised continue treatment and bill for more fees. residents at the same hospital. After an initial consultation, the ○○ Knowingly or flagrantly overcharge a client or wrongly submit psychiatrist turned the case over to the resident doctor. However, a bill to a client, insurance company or other third-party payer. the resident doctor was unable to consult regularly with his ○○ Fail to maintain billing records properly, which can be a supervisor. While in session one day, Sam disclosed that he was criminal offense as well. not sleeping at all. The resident adjusted Sam’s medication with ○○ Project personal need onto the client through negative the subsequent result that Sam’s ulcer was severely affected, countertransference. (Countertransference refers to projected requiring a medical procedure. feelings and behaviors onto clients that reflect practitioner ○○ Abandon clients. It is imperative that mental health psychological and physical personal history and negatively professionals do not abandon their clients due to failure to impact the therapeutic relationship.) pay or incompatibility. It is the professional’s job to transition ○○ Do not adhere to professional boundary ethics such as ignoring clients and pursue alternative treatment avenues before closing proper consent protocol or becoming physically demonstrative. a case. ○○ Accept favors, free merchandise or confidential information, ○○ Falsify records. such as stock tips from clients. ○○ Falsely claim curative abilities. ○○ Commit intentional harm that includes actual crime, ○○ Breach confidentiality. particularly when mental health professionals do not adhere

Reporting misconduct Mental health professionals have an obligation to report medical Unpreventable adverse event: An adverse event resulting from error by other practitioners to governing bodies as well as to client a complication that cannot be prevented given the current state of caregivers and clients themselves. knowledge. Generally, each state has an oversight or governing agency where Medical error: An adverse event or near-miss that is preventable with practitioners can make reports and or access complaint forms. They the current state of knowledge. can differ in complaint procedure and action. Nationally, The Joint Near-miss: An event or situation that could have resulted in an Commission on Accreditation of Health care Organizations (JCAHO) accident, injury or illness, but did not, either by chance or through conducts investigations. Professional associations monitor membership timely intervention. and usually have established protocols to investigate complaints as well. System: A regularly interacting or interdependent group of items These oversight or governing entities gather and analyze complaints, forming a unified whole. and determine probable cause and disciplinary action. If a complaint is determined to be a possible violation of law, it will be investigated by Systems error: An error that is not the result of an individual’s a legal designate. actions, but the predictable outcome of a series of actions and factors that comprise a diagnostic or treatment process. In general, JCAHO utilizes “root cause analysis” to examine what factors and associated processes relate most directly to the medical Since the inception of its sentinel event policy in 1995, JCAHO has error event, as well as root causes. In addition, JCAHO will examine compiled data, reflecting more than a thousand incidents. Root causes other risk factors and possible improvements or systems inserted to for medical error include: reduce risk of further error. Personnel are assigned responsibility ●● Inadequate safety or security of the physical environment. for implementing necessary improvements. The improvements are ●● Inadequate assessment or incomplete reassessment of the evaluated to determine their degree of efficacy. patient. Inappropriate assignment of the patient. ●● Incomplete examination of the patient. The following glossary defines common terms used in medical error ●● Infrequent or incomplete patient observations. analysis: ●● Inadequate staffing or lack of staff competency. Adverse event: An injury that was caused by medical management ●● Factors related to the unavailability or miscommunication of and that results in measurable disability. information among health care personnel and other caregivers. Error: The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures and systems.

SocialWork.EliteCME.com Page 18 Preventing medical error In order to avoid committing medical error, mental health practitioners ○○ Teaching assertiveness and encouraging questions. need to be proactive and conscientious beginning with first contact and ○○ Understanding professional limitations and making referrals. working with a continuum of care model by following an appropriate Case: Sara had established an excellent therapeutic relationship chain of communication that is initiated by obtaining consent, face to with her client, Georgia, an older woman. As time progressed face or phone conference, staff meetings and written communication. however, it was evident that Georgia was experiencing lapsed Remember: Confidentiality rules and regulations apply to e-mail judgment and forgetfulness. At Sara’s request, Georgia consulted communication as well. with her physician who referred her to a neurologist who diagnosed her with early Alzheimer’s disease. The neurologist in turn There are many steps practitioners can take to prevent medical error referred Georgia to a mental health practitioner who specialized in and ensure best practice treatment, in addition to assessing for medical Alzheimer’s protocol. Sara’s bond with Georgia was blurred as she error by other professionals. Practitioners must be mindful about their continued to see Georgia regularly, often comparing her work to the personal capabilities and seek medical or mental health assistance other specialized practitioner. Sara encouraged her elder client not when needed. Mental health practitioners should also: to mention that she was continuing to be seen by Sara. ●● Gather complete client background ○○ Checking in frequently with client/patient about their medical ○○ Gather a thorough medical and social history. or mental health treatment progress. ○○ Assess for substance abuse. ●● Maintain proper record keeping ○○ Obtain consent or waiver for release of information for all General guidelines for providers of psychological services other treating professionals. recommend that records be accurate, current and pertinent to ○○ Obtain medical and psychological test results. the records of essential maintained psychological services. ○○ Gather a compliance or noncompliance history. APA guidelines define “records” as any information, including ●● Obtain informed client consent information stored in a computer, that may be used to document The content of informed consent may vary depending upon the the nature, delivery, progress, or results of psychological services. client and treatment plan; however, informed consent generally Mental health professionals should maintain proper records by: necessitates that a client: ○○ Keeping notes and assessment forms current. It is not ○○ Has the capacity to consent. uncommon to read a file with contradictory and confusing ○○ Has been adequately informed of significant information background information. Unless charts are shared, medical concerning treatment processes and procedures. and mental health professionals can work at cross-purposes. ○○ Has been adequately informed of potential risks and benefits As a licensed mental health professional, it is imperative to of treatments for which generally recognized standards do not obtain releases and contact the other treating individuals. It is yet exist. important to record a lack of response after the query. ○○ Has freely and without undue influence expressed consent. ○○ Has provided consent that is appropriately documented. ○○ Reviewing forms, especially consents and medical protocols, verbally with clients. Forms must be individualized to meet When persons, due to age or mental status, are legally incapable of giving the needs of each client. Serious errors have been made when informed consent, mental health professionals must gain consent from a support staff has pulled out the wrong form and/or falsely legally authorized person; such substitute consent is legally permissible. recorded information. Check forms! ●● Thoroughly assess client by: ○○ Recording client information changes in file, and this includes ○○ Understanding client medications and his/her medication basic contact information as well as medication alterations. protocol. (If client’s medication has not been routinely ○○ Including client’s response to changes in medications or reviewed, appears ineffective or has been abused and has been mental health treatment. overly prescribed, the practitioner is obligated to contact the ○○ Noting changes in client compliance. prescribing physician, but not suggest alteration to client.) ○○ Noting other practitioner advice or treatment. ○○ Observe client for signs that indicate a previous misdiagnosis ○○ Maintaining neat and orderly files. or lack of diagnosis. ○○ Maintaining client files for the legally required period. The ○○ Observe client for signs of personality disorders. length of time varies from state to state. ○○ Observe client for signs of violence or paranoia. ○○ Keeping files in a secure location and all information ○○ Examine client for indicators of substance abuse. confidential. It is not uncommon for clients to request their ○○ Monitor client for signs of medical treatment noncompliance file/records several years after completing treatment. through ongoing medication review that includes self-report ●● For example, Alexa had provided expert opinion during a child regarding side effects. sexual abuse investigation several years ago. She’d kept her records ●● Build client trust by: in a locked file cabinet. They were not accessible to anyone but ○○ Reviewing guidelines for practitioner/client affiliation, such as herself. She had moved during the time between her investigation professional practice boundaries and client rights. and when a request was made for the case records. And while the ○○ Reviewing fees for professional service. required timeline for keeping files had lapsed, she was able to access ○○ Discussing mental health treatment protocol. the information which provided validation for her prior assessment. ○○ Sharing under what circumstances confidentiality can legally be breached, such as reporting child abuse. Remember: In 2003, the United States Department of Health and ○○ Avoiding intimidation or abusing professional authority. Human Services (HHS) issued new guidelines that apply specifically ○○ Working at partnering with clients. to psychiatrists. Because of HIPAA guidelines, psychiatrists now must ○○ Being consistently on time, returning phone calls and maintain two sets of records for each patient; regular medical records responding to other communication. and separate psychotherapy records entitled, “psychotherapy notes.” ○○ Being authentic about advocating on behalf of client. ○○ Utilizing proper channels to investigate a complaint. ●● More often than not, confidentiality is breached informally. ○○ Being honest. According to one study, over half of all psychologists have ○○ Encouraging clients to ask questions and seek out answers unintentionally disclosed confidential data. regarding their medical treatment as an active member of their ●● Stay current in best practice methodologies by: health care team. ○○ Participating in peer review and supervision.

Page 19 SocialWork.EliteCME.com ○○ Utilizing consultants. ○○ Assess professional and personal limitations. ○○ Participating in professional enhancement courses in standards ○○ Assess client/patient potential for therapeutic benefits through of practice. examining best interest of client. ○○ Reading professional literature. ○○ Develop a plan for termination that reflects client consideration ○○ Membership and participation in professional associations. with attention to the possibility that it will be received with ○○ Attending professional conferences. emotion or distress. ○○ Professional networking. ○○ Invite client into the process by reassessing therapy goals and ●● Professionally terminating or concluding treatment objects. Mental health professionals should establish a plan for the custody ○○ Allow time to process termination with client. Begin the and control of records in the event of the practitioner’s death, and termination process with enough time for your client to be should plan for the safe and effective transfer of client records to transitioned to a new therapist and/or process closure. Not another practitioner. allowing enough time misses an essential therapeutic step and ●● Considerations for terminating or concluding care: can place the practitioner at risk for medical error. Conclusion Medical error is a serious consideration in the rapidly changing health Mental health professionals are often working within health care teams care arena and is defined as “a failure of a planned intervention or to provide client/patient care, and in a position to communicate concerns the use of a wrong plan; as well as oversight of proper use of ethical to other providers and clients. Consequently, they are susceptible to protocol that causes an adverse event or near-miss that is preventable making medical errors and obligated to report medical errors by others. under the current state of knowledge.” Client/patient harm due to medical error includes permanent loss of trust, Mental health professionals have a responsibility to be aware of medical reversal or relapse, loss of funds, loss of necessary support systems, medical error, as well as learn strategies to minimize potential risk loss of client/patient safety, exacerbated medical/physical conditions, loss of for error. Medical errors can occur at any point in treatment, even in life or permanent physical or mental damage or disfigurement. preventive care, and are not limited to patient injury or death. Medical errors occur when health care practitioners demonstrate negligence, Depending on where they practice, mental health professionals are poor habituated behavior, lack of knowledge and intentional harm. governed by oversight entities that include, but are not limited to state Medical error can be reduced by gathering thorough client/patient licensing boards, professional associations and the Joint Commission background, thorough assessments, building client trust, maintaining on Accreditation of Health Care Organizations. proper record keeping and keeping current in best practice methodologies.

Bibliography ŠŠ Ackerman, R.H., Maslin-Ostrouski, P.; The Wounded Leader, Jossey-Bass, San ŠŠ Pope, Kenneth S., Tabachnik, K, Barbara G., Keith-Spiegel, Patricia; Ethics Franciso, 2002 of Practice: The Beliefs and Behaviors of Psychologists as Therapists, 42 AM. ŠŠ American Counseling Association, The Counselor and the Law (4th ed.), 1996 Psychologist 11, 993-1006 ŠŠ American Association for Marriage and Family Therapy – Code of Ethics ŠŠ A Report of the Surgeon General; Confidentiality of Mental Health Information: ŠŠ American Psychological Association – Code of Ethics Ethical, Legal and policy Issues, Chapter 7, Mental Health ŠŠ National Association of Social Workers – Code of Ethics ŠŠ National Board of Certified Counselors – Code of Ethics ŠŠ Terez T.; How to Create a Meaningful Workplace. Avon, MA: Adams Media MEDICAL ERRORS IN THE MENTAL HEALTH PROFESSION Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your final examination.

1. Medical errors can occur at any point in treatment, even in _____ 4. HIPAA provides special protections for psychotherapy notes. For care, and are not limited to patient injury or death. example, in order for them to qualify as “therapy notes” they must a. Family. meet certain conditions. One of these is that outside of very limited b. Preventative. exceptions, explicit within the statute, therapy notes may not be c. Child. disclosed under virtually any circumstances without the what? d. Out-patient. a. Doctor’s consent. b. Patient’s expressed authorization. 2. As more and more mental health clients are being treated for c. Patient’s family’s approval. complex physical and mental co-occurring conditions, mental d. Notification. health professionals often work with teams of ______specialists? 5. As a result of medical error, a patient or client may experience a. Medical association. a reversal in their mental or physical condition. As a result of b. Licensing board. medical error, they may choose to discontinue medication, take c. Clinical nurse. the wrong medication, halt necessary visits, abuse medications, or d. Intervention. seek ______treatment. a. Unnecessary additional. 3. As a result of medical error harm, permanent loss of trust by the b. Necessary second opinions. client/patient may occur and mental health clients can lose trust in c. More medications. the psychological or medical community due to the medical team’s d. Fail to eat. inability to share information pertinent ONLY to ______members. a. Staff. b. Family. c. Specific team. d. Research.

SocialWork.EliteCME.com Page 20 6. Most medical errors fall under the following categories: 9. An injury that was caused by medical management and that results negligence, habituated behavior, lack of knowledge, and ______. in measurable disability is called what? a. Intentional harm. a. Systems error. b. Fraudulent behavior. b. Near miss. c. Inattention to duty. c. Adverse event. d. Gainful opportunity. d. Inadequate event.

7. Some examples of habituated behavior regarding medical errors 10. To prevent medical errors, mental health practitioners should that mental health professionals exhibit include a lack of concern always gather a complete client background, obtain informed for the client’s wellbeing, or slow response and follow up with client consent, thoroughly assess client, build client ______, and regard to client calls or crisis. What is another example? maintain proper record keeping. a. Failing to charge the client appropriately for the service. a. Relationships. b. Taking on too many responsibilities. b. Confidence. c. Caring for only patients that are young. c. Files. d. Disregard for professional boundaries d. Trust.

8. Intentional harm by mental health professionals is reflected through medical errors when they project ____ needs onto the client, through negative counter-transference. a. Team. b. Personal. c. Negative. d. Other patient’s.

SWFL02ME17

Page 21 SocialWork.EliteCME.com Chapter 3: Domestic Violence

2 CE Hours

By: Kathryn Brohl, MA, LMFT and Rene’ Ledford, LCSW

Learning objectives ŠŠ To utilize the definition of domestic violence in order to facilitate ŠŠ To facilitate understanding and recognition of the cycle of violence domestic violence identification and intervention. and the impact of domestic violence on children and families. ŠŠ To facilitate mental health practitioner recognition of professional ŠŠ To educate the mental health practitioner on why domestic responsibility with regard to domestic violence. violence victims do not immediately leave their abusers.

Domestic violence statistics Domestic violence is an urgent public health problem with devastating ●● Nationally, 50 percent of all homeless women and children are on consequences for women, men, children, youth, and the elderly. the streets because of violence in the home. (There are nearly three Domestic violence has no age, gender, social, ethnic, geographic, times as many animal shelters in the United States as there are education, economic, or race boundaries. There is no typical victim, yet shelters for battered women and their children.) it affects the health and well being of all persons involved in the crime; ●● Women are most likely to be murdered when attempting to leave in particular, contributing to children in care. As a matter of fact, the an abusive relationship. frequency and severity of violence among lower income people is equal ●● In an attempt to punish the mother, there is a high risk of child to the frequency and severity in the middle and upper classes. abduction by the domestic violence batterer. ●● 25 percent of 235 women studied reported that husbands continued For example, according to the U.S. Department of Justice, intimate to make threats against their lives during child visitations. persons such as husbands, ex-husbands, boyfriends, or ex-boyfriends – ●● 73 percent of battered women seek emergency medical care for commit 29 percent of all violence against women. injuries sustained after leaving their batterer. Further, of nearly 18 percent of American women surveyed, 17.7 ●● Approximately 2 million children in the United States are seriously million, have been raped or been a victim of attempted rape during abused by their parents, guardians, or others each year and their lifetime, according to a collaborative study on violence jointly approximately 20 percent of children will be sexually abused in funded by the Department of Health and Human Services and the someway, usually by someone they know – before becoming adults. Department of Justice. ●● 900,000 parents are beaten or abused by their children each year. The Elder Abuse Incidence study found that approximately 551,011 Each year between 2 million and 4 million women are battered, and elder persons were abused or neglected in a one-year period (1996). 2,000 of these battered women will die of their injuries. ●● One study found that children of abused mothers were 57 times Domestic violence is the single largest cause of injury to women more likely to have been harmed because of intimate partner between the ages of 15 and 44 in the United States, more than violence between their parents, compared with children of non- muggings, car accidents and rapes combined. abused mothers. Other statistics include: ●● Medical expenses, alone, from domestic violence range between 3 to Remember: It is not unusual for battered victims to separate 5 million dollars annually, but the total cost, including court, police, and reunite with their batterers six to seven times before leaving shelters, jail, job loss, etc…. is approximately $67,000,000 annually. permanently. They leave through divorce or through death.

Domestic violence – Definition In general domestic violence can be defined as any assault, aggravated demonstrated through a Power and Control Wheel. For example, it can assault, battery, aggravated battery, sexual assault, sexual battery, be demonstrated in the following ways: stalking, aggravated stalking, kidnapping, false imprisonment, or any ●● Emotional and psychological abuse. criminal offense resulting in physical injury or death of one family The victim can exhibit: or household member by another who is or was residing in the same ○○ Anxiety disorders. single dwelling unit. ○○ Mood disorders. A “family or household member” means spouse, former spouse, ○○ Suicide and suicidal ideation. persons related by blood or marriage, persons who are presently ○○ Somatic complaints. residing together as if a family, or have resided together in the past ○○ Substance abuse. as if a family, and persons who have a child in common regardless of ○○ Eating disorders. whether they have been married or have resided together at any time. ○○ High risk behaviors. ○○ Sleep disturbance. Domestic violence is not limited to physical abuse. Other tactics ●● Threats by the batterer against property, pets and other family include emotional and psychological abuse. These three tactics are members, and can include: ○○ Yelling, shouting, screaming.

SocialWork.EliteCME.com Page 22 ○○ Blaming. ○○ Threats to cause harm to self or victims. L VIOLENCE ICA SEX ○○ Put-downs. YS UA PH L ○○ Using children – to relay messages, induce guilt and to harass USING COERCION USING AND THREATS INTIMIDATION victim. Making and/or carrying out threats Making her afraid by ○○ Play mind games. to do something to hurt her, to using actions, gestures • commit suicide, to report her smashing things • ●● Using privilege by: to welfare • making her destroying her property USING drop charges • making • abusing pets • USING her do illegal things displaying weapons ○○ Treating victim like a servant. ECONOMIC EMOTIONAL ○○ Behaving like a “master of the castle.” ABUSE ABUSE Preventing her from getting or Putting her down • making ○○ Defining male and female roles. keeping a job • making her ask for her feel bad about herself • money • giving her an allowance • calling her names • making her ●● Destruction of belongings. taking her money • not letting her think she’s crazy • playing mind know about or have access to POWER games • humiliating her • making ●● Causing economic dependence by controlling finances and assets. family income her feel guilty AND ●● Isolating the victim from any and all outside support, including USING MALE PRIVILAGES USING ISOLATION Treating her like a servant • CONTROL Controlling what she does, who family and friends. making all the big decisions • she sees and talks to, what she acting like the “master of the reads, where she goes • limiting castle” • being the one to her outside involvement • using Physical domestic violence includes: de ne men’s and women’s jealousy to justify actions USING roles MINIMIZING, ●● Shooting, stabbing, pushing, grabbing, scratching, shaking CHILDREN Making her feel guilty DENYING AND slapping, hitting, choking, kicking, biting, throwing objects. about the children • BLAMING using the children to relay Making light of the abuse ●● Stalking. messages • using visitation to And not taking her concerns harass her • threatening to take about it seriously • saying the ●● Sexual assault, sexual battery. the children away abuse didn’t happen • shifting responsibility for abusive ●● Reproductive control through denying access to contraceptives or behaviour • saying she forced sterilization. P caused it HY L ●● False imprisonment. SI UA CAL SEX ●● Kidnapping. VIOLENCE ●● Murder. Figure 1. The Power and Control Wheel

The Duluth Model Wheels

Signs of domestic violence It is important to screen clients for domestic violence as you acquire ●● Abusing children, as well as other vulnerable populations. a social history. If further investigation is needed, domestic violence Victims of domestic violence may have experienced childhood screening instruments are available through your local domestic abuse or other trauma that has modeled inappropriate parenting for violence agency. When appropriate, ask clients the list of queries them as adults. Hence, their coping skills can be marginal, especially generated from the screening instrument. when stressed. Their aptitude for handling work and building healthy In general, victims of repeated domestic violence can, over time, relationships can be impaired if they experience a mental health experience more serious consequences than victims of one-time incidents. problem due to their domestic violence situation as well. In addition, if victims are abusing drugs or alcohol their ability to parent their Outward physical indicators or signs are often present within a children or work with other vulnerable populations is diminished. domestic violence relationship, but there are other signs in victims that reflect battering and include: Other physical signs can include: ●● Depression and other mental and emotional disorders. ●● Contusion or injuries in the head, neck, cheek. Domestic violence creates oppression and depression in victims ●● Evidence of alcohol or drug use. because its theme revolves around power and control. Because ●● Injuries during pregnancy. some abusers (victimizers) often throw their victims off guard ●● Injuries that suggest a defensive posture. following the “honeymoon” phase in the cycle of violence, anxiety ●● Injuries that appear inconsistent with victim’s explanation. disorders can be present as well. In addition Posttraumatic Stress ●● Gastrointestinal disorders. Disorder can occur following the extreme fear and helplessness ●● Injuries that indicate sexual assault/rape. victims experience during their assault. ●● Knife wounds. ●● Difficulty maintaining employment. ●● Broken bones. Physical signs of domestic violence inhibit victims and can cause ●● Headaches. them to miss work. They may also fear retribution at work by the ●● Gynecological disorders. victimizer. In addition, depression may keep victims from meeting ●● Back pain. deadlines and getting to work on time. If transportation has been ●● Pelvic pain. denied by abusers, victims can literally not get to work, unless they ●● Heart and circulatory conditions. have access to public transportation. In addition, day care remains ●● Sexually transmitted diseases. a major issue for women with children. ●● Central nervous system disorders. ●● Becoming welfare recipients. ●● Symptoms of post-traumatic stress disorder that include: In their effort to maintain control victimizers often control purse ○○ Emotional detachment. strings and may withhold child and living support. If victims have ○○ Sleep disturbances. been isolated and do not have visible means of support welfare is ○○ Hyper-arousal. an avenue that enables victims to temporarily “get on their feet.” ○○ Hyper-vigilance. ●● Becoming homeless. ○○ Flashbacks. Homelessness remains a serious problem among victims of ○○ Self-mutilation. domestic violence due to all the factors listed, as well as the ○○ Mood disorders. absence of family availability and/or support. ○○ High risk behavior. ○○ Aggressive and oppositional behavior.

Page 23 SocialWork.EliteCME.com Victim and batterer behavioral signs: Domestic violence batterers can: Domestic violence victims may: ●● Become defensive, aggressive or angry when questioned. ●● Seem evasive. ●● Be overly solicitous and answer questions for victim. ●● Embarrassed. ●● Set up communication barriers between victim and helpers. ●● Provide false information. ●● Be overly protective and controlling of victim. ●● Seem unconcerned about injuries. ●● Demonstrate lack of concern for victim. ●● Be overly solicitous. ●● Exhibit anti-social behaviors. ●● Delay seeking assistance. ●● Visit doctor/hospital multiple times. ●● Be overly protective of the batterer.

The cycle of violence In general, there are three phases associated with a cycle of domestic During the second phase, the batterer loses control. The episode is violence. Power and control is demonstrated throughout the cycle by violent and can be short, or last a long time. batterers through: During the third phase there is a period of calm, and often reconciliation. ●● Physical abuse. Forgiveness is sought, while the victim is hopeful and wishes to forget ●● Psychological abuse. the incident. The calm, reconciliation period may not occur at all, but ●● Emotional abuse. in general, it is called a “honeymoon” period. This is when attempts at In the initial stage, tension develops and escalates. During this phase, gaining forgiveness and intimacy are demonstrated by the batterer. incidents considered minor by the victim occur. The victim believes As time passes, the cycle begins again and the phases occur closer that the situation is temporary and that she/he will be able to control it. together, as the incidents become more serious.

Reporting domestic violence Battery is a crime! Yet, few states specifically require reporting of adult-to- Mandatory reporting of adult-to-adult domestic violence remains adult domestic violence. Some states report mandatory arrest of batterers. somewhat controversial because victims are sometimes put at greater Few jurisdictions aggressively pursue cases of domestic violence and risk of injury or death. Studies show that women who leave batterers prosecute batterers even when victims refuse to press charges. However, are at 75 percent greater risk of being killed by them. virtually all jurisdictions impose civil or criminal penalties for failing to report suspected incidents of child abuse or neglect.

Domestic violence screening barriers Domestic violence education and intervention have come a long way funding for domestic violence prevention, education and intervention since first initiatives began in the 1970’s. However, cultural barriers continues as a barrier to eradicating the problem. continue to inhibit victim and other domestic violence reporting, as Interventionists such as law enforcement, legal, medical, and mental well as prevention and intervention. Domestic violence barriers often health professionals exhibit varying degrees of concern that reflect reflect community norms, values and attitudes. Accessing adequate their spiritual, personal, and professional values, and commitment to advocating against crimes of domestic violence.

Why do victims stay in domestic violence situations? And repeat domestic violence with new partners? There are several reasons why victims continue to stay in violent Fear of physical harm or death to self or others is another pressing relationships, as well as enter into new abusive partnerships. Very often, factor. Batterers do kill, and often tell their victims that separating would victims have been conditioned by childhood exposure to domestic prompt them to murder. In other instances, victims fear permanent violence and/or have witnessed power and control conflicts between separation from their children or loss of status or reputation. parents and other caregivers. They have literally been patterned to seek out Victims may also experience fear and guilt that their children may be violent partners, and have not learned alternative, healthy intimacy skills. permanently separated from the batterer. They may feel that they cannot care for their children without help from their partner or they over Remember! This does not mean that victims of domestic violence empathize with the batterer’s potential loss of parental involvement. are not capable of engaging in healthy relationships, nor that all Victims of domestic violence also fear isolation from friends, family childhood victims of domestic violence seek out abusive partners. or traditional support systems such as the church or social community. For example, if their faith community impresses upon victims the In some cases of domestic violence victims stay in the abusive importance of staying wedded, victims can fear its rejection and relationship because their batterers are familiar to them. They may feel subsequent isolation. most comfortable because of their relationship, family or other histories. Low self esteem also drives decision making for victims. Very often Victims often stay for financial reasons. They may not have skills, they feel unlovable and believe that they “deserve what they get.” education, or confidence to sustain a separation. And they may have Their beliefs are tied to earlier experiences that create poor self worth parenting responsibilities that keep them economically tied to the abuser. and assertive skills. Too, they may have developed low self-esteem as a result of on-going put downs by their batterers.

SocialWork.EliteCME.com Page 24 Mental health practitioner responsibility Mental health professionals have a responsibility to screen their clients ●● History of abuse or violence. for domestic violence as part of gathering background information. ●● Answers that reflect domestic violence inventory. During the screening process keep in mind that one symptom of post- ●● Protective factors such as individual strengths, family and social traumatic stress disorder is avoidance about discussion of traumatic support. experiences. Therefore, the most appropriate initial query may be When asking questions be specific with regard to: introduced through a metaphorical story that allows the listener ●● Whether the client feels in danger now or in the past. to relate to a metaphor about her/his experience, without feeling ●● Specific types of abuse to victim and/or children. overwhelmed. ●● Cycle of violence patterns. Keeping in mind the presenting condition of your client include ●● Threats or intimidation. questions that address client: Practitioners also have an obligation to assist victims by helping them ●● Fears. devise safety plans and de-escalation practices. In addition, mental ●● Safety. health professionals must be prepared to report domestic violence crime.

What is a safety plan? A safety plan is a strategy that addresses victim safety before, during and after an incident has occurred. Safety plans are also developed NONVIOLENCE for leaving batterers, because leaving them can be the most dangerous time for victims. NEGOTIATION NON-THREATENING AND FAIRNESS BEHAVIOR Safety plans can be strategies for dating, as well. For example, if Seeking mutually satisfying Talking and acting so resolutions to con ict that she feels safe and women know what to do when they feel threatened during a dating • accepting change comfortable expressing • being willing to herself and doing experience, they are more able to escape. compromise. things. RESPECT ECONOMIC Listening to her PARTNERSHIP non-judgmentally Keep in mind the following when assisting your client: • being emotionally arming Making money decisions and understanding 1. Help clients understand the cycle of violence dynamics so that together • valuing opinions. • making sure both partners benet they can recognize what happens as tension builds. In addition, from nancial arrangements. share the Equality Wheel that explains non-violent behavior. EQUALITY 2. Give them specific plans for leaving as tension mounts. SHARED RESPONSIBILITIES TRUST AND SUPPORT Mutually agreeing on a fair Supporting her goals in life 3. Tell them to avoid locations in the home where there may be distribution of work • respecting her right to her own • making family decisions feelings, friends, activities and weapons such as the kitchen or workroom. together. opinions. 4. Ask clients to identify exits in their home. 5. Ask them to keep a hidden, packed bag. REPONSIBLE HONESTY AND PARENTING ACCOUNTABILITY 6. Relay an escape code to children, friends and neighbors that Sharing parental Accepting responsibility responsibilities for self signals them to call the police. • being a positive non-violent • acknowledging past use of model for the children. violence 7. Open a bank account in their own name. • admitting being wrong • communicating openly 8. Keep their necessary escape items handy. and truthfully. 9. Know the domestic violence shelter location and phone number. N Victims may need to seek legal council and/or obtain an Injunction ONVIOLENCE for Protection Order. Mental health professionals should advise their clients that with the Order of Protection, they should call the police if their batterer violates the order. Tell clients to keep the Order close by Figure 2. The Equality Wheel and inform close friends, school officials and family that it exists. In addition, mental health practitioners should keep in mind that victims, Inform your clients that they may need to let their work associates when planning to leave their domestic violent situation need to take: know about their circumstance and encourage clients to plan for their ●● Driver’s license. safety traveling to and from work. ●● Birth certificates. If clients are contemplating reuniting with their batterer, strongly ●● Money. encourage batterer intervention programs, victim of violence support ●● Any legal agreements. group participation, on-going information gathering through books ●● Bank – checkbooks. and local domestic violence prevention and intervention. With the ●● Family heirlooms. exception of special circumstances, domestic violence experts do not ●● Insurance papers and information. recommend couple’s counseling because of possible retaliation by ●● Medications/prescriptions. batterers toward victims following sessions. ●● Keys – house and car and safety deposit. Mental health professionals are obligated to be role models and ●● Address book. educate clients on healthy functioning. Providing contact information ●● Social security card. and referral sources, as well as education materials such as the ●● Public assistance documentation. Equality Wheel strengthens clients. ●● Work permits. ●● School records. The Equality Wheel identifies non-violent behavior that emphasizes ●● Green card. relationship negotiation and fairness, non-threatening behavior, ●● Passport. respect, trust, support, honesty and accountability, responsible ●● Divorce papers. parenting, shared responsibility and economic partnership. ●● Children’s favorite items such as blanket, bottle, stuffed toy.

Page 25 SocialWork.EliteCME.com When victims have separated from their batterer ask them to: 1. Change their window and door locks as soon as possible. Remember – Mental health practitioners have an obligation to 2. Continue to discuss safety plans with their children. tell their clients that: 3. Inform their children’s school or day care about who is permitted ●● No one deserves to be abused. to pick them up, and when appropriate. ●● One person cannot be the cause of another person’s violence. 4. Inform their neighbors and landlord if batterer is not allowed near ●● They are not alone. the residence. ●● Pushing, shoving, slapping are acts of crime. ●● While conflict is inevitable, violence is a choice. ●● The batterer is responsible and needs help. ●● They are not bad. ●● Substance abuse does not minimize the crime. ●● Domestic violence is a crime.

Conclusion Domestic violence is a crime of power and control that encompasses Reasons why victims do not leave their batterers have to do with low physical, psychological and emotional abuse. Medical expenses as a self esteem, economic dependency, no education or job skills, and fear result of domestic violence cost approximately 3 to 5 million dollars of death. a year and effects between 2 and 4 million women, although men are Mental health practitioners have an obligation to screen clients for battered as well. Domestic violence seriously impacts children and domestic violence as part of their information gathering. There are contributes to the number of children in/out of home care. several recommendations mental health practitioners can make to their Victims of domestic violence exhibit various psychological signs of clients if domestic violence is not reported. abuse, in addition to physical signs. Some include mental health and National Domestic Violence Hotline eating disorders, suicide and suicidal ideation. 1-800-799-7233 (SAFE) TDD 1-800-787-3224

Bibliography ŠŠ American Bar Association of Domestic Violence ŠŠ Jones, Meresa, “Advanced Domestic Violence Training, The Learning Institute, ŠŠ Appel AE, Holden GW, The co-occurrence of spouse and physical child abuse: a Children’s Home Society of Florida, Orlando, Florida, 2005. review and appraisal. Journal of Family Psychology 1998;12:578-99 ŠŠ Coker, AL, Davis KE, Arias I, Desai S, Sanderson M, Brandt HM, Physical and ŠŠ Batterer Intervention Services Coalition mental health effects of intimate partner violence for men and women. American ŠŠ Domestic Violence Intervention Center, http://dvic.org/Myths-and-Facts-about- Journal of preventive Medicine, 20002;23(4):260-8. Domestic- Violence. php, [email protected] ŠŠ Kantor GK, Jasinski Jl, Dynamics and risk factors in partner violence. ŠŠ Duluth-model.org, Minnesota Program Development, Inc. ŠŠ MedlinePlus, hjttp://www.nlm.nih.gov/medlineplus/print/news/fullstory_28963.html ŠŠ Family Violence Prevention Fund, http://endabuse.org ŠŠ Minnesota Program Development, Inc., www.deluth-model.org/wheels.html. ŠŠ Fleury, RE, Sullivan, CM, Bybee DI, When ending the relationship does not end the ŠŠ National Violence Against Women Survey, pub #: NCJ183781, Department of Justice, violence. Women’s experiences of violence by former partners. Violence Against Washington DC, 2000 Women, 2000;6 1363-83 ŠŠ National Coalition against Domestic Violence, http://www.ncady.org

SocialWork.EliteCME.com Page 26 DOMESTIC VIOLENCE Final Examination Questions Select the best answer for each question and proceed to SocialWork.EliteCME.com to complete your final examination.

1. Each year between 2 million and ____ women are battered, and 6. Domestic violence victims stay in the abusive relationship 2,000 of these battered women will die of their injuries. because: a. 2.5 million. a. Their batterers are familiar to them. b. 3 million. b. For financial reasons. c. 4 million. c. Fear of physical harm or death to self or others. d. 7 million. d. All of the above.

2. It is not unusual for battered victims to separate and reunite with 7. Victims may need to seek legal counsel and/or obtain an Injunction their batterers ______times before leaving permanently. They for Protection Order. Mental health professionals should advise leave through divorce or through death. their clients that with the Order of Protection, they should call the a. Two to three. police if: b. Three to four. a. Their batterer apologizes. c. Six to seven. b. Their batterer goes to a bar. d. Nine to ten. c. Their batterer engages in another relationship. d. Their batterer violates the order. 3. Outward physical indicators or signs are often present within a domestic violence relationship, other signs in victims that reflect 8. If clients are contemplating reuniting with their batterer, strongly battering include all of the following EXCEPT: encourage: a. Depression and other mental and emotional disorders. a. Batterer intervention programs. b. Becoming welfare recipients. b. Victim of violence support group participation. c. Lowered intelligence. c. On-going information gathering through books and local d. Difficulty maintaining employment. domestic violence prevention and intervention. d. All of the above. 4. Domestic violence victims may: a. Provide false information. 9. The Equality Wheel identifies non-violent behavior that b. Seem unconcerned about injuries. emphasizes relationship: c. Be overly protective of the batterer. a. Negotiation and fairness. d. All of the above. b. Minimizing, denying and blaming. c. Using children. 5. In general, there are ___ phases associated with a cycle of d. All of the above. domestic violence. a. Two. 10. When victims have separated from their batterer ask them to: b. Three. a. Change their window and door locks as soon as possible. c. Five. b. Continue to discuss safety plans with their children. d. Six. c. Inform their children’s school or day care about who is permitted to pick them up, and when appropriate. d. All of the above.

SWFL02DV17

Page 27 SocialWork.EliteCME.com Chapter 4: Florida Law for the Social Worker, Mental Health Counselor, and Marriage and Family Therapist 3 CE Hours

By: Deborah Converse, MA, NBCT, Clinical Ed.

Learning objectives ŠŠ Explain the difference between definition and duties of the clinical ŠŠ List and define five infractions from the Florida Statutes on social worker and certified master social worker. discipline in the three professions covered in this course and the ŠŠ List and discuss the 2013 additions to Florida Statutes that inform penalties for each. social work, mental health counseling and marriage and family ŠŠ Identify five characteristics of quality parenting listed in the therapy with dependent children. Florida Statutes and give five examples of social work, counseling ŠŠ Define four elements in the Florida Statute that direct the practice and therapy practice to promote quality parenting. of clinical social work. ŠŠ List and discuss four duties of the social worker, mental health ŠŠ Identify six areas of practice included in the Florida Statute counselor and marriage and family therapist within the Nancy C. definition of marriage and family therapy. Detert Common Sense and Compassion Independent Living Act. ŠŠ Explain six duties listed in the Florida Statute definition of mental ŠŠ Under the Procedures and Jurisdiction section of the Independent health counseling. Living Act, identify three actions the court may take and explain ŠŠ Compare and contrast the services of the marriage and family the circumstances to warrant that action. therapist, mental health counselor and social worker. ŠŠ Describe five situations listed in the Florida Statutes that indicate ŠŠ Identify five social work, mental health counseling and marriage the need for disclosure of information related to “duty to warn,” and family therapy services included in the legislative intent of the and explain five strategies to address these in practice. Florida Mental Health Act. ŠŠ List and explain five potential liability issues inherent in the use of ŠŠ Identify and discuss three key elements in the statutes for the Right technology for long- distance therapy and supervision. to Individual Dignity statute. ŠŠ Identify the AAMFT, NASW, and AMHCA guidelines for information ŠŠ According to Florida Statutes, identify and give three examples of disclosure for “duty to warn,” and compare and contrast them to the social work, counselor and therapist collaboration in the service Florida Statutes. delivery for Exceptional Student Education. ŠŠ Compare and contrast the Florida Statutes and the HIPAA Privacy ŠŠ Define the goals of the Quality of Treatment statute and three Rule on the use of technology and give three examples from each. methods identified to meet those goals. ŠŠ List the guidelines from the AAMFT, NASW and AMHCA codes of ethics on the use of technology in service delivery and as compared to the directives in the Florida Statutes. Introduction The Florida Statutes are state laws that are arranged by titles, chapters, The increasing use of electronics in conducting services and supervision, parts, and sections. They are considered permanent, but are reviewed which includes transmitting information using technology, requires the and updated annually and may be amended, altered, or repealed. practitioner to stay current on changes in Florida law and the Code of Two significant laws were passed in 2013 that affect social work, Ethics of the governing boards that inform their profession. Legislators counseling and therapy with dependent children that will take effect in in Florida and the national governing boards are in the process of writing 2014. The profession and practice of social work, mental health counseling laws to keep pace with new technology systems and policies to protect and marriage and family therapy is addressed in numerous Florida law clients’ privacy. statutes, and many updates to the laws involve the inclusion of social Florida law must be studied carefully as it relates to the national workers, mental health counselors, and marriage and family therapists boards that govern these professions including NASW, AMHCA, for implementation. This mirrors the recent passage of the Affordable AAMFT and the ASWB ethics codes and the HIPAA Privacy Rule. The Care Act, which defines the important role of these professions in the professions of social work, mental health counseling and marriage and Accountable Care Organization and the HEARTH Act Continuum of Care. family therapy in Florida are governed by a wide range of statutes that Because the statutes may be updated each year, they should be cover practice in schools, nursing homes, homeless shelters, outreach reviewed annually, which is easily done because they are arranged in communities, agencies for individuals with disabilities, hospice by subject and year. It is important to check the date when a new agencies, mental health and rehab facilities, public, private, charitable statute goes into effect because it may necessitate changes in policies, and non-profit organizations. procedures, practice and service delivery. Social workers, mental health counselors and marriage and family therapists In the past, liability cases have revolved around confidentiality, practice in their area of competency, and in some cases there are a number dual relationship boundary issues, and information storage and of statutes that apply to their work. Multiple statutes govern the practice transmission. Many ethical violations resulting in liability cases of these professions and their agency supervisors who direct staff as they against social workers, counselors and therapists relate to boundary carry out their duties in administration, education, and support. The statutes issues involving sexual misconduct. inform the way the administrators manage funds and resources for the agency, and their work as advocates and community health team members.

SocialWork.EliteCME.com Page 28 Title XXXII: Regulation of Professions and Occupations Chapter 491: Clinical Counseling, and Psychotherapy Services The greatest number of Florida Statutes related to social work, mental procedures, or use of electroconvulsive therapy. In addition, health counseling and marriage and family therapy are found in this this definition shall not be construed to permit any person title and chapter. licensed, provisionally licensed, registered, or certified 491.003 Definitions. —As used in this chapter: pursuant to this chapter to describe or label any test, report, or (1) “Board” means the Board of Clinical Social Work, Marriage and procedure as “psychological,” except to relate specifically to Family Therapy, and Mental Health Counseling. the definition of practice authorized in this subsection. (2) “Clinical social worker” means a person licensed under this (d) The definition of “clinical social work” contained in this chapter to practice clinical social work. subsection includes all services offered directly to the (3) “Clinical social work experience” is defined as a period during general public or through organizations, whether public which the applicant provides clinical social work services, including or private, and applies whether payment is requested or assessment, diagnosis, treatment, and evaluation of clients; provided received for services rendered. that at least 50 percent of the hours worked consist of providing (8) The “practice of marriage and family therapy” is defined as the use psychotherapy and counseling services directly to clients. of scientific and applied marriage and family theories, methods, (4) “Department” means the Department of Health. and procedures for the purpose of describing, evaluating, and (5) “Marriage and family therapist” means a person licensed under modifying marital, family, and individual behavior, within the this chapter to practice marriage and family therapy. context of marital and family systems, including the context of (6) “Mental health counselor” means a person licensed under this marital formation and dissolution, and is based on marriage and chapter to practice mental health counseling. family systems theory, marriage and family development, human (7) The “practice of clinical social work” is defined as the use of development, normal and abnormal behavior, psychopathology, scientific and applied knowledge, theories, and methods for human sexuality, psychotherapeutic and marriage and family the purpose of describing, preventing, evaluating, and treating therapy theories and techniques. The practice of marriage and individual, couple, marital, family, or group behavior, based on family therapy includes methods of a psychological nature used the person-in-situation perspective of psychosocial development, to evaluate, assess, diagnose, treat, and prevent emotional and normal and abnormal behavior, psychopathology, unconscious mental disorders or dysfunctions (whether cognitive, affective, or motivation, interpersonal relationships, environmental stress, behavioral), sexual dysfunction, behavioral disorders, alcoholism, differential assessment, differential planning, and data gathering. and substance abuse. The practice of marriage and family therapy The purpose of such services is the prevention and treatment of includes, but is not limited to, marriage and family therapy, undesired behavior and enhancement of mental health. The practice psychotherapy, including behavioral family therapy, hypnotherapy, of clinical social work includes methods of a psychological nature and sex therapy. The practice of marriage and family therapy used to evaluate, assess, diagnose, treat, and prevent emotional and also includes counseling, behavior modification, consultation, mental disorders and dysfunctions (whether cognitive, affective, or client-centered advocacy, crisis intervention, and the provision of behavioral), sexual dysfunction, behavioral disorders, alcoholism, needed information and education to clients, when using methods and substance abuse. The practice of clinical social work includes, of a psychological nature to evaluate, assess, diagnose, treat, and but is not limited to, psychotherapy, hypnotherapy, and sex therapy. prevent emotional and mental disorders and dysfunctions (whether The practice of clinical social work also includes counseling, cognitive, affective, or behavioral), sexual dysfunction, behavioral behavior modification, consultation, client-centered advocacy, disorders, alcoholism, or substance abuse. The practice of marriage crisis intervention, and the provision of needed information and and family therapy may also include clinical research into more education to clients, when using methods of a psychological nature effective psychotherapeutic modalities for the treatment and to evaluate, assess, diagnose, treat, and prevent emotional and prevention of such conditions. mental disorders and dysfunctions (whether cognitive, affective, or (a) Marriage and family therapy may be rendered to individuals, behavioral), sexual dysfunction, behavioral disorders, alcoholism, including individuals affected by termination of marriage, or substance abuse. The practice of clinical social work may also to couples, whether married or unmarried, to families, or to include clinical research into more effective psychotherapeutic groups. modalities for the treatment and prevention of such conditions. (b) The use of specific methods, techniques, or modalities within (a) Clinical social work may be rendered to individuals, the practice of marriage and family therapy is restricted to including individuals affected by the termination of marriage and family therapists appropriately trained in the marriage, and to marriages, couples, families, groups, use of such methods, techniques, or modalities. organizations, and communities. (c) The terms “diagnose” and “treat,” as used in this chapter, (b) The use of specific methods, techniques, or modalities within when considered in isolation or in conjunction with any the practice of clinical social work is restricted to clinical provision of the rules of the board, shall not be construed social workers appropriately trained in the use of such to permit the performance of any act which marriage and methods, techniques, or modalities. family therapists are not educated and trained to perform, (c) The terms “diagnose” and “treat,” as used in this chapter, including, but not limited to, admitting persons to hospitals when considered in isolation or in conjunction with any for treatment of the foregoing conditions, treating persons provision of the rules of the board, shall not be construed in hospitals without medical supervision, prescribing to permit the performance of any act which clinical social medicinal drugs as defined in chapter 465, authorizing clinical workers are not educated and trained to perform, including, laboratory procedures pursuant to chapter 483, or radiological but not limited to, admitting persons to hospitals for treatment procedures, or use of electroconvulsive therapy. In addition, of the foregoing conditions, treating persons in hospitals this definition shall not be construed to permit any person without medical supervision, prescribing medicinal drugs licensed, provisionally licensed, registered, or certified as defined in chapter 465, authorizing clinical laboratory pursuant to this chapter to describe or label any test, report, or procedures pursuant to chapter 483, or radiological procedure as “psychological,” except to relate specifically to the definition of practice authorized in this subsection.

Page 29 SocialWork.EliteCME.com (d) The definition of “marriage and family therapy” contained (12) “Provisional mental health counselor licensee” means a person in this subsection includes all services offered directly to provisionally licensed under this chapter to provide mental health the general public or through organizations, whether public counseling services under supervision. or private, and applies whether payment is requested or (13) “Psychotherapist” means a clinical social worker, marriage and received for services rendered. family therapist, or mental health counselor licensed pursuant to (9) The “practice of mental health counseling” is defined as the use this chapter. of scientific and applied behavioral science theories, methods, and (14) “Registered clinical social worker intern” means a person techniques for the purpose of describing, preventing, and treating registered under this chapter who is completing the postgraduate undesired behavior and enhancing mental health and human clinical social work experience requirement specified in s. development and is based on the person-in-situation perspectives 491.005(1)(c). derived from research and theory in personality, family, group, and (15) “Registered marriage and family therapist intern” means a person organizational dynamics and development, career planning, cultural registered under this chapter who is completing the post-master’s diversity, human growth and development, human sexuality, clinical experience requirement specified in s. 491.005(3)(c). normal and abnormal behavior, psychopathology, psychotherapy, (16) “Registered mental health counselor intern” means a person and rehabilitation. The practice of mental health counseling registered under this chapter who is completing the post-master’s includes methods of a psychological nature used to evaluate, assess, clinical experience requirement specified in s. 491.005(4)(c). diagnose, and treat emotional and mental dysfunctions or disorders (17) “Social worker” means a person who has a bachelor’s, master’s, (whether cognitive, affective, or behavioral), behavioral disorders, or doctoral degree in social work. interpersonal relationships, sexual dysfunction, alcoholism, and 491.004 Board of Clinical Social Work, Marriage and Family substance abuse. The practice of mental health counseling includes, Therapy, and Mental Health Counseling. — but is not limited to, psychotherapy, hypnotherapy, and sex therapy. (1) There is created within the department the Board of Clinical The practice of mental health counseling also includes counseling, Social Work, Marriage and Family Therapy, and Mental Health behavior modification, consultation, client-centered advocacy, Counseling composed of nine members appointed by the crisis intervention, and the provision of needed information and Governor and confirmed by the Senate. education to clients, when using methods of a psychological nature (2) to evaluate, assess, diagnose, treat, and prevent emotional and (a) Six members of the board shall be persons licensed under mental disorders and dysfunctions (whether cognitive, affective, or this chapter as follows: behavioral), behavioral disorders, sexual dysfunction, alcoholism, 1. Two members shall be licensed practicing clinical or substance abuse. The practice of mental health counseling may social workers. also include clinical research into more effective psychotherapeutic 2. Two members shall be licensed practicing marriage and modalities for the treatment and prevention of such conditions. family therapists. (a) Mental health counseling may be rendered to individuals, 3. Two members shall be licensed practicing mental health including individuals affected by the termination of counselors. marriage, and to couples, families, groups, organizations, (b) Three members shall be citizens of the state who are not and communities. and have never been licensed in a mental health-related (b) The use of specific methods, techniques, or modalities within profession and who are in no way connected with the the practice of mental health counseling is restricted to practice of any such profession. mental health counselors appropriately trained in the use of (3) No later than January 1, 1988, the Governor shall appoint nine such methods, techniques, or modalities. members of the board as follows: (c) The terms “diagnose” and “treat,” as used in this chapter, (a) Three members for terms of 2 years each. when considered in isolation or in conjunction with any (b) Three members for terms of 3 years each. provision of the rules of the board, shall not be construed (c) Three members for terms of 4 years each. to permit the performance of any act which mental health (4) As the terms of the initial members expire, the Governor shall counselors are not educated and trained to perform, including, appoint successors for terms of 4 years; and those members shall but not limited to, admitting persons to hospitals for treatment serve until their successors are appointed. of the foregoing conditions, treating persons in hospitals (5) The board shall adopt rules pursuant to ss. 120.536(1) and 120.54 without medical supervision, prescribing medicinal drugs to implement and enforce the provisions of this chapter. as defined in chapter 465, authorizing clinical laboratory (6) All applicable provisions of chapter 456 relating to activities of procedures pursuant to chapter 483, or radiological regulatory boards shall apply to the board. procedures, or use of electroconvulsive therapy. In addition, this definition shall not be construed to permit any person 491.005 Licensure by examination. — licensed, provisionally licensed, registered, or certified (1) Clinical social work. —Upon verification of documentation pursuant to this chapter to describe or label any test, report, or and payment of a fee not to exceed $200, as set by board rule, procedure as “psychological,” except to relate specifically to plus the actual per applicant cost to the department for purchase the definition of practice authorized in this subsection. of the examination from the American Association of State (d) The definition of “mental health counseling” contained in Social Worker’s Boards or a similar national organization, the this subsection includes all services offered directly to the department shall issue a license as a clinical social worker to an general public or through organizations, whether public applicant who the board certifies: or private, and applies whether payment is requested or (a) Has made application therefore and paid the appropriate fee. received for services rendered. (b) (10) “Provisional clinical social worker licensee” means a person 1. Has received a doctoral degree in social work from a provisionally licensed under this chapter to provide clinical social graduate school of social work which at the time the work services under supervision. applicant graduated was accredited by an accrediting (11) “Provisional marriage and family therapist licensee” means agency recognized by the United States Department of a person provisionally licensed under this chapter to provide Education or has received a master’s degree in social marriage and family therapy services under supervision. work from a graduate school of social work which at the time the applicant graduated:

SocialWork.EliteCME.com Page 30 a. Was accredited by the Council on Social Work be considered toward completion of education requirements Education; for licensure unless an official of the graduate program b. Was accredited by the Canadian Association of certifies in writing on the graduate school’s stationery that a Schools of Social Work; or specific course, which students enrolled in the same graduate c. Has been determined to be a program equivalent program were ordinarily required to complete at the graduate to programs approved by the Council on Social level, was waived or exempted based on completion of a Work Education by the Foreign Equivalency similar course at the baccalaureate level. If this condition is Determination Service of the Council on Social met, the board shall apply the baccalaureate course named Work Education. An applicant who graduated toward the education requirements. from a program at a university or college outside (b) An applicant from a master’s or doctoral program in social of the United States or Canada must present work which did not emphasize direct patient or client documentation of the equivalency determination services may complete the clinical curriculum content from the council in order to qualify. requirement by returning to a graduate program accredited 2. The applicant’s graduate program must have by the Council on Social Work Education or the Canadian emphasized direct clinical patient or client health care Association of Schools of Social Work, or to a clinical social services, including, but not limited to, coursework in work graduate program with comparable standards, in order clinical social work, psychiatric social work, medical to complete the education requirements for examination. social work, social casework, psychotherapy, or group However, a maximum of 6 semester or 9 quarter hours of the therapy. The applicant’s graduate program must have clinical curriculum content requirement may be completed included all of the following coursework: by credit awarded for independent study coursework as a. A supervised field placement that was part of defined by board rule. the applicant’s advanced concentration in direct (3) Marriage and family therapy. —Upon verification of practice, during which the applicant provided documentation and payment of a fee not to exceed $200, as set by clinical services directly to clients. board rule, plus the actual cost to the department for the purchase b. Completion of 24 semester hours or 32 quarter of the examination from the Association of Marital and Family hours in theory of human behavior and practice Therapy Regulatory Board, or similar national organization, the methods as courses in clinically oriented department shall issue a license as a marriage and family therapist services, including a minimum of one course in to an applicant who the board certifies: psychopathology, and no more than one course (a) Has made application therefore and paid the appropriate fee. in research, taken in a school of social work (b) accredited or approved pursuant to subparagraph 1. 1. Has a minimum of a master’s degree with major emphasis 3. If the course title which appears on the applicant’s in marriage and family therapy, or a closely related field, transcript does not clearly identify the content of the and has completed all of the following requirements: coursework, the applicant shall be required to provide a. Thirty-six semester hours or 48 quarter hours additional documentation, including, but not limited to, a of graduate coursework, which must include a syllabus or catalog description published for the course. minimum of 3 semester hours or 4 quarter hours (c) Has had not less than 2 years of clinical social work experience, of graduate-level course credits in each of the which took place subsequent to completion of a graduate following nine areas: dynamics of marriage and degree in social work at an institution meeting the accreditation family systems; marriage therapy and counseling requirements of this section, under the supervision of a licensed theory and techniques; family therapy and clinical social worker or the equivalent who is a qualified counseling theory and techniques; individual supervisor as determined by the board. An individual who human development theories throughout the life intends to practice in Florida to satisfy clinical experience cycle; personality theory or general counseling requirements must register pursuant to s. 491.0045 prior to theory and techniques; psychopathology; human commencing practice. If the applicant’s graduate program sexuality theory and counseling techniques; was not a program which emphasized direct clinical patient or psychosocial theory; and substance abuse theory client health care services as described in subparagraph (b) 2., and counseling techniques. Courses in research, the supervised experience requirement must take place after the evaluation, appraisal, assessment, or testing applicant has completed a minimum of 15 semester hours or 22 theories and procedures; thesis or dissertation quarter hours of the coursework required. A doctoral internship work; or practicum, internships, or fieldwork may may be applied toward the clinical social work experience not be applied toward this requirement. requirement. The experience requirement may be met by work b. A minimum of one graduate-level course of 3 performed on or off the premises of the supervising clinical semester hours or 4 quarter hours in legal, ethical, social worker or the equivalent, provided the off-premises and professional standards issues in the practice work is not the independent private practice rendering of of marriage and family therapy or a course clinical social work that does not have a licensed mental health determined by the board to be equivalent. professional, as determined by the board, on the premises at the c. A minimum of one graduate-level course of 3 same time the intern is providing services. semester hours or 4 quarter hours in diagnosis, (d) Has passed a theory and practice examination provided by appraisal, assessment, and testing for individual the department for this purpose. or interpersonal disorder or dysfunction; and a (e) Has demonstrated, in a manner designated by rule of the minimum of one 3-semester-hour or 4-quarter- board, knowledge of the laws and rules governing the hour graduate-level course in behavioral research practice of clinical social work, marriage and family therapy, which focuses on the interpretation and application and mental health counseling. of research data as it applies to clinical practice. (2) Clinical social work. — Credit for thesis or dissertation work, practicum, (a) Notwithstanding the provisions of paragraph (1)(b), internships, or fieldwork may not be applied coursework which was taken at a baccalaureate level shall not toward this requirement.

Page 31 SocialWork.EliteCME.com d. A minimum of one supervised clinical practicum, the post-master’s level under the supervision of a licensed internship, or field experience in a marriage and marriage and family therapist with at least 5 years of family counseling setting, during which the student experience, or the equivalent, who is a qualified supervisor provided 180 direct client contact hours of marriage as determined by the board. An individual who intends and family therapy services under the supervision to practice in Florida to satisfy the clinical experience of an individual who met the requirements for requirements must register pursuant to s. 491.0045 prior to supervision under paragraph (c). This requirement commencing practice. If a graduate has a master’s degree may be met by a supervised practice experience with a major emphasis in marriage and family therapy or a which took place outside the academic arena, but closely related field that did not include all the coursework which is certified as equivalent to a graduate-level required under sub-subparagraphs (b) 1.a.-c., credit for the practicum or internship program which required post-master’s level clinical experience shall not commence a minimum of 180 direct client contact hours of until the applicant has completed a minimum of 10 of the marriage and family therapy services currently courses required under sub-subparagraphs (b)1.a. -c., as offered within an academic program of a college determined by the board, and at least 6 semester hours or 9 or university accredited by an accrediting agency quarter hours of the course credits must have been completed approved by the United States Department of in the area of marriage and family systems, theories, or Education, or an institution which is publicly techniques. Within the 3 years of required experience, the recognized as a member in good standing with applicant shall provide direct individual, group, or family the Association of Universities and Colleges of therapy and counseling, to include the following categories Canada or a training institution accredited by of cases: unmarried dyads, married couples, separating and the Commission on Accreditation for Marriage divorcing couples, and family groups including children. and Family Therapy Education recognized by A doctoral internship may be applied toward the clinical the United States Department of Education. experience requirement. The clinical experience requirement Certification shall be required from an official of may be met by work performed on or off the premises of the such college, university, or training institution. supervising marriage and family therapist or the equivalent, 2. If the course title which appears on the applicant’s provided the off-premises work is not the independent transcript does not clearly identify the content of the private practice rendering of marriage and family therapy coursework, the applicant shall be required to provide services that does not have a licensed mental health additional documentation, including, but not limited to, a professional, as determined by the board, on the premises at syllabus or catalog description published for the course. the same time the intern is providing services. (d) Has passed a theory and practice examination provided by The required master’s degree must have been received in the department for this purpose. an institution of higher education which at the time the (e) Has demonstrated, in a manner designated by rule of the applicant graduated was: fully accredited by a regional board, knowledge of the laws and rules governing the accrediting body recognized by the Commission on practice of clinical social work, marriage and family therapy, Recognition of Postsecondary Accreditation; publicly and mental health counseling. recognized as a member in good standing with the (f) For the purposes of dual licensure, the department shall Association of Universities and Colleges of Canada; license as a marriage and family therapist any person or an institution of higher education located outside who meets the requirements of s. 491.0057. Fees for dual the United States and Canada, which at the time the licensure shall not exceed those stated in this subsection. applicant was enrolled and at the time the applicant (4) Mental health counseling. —Upon verification of documentation graduated maintained a standard of training substantially and payment of a fee not to exceed $200, as set by board rule, equivalent to the standards of training of those institutions plus the actual per applicant cost to the department for purchase in the United States which are accredited by a regional of the examination from the Professional Examination Service accrediting body recognized by the Commission on for the National Academy of Certified Clinical Mental Health Recognition of Postsecondary Accreditation. Such Counselors or a similar national organization, the department foreign education and training must have been received shall issue a license as a mental health counselor to an applicant in an institution or program of higher education who the board certifies: officially recognized by the government of the country (a) Has made application therefore and paid the appropriate fee. in which it is located as an institution or program to (b) train students to practice as professional marriage and 1. Has a minimum of an earned master’s degree from family therapists or psychotherapists. The burden of a mental health counseling program accredited by establishing that the requirements of this provision have the Council for the Accreditation of Counseling and been met shall be upon the applicant, and the board shall Related Educational Programs that consists of at least require documentation, such as, but not limited to, an 60 semester hours or 80 quarter hours of clinical and evaluation by a foreign equivalency determination service, didactic instruction, including a course in human as evidence that the applicant’s graduate degree program sexuality and a course in substance abuse. If the and education were equivalent to an accredited program master’s degree is earned from a program related to in this country. An applicant with a master’s degree from the practice of mental health counseling that is not a program, which did not emphasize marriage and family accredited by the Council for the Accreditation of therapy, may complete the coursework requirement in a Counseling and Related Educational Programs, then training institution fully accredited by the Commission on the coursework and practicum, internship, or fieldwork Accreditation for Marriage and Family Therapy Education must consist of at least 60 semester hours or 80 quarter recognized by the United States Department of Education. hours and meet the following requirements: (c) Has had not less than 2 years of clinical experience during a. Thirty-three semester hours or 44 quarter hours which 50 percent of the applicant’s clients were receiving of graduate coursework, which must include a marriage and family therapy services, which must be at minimum of 3 semester hours or 4 quarter hours of

SocialWork.EliteCME.com Page 32 graduate-level coursework in each of the following (c) Has had not less than 2 years of clinical experience in mental 11 content areas: counseling theories and practice; health counseling, which must be at the post-master’s level human growth and development; diagnosis and under the supervision of a licensed mental health counselor treatment of psychopathology; human sexuality; or the equivalent who is a qualified supervisor as determined group theories and practice; individual evaluation by the board. An individual who intends to practice in and assessment; career and lifestyle assessment; Florida to satisfy the clinical experience requirements research and program evaluation; social and must register pursuant to s. 491.0045 prior to commencing cultural foundations; counseling in community practice. If a graduate has a master’s degree with a major settings; and substance abuse. Courses in research, related to the practice of mental health counseling that thesis or dissertation work, practicum, internships, did not include all the coursework required under sub- or fieldwork may not be applied toward this subparagraphs (b)1.a.-b., credit for the post-master’s level requirement. clinical experience shall not commence until the applicant b. A minimum of 3 semester hours or 4 quarter hours has completed a minimum of seven of the courses required of graduate-level coursework in legal, ethical, and under sub-subparagraphs (b)1.a.-b., as determined by the professional standards issues in the practice of board, one of which must be a course in psychopathology or mental health counseling, which includes goals, abnormal psychology. A doctoral internship may be applied objectives, and practices of professional counseling toward the clinical experience requirement. The clinical organizations, codes of ethics, legal considerations, experience requirement may be met by work performed standards of preparation, certifications and on or off the premises of the supervising mental health licensing, and the role identity and professional counselor or the equivalent, provided the off-premises work obligations of mental health counselors. Courses is not the independent private practice rendering of services in research, thesis or dissertation work, practicum, that does not have a licensed mental health professional, as internships, or fieldwork may not be applied toward determined by the board, on the premises at the same time this requirement. the intern is providing services. c. The equivalent, as determined by the board, (d) Has passed a theory and practice examination provided by of at least 1,000 hours of university-sponsored the department for this purpose. supervised clinical practicum, internship, or field (e) Has demonstrated, in a manner designated by rule of the experience as required in the accrediting standards board, knowledge of the laws and rules governing the of the Council for Accreditation of Counseling practice of clinical social work, marriage and family therapy, and Related Educational Programs for mental and mental health counseling. health counseling programs. This experience may (5) Internship. —An individual who is registered as an intern and not be used to satisfy the post-master’s clinical has satisfied all of the educational requirements for the profession experience requirement. for which the applicant seeks licensure shall be certified as having 2. If the course title which appears on the applicant’s met the educational requirements for licensure under this section. transcript does not clearly identify the content of the (6) Rules—The board may adopt rules necessary to implement any coursework, the applicant shall be required to provide education or experience requirement of this section for licensure additional documentation, including, but not limited to, a as a clinical social worker, marriage and family therapist, or syllabus or catalog description published for the course. mental health counselor. Education and training in mental health counseling 491.009 Discipline. — must have been received in an institution of higher (1) The following acts constitute grounds for denial of a license or education which at the time the applicant graduated disciplinary action, as specified in s. 456.072(2): was: fully accredited by a regional accrediting body (a) Attempting to obtain, obtaining, or renewing a license, recognized by the Commission on Recognition of registration, or certificate under this chapter by bribery or Postsecondary Accreditation; publicly recognized as fraudulent misrepresentation or through an error of the board a member in good standing with the Association of or the department. Universities and Colleges of Canada; or an institution of (b) Having a license, registration, or certificate to practice a higher education located outside the United States and comparable profession revoked, suspended, or otherwise Canada, which at the time the applicant was enrolled acted against, including the denial of certification or and at the time the applicant graduated maintained licensure by another state, territory, or country. a standard of training substantially equivalent to the (c) Being convicted or found guilty of, regardless of standards of training of those institutions in the United adjudication, or having entered a plea of nolo contendere States which are accredited by a regional accrediting to, a crime in any jurisdiction which directly relates to the body recognized by the Commission on Recognition of practice of his or her profession or the ability to practice Postsecondary Accreditation. Such foreign education his or her profession. However, in the case of a plea of nolo and training must have been received in an institution contendere, the board shall allow the person who is the or program of higher education officially recognized by subject of the disciplinary proceeding to present evidence the government of the country in which it is located as in mitigation relevant to the underlying charges and an institution or program to train students to practice as circumstances surrounding the plea. mental health counselors. The burden of establishing (d) False, deceptive, or misleading advertising or obtaining a fee that the requirements of this provision have been or other thing of value on the representation that beneficial met shall be upon the applicant, and the board shall results from any treatment will be guaranteed. require documentation, such as, but not limited to, an (e) Advertising, practicing, or attempting to practice under a evaluation by a foreign equivalency determination name other than one’s own. service, as evidence that the applicant’s graduate degree (f) Maintaining a professional association with any person who program and education were equivalent to an accredited the applicant, licensee, registered intern, or certificate holder program in this country.

Page 33 SocialWork.EliteCME.com knows, or has reason to believe, is in violation of this chapter enforcement in the circuit court in the circuit in which the or of a rule of the department or the board. licensee, registered intern, or certificate holder resides or (g) Knowingly aiding, assisting, procuring, or advising any does business. The licensee, registered intern, or certificate nonlicensed, nonregistered, or noncertified person to hold holder against whom the petition is filed shall not be himself or herself out as licensed, registered, or certified named or identified by initials in any public court records under this chapter. or documents, and the proceedings shall be closed to the (h) Failing to perform any statutory or legal obligation placed public. The department shall be entitled to the summary upon a person licensed, registered, or certified under this procedure provided in s. 51.011. A licensee, registered chapter. intern, or certificate holder affected under this paragraph (i) Willfully making or filing a false report or record; failing shall at reasonable intervals be afforded an opportunity to file a report or record required by state or federal law; to demonstrate that he or she can resume the competent willfully impeding or obstructing the filing of a report or practice for which he or she is licensed, registered, or record; or inducing another person to make or file a false certified with reasonable skill and safety to patients. report or record or to impede or obstruct the filing of a report (q) Performing any treatment or prescribing any therapy which, or record. Such report or record includes only a report or by the prevailing standards of the mental health professions record, which requires the signature of a person licensed, in the community, would constitute experimentation on registered, or certified under this chapter. human subjects, without first obtaining full, informed, and (j) Paying a kickback, rebate, bonus, or other remuneration written consent. for receiving a patient or client, or receiving a kickback, (r) Failing to meet the minimum standards of performance in rebate, bonus, or other remuneration for referring a patient professional activities when measured against generally or client to another provider of mental health care services prevailing peer performance, including the undertaking or to a provider of health care services or goods; referring of activities for which the licensee, registered intern, or a patient or client to oneself for services on a fee-paid basis certificate holder is not qualified by training or experience. when those services are already being paid for by some other (s) Delegating professional responsibilities to a person whom public or private entity; or entering into a reciprocal referral the licensee, registered intern, or certificate holder knows or agreement. has reason to know is not qualified by training or experience (k) Committing any act upon a patient or client which would to perform such responsibilities. constitute sexual battery or which would constitute sexual (t) Violating a rule relating to the regulation of the profession misconduct as defined pursuant to s. 491.0111. or a lawful order of the department or the board previously (l) Making misleading, deceptive, untrue, or fraudulent entered in a disciplinary hearing. representations in the practice of any profession licensed, (u) Failure of the licensee, registered intern, or certificate holder registered, or certified under this chapter. to maintain in confidence a communication made by a (m) Soliciting patients or clients personally, or through an agent, patient or client in the context of such services, except as through the use of fraud, intimidation, undue influence, or a provided in s. 491.0147. form of overreaching or vexatious conduct. (v) Making public statements which are derived from test data, (n) Failing to make available to a patient or client, upon client contacts, or behavioral research and which identify or written request, copies of tests, reports, or documents in the damage research subjects or clients. possession or under the control of the licensee, registered (w) Violating any provision of this chapter or chapter 456, or any intern, or certificate holder which have been prepared for and rules adopted pursuant thereto. paid for by the patient or client. (2) The department, or, in the case of psychologists, the board, may (o) Failing to respond within 30 days to a written enter an order denying licensure or imposing any of the penalties communication from the department or the board concerning in s. 456.072(2) against any applicant for licensure or licensee any investigation by the department or the board, or failing who is found guilty of violating any provision of subsection (1) of to make available any relevant records with respect to any this section or who is found guilty of violating any provision of s. investigation about the licensee’s, registered intern’s, or 456.072(1). certificate holder’s conduct or background. 491.002 Intent. —The Legislature finds that as society becomes (p) Being unable to practice the profession for which he or she increasingly complex, emotional survival is equal in importance to is licensed, registered, or certified under this chapter with physical survival. Therefore, in order to preserve the health, safety, reasonable skill or competence as a result of any mental and welfare of the public, the Legislature must provide privileged or physical condition or by reason of illness; drunkenness; communication for members of the public or those acting on their behalf or excessive use of drugs, narcotics, chemicals, or any to encourage needed or desired counseling, clinical and psychotherapy other substance. In enforcing this paragraph, upon a services, or certain other services of a psychological nature to be finding by the State Surgeon General, the State Surgeon sought out. The Legislature further finds that, since such services assist General’s designee, or the board that probable cause exists the public primarily with emotional survival, which in turn affects to believe that the licensee, registered intern, or certificate physical and psychophysical survival, the practice of clinical social holder is unable to practice the profession because of work, marriage and family therapy, and mental health counseling by the reasons stated in this paragraph, the department shall persons not qualified to practice such professions presents a danger have the authority to compel a licensee, registered intern, to public health, safety, and welfare. The Legislature finds that, to or certificate holder to submit to a mental or physical further secure the health, safety, and welfare of the public and also to examination by psychologists, physicians, or other licensees encourage professional cooperation among all qualified professionals, under this chapter, designated by the department or board. the Legislature must assist the public in making informed choices of If the licensee, registered intern, or certificate holder refuses such services by establishing minimum qualifications for entering into to comply with such order, the department’s order directing and remaining in the respective professions. the examination may be enforced by filing a petition for

SocialWork.EliteCME.com Page 34 491.004 Board of Clinical Social Work, Marriage and Family of s. 491.005 that are in effect through December 31, 2000, Therapy, and Mental Health Counseling. — will have met the educational requirements for licensure for the (1) There is created within the department the Board of Clinical profession for which he or she has applied. Social Work, Marriage and Family Therapy, and Mental Health (5) Individuals who have commenced the experience requirement as Counseling composed of nine members appointed by the specified in s. 491.005(1)(c), (3)(c), or (4)(c) but failed to register Governor and confirmed by the Senate. as required by subsection (1) shall register with the department (2) before January 1, 2000. Individuals who fail to comply with this (a) Six members of the board shall be persons licensed under subsection shall not be granted a license, and any time spent by this chapter as follows: the individual completing the experience requirement prior to 1. Two members shall be licensed practicing clinical registering as an intern shall not count toward completion of such social workers. requirement. 2. Two members shall be licensed practicing marriage and 491.0057 Dual licensure as a marriage and family therapist. —The family therapists. department shall license as a marriage and family therapist any person 3. Two members shall be licensed practicing mental health who demonstrates to the board that he or she: counselors. (1) Holds a valid, active license as a psychologist under chapter 490 (b) Three members shall be citizens of the state who are not or as a clinical social worker or mental health counselor under and have never been licensed in a mental health-related this chapter, or is certified under s.464.012 as an advanced profession and who are in no way connected with the registered nurse practitioner who has been determined by the practice of any such profession. Board of Nursing as a specialist in psychiatric mental health. (3) No later than January 1, 1988, the Governor shall appoint nine (2) Has held a valid, active license for at least 3 years. members of the board as follows: (3) Has passed the examination provided by the department for (a) Three members for terms of 2 years each. marriage and family therapy. (b) Three members for terms of 3 years each. (c) Three members for terms of 4 years each. 491.006 Licensure or certification by endorsement. — (4) As the terms of the initial members expire, the Governor shall (1) The department shall license or grant a certificate to a person in appoint successors for terms of 4 years; and those members shall a profession regulated by this chapter who, upon applying to the serve until their successors are appointed. department and remitting the appropriate fee, demonstrates to the (5) The board shall adopt rules pursuant to ss. 120.536(1) and 120.54 board that he or she: to implement and enforce the provisions of this chapter. (a) Has demonstrated, in a manner designated by rule of the (6) All applicable provisions of chapter 456 relating to activities of board, knowledge of the laws and rules governing the regulatory boards shall apply to the board. practice of clinical social work, marriage and family therapy, (7) The board shall maintain its official headquarters in the City of and mental health counseling. Tallahassee. (b) 1. Holds an active valid license to practice and has 491.0045 Intern registration; requirements. — actively practiced the profession for which licensure (1) Effective January 1, 1998, an individual who intends to practice is applied in another state for 3 of the last 5 years in Florida to satisfy the postgraduate or post-master’s level immediately preceding licensure. experience requirements, as specified in s.491.005 (1)(c), (3)(c), 2. Meets the education requirements of this chapter for the or (4)(c), must register as an intern in the profession for which he profession for which licensure is applied. or she is seeking licensure prior to commencing the post-master’s 3. Has passed a substantially equivalent licensing experience requirement or an individual who intends to satisfy examination in another state or has passed the licensure part of the required graduate-level practicum, internship, or examination in this state in the profession for which the field experience, outside the academic arena for any profession, applicant seeks licensure. must register as an intern in the profession for which he or she is 4. Holds a license in good standing, is not under investigation seeking licensure prior to commencing the practicum, internship, for an act that would constitute a violation of this chapter, or field experience. and has not been found to have committed any act that (2) The department shall register as a clinical social worker intern, would constitute a violation of this chapter. The fees paid marriage and family therapist intern, or mental health counselor by any applicant for certification as a master social worker intern each applicant who the board certifies has: under this section are nonrefundable. (a) Completed the application form and remitted a (2) The department shall not issue a license or certificate by nonrefundable application fee not to exceed $200, as set by endorsement to any applicant who is under investigation in this or board rule; another jurisdiction for an act which would constitute a violation (b) of this chapter until such time as the investigation is complete, at 1. Completed the education requirements as specified in which time the provisions of s. 491.009 shall apply. s. 491.005(1)(c), (3)(c), or (4)(c) for the profession for which he or she is applying for licensure, if needed; and 491.0065 Requirement for instruction on HIV and AIDS. —The 2. Submitted an acceptable supervision plan, as board shall require, as a condition of granting a license under this determined by the board, for meeting the practicum, chapter, that an applicant making initial application for licensure internship, or field work required for licensure that was complete an education course acceptable to the board on human not satisfied in his or her graduate program. immunodeficiency virus and acquired immune deficiency syndrome. (c) Identified a qualified supervisor. An applicant who has not taken a course at the time of licensure shall, (3) An individual registered under this section must remain under upon submission of an affidavit showing good cause, be allowed 6 supervision until he or she is in receipt of a license or a letter months to complete this requirement. from the department stating that he or she is licensed to practice 491.007 Renewal of license, registration, or certificate. — the profession for which he or she applied. (1) The board or department shall prescribe by rule a method for the (4) An individual who has applied for intern registration on or before biennial renewal of licenses or certificates at a fee set by rule, not December 31, 2001, and has satisfied the education requirements to exceed $250.

Page 35 SocialWork.EliteCME.com (2) Each applicant for renewal shall present satisfactory evidence (b) “Therapeutic deception” means a representation to the client that, in the period since the license or certificate was issued, the that sexual contact by the psychotherapist is consistent with applicant has completed continuing education requirements set or part of the treatment of the client. by rule of the board or department. Not more than 25 classroom (c) “Sexual misconduct” means the oral, anal, or vaginal hours of continuing education per year shall be required. A penetration of another by, or contact with, the sexual organ certified master social worker is exempt from the continuing of another or the anal or vaginal penetration of another by education requirements for the first renewal of the certificate. any object. (3) The board or department shall prescribe by rule a method for the (d) “Client” means a person to whom the services of a biennial renewal of an intern registration at a fee set by rule, not psychotherapist are provided. to exceed $100. 491.012 Violations; penalty; injunction. — 491.008 Inactive status; reactivation of licenses; fees. — (1) It is unlawful and a violation of this chapter for any person to: (1) Inactive status is the licensure status that results when a licensee (a) Use the following titles or any combination thereof, unless has applied to be placed on inactive status and has paid a $50 fee she or he holds a valid, active license as a clinical social to the department. worker issued pursuant to this chapter: (a) An inactive license may be renewed biennially for $50 per 1. “Licensed clinical social worker.” biennium. 2. “Clinical social worker.” (b) An inactive license may be reactivated by submitting an 3. “Licensed social worker.” application to the department, completing the continuing 4. “Psychiatric social worker.” education requirements, complying with any background 5. “Psychosocial worker.” investigation required, complying with other requirements (b) Use the following titles or any combination thereof, unless prescribed by the board, and paying a $50 reactivation she or he holds a valid, active license as a marriage and fee plus the current biennial renewal fee at the time of family therapist issued pursuant to this chapter: reactivation. 1. “Licensed marriage and family therapist.” (2) The board may adopt rules relating to inactive licenses and the 2. “Marriage and family therapist.” reactivation of licenses. 3. “Marriage counselor.” 4. “Marriage consultant.” 491.0085 Continuing education and laws and rules courses; 5. “Family therapist.” approval of providers, programs, and courses; proof of 6. “Family counselor.” completion. — 7. “Family consultant.” (1) Continuing education providers, programs, and courses and (c) Use the following titles or any combination thereof, unless laws and rules courses and their providers and programs shall be she or he holds a valid, active license as a mental health approved by the department or the board. counselor issued pursuant to this chapter: (2) The department or the board has the authority to set a fee not 1. “Licensed mental health counselor.” to exceed $200 for each applicant who applies for or renews 2. “Mental health counselor.” provider status. Such fees shall be deposited into the Medical 3. “Mental health therapist.” Quality Assurance Trust Fund. 4. “Mental health consultant.” (3) Proof of completion of the required number of hours of (d) Use the terms psychotherapist, sex therapist, or juvenile continuing education and completion of the laws and rules sexual offender therapist unless such person is licensed course shall be submitted to the department or the board in the pursuant to this chapter or chapter 490, or is certified under manner and time specified by rule and on forms provided by the s. 464.012 as an advanced registered nurse practitioner who department or the board. has been determined by the Board of Nursing as a specialist (4) The department or the board shall adopt rules and guidelines to in psychiatric mental health and the use of such terms is administer and enforce the provisions of this section. within the scope of her or his practice based on education, 491.0111 Sexual misconduct. —Sexual misconduct by any person training, and licensure. licensed or certified under this chapter, in the practice of her or his (e) Present as her or his own the clinical social work, marriage profession, is prohibited. Sexual misconduct shall be defined by rule. and family therapy, or mental health counseling license of 491.0112 Sexual misconduct by a psychotherapist; penalties. — another. (1) Any psychotherapist who commits sexual misconduct with a (f) Give false or forged evidence to the board or a member client, or former client when the professional relationship was thereof for the purpose of obtaining a license. terminated primarily for the purpose of engaging in sexual (g) Use or attempt to use a license issued pursuant to this contact, commits a felony of the third degree, punishable as chapter which has been revoked or is under suspension. provided in s. 775.082 or s. 775.083; however, a second or (h) Knowingly conceal information relative to violations of this subsequent offense is a felony of the second degree, punishable as chapter. provided in s. 775.082, s. 775.083, or s. 775.084. (i) Practice clinical social work in this state for compensation, (2) Any psychotherapist who violates subsection (1) by means of unless the person holds a valid, active license to practice therapeutic deception commits a felony of the second degree clinical social work issued pursuant to this chapter or is an punishable as provided in s. 775.082, s. 775.083, or s. 775.084. intern registered pursuant to s. 491.0045. (3) The giving of consent by the client to any such act shall not be a (j) Practice marriage and family therapy in this state for defense to these offenses. compensation, unless the person holds a valid, active license (4) For the purposes of this section: to practice marriage and family therapy issued pursuant to (a) The term “psychotherapist” means any person licensed this chapter or is an intern registered pursuant to s. 491.0045. pursuant to chapter 458, chapter 459, part I of chapter (k) Practice mental health counseling in this state for 464, chapter 490, or chapter 491, or any other person compensation, unless the person holds a valid, active license who provides or purports to provide treatment, diagnosis, to practice mental health counseling issued pursuant to this assessment, evaluation, or counseling of mental or emotional chapter or is an intern registered pursuant to s. 491.0045. illness, symptom, or condition.

SocialWork.EliteCME.com Page 36 (l) Use the following titles or any combination thereof, unless compensation is received by him or her, or when such activities he or she holds a valid registration as an intern issued are performed, with or without compensation, by a person for or pursuant to this chapter: under the auspices or sponsorship, individually or in conjunction 1. “Registered clinical social worker intern.” with others, of an established and legally cognizable church, 2. “Registered marriage and family therapist intern.” denomination, or sect, and when the person rendering service 3. “Registered mental health counselor intern.” remains accountable to the established authority thereof. (m) Use the following titles or any combination thereof, unless (4) No person shall be required to be licensed, provisionally licensed, he or she holds a valid provisional license issued pursuant to registered, or certified under this chapter who: this chapter: (a) Is a salaried employee of a government agency; a 1. “Provisional clinical social worker licensee.” developmental disability facility or program; a mental health, 2. “Provisional marriage and family therapist licensee.” alcohol, or drug abuse facility operating under chapter 3. “Provisional mental health counselor licensee.” 393, chapter 394, or chapter 397; the statewide child care (n) Effective October 1, 2000, practice juvenile sexual offender resource and referral network operating under s. 1002.92; therapy in this state, as the practice is defined in s.491.0144 , a child-placing or child-caring agency licensed pursuant to for compensation, unless the person holds an active license chapter 409; a domestic violence center certified pursuant to issued under this chapter and meets the requirements to chapter 39; an accredited academic institution; or a research practice juvenile sexual offender therapy. An unlicensed institution, if such employee is performing duties for which he person may be employed by a program operated by or or she was trained and hired solely within the confines of such under contract with the Department of Juvenile Justice or agency, facility, or institution, so long as the employee is not the Department of Children and Families if the program held out to the public as a clinical social worker, mental health employs a professional who is licensed under chapter 458, counselor, or marriage and family therapist. chapter 459, s. 490.0145, or s. 491.0144 who manages or (b) Is a salaried employee of a private, nonprofit organization supervises the treatment services. providing counseling services to children, youth, and (2) It is unlawful and a violation of this chapter for any person to families, if such services are provided for no charge, if describe her or his services using the following terms or any such employee is performing duties for which he or she derivative thereof, unless such person holds a valid, active license was trained and hired, so long as the employee is not held under this chapter or chapter 490, or is certified under s.464.012 out to the public as a clinical social worker, mental health as an advanced registered nurse practitioner who has been counselor, or marriage and family therapist. determined by the Board of Nursing as a specialist in psychiatric (c) Is a student providing services regulated under this chapter mental health and the use of such terms is within the scope of her who is pursuing a course of study which leads to a degree in or his practice based on education, training, and licensure: a profession regulated by this chapter, is providing services (a) “Psychotherapy.” in a training setting, provided such services and associated (b) “Sex therapy.” activities constitute part of a supervised course of study, and (c) “Sex counseling.” is designated by the title “student intern.” (d) “Clinical social work.” (d) Is not a resident of this state but offers services in this state, (e) “Psychiatric social work.” provided: (f) “Marriage and family therapy.” 1. Such services are performed for no more than 15 days (g) “Marriage and family counseling.” in any calendar year; and (h) “Marriage counseling.” 2. Such nonresident is licensed or certified to practice the (i) “Family counseling.” services provided by a state or territory of the United (j) “Mental health counseling.” States or by a foreign country or province. (3) Any person who violates any provision of subsection (1) or (5) No provision of this chapter shall be construed to limit the subsection (2) commits a misdemeanor of the first degree, practice of any individual who solely engages in behavior punishable as provided in s. 775.082 or s. 775.083. analysis so long as he or she does not hold himself or herself (4) The department may institute appropriate judicial proceedings to out to the public as possessing a license issued pursuant to this enjoin violation of this section. chapter or use a title protected by this chapter. 491.014 Exemptions. — (6) Nothing in subsections (2)-(4) shall exempt any person from the (1) No provision of this chapter shall be construed to limit the practice provisions of s. 491.012(1)(a)-(c), (l), and (m). of physicians licensed pursuant to chapter 458 or chapter 459, or (7) Except as stipulated by the board, the exemptions contained in psychologists licensed pursuant to chapter 490, so long as they do not this section do not apply to any person licensed under this chapter unlawfully hold themselves out to the public as possessing a license, whose license has been suspended or revoked by the board or provisional license, registration, or certificate issued pursuant to another jurisdiction. this chapter or use a professional title protected by this chapter. (8) Nothing in this section shall be construed to exempt a person from (2) No provision of this chapter shall be construed to limit the meeting the minimum standards of performance in professional practice of nursing, school psychology, or psychology, or to activities when measured against generally prevailing peer prevent qualified members of other professions from doing work performance, including the undertaking of activities for which the of a nature consistent with their training and licensure, so long person is not qualified by training or experience. as they do not hold themselves out to the public as possessing 491.0141 Practice of hypnosis. —A person licensed under this a license, provisional license, registration, or certificate issued chapter who is qualified as determined by the board may practice pursuant to this chapter or use a title protected by this chapter. hypnosis as defined in s. 485.003(1). The provisions of this chapter (3) No provision of this chapter shall be construed to limit the may not be interpreted to limit or affect the right of any person performance of activities of a rabbi, priest, minister, or member qualified pursuant to chapter 485 to practice hypnosis pursuant to of the clergy of any religious denomination or sect, or use of the that chapter or to practice hypnosis for nontherapeutic purposes, so terms “Christian counselor” or “Christian clinical counselor” long as such person does not hold herself or himself out to the public when the activities are within the scope of the performance as possessing a license issued pursuant to this chapter or use a title of his or her regular or specialized ministerial duties and no protected by this chapter.

Page 37 SocialWork.EliteCME.com 491.0143 Practice of sex therapy. —Only a person licensed by or physical sexual activity outside the scope of the professional this chapter who meets the qualifications set by the board may hold practice of such health care profession. Sexual misconduct in the herself or himself out as a sex therapist. The board shall define these practice of a health care profession is prohibited. qualifications by rule. In establishing these qualifications, the board (2) Each board within the jurisdiction of the department, or the may refer to the sexual disorder and sexual dysfunction sections of the department if there is no board, shall refuse to admit a candidate most current edition of the Diagnostic and Statistical Manual of the to any examination and refuse to issue a license, certificate, or American Psychiatric Association or other relevant publications. registration to any applicant if the candidate or applicant has: 491.0144 The practice of juvenile sexual offender therapy. —Only (a) Had any license, certificate, or registration to practice any a person licensed by this chapter who meets the qualifications set by profession or occupation revoked or surrendered based the board may hold himself or herself out as a juvenile sexual offender on a violation of sexual misconduct in the practice of that therapist, except as provided in s. 490.0145. The board shall determine profession under the laws of any other state or any territory these qualifications. The board shall require training and coursework in or possession of the United States and has not had that the specific areas of juvenile sexual offender behaviors, treatments, and license, certificate, or registration reinstated by the licensing related issues. In establishing these qualifications, the board may refer authority of the jurisdiction that revoked the license, to the sexual disorder and dysfunction sections of the most current certificate, or registration; or edition of the Diagnostic and Statistical Manual of the American (b) Committed any act in any other state or any territory or Psychiatric Association, Association for the Treatment of Sexual possession of the United States, which if committed in this Abusers Practitioner’s Handbook, or other relevant publications. state would constitute sexual misconduct. 456.063 Sexual misconduct; disqualification for license, certificate, For purposes of this subsection, a licensing authority’s or registration. acceptance of a candidate’s relinquishment of a license (1) Sexual misconduct in the practice of a health care profession which is offered in response to or in anticipation of the filing means violation of the professional relationship through which of administrative charges against the candidate’s license the health care practitioner uses such relationship to engage or constitutes the surrender of the license. attempt to engage the patient or client, or an immediate family (3) Licensed health care practitioners shall report allegations of member, guardian, or representative of the patient or client in, or sexual misconduct to the department, regardless of the practice to induce or attempt to induce such person to engage in, verbal setting in which the alleged sexual misconduct occurred.

A case study There are additional rules in the Florida Statutes that explain in detail began having dreams about the therapist and started bringing him the more obvious violations of sexual misconduct that no one could gifts and food to have an “office picnic.” ever misconstrue as ethical. This case study is included because it After the dreams continued, the client realized the therapy was not is a Florida court decisions concerning the boundary issue of sexual addressing her needs, and her insurance was about to change and would misconduct brought against a licensed clinical social worker. This no longer cover the sessions. Though 40 sessions had occurred and 31 case applies the elements of the Florida Statutes that extend to mental invoices were billed, only 17 sessions were covered by case notes. health counselors and marriage and family therapists as well. The violations are clear and obviously unethical when reviewing the facts The client terminated the sessions, but later received services from of the case. Here is the summary from the 2004 court action: another therapist and the concepts of counter-transference and attachment were discussed. The first therapist continued to call the The client, a female and second grade teacher in Bradenton, began client at home to restart the sessions and he invited her to lunch. The working with the LCSW on an issue with her teenage son’s aggressive client refused, and when he called her again on New Year’s Day, she behavior after the parent’s divorce. The respondent (LCSW) saw the told him to never call again and he complied. son for a few sessions and them began to focus on the mother. The client brought a case against the LCSW based on Section At first the therapist sat in a chair at a normal distance, but after a 120.57(1), which covers court cases to protect consumers, and Statute few sessions, suggested they sit closer on the same couch. He asked 491 on sexual misconduct from the 2004 Florida Statutes. The Florida her some questions about her father, which caused her to become Court decided in favor of the client because the respondent did not emotional and cry, and he put his arm around her to console her. provide the minimum requirements for performance as a LCSW, As the sessions continued over several months, he suggested that committed numerous boundary issues related to the sexual misconduct, she lay down on the couch with her head on a pillow on his lap. He violated rules for case documentation, record maintenance and billing, referred to this as play therapy, which involved stroking her hair, and misused the method of play therapy which was not warranted at and eventually led to kissing her forehead. From there they began all in this case. and ended each session with a hug, and at one point he tried to kiss He was put on probation for five years, fined $2,000 dollars, ordered her on the neck but she resisted physically and verbally. to complete 100 hours of in-service training on boundary issues, Over a period of two years and 40 sessions, some four months apart, and required to practice and submit reports carefully scrutinized by the client began to have feelings for the social worker. The therapist a supervisor. The entire case can be reviewed online, and the Web began to ask about the client’s divorce and confided that he had address is included in the reference section for Case no. 2000- problems in his marriage and might consider a separation. The client 02291, DOH-04-1112.

491.0144 The practice of juvenile sexual offender therapy. —Only related issues. In establishing these qualifications, the board may refer a person licensed by this chapter who meets the qualifications set by to the sexual disorder and dysfunction sections of the most current the board may hold himself or herself out as a juvenile sexual offender edition of the Diagnostic and Statistical Manual of the American therapist, except as provided in s. 490.0145. The board shall determine Psychiatric Association, Association for the Treatment of Sexual these qualifications. The board shall require training and coursework in Abusers Practitioner’s Handbook, or other relevant publications. the specific areas of juvenile sexual offender behaviors, treatments, and

SocialWork.EliteCME.com Page 38 491.0145 Certified master social worker. —The department may 491.0148 Records. —Each psychotherapist who provides services as certify an applicant for a designation as a certified master social defined in this chapter shall maintain records. The board may adopt worker upon the following conditions: rules defining the minimum requirements for records and reports, (1) The applicant completes an application to be provided by the including content, length of time records shall be maintained, and department and pays a nonrefundable fee not to exceed $250 to transfer of either the records or a report of such records to a subsequent be established by rule of the department. The department must treating practitioner or other individual with written consent of the receive the completed application at least 60 days before the date client or clients. of the examination in order for the applicant to qualify to take the 491.0149 Display of license; use of professional title on scheduled exam. promotional materials. — (2) The applicant submits proof satisfactory to the department that (1) the applicant has received a doctoral degree in social work, or (a) A person licensed under this chapter as a clinical social a master’s degree with a major emphasis or specialty in clinical worker, marriage and family therapist, or mental health practice or administration, including, but not limited to, agency counselor, or certified as a master social worker shall administration and supervision, program planning and evaluation, conspicuously display the valid license issued by the staff development, research, community organization, community department or a true copy thereof at each location at which services, social planning, and human service advocacy. Doctoral the licensee practices his or her profession. degrees must have been received from a graduate school of social (b) work, which at the time the applicant was enrolled and graduated 1. A licensed clinical social worker shall include the was accredited by an accrediting agency approved by the United words “licensed clinical social worker” or the letters States Department of Education. Master’s degrees must have been “LCSW” on all promotional materials, including received from a graduate school of social work which at the time cards, brochures, stationery, advertisements, and signs, the applicant was enrolled and graduated was accredited by the naming the licensee. Council on Social Work Education or the Canadian Association of 2. A licensed marriage and family therapist shall include Schools of Social Work or by one that meets comparable standards. the words “licensed marriage and family therapist” (3) The applicant has had at least 3 years’ experience, as defined by or the letters “LMFT” on all promotional materials, rule, including, but not limited to, clinical services or administrative including cards, brochures, stationery, advertisements, activities as defined in subsection (2), 2 years of which must be at and signs, naming the licensee. the post-master’s level under the supervision of a person who meets 3. A licensed mental health counselor shall include the the education and experience requirements for certification as a words “licensed mental health counselor” or the letters certified master social worker, as defined by rule, or licensure as a “LMHC” on all promotional materials, including clinical social worker under this chapter. A doctoral internship may cards, brochures, stationery, advertisements, and signs, be applied toward the supervision requirement. naming the licensee. (4) Any person who holds a master’s degree in social work from (2) institutions outside the United States may apply to the department (a) A person registered under this chapter as a clinical social for certification if the academic training in social work has been worker intern, marriage and family therapist intern, or evaluated as equivalent to a degree from a school accredited by the mental health counselor intern shall conspicuously display Council on Social Work Education. Any such person shall submit the valid registration issued by the department or a true copy a copy of the academic training from the Foreign Equivalency thereof at each location at which the registered intern is Determination Service of the Council on Social Work Education. completing the experience requirements. (5) The applicant has passed an examination required by the (b) A registered clinical social worker intern shall include the department for this purpose. The nonrefundable fee for such words “registered clinical social worker intern,” a registered examination may not exceed $250 as set by department rule. marriage and family therapist intern shall include the words (6) Nothing in this chapter shall be construed to authorize a certified “registered marriage and family therapist intern,” and a master social worker to provide clinical social work services. registered mental health counselor intern shall include the 491.0147 Confidentiality and privileged communications. —Any words “registered mental health counselor intern” on all communication between any person licensed or certified under this promotional materials, including cards, brochures, stationery, chapter and her or his patient or client shall be confidential. This advertisements, and signs, naming the registered intern. secrecy may be waived under the following conditions: (3) (1) When the person licensed or certified under this chapter is a party (a) A person provisionally licensed under this chapter as a defendant to a civil, criminal, or disciplinary action arising from provisional clinical social worker licensee, provisional a complaint filed by the patient or client, in which case the waiver marriage and family therapist licensee, or provisional mental shall be limited to that action. health counselor licensee shall conspicuously display the (2) When the patient or client agrees to the waiver, in writing, or, valid provisional license issued by the department or a when more than one person in a family is receiving therapy, when true copy thereof at each location at which the provisional each family member agrees to the waiver, in writing. licensee is providing services. (3) When, in the clinical judgment of the person licensed or certified (b) A provisional clinical social worker licensee shall include under this chapter, there is a clear and immediate probability the words “provisional clinical social worker licensee,” a of physical harm to the patient or client, to other individuals, provisional marriage and family therapist licensee shall or to society and the person licensed or certified under this include the words “provisional marriage and family therapist chapter communicates the information only to the potential licensee,” and a provisional mental health counselor licensee victim, appropriate family member, or law enforcement or other shall include the words “provisional mental health counselor appropriate authorities. There shall be no liability on the part of, licensee” on all promotional materials, including cards, and no cause of action of any nature shall arise against, a person brochures, stationery, advertisements, and signs, naming the licensed or certified under this chapter for the disclosure of provisional licensee. otherwise confidential communications under this subsection.

Page 39 SocialWork.EliteCME.com 491.015 Duties of the department as to certified master social (a) Possesses at least a bachelor’s or master’s degree in social workers. — work from a social work program accredited by or from (1) All functions reserved to boards under chapter 456 shall be an institution that is an active candidate for accreditation exercised by the department with respect to the regulation of as a social work program by the Council on Social Work certified master social workers and in a manner consistent with Education; or the exercise of its regulatory functions. (b) Completes, at a university or college outside the United (2) The department shall adopt rules to implement and enforce States or Canada, a social work program determined by the provisions relating to certified master social workers. Foreign Equivalency Determination Service of the Council 491.016 Social work; use of title. — on Social Work Education to be equivalent to a bachelor’s or (1) A social worker is not authorized to conduct clinical social work master’s degree in social work. without obtaining and possessing a license or certification issued (3) This section does not apply to: pursuant to this chapter. (a) A person who, prior to July 1, 2008, used the title “social (2) It shall be a misdemeanor of the first degree, punishable as worker” in his or her employment. provided in s. 775.082 or s. 775.083, for a person, for or without (b) Employees providing social work services under compensation, to hold himself or herself out to the public as a administrative supervision in long-term care facilities social worker either directly or through a governmental or private licensed by the Agency for Health Care Administration. organization, entity, or agency unless that person: (4) The department shall adopt rules pursuant to ss. 120.536(1) and 120.54 to implement and enforce this section.

Collaboration and service delivery for exceptional student education Language addressing the collaboration of every individual who has (h) Marriage and family therapists as licensed under Chapter 491. a vested interest in the best interest of the child—including licensed (2) The collaboration of public and private instructional personnel professionals and the students’ family—has been added to Chapter shall be designed to enhance but not supplant the school district’s 2013-236. The following items are portions of this legislation, which responsibilities under the Individuals with Disabilities Education are applicable to school social workers. Act (IDEA). The school as the local education agency shall provide CHAPTER 2013-236 therapy services to meet the expectations provided in federal Committee Substitute for Senate Bill No. 1108 law and regulations and state statutes and rules. Collaboration of An act relating to exceptional student education; amending s. 1002.20, public and private instructional personnel will work to promote F.S.; prohibiting certain actions with respect to parent meetings with educational progress and assist students in acquiring essential school district personnel; providing requirements for meetings relating skills, including, but not limited to, readiness for pursuit of higher to exceptional student education and related services. education goals or employment. Where applicable, public and private instructional personnel shall undertake collaborative Section 5. programming. Coordination of services and plans between a public Section 1003.572, Florida Statutes, is created to read: school and private instructional personnel is encouraged to avoid 1003.572 Collaboration of public and private instructional duplication or conflicting services or plans. personnel. — (3) Private instructional personnel who are hired or contracted by (1) As used in this section, the term “private instructional personnel” parents to collaborate with public instructional personnel must means: be permitted to observe the student in the educational setting, (a) Individuals certified under s. 393.17 or licensed under collaborate with instructional personnel in the educational setting, chapter 490 or chapter 491 for applied behavior analysis and provide services in the educational setting according to the services as defined in ss. 627.6686 and 641.31098. following requirements: (b) Speech-language pathologists licensed under s. 468.1185. (a) The student’s public instructional personnel and principal (c) Occupational therapists licensed under part III of chapter 468. consent to the time and place. (d) Physical therapists licensed under chapter 486. (b) The private instructional personnel satisfy the requirements (e) Psychologists licensed under chapter 490. of s. 1012.32 or s. 1012.321. (f) Clinical social workers licensed under chapter 491. (4) The provision of private instructional personnel by a parent does (g) Mental health counselors as licensed under chapter 491. not constitute a waiver of the student’s or parent’s right to a free and appropriate public education under IDEA.

A word of caution Each county in Florida develops its own policies and procedures to The majority of legal action in Florida schools involves a student with implement the IDEA Act in its county. Some counties interpret the an IEP or 504 plan, so practitioners must be sure they receive training federal law differently than others, especially if the county adopts the to be knowledgeable about the responsibilities and procedures that structure of “school-based management.” IDEA may be interpreted must be followed to provide services to these student and parents. differently at each school, which makes it even more confusing if the There will be district level administrators in each county who can practitioner is responsible for more than one school. deliver this training in conjunction with the practitioner’s agency All practitioners who provide service to a number of students in administrators. Furthermore, all school-related staff members and Exceptional Education Programs must be familiar with the IEP or 504 contractors working with the young client must study Florida’s IDEA Plan that governs the student’s educational program in that school as Act in its entirety. compared to the Florida Statutes.

SocialWork.EliteCME.com Page 40 Title XXIX: Public Health Chapter 394 Mental Health Florida Mental Health Act This is a comprehensive law that covers all aspects of mental health (10) “Facility” means any hospital, community facility, public or services in the state of Florida and is summarized as follows: private facility, or receiving or treatment facility providing for the 394.453 Legislative intent. —It is the intent of the Legislature to evaluation, diagnosis, care, treatment, training, or hospitalization authorize and direct the Department of Children and Family Services of persons who appear to have a mental illness or have been to evaluate, research, plan, and recommend to the Governor and the diagnosed as having a mental illness. “Facility” does not include Legislature programs designed to reduce the occurrence, severity, any program or entity licensed pursuant to chapter 400 or chapter duration, and disabling aspects of mental, emotional, and behavioral 429. disorders. It is the intent of the Legislature that treatment programs for (11) “Guardian” means the natural guardian of a minor, or a person such disorders shall include, but not be limited to, comprehensive health, appointed by a court to act on behalf of a ward’s person if the social, educational, and rehabilitative services to persons requiring ward is a minor or has been adjudicated incapacitated. intensive short-term and continued treatment in order to encourage (12) “Guardian advocate” means a person appointed by a court to them to assume responsibility for their treatment and recovery. It is make decisions regarding mental health treatment on behalf of a intended that such persons be provided with emergency service and patient who has been found incompetent to consent to treatment temporary detention for evaluation when required; that they be admitted pursuant to this part. The guardian advocate may be granted to treatment facilities on a voluntary basis when extended or continuing specific additional powers by written order of the court, as care is needed and unavailable in the community; that involuntary provided in this part. placement be provided only when expert evaluation determines that (13) “Hospital” means a facility as defined in s. 395.002 and licensed it is necessary; that any involuntary treatment or examination be under chapter 395 and part II of chapter 408. accomplished in a setting which is clinically appropriate and most likely (14) “Incapacitated” means that a person has been adjudicated to facilitate the person’s return to the community as soon as possible; incapacitated pursuant to part V of chapter 744 and a guardian of and that individual dignity and human rights be guaranteed to all persons the person has been appointed. who are admitted to mental health facilities or who are being held (15) “Incompetent to consent to treatment” means that a person’s under s. 394.463. It is the further intent of the Legislature that the least judgment is so affected by his or her mental illness that the person restrictive means of intervention be employed based on the individual lacks the capacity to make a well-reasoned, willful, and knowing needs of each person, within the scope of available services. It is the decision concerning his or her medical or mental health treatment. policy of this state that the use of restraint and seclusion on clients is (16) “Law enforcement officer” means a law enforcement officer as justified only as an emergency safety measure to be used in response to defined in s. 943.10. imminent danger to the client or others. It is, therefore, the intent of the (17) “Mental health overlay program” means a mobile service which Legislature to achieve an ongoing reduction in the use of restraint and provides an independent examination for voluntary admissions seclusion in programs and facilities serving persons with mental illness. and a range of supplemental onsite services to persons with a mental illness in a residential setting such as a nursing home, 394.455 Definitions. —As used in this part, unless the context clearly assisted living facility, adult family-care home, or nonresidential requires otherwise, the term: setting such as an adult day care center. Independent (1) “Administrator” means the chief administrative officer of a examinations provided pursuant to this part through a mental receiving or treatment facility or his or her designee. health overlay program must only be provided under contract (2) “Clinical psychologist” means a psychologist as defined in s. with the department for this service or be attached to a public 490.003(7) with 3 years of postdoctoral experience in the practice receiving facility that is also a community mental health center. of clinical psychology, inclusive of the experience required for (18) “Mental illness” means an impairment of the mental or emotional licensure, or a psychologist employed by a facility operated by processes that exercise conscious control of one’s actions or of the United States Department of Veterans Affairs that qualifies as the ability to perceive or understand reality, which impairment a receiving or treatment facility under this part. substantially interferes with the person’s ability to meet the (3) “Clinical record” means all parts of the record required to ordinary demands of living. For the purposes of this part, the term be maintained and includes all medical records, progress does not include a developmental disability as defined in chapter notes, charts, and admission and discharge data, and all other 393, intoxication, or conditions manifested only by antisocial information recorded by a facility which pertains to the patient’s behavior or substance abuse impairment. hospitalization or treatment. (19) “Mobile crisis response service” means a nonresidential crisis (4) “Clinical social worker” means a person licensed to practice as service attached to a public receiving facility and available 24 defined under chapter 491. hours a day, 7 days a week, through which immediate intensive (5) “Community facility” means any community service provider assessments and interventions, including screening for admission contracting with the department to furnish substance abuse or into a receiving facility, take place for the purpose of identifying mental health services under part IV of this chapter. appropriate treatment services. (6) “Community mental health center or clinic” means a publicly (20) “Patient” means any person who is held or accepted for mental funded, not-for-profit center which contracts with the department health treatment. for the provision of inpatient, outpatient, day treatment, or (21) “Physician” means a medical practitioner licensed under emergency services. chapter 458 or chapter 459 who has experience in the diagnosis (7) “Court,” unless otherwise specified, means the circuit court. and treatment of mental and nervous disorders or a physician (8) “Department” means the Department of Children and Family employed by a facility operated by the United States Department Services. of Veterans Affairs which qualifies as a receiving or treatment (9) “Express and informed consent” means consent voluntarily given facility under this part. in writing, by a competent person, after sufficient explanation and (22) “Private facility” means any hospital or facility operated by a disclosure of the subject matter involved to enable the person to for-profit or not-for-profit corporation or association that provides make a knowing and willful decision without any element of force, mental health services and is not a public facility. fraud, deceit, duress, or other form of constraint or coercion.

Page 41 SocialWork.EliteCME.com (23) “Psychiatric nurse” means a registered nurse licensed under (33) “Service provider” means any public or private receiving facility, part I of chapter 464 who has a master’s degree or a doctorate an entity under contract with the Department of Children and in psychiatric nursing and 2 years of post-master’s clinical Family Services to provide mental health services, a clinical experience under the supervision of a physician. psychologist, a clinical social worker, a marriage and family (24) “Psychiatrist” means a medical practitioner licensed under therapist, a mental health counselor, a physician, a psychiatric chapter 458 or chapter 459 who has primarily diagnosed and nurse as defined in subsection (23), or a community mental health treated mental and nervous disorders for a period of not less than center or clinic as defined in this part. 3 years, inclusive of psychiatric residency. (34) “Involuntary examination” means an examination performed (25) “Public facility” means any facility that has contracted with under s. 394.463 to determine if an individual qualifies for the department to provide mental health services to all persons, involuntary inpatient treatment under s. 394.467(1) or involuntary regardless of their ability to pay, and is receiving state funds for outpatient treatment under s. 394.4655(1). such purpose. (35) “Involuntary placement” means either involuntary outpatient (26) “Receiving facility” means any public or private facility designated treatment pursuant to s. 394.4655 or involuntary inpatient by the department to receive and hold involuntary patients under treatment pursuant to s. 394.467. emergency conditions or for psychiatric evaluation and to provide (36) “Marriage and family therapist” means a person licensed as a short-term treatment. The term does not include a county jail. marriage and family therapist under chapter 491. (27) “Representative” means a person selected to receive notice of (37) “Mental health counselor” means a person licensed as a mental proceedings during the time a patient is held in or admitted to a health counselor under chapter 491. receiving or treatment facility. (38) “Electronic means” means a form of telecommunication (28) that requires all parties to maintain visual as well as audio (a) “Restraint” means a physical device, method, or drug used to communication. control behavior. A physical restraint is any manual method Note: Under the Affordable Care Act, social workers, mental health or physical or mechanical device, material, or equipment counselors and marriage and family therapists are named as valuable attached or adjacent to the individual’s body so that he or members of the accountable care organizations, so it is important for she cannot easily remove the restraint and which restricts them to be knowledgeable about the roles of other professionals on the freedom of movement or normal access to one’s body. health care team, be aware of the resources and facilities available in (b) A drug used as a restraint is a medication used to control the community, and serve as advocates to become involved in making the person’s behavior or to restrict his or her freedom of policy for quality health care. movement and is not part of the standard treatment regimen of a person with a diagnosed mental illness who is a client 394.457 Operation and administration. — of the department. Physically holding a person during a (1) Administration. —The Department of Children and Family procedure to forcibly administer psychotropic medication is Services is designated the “Mental Health Authority” of Florida. a physical restraint. The department and the Agency for Health Care Administration (c) Restraint does not include physical devices, such as shall exercise executive and administrative supervision over all orthopedically prescribed appliances, surgical dressings and mental health facilities, programs, and services. bandages, supportive body bands, or other physical holding (2) Responsibilities of the department. —The department is when necessary for routine physical examinations and tests; responsible for: or for purposes of orthopedic, surgical, or other similar (a) The planning, evaluation, and implementation of a complete medical treatment; when used to provide support for the and comprehensive statewide program of mental health, achievement of functional body position or proper balance; including community services, receiving and treatment or when used to protect a person from falling out of bed. facilities, child services, research, and training as authorized (29) “Seclusion” means the physical segregation of a person in any and approved by the Legislature, based on the annual fashion or involuntary isolation of a person in a room or area program budget of the department. The department is from which the person is prevented from leaving. The prevention also responsible for the coordination of efforts with other may be by physical barrier or by a staff member who is acting in a departments and divisions of the state government, county manner, or who is physically situated, so as to prevent the person and municipal governments, and private agencies concerned from leaving the room or area. For purposes of this chapter, the with and providing mental health services. It is responsible term does not mean isolation due to a person’s medical condition for establishing standards, providing technical assistance, and or symptoms. exercising supervision of mental health programs of, and the (30) “Secretary” means the Secretary of Children and Family Services. treatment of patients at, community facilities, other facilities (31) “Transfer evaluation” means the process, as approved by the for persons who have a mental illness, and any agency or appropriate district office of the department, whereby a person facility providing services to patients pursuant to this part. who is being considered for placement in a state treatment (b) The publication and distribution of an information handbook facility is first evaluated for appropriateness of admission to the to facilitate understanding of this part, the policies and facility by a community-based public receiving facility or by a procedures involved in the implementation of this part, and community mental health center or clinic if the public receiving the responsibilities of the various providers of services under facility is not a community mental health center or clinic. this part. It shall stimulate research by public and private (32) “Treatment facility” means any state-owned, state-operated, agencies, institutions of higher learning, and hospitals in the or state-supported hospital, center, or clinic designated by the interest of the elimination and amelioration of mental illness. department for extended treatment and hospitalization, beyond that (3) Power to contract. —The department may contract to provide, provided for by a receiving facility, of persons who have a mental and be provided with, services and facilities in order to carry out illness, including facilities of the United States Government, and its responsibilities under this part with the following agencies: any private facility designated by the department when rendering public and private hospitals; receiving and treatment facilities; such services to a person pursuant to the provisions of this part. clinics; laboratories; departments, divisions, and other units of state Patients treated in facilities of the United States Government shall government; the state colleges and universities; the community be solely those whose care is the responsibility of the United States colleges; private colleges and universities; counties, municipalities, Department of Veterans Affairs. and any other governmental unit, including facilities of the United

SocialWork.EliteCME.com Page 42 States Government; and any other public or private entity which (7) Payment for care of patients. —Fees and fee collections provides or needs facilities or services. Baker Act funds for for patients in state-owned, state-operated, or state-supported community inpatient, crisis stabilization, short-term residential treatment facilities shall be according to s. 402.33. treatment, and screening services must be allocated to each county 394.4572 Screening of mental health personnel. — pursuant to the department’s funding allocation methodology. (1) Notwithstanding s. 287.057(3)(e), contracts for community-based (a) The department and the Agency for Health Care Baker Act services for inpatient, crisis stabilization, short-term Administration shall require level 2 background screening residential treatment, and screening provided under this part, other pursuant to chapter 435 for mental health personnel. “Mental than those with other units of government, to be provided for the health personnel” includes all program directors, professional department must be awarded using competitive sealed bids if the clinicians, staff members, and volunteers working in public county commission of the county receiving the services makes or private mental health programs and facilities who have a request to the department’s district office by January 15 of the direct contact with individuals held for examination or contracting year. The district may not enter into a competitively bid admitted for mental health treatment. For purposes of this contract under this provision if such action will result in increases chapter, employment screening of mental health personnel of state or local expenditures for Baker Act services within the also includes, but is not limited to, employment screening as district. Contracts for these Baker Act services using competitive provided under chapter 435 and s. 408.809. sealed bids are effective for 3 years. The department shall adopt (b) Students in the health care professions who are interning in a rules establishing minimum standards for such contracted services mental health facility licensed under chapter 395, where the and facilities and shall make periodic audits and inspections to primary purpose of the facility is not the treatment of minors, assure that the contracted services are provided and meet the are exempt from the fingerprinting and screening requirements standards of the department. if they are under direct supervision in the actual physical (4) Application for and acceptance of gifts and grants. —The presence of a licensed health care professional. department may apply for and accept any funds, grants, gifts, (c) A volunteer who assists on an intermittent basis for less than or services made available to it by any agency or department of 10 hours per month is exempt from the fingerprinting and the Federal Government or any other public or private agency screening requirements if a person who meets the screening or individual in aid of mental health programs. All such moneys requirement of paragraph (a) is always present and has the shall be deposited in the State Treasury and shall be disbursed as volunteer within his or her line of sight. provided by law. (d) Mental health personnel working in a facility licensed under (5) Rules. — chapter 395 who work on an intermittent basis for less than 15 (a) The department shall adopt rules establishing forms and hours per week of direct, face-to-face contact with patients, procedures relating to the rights and privileges of patients and who are not listed on the Department of Law Enforcement seeking mental health treatment from facilities under this part. Career Offender Search or the Dru Sjodin National Sex (b) The department shall adopt rules necessary for the Offender Public Website, are exempt from the fingerprinting implementation and administration of the provisions of this and screening requirements, except that persons working in a part, and a program subject to the provisions of this part mental health facility where the primary purpose of the facility shall not be permitted to operate unless rules designed to is the mental health treatment of minors must be fingerprinted ensure the protection of the health, safety, and welfare of the and meet screening requirements. patients treated through such program have been adopted. (2) The department or the Agency for Health Care Administration Rules adopted under this subsection must include provisions may grant exemptions from disqualification as provided in governing the use of restraint and seclusion which are chapter 435. consistent with recognized best practices and professional judgment; prohibit inherently dangerous restraint or 394.4573 Continuity of care management system; measures of seclusion procedures; establish limitations on the use and performance; reports. duration of restraint and seclusion; establish measures to (1) For the purposes of this section: ensure the safety of program participants and staff during (a) “Case management” means those activities aimed at an incident of restraint or seclusion; establish procedures assessing client needs, planning services, linking the for staff to follow before, during, and after incidents of service system to a client, coordinating the various system restraint or seclusion; establish professional qualifications components, monitoring service delivery, and evaluating the of and training for staff who may order or be engaged in effect of service delivery. the use of restraint or seclusion; and establish mandatory (b) “Case manager” means an individual who works with reporting, data collection, and data dissemination procedures clients, and their families and significant others, to provide and requirements. Rules adopted under this subsection must case management. require that each instance of the use of restraint or seclusion (c) “Client manager” means an employee of the department be documented in the record of the patient. who is assigned to specific provider agencies and geographic (c) The department shall adopt rules establishing minimum areas to ensure that the full range of needed services is standards for services provided by a mental health overlay available to clients. program or a mobile crisis response service. (d) “Continuity of care management system” means a system (6) Personnel. — that assures, within available resources, that clients have (a) The department shall, by rule, establish minimum standards access to the full array of services within the mental health of education and experience for professional and technical services delivery system. personnel employed in mental health programs, including (2) The department is directed to implement a continuity of care members of a mobile crisis response service. management system for the provision of mental health care, (b) The department shall design and distribute appropriate through the provision of client and case management, including materials for the orientation and training of persons actively clients referred from state treatment facilities to community mental engaged in implementing the provisions of this part relating health facilities. Such system shall include a network of client to the involuntary examination and placement of persons managers and case managers throughout the state designed to: who are believed to have a mental illness.

Page 43 SocialWork.EliteCME.com (a) Reduce the possibility of a client’s admission or readmission (d) Require that any public receiving facility initiating a patient to a state treatment facility. transfer to a licensed hospital for acute care mental health (b) Provide for the creation or designation of an agency in each services not accessible through the public receiving facility county to provide single intake services for each person shall notify the hospital of such transfer and send all records seeking mental health services. Such agency shall provide relating to the emergency psychiatric or medical condition. information and referral services necessary to ensure that (3) The department is directed to develop and include in contracts clients receive the most appropriate and least restrictive with service providers measures of performance with regard to form of care, based on the individual needs of the person goals and objectives as specified in the state plan. Such measures seeking treatment. Such agency shall have a single telephone shall use, to the extent practical, existing data collection methods number, operating 24 hours per day, 7 days per week, where and reports and shall not require, as a result of this subsection, practicable, at a central location, where each client will have additional reports on the part of service providers. The department a central record. shall plan monitoring visits of community mental health facilities (c) Advocate on behalf of the client to ensure that all with other state, federal, and local governmental and private appropriate services are afforded to the client in a timely and agencies charged with monitoring such facilities. dignified manner.

Patient rights 394.459 Rights of patients. — is a minor, express and informed consent for admission or (1) Right to individual dignity.—It is the policy of this state that treatment shall also be requested from the patient’s guardian. the individual dignity of the patient shall be respected at all Express and informed consent for admission or treatment times and upon all occasions, including any occasion when the of a patient under 18 years of age shall be required from the patient is taken into custody, held, or transported. Procedures, patient’s guardian, unless the minor is seeking outpatient facilities, vehicles, and restraining devices utilized for criminals crisis intervention services under s. 394.4784. Express and or those accused of crime shall not be used in connection with informed consent for admission or treatment given by a persons who have a mental illness, except for the protection patient who is under 18 years of age shall not be a condition of the patient or others. Persons who have a mental illness of admission when the patient’s guardian gives express and but who are not charged with a criminal offense shall not be informed consent for the patient’s admission pursuant to s. detained or incarcerated in the jails of this state. A person who 394.463 or s. 394.467. is receiving treatment for mental illness shall not be deprived of 2. Before giving express and informed consent, the following any constitutional rights. However, if such a person is adjudicated information shall be provided and explained in plain incapacitated, his or her rights may be limited to the same extent language to the patient, or to the patient’s guardian if the the rights of any incapacitated person are limited by law. patient is 18 years of age or older and has been adjudicated (2) Right to treatment.— incapacitated, or to the patient’s guardian advocate if the (a) A person shall not be denied treatment for mental illness patient has been found to be incompetent to consent to and services shall not be delayed at a receiving or treatment treatment, or to both the patient and the guardian if the facility because of inability to pay. However, every patient is a minor: the reason for admission or treatment; reasonable effort to collect appropriate reimbursement for the proposed treatment; the purpose of the treatment to the cost of providing mental health services to persons be provided; the common risks, benefits, and side effects able to pay for services, including insurance or third-party thereof; the specific dosage range for the medication, when payments, shall be made by facilities providing services applicable; alternative treatment modalities; the approximate pursuant to this part. length of care; the potential effects of stopping treatment; (b) It is further the policy of the state that the least restrictive how treatment will be monitored; and that any consent given appropriate available treatment be utilized based on the for treatment may be revoked orally or in writing before or individual needs and best interests of the patient and during the treatment period by the patient or by a person consistent with optimum improvement of the patient’s who is legally authorized to make health care decisions on condition. behalf of the patient. (c) Each person who remains at a receiving or treatment facility (b) In the case of medical procedures requiring the use of a for more than 12 hours shall be given a physical examination general anesthetic or electroconvulsive treatment, and by a health practitioner authorized by law to give such prior to performing the procedure, express and informed examinations, within 24 hours after arrival at such facility. consent shall be obtained from the patient if the patient is (d) Every patient in a facility shall be afforded the opportunity legally competent, from the guardian of a minor patient, to participate in activities designed to enhance self-image from the guardian of a patient who has been adjudicated and the beneficial effects of other treatments, as determined incapacitated, or from the guardian advocate of the patient if by the facility. the guardian advocate has been given express court authority (e) Not more than 5 days after admission to a facility, each to consent to medical procedures or electroconvulsive patient shall have and receive an individualized treatment treatment as provided under s. 394.4598. plan in writing which the patient has had an opportunity to (c) When the department is the legal guardian of a patient, or assist in preparing and to review prior to its implementation. is the custodian of a patient whose physician is unwilling to The plan shall include a space for the patient’s comments. perform a medical procedure, including an electroconvulsive (3) Right to express and informed patient consent. — treatment, based solely on the patient’s consent and whose (a) 1. Each patient entering treatment shall be asked to give guardian or guardian advocate is unknown or unlocatable, express and informed consent for admission or treatment. the court shall hold a hearing to determine the medical If the patient has been adjudicated incapacitated or found necessity of the medical procedure. The patient shall be to be incompetent to consent to treatment, express and physically present, unless the patient’s medical condition informed consent to treatment shall be sought instead from precludes such presence, represented by counsel, and the patient’s guardian or guardian advocate. If the patient provided the right and opportunity to be confronted with,

SocialWork.EliteCME.com Page 44 and to cross-examine, all witnesses alleging the medical reasonable examination of such mail and may regulate the necessity of such procedure. In such proceedings, the burden disposition of such items or substances. of proof by clear and convincing evidence shall be on the (c) Each facility must permit immediate access to any patient, party alleging the medical necessity of the procedure. subject to the patient’s right to deny or withdraw consent (d) The administrator of a receiving or treatment facility at any time, by the patient’s family members, guardian, may, upon the recommendation of the patient’s attending guardian advocate, representative, Florida statewide or local physician, authorize emergency medical treatment, advocacy council, or attorney, unless such access would be including a surgical procedure, if such treatment is deemed detrimental to the patient. If a patient’s right to communicate lifesaving, or if the situation threatens serious bodily harm or to receive visitors is restricted by the facility, written to the patient, and permission of the patient or the patient’s notice of such restriction and the reasons for the restriction guardian or guardian advocate cannot be obtained. shall be served on the patient, the patient’s attorney, and the (4) Quality of treatment.— patient’s guardian, guardian advocate, or representative; and (a) Each patient shall receive services, including, for a patient such restriction shall be recorded on the patient’s clinical placed under s. 394.4655, those services included in the record with the reasons therefor. The restriction of a patient’s court order which are suited to his or her needs, and which right to communicate or to receive visitors shall be reviewed shall be administered skillfully, safely, and humanely with at least every 7 days. The right to communicate or receive full respect for the patient’s dignity and personal integrity. visitors shall not be restricted as a means of punishment. Each patient shall receive such medical, vocational, Nothing in this paragraph shall be construed to limit the social, educational, and rehabilitative services as his or provisions of paragraph (d). her condition requires in order to live successfully in the (d) Each facility shall establish reasonable rules governing community. In order to achieve this goal, the department is visitors, visiting hours, and the use of telephones by patients directed to coordinate its mental health programs with all in the least restrictive possible manner. Patients shall have other programs of the department and other state agencies. the right to contact and to receive communication from their (b) Facilities shall develop and maintain, in a form accessible to attorneys at any reasonable time. and readily understandable by patients and consistent with (e) Each patient receiving mental health treatment in any facility rules adopted by the department, the following: shall have ready access to a telephone in order to report an 1. Criteria, procedures, and required staff training for alleged abuse. The facility staff shall orally and in writing any use of close or elevated levels of supervision, inform each patient of the procedure for reporting abuse and of restraint, seclusion, or isolation, or of emergency shall make every reasonable effort to present the information treatment orders, and for the use of bodily control and in a language the patient understands. A written copy of that physical management techniques. procedure, including the telephone number of the central 2. Procedures for documenting, monitoring, and requiring abuse hotline and reporting forms, shall be posted in plain clinical review of all uses of the procedures described view. in subparagraph 1. and for documenting and requiring (f) The department shall adopt rules providing a procedure review of any incidents resulting in injury to patients. for reporting abuse. Facility staff shall be required, as a 3. A system for investigating, tracking, managing, and condition of employment, to become familiar with the responding to complaints by persons receiving services requirements and procedures for the reporting of abuse. or individuals acting on their behalf. (6) Care and custody of personal effects of patients.—A patient’s (c) A facility may not use seclusion or restraint for punishment, right to the possession of his or her clothing and personal effects to compensate for inadequate staffing, or for the convenience shall be respected. The facility may take temporary custody of of staff. Facilities shall ensure that all staff are made aware such effects when required for medical and safety reasons. A of these restrictions on the use of seclusion and restraint and patient’s clothing and personal effects shall be inventoried upon shall make and maintain records which demonstrate that this their removal into temporary custody. Copies of this inventory information has been conveyed to individual staff members. shall be given to the patient and to the patient’s guardian, (5) Communication, abuse reporting, and visits.— guardian advocate, or representative and shall be recorded in the (a) Each person receiving services in a facility providing mental patient’s clinical record. This inventory may be amended upon health services under this part has the right to communicate the request of the patient or the patient’s guardian, guardian freely and privately with persons outside the facility unless advocate, or representative. The inventory and any amendments it is determined that such communication is likely to be to it must be witnessed by two members of the facility staff and harmful to the person or others. Each facility shall make by the patient, if able. All of a patient’s clothing and personal available as soon as reasonably possible to persons receiving effects held by the facility shall be returned to the patient services a telephone that allows for free local calls and immediately upon the discharge or transfer of the patient from the access to a long-distance service. A facility is not required to facility, unless such return would be detrimental to the patient. If pay the costs of a patient’s long-distance calls. The telephone personal effects are not returned to the patient, the reason must shall be readily accessible to the patient and shall be placed be documented in the clinical record along with the disposition so that the patient may use it to communicate privately and of the clothing and personal effects, which may be given instead confidentially. The facility may establish reasonable rules to the patient’s guardian, guardian advocate, or representative. for the use of this telephone, provided that the rules do not As soon as practicable after an emergency transfer of a patient, interfere with a patient’s access to a telephone to report the patient’s clothing and personal effects shall be transferred to abuse pursuant to paragraph (e). the patient’s new location, together with a copy of the inventory (b) Each patient admitted to a facility under the provisions of and any amendments, unless an alternate plan is approved by the this part shall be allowed to receive, send, and mail sealed, patient, if able, and by the patient’s guardian, guardian advocate, unopened correspondence; and no patient’s incoming or or representative. outgoing correspondence shall be opened, delayed, held, or (7) Voting in public elections.—A patient who is eligible to vote censored by the facility unless there is reason to believe that according to the laws of the state has the right to vote in the it contains items or substances which may be harmful to the primary and general elections. The department shall establish patient or others, in which case the administrator may direct

Page 45 SocialWork.EliteCME.com rules to enable patients to obtain voter registration forms, provisions of this act by members of the Florida statewide and local applications for vote-by-mail ballots, and vote-by-mail ballots. advocacy councils. (8) Habeas corpus.— 394.4597 Persons to be notified; patient’s representative. — (a) At any time, and without notice, a person held in a receiving (1) Voluntary patients. —At the time a patient is voluntarily or treatment facility, or a relative, friend, guardian, guardian admitted to a receiving or treatment facility, the identity and advocate, representative, or attorney, or the department, contact information of a person to be notified in case of an on behalf of such person, may petition for a writ of habeas emergency shall be entered in the patient’s clinical record. corpus to question the cause and legality of such detention (2) Involuntary patients. — and request that the court order a return to the writ in (a) At the time a patient is admitted to a facility for involuntary accordance with chapter 79. Each patient held in a facility examination or placement, or when a petition for involuntary shall receive a written notice of the right to petition for a writ placement is filed, the names, addresses, and telephone of habeas corpus. numbers of the patient’s guardian or guardian advocate, or (b) At any time, and without notice, a person who is a patient representative if the patient has no guardian, and the patient’s in a receiving or treatment facility, or a relative, friend, attorney shall be entered in the patient’s clinical record. guardian, guardian advocate, representative, or attorney, or (b) If the patient has no guardian, the patient shall be asked the department, on behalf of such person, may file a petition to designate a representative. If the patient is unable or in the circuit court in the county where the patient is being unwilling to designate a representative, the facility shall held alleging that the patient is being unjustly denied a right select a representative. or privilege granted herein or that a procedure authorized (c) The patient shall be consulted with regard to the selection herein is being abused. Upon the filing of such a petition, the of a representative by the receiving or treatment facility and court shall have the authority to conduct a judicial inquiry shall have authority to request that any such representative and to issue any order needed to correct an abuse of the be replaced. provisions of this part. (d) When the receiving or treatment facility selects a representative, (c) The administrator of any receiving or treatment facility first preference shall be given to a health care surrogate, if receiving a petition under this subsection shall file the the patient has previously selected one. If the patient has not petition with the clerk of the court on the next court working previously selected a health care surrogate, the selection, except day. for good cause documented in the patient’s clinical record, shall (d) No fee shall be charged for the filing of a petition under this be made from the following list in the order of listing: subsection. 1. The patient’s spouse. (9) Violations. —The department shall report to the Agency for 2. An adult child of the patient. Health Care Administration any violation of the rights or 3. A parent of the patient. privileges of patients, or of any procedures provided under this 4. The adult next of kin of the patient. part, by any facility or professional licensed or regulated by 5. An adult friend of the patient. the agency. The agency is authorized to impose any sanction 6. The appropriate Florida local advocacy council as authorized for violation of this part, based solely on the provided in s. 402.166. investigation and findings of the department. (e) A licensed professional providing services to the patient under (10) Liability for violations.—Any person who violates or abuses any this part, an employee of a facility providing direct services rights or privileges of patients provided by this part is liable for to the patient under this part, a department employee, a damages as determined by law. Any person who acts in good faith person providing other substantial services to the patient in a in compliance with the provisions of this part is immune from professional or business capacity, or a creditor of the patient civil or criminal liability for his or her actions in connection with shall not be appointed as the patient’s representative. the admission, diagnosis, treatment, or discharge of a patient to or from a facility. However, this section does not relieve any person 394.4598 Guardian advocate. — from liability if such person commits negligence. (1) The administrator may petition the court for the appointment of (11) Right to participate in treatment and discharge planning.— a guardian advocate based upon the opinion of a psychiatrist that The patient shall have the opportunity to participate in treatment the patient is incompetent to consent to treatment. If the court finds and discharge planning and shall be notified in writing of his or that a patient is incompetent to consent to treatment and has not her right, upon discharge from the facility, to seek treatment from been adjudicated incapacitated and a guardian with the authority the professional or agency of the patient’s choice. to consent to mental health treatment appointed, it shall appoint (12) Posting of notice of rights of patients.—Each facility shall post a guardian advocate. The patient has the right to have an attorney a notice listing and describing, in the language and terminology represent him or her at the hearing. If the person is indigent, the that the persons to whom the notice is addressed can understand, court shall appoint the office of the public defender to represent the rights provided in this section. This notice shall include him or her at the hearing. The patient has the right to testify, cross- a statement that provisions of the federal Americans with examine witnesses, and present witnesses. The proceeding shall be Disabilities Act apply and the name and telephone number of a recorded either electronically or stenographically, and testimony person to contact for further information. This notice shall be shall be provided under oath. One of the professionals authorized to posted in a place readily accessible to patients and in a format give an opinion in support of a petition for involuntary placement, easily seen by patients. This notice shall include the telephone as described in s. 394.4655 or s. 394.467, must testify. A guardian numbers of the Florida local advocacy council and Advocacy advocate must meet the qualifications of a guardian contained in Center for Persons with Disabilities, Inc.Youth and young adult part IV of chapter 744, except that a professional referred to in rights. this part, an employee of the facility providing direct services to the patient under this part, a departmental employee, a facility 394.4595 Florida statewide and local advocacy councils; access to administrator, or member of the Florida local advocacy council patients and records. —Any facility designated by the department as shall not be appointed. A person who is appointed as a guardian a receiving or treatment facility must allow access to any patient and advocate must agree to the appointment. the clinical and legal records of any patient admitted pursuant to the (2) A facility requesting appointment of a guardian advocate must, prior to the appointment, provide the prospective guardian

SocialWork.EliteCME.com Page 46 advocate with information about the duties and responsibilities of (b) An adult child of the patient. guardian advocates, including the information about the ethics of (c) A parent of the patient. medical decision making. Before asking a guardian advocate to (d) The adult next of kin of the patient. give consent to treatment for a patient, the facility shall provide to (e) An adult friend of the patient. the guardian advocate sufficient information so that the guardian (f) An adult trained and willing to serve as guardian advocate advocate can decide whether to give express and informed for the patient. consent to the treatment, including information that the treatment (6) If a guardian with the authority to consent to medical treatment is essential to the care of the patient, and that the treatment has not already been appointed or if the patient has not already does not present an unreasonable risk of serious, hazardous, or designated a health care surrogate, the court may authorize the irreversible side effects. Before giving consent to treatment, the guardian advocate to consent to medical treatment, as well as guardian advocate must meet and talk with the patient and the mental health treatment. Unless otherwise limited by the court, a patient’s physician in person, if at all possible, and by telephone, guardian advocate with authority to consent to medical treatment if not. The decision of the guardian advocate may be reviewed shall have the same authority to make health care decisions and by the court, upon petition of the patient’s attorney, the patient’s be subject to the same restrictions as a proxy appointed under part family, or the facility administrator. IV of chapter 765. Unless the guardian advocate has sought and (3) Prior to a guardian advocate exercising his or her authority, the received express court approval in proceeding separate from the guardian advocate shall attend a training course approved by the proceeding to determine the competence of the patient to consent court. This training course, of not less than 4 hours, must include, to medical treatment, the guardian advocate may not consent to: at minimum, information about the patient rights, psychotropic (a) Abortion. medications, diagnosis of mental illness, the ethics of medical (b) Sterilization. decision making, and duties of guardian advocates. This training (c) Electroconvulsive treatment. course shall take the place of the training required for guardians (d) Psychosurgery. appointed pursuant to chapter 744. (e) Experimental treatments that have not been approved by a (4) The information to be supplied to prospective guardian advocates federally approved institutional review board in accordance prior to their appointment and the training course for guardian with 45 C.F.R. part 46 or 21 C.F.R. part 56. The court must advocates must be developed and completed through a course base its decision on evidence that the treatment or procedure developed by the department and approved by the chief judge is essential to the care of the patient and that the treatment of the circuit court and taught by a court-approved organization. does not present an unreasonable risk of serious, hazardous, Court-approved organizations may include, but are not limited to, or irreversible side effects. The court shall follow the community or junior colleges, guardianship organizations, and procedures set forth in subsection (1) of this section. the local bar association or The Florida Bar. The court may, in (7) The guardian advocate shall be discharged when the patient is its discretion, waive some or all of the training requirements for discharged from an order for involuntary outpatient placement or guardian advocates or impose additional requirements. The court involuntary inpatient placement or when the patient is transferred shall make its decision on a case-by-case basis and, in making from involuntary to voluntary status. The court or a hearing its decision, shall consider the experience and education of the officer shall consider the competence of the patient pursuant guardian advocate, the duties assigned to the guardian advocate, to subsection (1) and may consider an involuntarily placed and the needs of the patient. patient’s competence to consent to treatment at any hearing. Upon (5) In selecting a guardian advocate, the court shall give preference to sufficient evidence, the court may restore, or the hearing officer a health care surrogate, if the patient has already designated one. may recommend that the court restore, the patient’s competence. If the patient has not previously selected a health care surrogate, A copy of the order restoring competence or the certificate of except for good cause documented in the court record, the selection discharge containing the restoration of competence shall be shall be made from the following list in the order of listing: provided to the patient and the guardian advocate. (a) The patient’s spouse.

Professional rights 394.460 Rights of professionals. —No professional referred to in the release of information and clinical records to appropriate this part shall be required to accept patients for treatment of mental, persons to ensure the continuity of the patient’s health care emotional, or behavioral disorders. Such participation shall be or mental health care. voluntary. (b) The patient is represented by counsel and the records are 394.4615 Clinical records; confidentiality. — needed by the patient’s counsel for adequate representation. (1) A clinical record shall be maintained for each patient. The (c) The court orders such release. In determining whether there is record shall include data pertaining to admission and such other good cause for disclosure, the court shall weigh the need for information as may be required under rules of the department. A the information to be disclosed against the possible harm of clinical record is confidential and exempt from the provisions of disclosure to the person to whom such information pertains. s. 119.07(1). Unless waived by express and informed consent, by (d) The patient is committed to, or is to be returned to, the the patient or the patient’s guardian or guardian advocate or, if the Department of Corrections from the Department of Children patient is deceased, by the patient’s personal representative or the and Families, and the Department of Corrections requests family member who stands next in line of intestate succession, the such records. These records shall be furnished without confidential status of the clinical record shall not be lost by either charge to the Department of Corrections. authorized or unauthorized disclosure to any person, organization, (3) Information from the clinical record may be released in the or agency. following circumstances: (2) The clinical record shall be released when: (a) When a patient has declared an intention to harm other (a) The patient or the patient’s guardian authorizes the release. persons. When such declaration has been made, the The guardian or guardian advocate shall be provided access administrator may authorize the release of sufficient to the appropriate clinical records of the patient. The patient information to provide adequate warning to the person or the patient’s guardian or guardian advocate may authorize threatened with harm by the patient.

Page 47 SocialWork.EliteCME.com (b) When the administrator of the facility or secretary of the harmful to the patient. If the patient’s right to inspect his or her department deems release to a qualified researcher as defined clinical record is restricted by the facility, written notice of such in administrative rule, an aftercare treatment provider, or an restriction shall be given to the patient and the patient’s guardian, employee or agent of the department is necessary for treatment guardian advocate, attorney, and representative. In addition, the of the patient, maintenance of adequate records, compilation of restriction shall be recorded in the clinical record, together with treatment data, aftercare planning, or evaluation of programs. the reasons for it. The restriction of a patient’s right to inspect For the purpose of determining whether a person meets the his or her clinical record shall expire after 7 days but may be criteria for involuntary outpatient placement or for preparing renewed, after review, for subsequent 7-day periods. (11) Any person who fraudulently alters, defaces, or falsifies the the proposed treatment plan pursuant to s. 394.4655, the clinical record may be released to the state attorney, the clinical record of any person receiving mental health services in public defender or the patient’s private legal counsel, the a facility subject to this part, or causes or procures any of these court, and to the appropriate mental health professionals, offenses to be committed, commits a misdemeanor of the second including the service provider identified in s.394.4655 (6) degree, punishable as provided in s. 775.082 or s. 775.083. (b)2., in accordance with state and federal law. 394.4787 Definitions; ss. 394.4786, 394.4787, 394.4788, and (4) Information from clinical records may be used for statistical and 394.4789. —As used in this section and ss. 394.4786, 394.4788, and research purposes if the information is abstracted in such a way as 394.4789: to protect the identity of individuals. (1) “Acute mental health services” means mental health services (5) Information from clinical records may be used by the Agency provided through inpatient hospitalization. for Health Care Administration, the department, and the Florida (2) “Agency” means the Agency for Health Care Administration. advocacy councils for the purpose of monitoring facility activity (3) “Charity care” means that portion of hospital charges for care and complaints concerning facilities. provided to a patient whose family income for the 12 months (6) Clinical records relating to a Medicaid recipient shall be furnished preceding the determination is equal to or below 150 percent of to the Medicaid Fraud Control Unit in the Department of Legal the current federal nonfarm poverty guideline or the amount of Affairs, upon request. hospital charges due from the patient which exceeds 25 percent of (7) Any person, agency, or entity receiving information pursuant to the annual family income and for which there is no compensation. this section shall maintain such information as confidential and Charity care shall not include administrative or courtesy exempt from the provisions of s. 119.07(1). discounts, contractual allowances to third party payors, or failure (8) Any facility or private mental health practitioner who acts in of a hospital to collect full charges due to partial payment by good faith in releasing information pursuant to this section is not governmental programs. subject to civil or criminal liability for such release. (4) “Indigent” means an individual whose financial status would (9) Nothing in this section is intended to prohibit the parent or next qualify him or her for charity care. of kin of a person who is held in or treated under a mental health (5) “Operating expense” means all common and accepted costs facility or program from requesting and receiving information appropriate in developing and maintaining the operating of the limited to a summary of that person’s treatment plan and current patient care facility and its activities. physical and mental condition. Release of such information shall be (6) “PMATF” means the Public Medical Assistance Trust Fund. in accordance with the code of ethics of the profession involved. (7) “Specialty psychiatric hospital” means a hospital licensed by the (10) Patients shall have reasonable access to their clinical records, agency pursuant to s. 395.002(28) and part II of chapter 408 as a unless such access is determined by the patient’s physician to be specialty psychiatric hospital.

Youth and young adult rights 65C-31.002 Case Management for Young Adults Formerly in (e) The frequency of contact by the services worker with the Foster Care. young adult shall be determined by the young adult in (1) The services that shall be provided to young adults formerly in consultation with the services worker. foster care to transition successfully to independent living shall (3) Preparation and Education of the Child/Youth Age 16-17 in Foster include, as appropriate for the individual young adult: Care. The services worker shall arrange or provide the services (a) Aftercare support services, necessary to ensure that preparation/education for the young adult (b) Road to Independence Scholarship Program, and formerly in foster care to achieve independence occurs. (c) Transitional support services, as specified in Section (4) Initial Application, Renewal and Reinstatement for the Road 409.1451(5)(c)1., F.S. to Independence Scholarship. The Road to Independence Act (2) Case Management/Contact with Young Adults Formerly in Foster provides specific direction for young adults formerly in foster Care/Support by Services Worker. care to renew or continue receiving benefits and to reinstate (a) Depending upon the stated wishes and needs of the young benefits for young adults whose scholarship benefits were adult formerly in foster care, services worker support interrupted and who wishes to begin receiving benefits again. through home visits, office visits, and other types of contact (5) Selecting the Appropriate Funding Source for Young Adult shall occur. Services (Chafee or ETV). (b) A plan for transition is required for all recipients of (a) Two major types of federal funding sources are available to scholarship and/or transitional support funds. support the program for young adults formerly in foster care: (c) The services worker shall arrange and provide services to Chafee funds and Education and Training Voucher (ETV) support young adults formerly in foster care between the funds. The services worker shall determine the appropriate ages of 18 and up to his or her 23rd birthday. fund in order to comply with federal regulations and to (d) The services worker shall provide young adults formerly in maximize available funding. foster care with developmental disabilities, mental health (b) ETV funds have more restrictions than Chafee funds and needs, and/or other special needs more contact, as necessary, shall be used for eligible students as the first option. to assist in the ability of the young adult to transition 1. ETV may be used only for eligible students attending a successfully to independent living. postsecondary (college, university or vocational) school either part-time or full-time.

SocialWork.EliteCME.com Page 48 2. Chafee funds may be used for any of the young adult 3. Initial application must be completed before 21st birthday. services identified in Florida Statutes, though not for 4. Benefits from this and other federal educational young adults age 21 or 22. assistance sources may not exceed the young adult’s 3. State funds must be used for young adults age 21 and “cost of attendance” at an “institution of higher 22 if they are not eligible for ETV funds. education,” as defined by federal statute. (6) Young Adults Formerly in Foster Care with Children of Their Own. 5. The young adult must be attending an institution of (a) The services worker shall determine which funds may be higher education. used for children whose parents are young adults formerly in 6. The young adult may receive a maximum of $5000 per foster care. year towards the payment of RTI Scholarship awards. (b) If the parent of a child in a dependency case is a young adult 7. For a student attending an institution of higher education formerly in foster care, the processes required in Chapter on a part-time basis, ETV funds of up to $5000 per year 39, F.S., for any parent still apply. Case planning, case may be used to pay for Transitional Support Services. management and required contacts shall continue as with 8. The young adult shall provide proof of enrollment and any other dependency case. satisfactory progress. (7) Selection of Placements for Young Adults Formerly in Foster (b) Application for ETV Funds. Care. Prior to his or her 18th birthday, each young adult formerly 1. Students applying for the Road to Independence in foster care shall choose the placement that best suits his or her (RTI) Scholarship will use the application form needs. The services worker assigned to work with a young adult “Road to Independence Scholarship and/or ETV shall provide information to the young adult so as to assist in the Funds Application”, CF-FSP 5295, September 2005, best decision making. incorporated by reference, unless they are attending school (a) If the young adult elects to reside in the same or different part-time. If determined eligible for ETV, a portion of the licensed placement after reaching age 18, the services student’s RTI scholarship award will be covered by ETV worker assigned to work with the young adult shall assist funds. The maximum per student per year is $5000. both the placement provider and the young adult understand 2. Students attending school at least part-time may receive the roles and the responsibilities of continuing this ETV funds. These students shall complete the “Transitional placement after the young adult’s eighteenth birthday. Support Eligibility and/or Education Training Vouchers (b) A young adult who continues with the foster family shall not (ETV) Funds Application” CF-FSP 5292, September be included as a child in calculating any licensing restriction 2005, incorporated by reference, and can receive up to on the number of children in the foster home. $5000 per year, which may be funded by ETV. (8) Implementation Plan, Steps for Effective Implementation. 3. ETV funds are used for educational assistance currently (a) Program for Young Adults Formerly in Foster Care. This authorized in Florida Statutes. The only new eligible plan shall be used in order to develop each departmental group is young adults formerly in foster care adopted at district/ region or contracted service provider specific age 16 or 17. implementation plan. 4. Chafee funds shall be used to cover the costs of Road (b) Steps for Effective Implementation: to Independence Scholarships for high school/GED 1. Departmental districts/regions and contracted service students, for those students attending institutions not providers shall designate staff responsible for receiving meeting the federal definition of higher education, for inquiries about services available to young adults transitional support services (exclusive of support for formerly in foster care. The departmental district/region attendance at institutions of higher education), and for and contracted service providers shall also develop aftercare services. methods to provide information about ETV, prior to 5. Upon application for any independent living services, their 18th birthday, to youth adopted from foster care youth shall be provided with information regarding at ages 16 and 17, and to perform outreach for those the appeal process, as well as the “Independent Living adopted since July 1, 1999. Benefits Due Process Rights” brochure, CF/PI 175- 2. District/region and/or contracted service providers shall 11, September 2005, incorporated by reference. This develop a process with fiscal/budget staff to ensure includes applications for services made in anticipation expedited and/or emergency assistance is provided. of the youth’s 18th birthday. 3. District/region and/or contracted service providers shall 65C-31.003 Aftercare Support Services for Young Adults Formerly develop a tracking system for approved cash assistance in Foster Care. payments until such time as HSN can capture this (1) The services worker shall provide support to young adults information. formerly in foster care through making of service referrals in the 4. Pursuant to Chapter 39 and Section 409.1451, Florida community to assist young adults in developing “the skills and Statutes, district/region and community-based care abilities necessary for independent living”. agencies must inform all youth aging out of foster care, (2) Eligibility for Aftercare Support. A young adult who leaves foster prior to age 18, of these benefits. care at age 18 but requests services prior to his or her 23rd birthday (9) Education and Training Voucher Funds. shall be eligible for aftercare support services. There is no formal (a) Education and Training Voucher (ETV) Program Requirements. written application to receive aftercare support service referrals. 1. Young adult must have been: (3) Application Process for Aftercare Support Cash Assistance. a. Adjudicated dependent, pursuant to Chapter 39, (a) The services worker shall assist the young adult to receive F.S., have been in the custody of the State of cash assistance for housing, electric, water, gas, sewer service, Florida on his or her 18th birthday and have spent food, and any other provisions permitted under Section at least 6 months in foster care prior to reaching 409.1451(5)(a), F.S. Prior to arranging for the provision his or her 18th birthday; or of cash assistance, the services worker shall explore the b. Adopted from the Florida foster care system at age feasibility of agreements with community providers to waive 16 or 17 as of July 1, 1999; fees, contacting relatives and other such options. 2. Young adults are potentially eligible for services from age 18 through age 22.

Page 49 SocialWork.EliteCME.com (b) The young adult shall complete the “Aftercare Support provider. The Independent Living services worker Services Cash Assistance Application”, CF-FSP 5294, shall have 10 working days to review the application September 2005, incorporated by reference. and approve or deny the scholarship award or, if not (c) If a young adult requests further services, see Rule 65C- the approval authority, shall forward the request to the 31.005, F.A.C., Transitional Support Services for Young approval authority early enough to have it approved Adults Formerly in Foster Care. within the ten-day period. (4) Payment Requirements for Aftercare Support Services Recipients. 3. If approved, the services worker or Independent Living The services worker responsible for the case shall choose between services worker shall notify the youth in writing within making one payment directly to the young adult formerly in foster 10 working days of the determination. The monthly care or, at the request of the young adult, paying all or a portion scholarship award shall be distributed at the beginning of the funds to a service provider. of the month that the recipient turns 18 years of age or, 65C-31.004 Road to Independence Scholarship. if approval occurs after the youth’s 18th birthday, at (1) Initial Application for Scholarship Eligibility. Each student, with the the beginning of the next month following approval of assistance of the services worker if requested by the young adult, the application. For youth approved prior to their 18th shall complete an RTI Scholarship Application. This application shall birthday, the first monthly scholarship award shall not be completed and signed by the student, reviewing authority and be prorated regardless of the day of the month recipient approval authority and a copy must be placed in the case file. turns 18 years of age. (a) For the initial award, a young adult formerly in foster care must: 4. If the application is denied, the services worker or services 1. Be age 18, 19 or 20; worker shall notify the youth in writing within 10 working 2. Have been a dependent child pursuant to Chapter 39; days of the determination and shall provide the youth the 3. Be or have been in the legal and/or physical custody of procedure for filing an appeal and the “Independent Living the Department of Children and Family Services at the Benefits Due Process Rights” brochure, CF/PI 175-11, time of his or her 18th birthday. September 2005, incorporated by reference, and notify 4. Have spent at least 6 months in foster care before the youth of other available benefits, including transitional reaching his or her 18th birthday, which may include the support services or aftercare support. time the youth spent in shelter status in state custody; 5. If a young adult formerly in foster care did not complete 5. Be a resident of Florida per Section 1009.40, F.S.; and the application process prior to his or her 18th birthday, 6. Meet one of the following educational requirements: or if the application was not approved, the young adult a. Earned a standard high school diploma or its may apply once prior to his or her 21st birthday. The equivalent as described in Sections 1003.43 or eligibility requirements contained in paragraph 65C- 1003.435, F.S., or earned a special diploma or special 31.004(1)(a), F.A.C., apply. No retroactive benefits are certificate of completion as described in Section available due to delayed completion of the application 1003.438, F.S., and has been admitted for full-time process by the youth. enrollment in an eligible postsecondary education (2) Scholarship Renewal. The services worker shall evaluate for institution as defined in Section 1009.533, F.S. renewal each scholarship award annually during the 90-day b. Is enrolled full time in an accredited high school, period before the student’s birthday. In order to be eligible for a unless he or she has a documented disability renewal award for the subsequent year the student shall: and has provided documentation that part-time (a) Complete the number of hours, or the equivalent considered attendance is a necessary accommodation; or full time by the educational institution, in the last academic c. Is enrolled full time in an accredited adult year in which the young adult earned a scholarship, except education program designed to provide the student for a young adult who meets the requirements of Section with a high school diploma or its equivalent, 1009.41, F.S. unless he or she has a documented disability (b) Maintain appropriate progress as required by the educational and has provided documentation that part-time institution, except that, if the young adult’s progress is attendance is a necessary accommodation. insufficient to renew the scholarship at any time during the (b) In addition, young adults age 18 up to their 23rd birthday eligibility period, the young adult may restore eligibility by who were adopted from foster care at age 16 or 17 and are improving his or her progress to the required level. attending an institution of higher education, whether on a (3) Scholarship Reinstatement. A student who has lost eligibility for full or part time basis, and meet the other criteria set forth for the RTI scholarship or who choose not to renew the award may scholarship eligibility are eligible to receive the scholarship apply for reinstatement one time before his or her 23rd birthday award. The same application shall be used for children using “Road to Independence Scholarship and/or Education adopted at age 16 or 17 applying for ETV funds. These Training Vouchers (ETV) Funds Reinstatement Application”, CF- funds are intended to assist in meeting the student’s living FSP 5297, September 2005, incorporated by reference. In order to expenses or provide for basic personal needs. be eligible for reinstatement the student must meet the eligibility (c) Application Process for Scholarship. criteria and the criteria for scholarship renewal. 1. The services worker shall assist each youth between the (4) RTI Scholarship Needs Assessment. An RTI Needs Assessment ages 17 years, 6 months and 18 years of age to apply for must be completed on each student who has been awarded the the Road to Independence Scholarship. The youth shall: RTI scholarship. a. Complete the application. (a) State Requirements. The amount of the award, whether it is b. Obtain document of proof of enrollment. being used by a young adult working toward completion of 2. Each departmental district/region or contracted service a high school diploma or its equivalent or working toward provider shall designate a services worker to assist completion of a postsecondary education program, shall be each young adult applying for or receiving independent determined based on an assessment of the funding needs living services. The young adult shall submit his or her of the young adult. This assessment shall consider the application to the Independent Living services worker young adult’s living and educational costs and other grants, designated by the department or its contracted service scholarships, waivers, earnings, and other income to be received by the young adult.

SocialWork.EliteCME.com Page 50 (b) Federal Requirements. The total amount of ETV funds and (a) Pursuant to federal documentation requirements, for any other federal educational assistance to the young adult each young adult receiving funding from the Road to shall not exceed the young adult’s cost of attendance. Independence Scholarship, transitional support services and/ (5) Payment Requirements for Scholarship Recipients. or aftercare support services the department or its contracted (a) The services worker responsible for the case shall determine service provider shall have an active case and a case file how the monthly scholarship awards will be paid according containing at minimum: to either of the two following methods: 1. A document that contains current demographic 1. Direct payment to the young adult, information on the student such as, name, address, 2. Payment of a portion of the scholarship award to a DOB, social security number, school attending, etc. service provider and the balance to the young adult, if 2. Completed applications signed by the young adult and requested by the young adult. If the young adult makes review and approval authorities. this request, it must be made in writing. 3. Follow up renewal applications or evidence of review (b) ETV funds are available pursuant to the following: of transitional support services cases. 1. For students attending an institution of higher 4. Completed Needs Assessments for RTI cases. education, including community college, university 5. Documentation to support eligibility requirements for or vocational education courses. High school or GED the services provided. attendance does not qualify. (b) When requesting documentation from the young adult, 2. For youth adopted at age 16 or 17 from foster care who the services worker shall use “Request for Road to are attending an institution of higher learning. Independence Scholarship Documentation” CF-FSP 5302, 3. Part-time attendance at an institution of higher September 2005, incorporated by reference. education may qualify young adults under Florida’s (2) Documentation Requirements for Aftercare Support Services. The transitional support services component. following documentation requirements apply to both referrals and (c) Renewal of Road to Independence Scholarships. cash assistance. 1. Young adults formerly in foster care are required to (a) Requests for Aftercare Support service referrals shall be renew their scholarships on an annual basis. recorded in the young adult’s case file. 2. Departmental districts/regions or contracted service (b) Requests for Aftercare support cash assistance shall be provider agencies shall develop a plan for renewal of recorded in the young adult’s case file. The application shall scholarships. At a minimum, the plan shall address the be kept in a hard copy file. tracking and scheduling of scholarship renewals and (c) The services worker shall verify the young adult is in need of those staff responsible for notifying for these activities services through an eviction notice; utility cut-off notice or as well as notifying the scholarship recipient of his or similar document; estimate of move-in costs, or by assessing her obligations during the renewal period. the situation through an interview with the young adult. 3. Each approved award shall be evaluated and renewed (3) Documentation Requirements for Road to Independence during the 90-day period prior to the young adult’s Scholarship. The services worker or other designated staff of birthday. the department or its contracted service provider shall maintain 4. If the young adult is awarded a scholarship within 90 the following documentation in the case file of each young days prior to his or her next birthday, he/she is not adult receiving the Road to Independence Scholarship to verify required to file for renewal until the following birthday. the young adult’s eligibility for the initial application, ongoing 5. For young adults who were adopted from foster care eligibility, at renewal and for reinstatement. at age 16 or 17, the same procedures established above (a) Initial Scholarship Approval Documentation Requirements. shall be followed when renewing their ETV funds. In order for a student to be eligible for the Road to (d) Eligibility to Renew Road to Independence Scholarships. Independence Scholarship. The young adult shall: 1. Documentation of application(s) for the RTI Scholarship, 1. Make one application for the initial award prior to his including the initial, renewal and reinstatement or her 21st birthday. applications. The services worker shall maintain the 2. Complete the number of hours, or the equivalent following documentation in the young adult’s case file: considered full time by the educational institution, in a. Renewal checklists, the last academic year in which the young adult earned b. Chronological entries of contacts made, a scholarship, except for a young adult who meets the c. All completed scholarship applications, requirements of Section 1009.41, F.S. including as appropriate, the initial, renewal and 3. Maintain appropriate progress as required by the reinstatement applications, educational institution, except that, if the young adult’s d. A log of financial disbursements, and progress is insufficient to renew the scholarship at any e. Any other pertinent supporting documentation. time during the eligibility period, the young adult may 2. Documentation for Eligibility Requirements. restore eligibility by improving his or her progress to a. Each student, with the assistance of the services the required level. worker, shall complete an RTI Scholarship (e) Documentation Requirements for Scholarship Recipients. Application. This “application” shall be completed All eligible recipients shall: and signed by the student, reviewing authority and 1. Provide documentation of enrollment in a high school approval authority and a copy shall be placed in or institution of higher education; and the case file. 2. Provide documentation of progress made in his or her b. Adjudication of dependency shall be documented course of study during the most recently completed by placement in the case file of at least one of the school term. following documents: 65C-31.006 Young Adult Services Documentation Requirements. (I) Adjudicatory Order if there is follow up (1) General Documentation Requirements. documentation indicating that the student was placed in foster care.

Page 51 SocialWork.EliteCME.com (II) Dispositional Order if the order placed the (II) If the student is enrolled fewer than 12 hours, student in foster care or if there is follow up a current enrollment form or letter from the documentation indication that the student was institution stating that the student is enrolled placed in foster care. full-time. (III) Judicial Review Order if the order indicates b. Full-time enrollment by the student in vocational that the student was adjudicated dependent school, high school or GED shall be documented and placed in foster care. The Judicial Review by placement in the case file of an enrollment form Social Study Report shall be an acceptable or letter from the school that states that he or she is source of supporting documentation if a full-time student. information regarding adjudication of c. Students must be able to periodically prove that dependency and status in foster care are they continue to be enrolled and attending school mentioned in the report. full-time. This shall be verified by placement in the (IV) A Criminal Justice Information System case file of at least one of the following forms of (CJIS) if it is a complete report that includes documentation: adjudication date and date placed in foster (I) A progress report from the school. care. (II) Document in case notes that a school official c. Documentation that the student was living in has been contacted and has verified continued licensed foster care at age 18 shall be provided full-time enrollment of the student. The name, by placement in the case file of at least one of the title, school and phone number for the school following documents: official who has been contacted shall also be (I) Judicial Review Order or other Court Order if included in the case note. the order indicates that the student was living d. At the end of each semester the student shall in foster care on his or her 18th birthday. provide the following documents and a copy shall The order may contain language releasing be placed in the case file: child from foster care on 18th birthday. (I) A report card showing completion of classes The Judicial Review Social Study Report registered for previously; and shall be an acceptable source of supporting (II) An enrollment form or letter from the documentation if information regarding educational institution showing full-time adjudication of dependency and status in enrollment for the following semester. foster care are mentioned in the report. (b) Scholarship Renewal Documentation Requirements. (II) An Integrated Child Welfare Services 1. For each student the services worker shall complete a Information System (ICWSIS) printout “Road to Independence Scholarship and/or ETV Funds showing child in placement on 18th birthday Renewal Checklist” CF-FSP 5296, September 2005, if other supporting documentation such as incorporated by reference. The completed checklist shall orders are in the file verifying that the child be signed by the student, reviewing authority and approval was in custody of the department. authority and a copy shall be placed in the case file. d. Documentation that the student spent at least six 2. The case file shall also contain: months in foster care before reaching his or her 18th a. Proof of full-time enrollment at the institution, birthday shall be provided by placement in the case unless exempted, and file of at least one of the following documents: b. Proof of satisfactory progress at the institution. (I) An Integrated Child Welfare Services (c) Scholarship Reinstatement Documentation Requirements. Information System (ICWSIS) printout 1. Each student who wishes to apply for reinstatement providing at least six months of residing shall complete a “Road to Independence Scholarship in licensed care prior to the students 18th and/or Education Training Vouchers (ETV) Funds birthday if other supporting documentation Reinstatement Application”, CF-FSP 5297, September such as orders are in the file verifying that the 2005, incorporated by reference. child was in custody of the department. 2. This application shall be completed and signed by the (II) A Statewide Automated Child Welfare student, reviewing authority and approval authority and Information System printout showing six a copy shall be placed in the case file. months of licensed placement. 3. The case file shall also contain: e. Documentation that the student is a Florida a. Proof of eligibility, resident shall be provided by placement in the case b. Proof of full-time enrollment at the institution, file of at least one of the following documents: unless exempted, and (I) Driver’s license or Florida Identification card. c. Proof of satisfactory progress at the institution. (II) Document proving Florida residence, (d) RTI Scholarship Needs Assessment. An RTI Needs including but not limited to, a copy of an Assessment shall be completed on each student who has RTI check, an electric bill, a lease, a current been awarded the RTI scholarship. See Rule 65C-31.007, school enrollment form. F.A.C., High School Needs Assessment, and Rule 65C- 3. Documentation for Educational Requirements. 31.008, F.A.C., Postsecondary Needs Assessment. a. Full-time enrollment by the student in university, (4) Documentation Requirements for Transitional Support Services. college or community college shall be documented (a) A case shall be open in the Statewide Automated Child Welfare by placement in the case file of at least one of the Information System and a hard copy case folder is required for following documents: any documentation not contained in the electronic system. (I) A current enrollment form or letter from (b) Staff are required to maintain the following documentation the institution clearly showing the student in the youth’s case file: chronological entries to document enrolled for at least 12 credit hours. face to face contacts, phone calls, and other contacts such as letters, facsimile transmissions or e-mail correspondence,

SocialWork.EliteCME.com Page 52 documentation of referrals for services and documentation of (c) Other required documentation for Transitional Support young adults progress in attaining his or her transition plan, Services that shall be maintained in the case file is: including: 1. The completed transitional support services application, 1. Completing the attached application, 2. The completed transitional plan, and 2. Obtaining a copy of documentation of grade point 3. Documentation that the young adult meets the average, requirements for eligibility for transitional support 3. Obtaining document of proof of enrollment, services. 4. Performing any other specific tasks identified in transition plan.

NOTE: The following sections, entitled “Independent Living” and “Quality Parenting”, are excerpted from the most recent revisions and additions to legislation as of this writing. It is quite extensive. For the purpose of this course, it is edited to focus on social work applications, but should be viewed in its entirety at http://laws.flrules.org/2013/178.

Independent living Citing this act as the Nancy C. Detert Common Sense and Compassion that the child has certain documents; requiring the department to update Independent Living Act, providing that when the court obtains the case plan; providing for review hearings for young adults in foster jurisdiction over a child who has been found to be dependent, the court care; amending s. 409.145, F.S.; requiring the department to develop retains jurisdiction until the child reaches 21 years of age; providing and implement a system of care for children in foster care; specifying exceptions; directing the Department of Children and Families to work the goals of the foster care system; requiring the department to assist in collaboration with the Board of Governors, the Florida College foster care caregivers to achieve quality parenting; specifying the System, and the Department of Education to help address the need roles and responsibilities of caregivers, the department, and others; for a comprehensive support structure in the academic arena to assist providing for transition from a caregiver; requiring information sharing; young adults who have been or remain in the foster care system. providing for the adoption and use of a “reasonable and prudent parent” CHAPTER 2013-178 standard; defining terms; providing for the application for the standard Committee Substitute for Senate Bill No. 1036 of care; providing for limiting liability of caregivers; specifying foster (Excerpt) care room and board rates; authorizing community-based care service providers to pay a supplemental monthly room and board payment to An act relating to independent living; providing a short title; amending foster parents for providing certain services; directing the department s. 39.013, F.S.; requiring the Department of Children and Families, to adopt rules; deleting obsolete provisions; amending s. 409.1451, the community-based care provider, and others to assist a child in F.S.; providing for the Road to Independence program; providing developing a transition plan after the child reaches 17 years of age legislative findings and intent; providing for postsecondary services and requiring a meeting to develop the plan; specifying requirements and supports; specifying aftercare services; providing for appeals of a and procedures for the transition plan; requiring periodic review of determination of eligibility; providing for portability of services across the transition plan; requiring the court to approve the transition plan county lines and between lead agencies; providing for accountability; before the child leaves foster care and the court terminates jurisdiction; creating the Independent Living Services Advisory Council; providing creating s. 39.6251, F.S.; providing definitions; providing that a young for membership and specifying the duties and functions of the council; adult may remain in foster care under certain circumstances after requiring reports and recommendations; directing the department to attaining 18 years of age; specifying criteria for extended foster care; adopt rules; amending s. 409.175; allowing for young adults remaining providing that the permanency goal for a young adult who chooses to in care to be considered in total number of children placed in a foster remain in care is transition from care to independent living; specifying home; directing the Department of Children and Families to work dates for eligibility for a young adult to remain in extended foster in collaboration with the Board of Governors, the Florida College care; providing for supervised living arrangements in extended foster System, and the Department of Education to help address the need care; authorizing a young adult to return to foster care under certain for a comprehensive support structure in the academic arena to assist circumstances; specifying services that must be provided to the young young adults who have been or remain in the foster care system; adult; directing the court to retain jurisdiction and hold review hearings; providing for an annual report; directing the Department of Children amending s. 39.701, F.S.; revising judicial review of foster care cases; and Families in collaboration with the Florida Foster and Adoptive making technical changes; providing criteria for review hearings for Parent Association and the Quality Parenting Initiative to develop design children younger than 18 years of age; providing criteria for review training for caregivers; providing effective dates. hearings for children 17 years of age; requiring the department to verify

The Quality Parenting Initiative The second Florida law enacted in 2013 that applies to social work and able to learn about and be respectful of the child’s culture, with dependent children and youth is the Quality Parenting Initiative. religion and ethnicity, special physical or psychological needs, The Department of Children and Families in collaboration with the any circumstances unique to the child, and family relationships. Florida Foster and Adoptive Parent Association and the Quality The department, the community-based care lead agency, and other Parenting Initiative will design and disseminate training for caregivers agencies shall provide such caregiver with all available information on skill building on the life skills necessary for youth in the foster care necessary to assist the caregiver in determining whether he or she is system. This act shall take effect January 1, 2014 as approved by the able to appropriately care for a particular child. governor June 14, 2013. (a) Roles and responsibilities of caregivers. A caregiver shall: Excerpt from Section 7. Section 409.145: 1. Participate in developing the case plan for the child and (2) Quality Parenting. —A child in foster care shall be placed his or her family and work with others involved in his only with a caregiver who has the ability to care for the child, is or her care to implement this plan. This participation willing to accept responsibility for providing care, and is willing includes the caregiver’s involvement in all team meetings or court hearings related to the child’s care.

Page 53 SocialWork.EliteCME.com 2. Complete all training needed to improve skills in all relevant information concerning the child. Records and parenting a child who has experienced trauma due to information that are required to be shared with caregivers neglect, abuse, or separation from home, to meet the include, but are not limited to: child’s special needs, and to work effectively with 1. Medical, dental, psychological, psychiatric, and child welfare agencies, the court, the schools, and other behavioral history, as well as ongoing evaluation or community and governmental agencies. treatment needs; 3. Respect and support the child’s ties to members of 2. School records; his or her biological family and assist the child in 3. Copies of his or her birth certificate and, if appropriate, maintaining allowable visitation and other forms of immigration status documents; communication. 4. Consents signed by parents; 4. Effectively advocate for the child in the caregiver’s 5. Comprehensive behavioral assessments and other social care with the child welfare system, the court, and assessments; community agencies, including the school, childcare, 6. Court orders; health and mental health providers, and employers. 7. Visitation and case plans; 5. Participate fully in the child’s medical, psychological, 8. Guardian ad litem reports; and dental care as the caregiver would for his or her 9. Staffing forms; and biological child. 10. Judicial or citizen review panel reports and attachments 6. Support the child’s school success by participating in filed with the court, except confidential medical, school activities and meetings, including individual psychiatric, and psychological information regarding education plan meetings, assisting with school any party or participant other than the child. assignments, supporting tutoring programs, meeting Section 7. Section 409.145 also states: with teachers and working with an educational (3) Reasonable and Prudent Parent Standard. — surrogate if one has been appointed, and encouraging (c) Verification of services delivered. The department and each the child’s participation in extracurricular activities. community-based care lead agency shall verify that private 7. Work in partnership with other stakeholders to obtain agencies providing out-of-home care services to dependent and maintain records that are important to the child’s children have policies in place which are consistent with this well-being, including child resource records, medical section and that these agencies promote and protect the ability records, school records, photographs, and records of of dependent children to participate in age-appropriate extra- special events and achievements. curricular, enrichment, and social activities. 8. Ensure that the child in the caregiver’s care who is between 13 and 17 years of age learns and masters The statutes continue with directives to develop programs so young independent living skills. adults leaving dependency care have support to enter postsecondary 9. Ensure that the child in the caregiver’s care is aware education and other support services. It outlines eligibility of the requirements and benefits of the Road to requirements for aftercare. Independence Program. Excerpt from Section 8. Section 409.1451 The Road-to- 10. Work to enable the child in the caregiver’s care to Independence Program.— establish and maintain naturally occurring mentoring (1) Legislative Findings and Intent. — relationships. (a) The Legislature recognizes that most children and young (b) Roles and responsibilities of the department, the community- adults are resilient and, with adequate support, can expect to based care lead agency, and other agency staff. The be successful as independent adults. Not unlike many young department, the community-based care lead agency, and adults, some young adults who have lived in foster care need other agency staff shall: additional support and resources for a period of time after 1. Include a caregiver in the development and reaching 18 years of age. implementation of the case plan for the child and (b) The Legislature finds that while it is important to provide his or her family. The caregiver shall be authorized young adults who have lived in foster care with education to participate in all team meetings or court hearings and independent living skills, there is also a need to focus related to the child’s care and future plans. The more broadly on creating and preserving family relationships caregiver’s participation shall be facilitated through so that young adults have a permanent connection with at timely notification, an inclusive process, and alternative least one committed adult who provides a safe and stable methods for participation for a caregiver who cannot be parenting relationship. physically present. (c) It is the intent of the Legislature that young adults who 2. Develop and make available to the caregiver the choose to participate in the program receive the skills, information, services, training, and support that education, and support necessary to become self-sufficient the caregiver needs to improve his or her skills in and leave foster care with a lifelong connection to a parenting children who have experienced trauma due to supportive adult through the Road to Independence program, neglect, abuse, or separation from home, to meet these either through postsecondary education services and support, children’s special needs and to advocate effectively as provided in subsection (2), or aftercare services. with child welfare agencies, the courts, schools, and other community and governmental agencies. 3. Provide the caregiver with all information related to services and other benefits that are available to the child. Section 7. Section 409.145 further states: (d) Information Sharing —Whenever a foster home or residential group home assumes responsibility for the care of a child, the department and any additional providers shall make available to the caregiver as soon as is practicable

SocialWork.EliteCME.com Page 54 HIPAA and the duty to warn The Tarasoff Case in California changed many laws across the Social workers may learn information directly or indirectly that they country governing the disclosure of information by mental health believe warrants further investigation or action and then must decide practitioners. That case resulted from a university therapist, supervisor, what action to take in this critical area. The NASW instructs in the law enforcement agency and mental health facility that worked with Code of Ethics that these decisions should never be made without a client deemed dangerous. The client ultimately left therapy, was consultation with the agency supervisor, clinical social worker or released from a treatment facility, moved away and later committed a colleagues, NASW, state board and other governing agencies, stressing murder. This is an oversimplification, but the case led to changes in the the urgency in these cases. language and responsibility for practitioners to warn individuals who The American Mental Health Counseling Association Code of Ethics may be harmed by present or former clients. (AMHCA) 2010 revision provides the following information on This, of course, requires the disclosure of information that normally disclosure of information related to the duty to warn: would be considered confidential between provider and client. All The release of information without consent of the client may only 50 states have addressed the duty to warn but some jurisdictions do take place under the most extreme circumstances: the protection not mandate the responsibility to warn or restrict the disclosure. The of life (suicidality or homicidality), child abuse, and/ or abuse of Florida Statute indicates that confidential communication between the incompetent persons and elder abuse. Above all, mental health licensed or certified mental health worker and the patient or client may counselors are required to comply with state and federal statutes be waived in theses cases. concerning mandated reporting. The Florida Court of Appeal decision in the case of in Green v. Ross d) Mental health counselors (or their staff members) do not release (1997) held that the permissive language of this statute and the use of information by request unless accompanied by a specific release of the word may did not create or confirm the duty to warn, and no cause information or a valid court order. Mental health counselors make of action could be taken for failure to warn in the case against a mental every attempt to release only information necessary to comply with health worker (Tapp and Payne, 2011). That decision was based on a the request or valid court order. Mental health counselors are advised prior Florida appellate decision, Boynton v. Burglass in 1991, which to seek legal advice upon receiving a subpoena in order to respond dismissed a plaintiff’s complaint for failure to state a cause of action appropriately. against a psychiatrist under an alleged duty to warn (ibid). f) If clients are in danger, such as domestic violence or suicidality, The court case cited above supported the view that the Florida statute mental health counselors take steps to secure a safety plan, refer to is more permissive than some other states’ because the disclosure of appropriate resources, and if necessary contact appropriate support. confidential information is permitted but not required. This applies even in cases of potential harm and duty to warn a person who may be n) Mental health counselors may justify disclosing information a target of attack by a client. to identifiable third parties if clients disclose that they have a communicable or life threatening illness. However, prior to disclosing Florida Statutes govern confidentiality and privileged communication such information, mental health counselors must confirm the diagnosis along with the Federal Health Insurance Portability and Accountability with a medical provider. The intent of clients to inform a third party Act of 1996 (HIPAA). HIPAA governs the privacy and security of about their illness and to engage in possible behaviors that could patient information that may be shared by social workers, including be harmful to an identifiable third party must be assessed as part of information from case management notes. the process of determining whether a disclosure should be made to HIPAA is an extensive and detailed piece of federal legislation identifiable third parties. that contains directives for the security of patient protected health The American Association for Marriage and Family Therapy information (PHI), including the electronic transmission of (AAMFT) 2012 update does not specifically address disclosure of information. Because conflicts may arise between social workers’ duty confidential information concerning the duty to warn but provides the to protect client confidentiality and the duty to warn against clients’ following related guidelines: potential to harm themselves or others, the 2013 U.S. Department of Health and Human Services (HHS) provided statements that apply to Both law and ethics govern the practice of marriage and family health care providers, including social workers. therapy. When making decisions regarding professional behavior, marriage and family therapists must consider the AAMFT Code of The HIPAA Privacy Rule does not prevent the ability to disclose Ethics and applicable laws and regulations. If the AAMFT Code of necessary information about a patient to law enforcement, family Ethics prescribes a standard higher than that required by law, marriage members of the patient, or other persons, when the provider believes and family therapists must meet the higher standard of the AAMFT the patient presents a serious danger to himself or other people. HIPAA Code of Ethics. Marriage and family therapists comply with the allows the provider, consistent with applicable law and standards of mandates of law, but make known their commitment to the AAMFT ethical conduct, to alert those persons whom the provider believes are Code of Ethics and take steps to resolve the conflict in a responsible reasonably able to prevent or lessen the threat. manner. The AAMFT supports legal mandates for reporting of alleged Law 45 CFR § 164.512(j) and Fl. S. 491.0147 allow social workers, unethical conduct. mental health counselors and marriage and family therapists to 2.1 Disclosing Limits of Confidentiality. Marriage and family disclose or share a client’s PHI if they believe in good faith that therapists disclose to clients and other interested parties, as early as the disclosure of information “may prevent or lessen a serious and feasible in their professional contacts, the nature of confidentiality and imminent threat to the health or safety of a person or the public; and is possible limitations of the clients’ right to confidentiality. Therapists to a person or persons reasonably able to prevent or lessen the threat, review with clients the circumstances where confidential information including the target of the threat.” may be requested and where disclosure of confidential information This is referred to as “duty to warn or avert harm.” According to the may be legally required. Circumstances may necessitate repeated NASW Ethics Board (Morgan, 2013) the social worker’s “good-faith disclosures. belief” is one based upon the practitioner’s “actual knowledge or in 2.2 Written Authorization to Release Client Information. Marriage reliance on a credible representation by a person with apparent knowledge and family therapists do not disclose client confidences except by or authority,” such as a family member or other person (HHS, 2013). written authorization or waiver, or where mandated or permitted by

Page 55 SocialWork.EliteCME.com law. Verbal authorization will not be sufficient except in emergency 3. Seek the client’s consent for the social worker to warn a potential situations, unless prohibited by law. When providing couple, family or victim. group treatment, the therapist does not disclose information outside the 4. Disclose only the minimum amount necessary to protect the treatment context without a written authorization from each individual potential victim and the public. competent to execute a waiver. In the context of couple, family 5. Encourage the client to agree to a joint session with the potential or group treatment, the therapist may not reveal any individual’s victim to discuss the issues surrounding the threat (unless this confidences to others in the client unit without the prior written might increase the risk). permission of that individual. 6. Encourage the client to surrender any weapons he or she may The state of Florida enacted law that allows social workers to disclose have. information in accordance with the HHS directive, with some 7. Increase the frequency of therapeutic sessions and other forms of constraints. The Florida Statute allows disclosures by clinical social monitoring. workers to alert the “police, a parent or other family member, school 8. Be available or have a backup available, at least by telephone. administrators or campus police, and others who may be able to 9. Refer the client to a psychiatrist if medication might be intervene to avert harm from the threat.” appropriate and helpful or if a psychiatric evaluation appears to be warranted. The Florida Statute says, “The confidentiality between a clinical social 10. Consider hospitalization, preferably voluntary, if appropriate. worker may be waived when there is a clear and immediate probability of physical harm to the patient or client, to other individuals, or to When making decisions about disclosure of PHI, HIPAA and the society, and the clinical social worker communicates the information Florida Statutes must be reviewed. The University of Florida Legal only to the potential victim, appropriate family members, or law department has researched these areas and suggests the following: enforcement or other appropriate authorities.” (Fla. Stat. 491.0147(3). The HIPAA Privacy Rule provides an extensive list of permitted There are two major discrepancies between the Florida Statutes disclosures, however, where Florida State Statutes provide greater and the HIPAA Privacy Rule. HIPAA allows for the disclosure of privacy protections or privacy rights with respect to patients’ PHI, state PHI without the client’s authorization or consent in some special laws will apply, overriding HIPAA (UF, 2013). The Florida Statutes circumstances, including payment for health care services, or to law and HIPAA are in agreement with the mandatory requirement to enforcement for the investigation of criminal activity, including abuse disclose the following information: that has happened or potentially could happen in the future. The ●● Gunshot wounds and life-threatening injuries. Florida Statutes do not allow disclosure of information as follows: ○○ A physician, nurse, or employee of a hospital, sanitarium, 1. “Medical records, including those related to mental health, may clinic, or nursing home treating or receiving a request for not be furnished to, and the medical condition of a patient may treatment to report immediately to local law enforcement not be discussed with, any person other than the patient or the officials any gunshot wound or life-threatening injury patient’s legal representative or other health care practitioners and indicating an act of violence. (Statute 790.24). providers involved in the care or treatment of the patient, except ●● Suspected child abuse. upon written authorization of the patient.” (Fla. Statute 456.057(7) ○○ Any person, including a health care provider, who knows or (a). The confidentiality between a clinical social worker, mental has reasonable cause to suspect child abuse, abandonment health counselor, or psychotherapist may be waived when there is or neglect by a parent, legal custodian, caregiver, or other a clear and immediate probability of physical harm to the patient person responsible for the child’s welfare, to report such or client, to other individuals, or to society, and the clinical social knowledge or suspicion to the Department of Children and worker, mental health counselor, or psychotherapist communicates Families (DCF) Central Abuse Hotline. (Fla. Stat. 39.201(1). the information only to the potential victim, appropriate family ●● Vulnerable adult abuse. members, or law enforcement or other appropriate authorities. (Fla. ○○ Any person who knows or has reasonable cause to suspect Stat. 491.0147(3). (UF, 2013). the abuse, neglect or exploitation of vulnerable adults to 2. No exception is provided for disclosure of PHI to insurance immediately report such knowledge to the DCF Central companies for purposes of payment, or to law enforcement Abuse Hotline. (Fla. Stat. 415.1034(2). officials for an investigation. According to Florida Statutes, the ●● Sexual battery. social work agency is not allowed to confirm that the client has ○○ Two Florida Statutes cover reporting of a crime of sexual ever received services at all (UF, 2013). battery. ■■ Any person who observed the commission of a crime of In contrast to the Florida statutes, psychotherapy or case notes can be sexual battery must immediately report such offense to disclosed, but have some exclusions under HIPAA. Case notes include a law enforcement official. (Fla. Stat. 794.027). any notes that social workers take for their own use, rather than standard ■■ Florida’s School Law mandates instructional personnel or general documentation required in all cases. Under HIPAA, these or administrative personnel having knowledge that notes require consent or a waiver signed by clients before they can be a sexual battery has been committed by a student disclosed. Signed consent forms for authorizing the release of medical upon another student to report the offense to a law records do not cover psychotherapy or case notes unless the document enforcement agency having jurisdiction over the school specifically includes them in the consent form. These notes must be or over the place where the sexual battery occurred, if stored separately from the client’s records, and it is the decision of the not on the grounds of the school. (Fla. Stat. 1012.799). social worker to decide whether to keep and store the notes. This covers the social worker regardless of whether the Because Florida law may lead to confusion and is one of the states school or an outside agency employs them. that fall short of a clear requirement to warn, there are some guidelines ●● Deaths. to follow that have been effective in these situations. Reamer (2003) ○○ Any person who has reasonable cause to suspect that a child outlines 10 steps that may be followed when a social worker has died as a result of child abuse, abandonment, or neglect is reason to believe that a client poses a threat to another party: required to report his or her suspicion to the appropriate 1. Consult an attorney who is familiar with state law on the duty to medical examiner. (Fla. Stat. 39.201(3). warn or protect third parties. ○○ Any person in the district where a death occurs who 2. Consider asking the client to warn the victim (unless the social becomes aware of the death of any person in the state worker believes this contact would only increase the risk). occurring under the following circumstances, is required to

SocialWork.EliteCME.com Page 56 report such death and circumstances to the district medical ●● Disclosures to law enforcement. examiner. (Fla. Stat. 406.12): ○○ Florida Statutes direct medical records be furnished in any ■■ As a result of criminal violence. case or criminal action, unless otherwise prohibited by law, ■■ By accident. upon the issuance of a subpoena from a court of competent ■■ By suicide. jurisdiction, provided proper notice is given to the patient or ■■ Suddenly, when in apparent good health. the patient’s legal representative by the party seeking such ■■ Unattended by a practicing physician or other records. (Fla. Stat. 456.057(7)(a)(3). recognized practitioner. ●● Disabled drivers. ■■ In any prison or penal institution. ○○ Any physician, person or agency having knowledge of any ■■ In police custody. licensed drivers or applicant’s mental or physical disability ■■ In any suspicious or unusual circumstance. to drive or need to obtain or to wear a medical ID bracelet ■■ By criminal abortion. is authorized to report such knowledge to the Department ■■ By poison. of Highway Safety and Motor Vehicles. The report should ■■ By disease constituting a threat to public health. be in writing and limited to full name, DOB, address and ■■ By disease, injury of toxic agent resulting from description of the alleged disability of any person over 15 employment. years of age having mental or physical disorders that could ●● Public health surveillance. affect his or her driving ability. (Fla. Stat. 322.126(2). ○○ Florida Statutes mandate reporting of the following diseases ●● DUI and motor vehicle accidents. and injuries to the Florida Department of Health: ○○ When any health care provider who is providing medical ■■ Sexually transmissible diseases (Fla. Stat. 384.25). care in a health care facility to a person injured in a motor ■■ Tuberculosis (Fla. Stat. 392.53). vehicle crash, becomes aware, as a result of any blood ■■ Cancer (Fla. Stat. 385.202). test performed in the course of medical treatment, that the ■■ Adverse incidents involving medical treatment (Fla. person’s blood-alcohol levels meet or exceed 0.08 grams Stat. 459.026). of alcohol per 100 ml. of blood, the health care provider ●● Worker’s Compensation. may notify any law enforcement officer or law enforcement ○○ Florida Statutes mandate, upon the request of the employer, agency. The notice must be given within a reasonable time the carrier, an authorized, qualified rehabilitation provider, after the health care provider receives the test result. The or the attorney for the employer or carrier, that the medical notice is limited to the name of the person being treated, the records of an injured employee be furnished to those name of the person who drew the blood, the blood-alcohol persons and the medical condition of the injured employees level indicated by the test and the date and time of the be discussed with those persons, if the records and the administration of the test (Fla. Stat. 316.1933 (2)(a). discussions are restricted to conditions relating to the workplace injury. (Fla. Stat. 440.13(4)(c).

HIPAA and the use of long-distance technology in service delivery HIPAA Privacy Rules apply to the delivery of service to clients using The AMHCA Code of Ethics (2010) provides the following directives electronic systems over distances when direct service with clients is related to the use of technology in counseling: difficult. This allows the practitioner to reach more clients without expending time for travel and to reach clients in rural or underserved 6. Technology-Assisted Counseling areas. Technology-assisted counseling includes but is not limited to Skype is one of the most popular and widely used electronic systems computer, telephone, internet and other communication devices. used in the field of social work as well as for the delivery of medical Mental health counselors take reasonable steps to protect patients, and mental health services. After considerable study over the past clients, students, research participants and others from harm. Mental two years, the NASW has drawn some conclusions about the use of health counselors performing technology- assisted counseling comply technology as it relates to HIPAA federal Privacy Rules, which must with all other provisions of this Ethics Code. Mental health counselors: be followed in all states. The NASW, ASWB, AAMFT, AMHCA and HIPAA codes of ethics address the use of electronic systems, and a) Establish methods to ascertain the client’s identity and obtain these documents should be studied in detail. A brief summary of the alternative methods of contacting the client in an electronic emergency. guidelines from these organizations is included to for purposes of 6b) Electronically transfer client confidential information to authorized comparison. third-party recipients only when both the mental health counselor The AAMFT Code of Ethics includes the following guidelines on the and the authorized recipient have secure transfer and acceptance use of technology in therapy services: capabilities as state and federal laws regulate. 1.14 Electronic Therapy. Prior to commencing therapy services c) Ensure that clients are intellectually, emotionally, and physically through electronic means (including but not limited to phone and capable of using technology-assisted counseling services, and of Internet), marriage and family therapists ensure that they are compliant understanding the potential risks and/or limitations of such services. with all relevant laws for the delivery of such services. Additionally, d) Provide technology-assisted counseling services only in practice marriage and family therapists must: (a) determine that electronic areas within their expertise. Mental health counselors do not provide therapy is appropriate for clients, taking into account the clients’ services to clients in states where doing so would violate local intellectual, emotional, and physical needs; (b) inform clients of the licensure laws or regulations. potential risks and benefits associated with electronic therapy; (c) e) Confirm that the provision of technology-assisted counseling ensure the security of their communication medium; and (d) only services are not prohibited by or otherwise violate any applicable state commence electronic therapy after appropriate education, training, or or local statutes, rules, regulations or ordinances, codes of professional supervised experience using the relevant technology. membership organizations and certifying boards, and/or codes of state licensing boards.

Page 57 SocialWork.EliteCME.com A two-part NASW study on the use of Skype in social work provided The verdict is still out, and the NASW and ASWB are in the process the following information (Morgan, 2003): of researching and developing policy on technology for service ●● In the practice of clinical social work, if client billing to health delivery. There are many liability issues to consider when using Skype, insurance is done electronically, including a billing service that e-therapy, teletherapy and other forms of technology in the practice of bills electronically and clients who self pay, HIPAA rules apply to long-distance social work and supervision. all confidential client information. These include: ●● The social worker, as a covered entity under HIPAA, must ●● Missing critical clinical information: The client may provide comply with security measures that cover PHI that is stored or important information through facial expression, body language, transmitted electronically. In most cases, Skype transmissions gesture, and other nonverbal cues that may be missed through include confidential client PHI, and when used by a social worker, email, telephone or other electronic communication between HIPAA rules are in force. (45 CFR § 160.103). client and social worker. ○○ HIPAA rules protect the confidentiality and integrity of all ●● Handling crisis situations: The therapist may miss danger electronic systems the social worker assembles, stores, receives, signals and is so far away that distance may interfere with the maintains, shares or transmits that include client’s PHI. This client relationship. Clients may not turn to the social worker for includes all verbal, visual and auditory transmissions used in immediate concerns or in a crisis because they believe they are Skype and other teleconference transmission. too far away. ○○ The social worker is required by HIPAA to take measures ●● Misrepresentations or misunderstandings: Clients may disguise, to guard against any anticipated threats to the security and alter, misrepresent or attempt to deceive the social worker using privacy of the client’s PHI which may occur due to human email, phone or communication through technology that is easier errors, system error, or security breach. to do without face-to-face contact. Both the client and social ○○ HIPAA rules cover the social worker and all colleagues, staff, worker may miss information because of technology glitches or associates, and anyone who receives PHI electronically, so all transmission breaks. are required to protect the privacy and security of clients’ PHI. ●● Out-of-state concerns: The client may not be in the same state ○○ Social workers must be knowledgeable about the procedures where the social worker is licensed, which may be prohibited by and policies designed to protect PHI that is stored and law when delivering services across state or country borders. If transmitted using all forms of technology. The computer that a client is in Florida but the social worker is not, Florida statutes is used to Skype or transmit information may have additional may not be applied or followed. Conversely, which state would PHI stored for other clients as well. handle a malpractice case alleged against the Florida social ○○ The company that developed Skype recently stated that worker practicing with an out-of-state client? no type of counseling or therapy practice that includes ●● Too many clients: Technology may add speed and availability for PHI should be conducted using Skype because of privacy service but may lead to case loads too large to manage effectively. concerns and possible breach of security. ●● All laws, standards, and practice guidelines from the NASW ○○ Skype is not a system that was designed for the delivery Code of Ethics and Florida Statutes must be followed as if the of secure PHI in social services; the company prohibits social worker is meeting face to face with the client. If that level the practice; and PHI and confidential, privileged of quality service cannot occur using distance technology, it communication is not secure using this system. should be avoided. ○○ Social workers’ licenses only cover practice in Florida, so the use of Skype across state lines may be a liability issue and These are issues that must be considered, but at this time, the Florida could affect the malpractice insurance coverage they carry. Statutes do not cover the practice of social workers , mental health counselors, clinical social workers or marriage and family therapists The American Psychological Association (APA) has said: licensed in Florida with clients outside the borders of the state. In Skype is not an encrypted site and is, therefore, not a confidential addition to distance social work services to clients, many agency means of communication. Providing psychotherapy on supervisors use distance supervision. The latest information released in unencrypted sites is ill advised and thus, informed consent is 2013 from the NASW on long-distance supervision is as follows: important. Clients may prefer to meet via Skype and express no concern about the absence of encryption. Therefore, we suggest Distance Supervision that clients be made fully aware of the confidentiality concerns, The use of technology for supervision purposes is gradually and if they choose to meet through this medium, that the decision increasing. Video-conferencing is a growing technological tool used be documented by the psychologist (APA, 2013). to provide supervision, especially in remote areas. Some jurisdictions allow electronic means for supervision; others may limit the amount For these reasons, the use of Skype, or other videoconferencing of supervision that can be provided from a distance. When using technology not designed for health care providers, is not advised for technology to provide distance supervision, one must be aware of use in the practice of social work at this time. The best-practice update standards of best practice for providing this tool and be knowledgeable from the NASW in 2013 provides the following statement about of the statutes and regulations governing the provision of such technology use: services. Supervisors should be aware of the risks and benefits of using All applicable federal, provincial, and state laws should be technology in social work practice and implement them in the learning adhered to, including privacy and security rules that may process for supervisees (NASW, 2013). address patient rights, confidentiality, allowable disclosure, and documentation and include requirements regarding data protection, encryption, firewalls, and password protection.

SocialWork.EliteCME.com Page 58 Resources for further information Clinical Social Work Mental Health Counseling Association of Social Work Boards (ASWB) Phone: 800.255.6880 | American Counseling Association (ACA) Phone: 800.347.6647 | Fax: Fax: 540.829.0142 [email protected] 800.473.2329 Questions: ACA Web Idea Bank – Frequently Asked National Association of Social Work (NASW) – Florida Questions Chapter Phone: 850.224.2400 | Fax: 850.561.6279 [email protected] American Mental Health Counselor Association (AMHCA) Phone: Marriage and Family Therapy 800.326.2642 | Fax: 703.548.4775 Contact: http://www.amhca.org/ American Association of Marriage and Family Therapists service/contact.aspx (AAMFT) Phone: 703.838.9808 | Fax: 703.838.9805 [email protected] Florida Counseling Association (FCA) Phone: Association of Marriage and Family Therapists (AMFT)– Florida 305.814.9460 [email protected] or [email protected] Division Phone: 850.681.3639 | Fax: 850.681.0284 [email protected] Florida Mental Health Counselor Association (FMHCA) Phone: 813.221.5466 [email protected] National Board of Certified Counselors (NBCC) Phone: 336.574.0607 | Fax: 336.574.0017 [email protected]

References ŠŠ American Association of Marriage and Family Therapy (2012). AAMFT Code of ŠŠ National Association of Social Workers (2013) Clinical Practice Update. Retrieved Ethics. Retrieved September 19, 2014 from http://www.aamft.org/iMIS15/AAMFT/ August 2, 2013 from http://naswfl.org/ Content/Legal_Ethics/Code_of_Ethics.aspx ŠŠ National Association of Social Workers (2008). NASW Code of Ethics. NASW ŠŠ American Mental Health Counselors Association (2010). AMHCA Code of Ethics. Press: Wash., DC. Retrieved July 26, 2013 from http://www.socialworkers.org/ Retrieved September 19, 2014 from http://www.amhca.org/assets/content/AMHCA_ pubs/code/default.asp Code_of_Ethics_2010_update_1-20-13 ŠŠ National Association of Social Workers and Association of Social Work Boards. ŠŠ Boynton v. Burglass, (1991). 590 So. 2d 446 (Ct. of Appeal of Florida, 3rd District (2005). NASW and ASWB Standards For Technology and Social Work Practice. (1991). Retrieved July 28, 2013 fromhttp://www.socialworker.com/jswve/fall11/ Retrieved August 1, 2013 from www.socialworkers.org/practice/standards/ fall112.pdf NASWTechnologyStandards.pdf ŠŠ Division 29 (Psychotherapy) Report from the Task Force on Telepsychotherapy. ŠŠ Official Website of the Florida Legislature (2012-2013) Retrieved July 26, 2013 (2010). American Psychological Association. Retrieved July 26, 2013 from http:// from http://www.leg.state.fl.us/Welcome/index.cfm?CFID=300377769&CFTOK www.divisionofpsychotherapy.org/continuing-education/report-from-the-task-force- EN=87861201 on-telepsychother ŠŠ Polowy, C.I. and Morgan, S. (2011). Client Confidentiality and Privileged ŠŠ Ethical Principles of Psychologists and Code of Conduct. (2010) American Communications. NASW Law Note. NASW Press: Wash., DC. Retrieved July 27, Psychological Association. Retrieved July 27, 2013 from http://www.apa.org/ethics/ 2013 from http://nasw-wa.org/health-care-privacy-exceptions-to-avert-harm-and- code/index.aspx duty-to-warn/ ŠŠ Florida Department of State Library: Law Archives of Florida (2013), Retrieved ŠŠ Reamer, F. (2003). Social Work Malpractice and Liability (2nd Ed.). New York July 26, 2013 from http://laws.flrules.org/ ŠŠ Columbia University Press. Retrieved July 26, 2013 from http://www.socialworker. ŠŠ 42 CFR § 2.63 (2013). Confidential Communications. com/home/index2.php?option=com_content&do_pdf=1&id=193 ŠŠ Code of Federal Regulations - Title 42: Public Health (2010). Retrieved July 27, ŠŠ Since You Asked: Social Workers and Skype, Part I. (2013). National Association of 2013 from http://cfr.vlex.com/vid/2-63-confidential-communications-19800422 Social Workers - Illinois Chapter. Retrieved July, 26, 2013 from ŠŠ 45 CFR § 164.512 (2013). Electronic Code of Federal Regulations Retrieved July, ŠŠ http://naswil.org/news/networker/featured/since-you-asked-social-workers-and- 27, 2013 from www.ecfr.gov/cgi-bin/text-idx?c=ecfr;sid=ae3a570a5b3df38308f822f skype-part-i/ 5b32ec9a6;rgn=di... ŠŠ Tapp, K., Payne, D. Guidelines for Practitioners: A Social Work Perspective on ŠŠ Green v. Ross, 691 So. 2d 542 (Ct. of Appeal of Florida, 2nd District, (1997). Discharging the Duty to Protect. (2011). Journal of Social Work Values and Ethics, Retrieved July 26, 2013 from http://www.socialworker.com/jswve/fall11/fall112.pdf Volume 8, No. 2, Pg. 2-3Retrieved July 26, 2013 from http://www.socialworker.com/ ŠŠ HIPAA (1996). Retrieved July, 26,2013 from www.hhs.gov/ocr/privacy /hipaa/ jswve/fall11/fall112.pdf understanding/index.html ŠŠ State of Florida Board of Clinical Social Work (2004). Department of Health, Case ŠŠ Law Disclosures of PHI Under HIPAA and FLORIDA State Law. (2013). no. 2000-02291, DOH-04-1112.Retrieved August 1, 2013 from http://www.doh. University of Florida. Retrieved July 28, 2013 from http://privacy.health.ufl.edu/faq/ state.fl.us/mqa/FinalOrders/10-15-04/DOH-04-1112.pdf disclosures_matrix.shtml ŠŠ Tarasoff v. Regents of the University of California, 108 Cal. Rptr. 878 (Ct. App. ŠŠ Morgan, S. and Polowy, C.I. (2005). Social Workers and the Duty to Warn.2005. 1973); NASW Legal Defense Fund, Legal Issue of the Month. Retrieved July 30, 2013 from ŠŠ Reversed and Remanded, 13 Cal.3d 177 (1974); modified, 17 Cal.3d 425 (1977) https://www.socialworkers.org/ldf/legal_issue/2005/200502.asp ŠŠ Retrieved July 26, 2013 from http://www.publichealthlaw.net/Reader/docs/Tarasoff. ŠŠ Morgan, S. and Polowy, C.I. (2003). A First Look at the HIPAA Security pdf ŠŠ Standards. National Association of Social Workers, Legal Defense Fund, Legal Issue ŠŠ U.S. Department of Health and Human Services (2013). Message to Our Nation’s of the Month. (2003). Retrieved July 26, 2013 from https://www.socialworkers.org/ Health Care Providers. Retrieved July 28, 2013 from http://www.hhs.gov/ocr/office/ ldf/legal_issue/2003/200304.asp lettertonationhcp.pdf ŠŠ Morgan, S. (2013). Health Care Privacy Exceptions to Avert Harm and Duty to Warn ŠŠ Youth and Families Independent Living Services Child Welfare and Preservation. ŠŠ National Association of Social Workers. Retrieved July 28, 2013 from http://morgan (2012). Florida Department of Children and Families. Retrieved July 30, 2013 ,s.(2013).health care privacy exceptions to avert harm and duty to warn/ from DCFhttp://www.dcf.state.fl.us/programs/childwelfare/rule_development.shtml Children

Page 59 SocialWork.EliteCME.com Florida Law for the Social Worker, Mental Health Counselor, and Marriage and Family Therapist Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your final examination.

1. The professions of social work, mental health counseling and 7. The HIPAA Privacy Rule ______. marriage and family therapy in Florida ______. a. Does not prevent the ability to disclose necessary information a. Are governed by a wide range of Florida Statutes. about a patient to law enforcement, family members of the b. Falls under the jurisdiction of Title XXX Department of patient, or other persons, when the provider believes the Education. patient presents a serious danger to himself or other people. c. Are governed by their individual boards only. b. Says psychotherapy or case notes can never be disclosed. d. Are no longer regulated by the state. c. Provides an extensive list of permitted disclosures, and despite Florida State Statutes that provide greater privacy protections 2. Any communication between any person licensed or certified or privacy rights with respect to patients’ PHI, the HIPAA rule under this chapter and her or his patient or client shall be will apply. confidential. This secrecy may be waived ______. d. Does not agree with the Florida Statutes agree on shared a. When the client fails to pay his or her bill. information to any degree. b. When the person licensed or certified under this chapter is a party defendant to a civil, criminal, or disciplinary action 8. The American Mental Health Counseling Association Code of arising from a complaint filed by the patient or client. Ethics (AMHCA) 2010 revision provides which of the following c. When a patient or client gives verbal agreement to the waiver. information on disclosure of information related to the duty to warn? d. When one person in a family receiving therapy agrees to the a. The release of information without consent of the client may waiver. only take place under the most extreme circumstances: the protection of life (suicidality or homicidality), child abuse, 3. Private instructional personnel ______. and/ or abuse of incompetent persons and elder abuse. a. Excludes speech-language pathologists. b. There are no circumstances that allow the release of b. Collaboration may supplant the school district’s information without a specific court order. responsibilities under the Individuals with Disabilities c. Release of information is governed by the guidelines in HIPAA. Education Act. d. The therapist must get the consent of the client regardless of c. Provide mental health programs to all state employees. the extreme circumstances above. d. Involves collaboration to promote educational progress and assist students in acquiring essential skills. 9. According to a two-part NASW study on the use of Skype in social work, ______. 4. Aftercare services include: a. In the practice of clinical social work, if client billing to health a. Providing support to young adults formerly in foster care insurance is done electronically, HIPAA rules do not apply. through making of service referrals in the community to assist b. The company that developed Skype recently stated that young adults in developing “the skills and abilities necessary counseling or therapy practice that includes PHI may be safely for independent living.” conducted using Skype. b. No financial assistance for necessities. c. The American Psychological Association (APA) has c. Short-term assistance for housing. said: Skype is not an encrypted site and is, therefore, d. A guaranteed job. not a confidential means of communication. Providing psychotherapy on unencrypted sites is ill advised and thus, 5. Under the Quality Parenting Initiative, roles and responsibilities of informed consent is important. caregivers, a caregiver shall ______. d. Liability issues to consider when using Skype, e-therapy, a. Not be allowed to participate in developing a case plan for the teletherapy and other forms of technology in the practice of child. long-distance social work and supervision include boundary b. Work to help the child break ties to members of his or her violations. biological family. c. Refrain from attempting to advocate for the child with the 10. There are many liability issues to consider when using Skype, child welfare system, the court and community agencies. e-therapy, teletherapy and other forms of technology in the practice d. Participate fully in the child’s medical, psychological, and of long-distance social work and supervision. The Florida Statutes dental care. apply to long-distance social work, counseling and mental health therapy in one of the following ways? 6. The Florida Statute ______. a. Long- distance services are allowed by the statute. a. Is more restrictive than some other states’ because the b. The statutes do not address long-distance services at all. disclosure of confidential information is required. c. The Florida Statutes do not cover the practice of social b. Indicates that confidential communication between the workers, mental health counselors, clinical social workers or licensed or certified mental health worker and the patient or marriage and family therapists licensed in Florida with clients client may be waived in these cases. outside the borders of the state. c. Says “The confidentiality between a clinical social worker d. There is no risk to Florida licensed practitioners to engage in must be waived when there is a clear and immediate long-distance services with clients. probability of physical harm to the patient or client, to other individuals, or to society.” d. Provides an exception for disclosure of PHI to insurance companies for purposes of payment, or to law enforcement SWFL03FL17 officials for an investigation.

SocialWork.EliteCME.com Page 60 Chapter 5: Cultural Competence in Mental Health Practice Part 1: Principles, Preparation and Priorities for Practice 3 CE Hours

By: Deborah Converse, MA, NBCT, with: Kathryn Brohl, MA, LMFT and Rene’ Ledford, LCSW, BCBA

Learning objectives ŠŠ List and define five qualities required for effective mental health ŠŠ Identify and describe four themes of cultural competence in practice. effective practice. ŠŠ Describe four components of multi-cultural competency in mental ŠŠ List and define eight socio-cultural areas that a culturally competent health practice. practitioner must be prepared to assess and address with clients. ŠŠ Identify four barriers to multi-cultural competence in mental health ŠŠ Compare and contrast a group-specific approach and a practice and discuss strategies to avoid or overcome them. multidimensional approach as they inform cultural competence in ŠŠ Define five components of the HIPAA Privacy Rules that impact mental health practice. multicultural competence in mental health practice.

Introduction Demonstrating cultural competence is an integral part of mental health in practice with clients and their client groups. This type of counseling service delivery. On the national level this issue has received greater recognizes diversity and embraces approaches that support the worth, support as the United States government recognizes the influence and dignity, potential and uniqueness of individuals and their historical, impact of converging nationalities and cultures. Because divisions culture, economic, political and psychosocial context (ACA, 2005). of race, ethnicity and culture exist in the United States, there is an The National Association of Social Workers (NASW) notes in its revised increasing awareness of cultural competence and how it can eliminate Code of Ethics (2008) that social workers should understand culture and disparities in care for people of diverse racial, ethnic and cultural its function in human behavior in society, which requires recognizing the backgrounds. strengths that exist in all cultures. The counselor should have a knowledge While the population in the United States continues to diversify, the U.S. base of the client’s culture or be able to demonstrate competence in Department of Health and Human Services (DHHS, 2001) has continued the provision of services that are sensitive to the client’s culture and to to report disparities in mental health services for ethnic minorities. differences among people and cultural groups (NASW, 2008). Ethnic minorities are less likely to have access to and receive mental There is no specific form of counseling that is multicultural because “we health services, often receive a poorer quality of services, and are under- are all multicultural individuals, and everyone lives in a multicultural represented in mental health research (DHHS, 2001). society” (Arredondo et al., 1996). All counseling is multicultural. This In addition, ethnic minorities experience higher disability rates compared does not mean that mental health professionals need different counseling to European Americans (Smart and Smart, 1997). Disability and chronic theories and practices for all the possible groups in the society. No mental illness often co-exist with mental disorders, such as depression and anxiety health counselor can be prepared to counsel every possible client specific (Bairey-Mertz et al., 2002; Falvo, 2005). This points to the need for to his or her ethnic group. clinicians’ competency in addressing mental health concerns of minority Mental health counselors will need special preparation to work with clients clients with disabilities. However, many clinicians are inadequately from a particular group. It is here that knowledge of the backgrounds prepared to serve ethnically diverse populations (DHHS, 2001) or to of particular clients is necessary. Such knowledge provides a basis for address disability issues in counseling (Sue and Sue, 2003). understanding clients, colloquially, knowing “where the client is coming Given the consistent mental health service disparities, a lack of clinical from” (Patterson, 2004). Multicultural competencies simply provide a cultural competencies poses a significant problem that needs to be compendium of the elements of this knowledge. The knowledge is acquired addressed in the counseling field. Because of the significant role that not from specific academic courses but instead by living in the community training programs can play in enhancing the cultural competency of with the kind of clients mental health counselors serve in their practice. clinicians, DHHS recommends clinicians complete training programs that The assumption that simply having knowledge of the culture of the address the impact of culture on mental health and mental health services client will lead to more appropriate and effective therapy has not so they can provide culturally responsive services for minority clients. been established. Sue and Zane (1987) stated, “Recommendations The American Counseling Association in its 2005 Code of Ethics that admonished therapists to be culturally sensitive and to know the defines culture as membership in a socially constructed way of living culture of the client have not been very helpful.” They continue: that incorporates collective values, norms, boundaries and lifestyles. The major problem with approaches emphasizing either cultural These elements are created with others who share similar worldviews knowledge or cultural-specific techniques is that neither is linked including biological, psychosocial, historical, psychological and other to particular processes that result in effective psychotherapy. factors (ACA, 2005). Recommendations for knowledge of culture are necessary but The ACA states that multicultural/diversity competence comes when not sufficient for effective treatment. The knowledge must be counselors possess cultural diversity awareness, knowledge about self transformed into concrete operations and strategies. and others, and how this awareness and knowledge is applied effectively

Page 61 SocialWork.EliteCME.com Several researchers on multicultural counseling have gone beyond Indian youth, the counselor is likely to be confronted by passively counseling as a matter of knowledge and skills and have listed a nonverbal clients who listen and absorb knowledge selectively. number of practitioner characteristics or attitudes necessary for A counselor who expects clients to verbalize their feelings is not effective practice. Wohl (1976) noted that the healing function includes likely to have much to do with Native American Indian clients. a caring and concern on the part of the healer, and that therapy Several researchers have proposed that clients from ethnic minority groups promotes a special, close relationship. desire a structured relationship in which the mental health practitioner gives Pederson (1976) identified the “expectations of troubled contrasting advice and solutions to problems (Sue and Sue, 1990; Sue and Morishima culture clients and the personal qualities of a counselor as being closely 1982; Vontress, 1981). However, cultural groups are not pure and discrete, related to healthy change, accurate empathy, and non-possessive warmth but overlapping. The process of globalization is blurring the differences. and genuineness that are essential to effective mental health care.” The only workable product of a multicultural society is a society of Vontress (1976) emphasize the importance of rapport as “the emotional individuals who must ultimately absorb different cultures into themselves. bridge between the counselor and the counselee. Simply defined, In the current global society, few discrete classifications are possible. rapport constitutes a comfortable and unconstrained mutual trust and If classifications were possible, because every client belongs to a confidence between two persons.” number of combinations and permutations of these groups, the number Over time, it was recognized that professional confidence is inherent in would be staggering. Attempting to develop different theories, methods the personal qualities of the mental health practitioner. The competent and techniques for each of these groups would be an insurmountable mental health counselor is one who provides an effective therapeutic task. This approach is not only impossible, but also irrelevant and relationship. The nature of this relationship has long been known and harmful when counseling individual clients (Patterson, 2004). is the same regardless of the group to which the client belongs. Differences among clients fall into two kinds, accidental and essential. In the list of multicultural competencies developed by Arrendondo Cultural, ethnic and racial differences are accidental. The accident is in 1996, there is not a specific list of groups or specific treatments or the place of birth. But all clients are alike in one basic, essential way in techniques appropriate for each. Those therapeutic decisions are left that they are all human beings (Patterson, 2004). to the mental health practitioner. Pederson (1976) wrote “each cultural Pinker (1997) notes “surveys of the ethnographic literature show group requires a different set of skills, unique areas of emphasis, and that peoples of the world share an astonishingly detailed universal specific insights for effective counseling to occur.” In one early review, psychology.” The nature of all human beings provides the basis for a Peterson reported that: solution to the problem of multicultural counseling. What is needed Native American Indian culture presents unique requirements is a system of counseling or psychotherapy therapy based upon these for an effective counseling. When counseling Native American common characteristics.

A universal system of counseling or psychotherapy The essence of a universal system of mental health counseling (Patterson, their own values, and arriving at an individual solution are 1995) has long been known. It is what is known as client-centered therapy. core qualities that transcend culture.” There are five basic counselor qualities in this system (Rogers, 1957): 5. Structuring – There is another element in all counseling that 1. Respect for the client – This includes having trust in the client and is of particular importance in intercultural counseling. Vontress assumes that the client is capable of taking responsibility for himself (1976) says: or herself, and capable of making choices and decisions to resolve “On the whole, disadvantaged minority group members have problems. Moreover, he or she should be given the right to do so. had limited experiences with counselors and related therapeutic 2. Genuineness – Counseling is a real relationship. The counselor professionals. Their contacts have been mainly with people does not assume a role as an all- knowing expert, is not impersonal who tell them what they must and should do. Relationships and cold, but a real person. with professionals who placed major responsibility upon the 3. Empathetic understanding – Empathic understanding is more than individual for solving his own problems are few. Therefore, knowledge based on the group to which a person belongs. It requires the counselor working within such a context should structure that the mental health counselor be able to use this knowledge as and define his role to client. Counselors should indicate what, it applies to the unique client, which involves entering the client’s how, and why they choose to proceed in a certain way. Failure world and seeing it as he or she does. “The ability to convey to structure early and adequately in counseling can result in empathy in a culturally consistent and meaningful manner may be unfortunate misunderstanding (Sue and Zane, 1987). the crucial variable to engage the client” (Ibrahim, 1991). The only Failure to structure may also result in failure of the client to continue way mental health counselors can enter the world of the client is counseling. Structuring is necessary whenever the client does not with the permission of the client, who communicates the nature of know what is involved in the therapeutic relationship, how that mental his or her world to the practitioner through self-disclosure. Plus, health counselor will function, what is expected of the client, or if the client self-disclosure is the essence of counseling. The mental health client holds misconceptions about the process (Patterson, 2004). practitioner’s respect and genuineness facilitates client self–disclosure (Patterson, 2004). These professional qualities are not only essential for effective 4. Communication of empathy, respect and genuineness to counseling, they are also the elements of all facilitated interpersonal the client – This must be perceived, recognized and felt by the relations. They are neither time-bound nor culture-bound. client if the counselor is to be effective. This perception becomes Reviews of recommendations and suggestions for specific methods difficult with clients who differ from the therapist in culture, race, and techniques for counseling multicultural clients indicate there is no socioeconomic class, age and gender. Understanding of cultural evidence for the appropriateness or effectiveness of such methods. differences in verbal and nonverbal behaviors can be very helpful. Other methods suggested for counseling clients from other cultures are Sue and Sue (1990) explain: generally recognized, inextricable methods for which there is “Qualities such as respect and acceptance of the individual, evidence. It follows that we do not need specific competencies for unconditional positive regard, understanding the problem from multicultural clients, but we need methods and approaches that are the individual’ s perspective, allowing the client to explore effective with all kinds of clients. These methods constitute a universal system of counseling (Patterson, 2004).

SocialWork.EliteCME.com Page 62 The universal nature of counseling is reflected in the code of ethics for all In the 21st century, cultural competence includes recognizing mental health organizations. The National Association of Social Workers’ historical and social prejudices in assessment, misdiagnosis and primary mission is to enhance well-being and help meet the basic inference of pathology; minimizing bias; respecting diversity; support needs of all people, with particular attention to the needs of those who network involvement; communication; privacy; sexual orientation; are vulnerable, oppressed and living in poverty. The historic and defining environmental adaptation; social advocacy; and ethics competence. feature of social work is the profession’s focus on the individual’s well The continued growth in the number of individuals and families being in a social context and the well-being of society (NASW, 2008). from diverse backgrounds challenges counselors’ ability to meet the NASW states that the social work profession is rooted in a set of core needs of a growing and diverse society. In 1994, Sue, Arredondo and values. These core values, embraced throughout the profession’s history, McDavis published what became known as the multicultural counseling are the foundation of social work’s unique purpose and perspective: competency framework. These competencies provide a foundation for ●● Service. all counselors to focus on the cultural makeup of the counselor and ●● Social justice. client as well as how culture affects daily living in a diverse society. ●● Dignity and worth of all people. Cannon (2008) reported that the changing demographics of the United ●● Importance of human relationships. States population demand that counselor education programs provide ●● Integrity. training experiences that facilitate the development of multicultural ●● Competence. competent counselors. The growing population of diverse individuals These core values must be balanced within the context and complexity in the United States will put more pressure on counselors to be of the human experience. The ACA Code of Ethics Preamble states culturally competent in their service delivery. that the American Counseling Association serves educational, scientific During the American Counseling Association (ACA) 2010 conference, and professional organizations whose members work in a variety of the Multicultural Social Justice Leadership Development Academy settings and serve in multiple capacities. ACA members are dedicated (MSJLDA) was held to open a dialogue about the many issues in to the enhancement of human development throughout the lifespan. multicultural competence and social justice advocacy. The academy Association members recognize diversity and embrace a cross-cultural presented information about the development of multicultural approach in support of worth, dignity, potential and uniqueness of competence and offered suggestions to help participants improve their people within their social and cultural context (ACA, 2005). applications of multicultural competence.

What is multicultural competence? The definition of multicultural competence means in part to approach A third presenter, a woman of multiple heritages, represented a the counseling process from the context of the personal culture of the group that receives less attention from counselors and offered a self- client (Sue, Arrendondo and McDavis, 1994; Sue and Sue, 2007). assessment tool to determine attendees’ individual competence as a Professional ethics compel counselors to ensure that their cultural socially just, multicultural counselor. She also presented a theory on values and biases do not override those of the client (ACA, 2005). how to help unlink one’s personal ego from functioning in the role Presenters at the MSJLDA conference shared personal examples of their of multicultural counselor. The final presenter, a male with multiple individual cultures and how these impacted their personal and professional heritages, submitted written materials for participants, focusing the lives, including professional self-awareness, knowledge and skills. discussion on the development of multicultural competent leaders. They also shared experiences that included several variables of The conference was based on multicultural competence as outlined by discrimination. For example, one of the presenters, an immigrant from the American Counseling Association (ACA, 2005) and the Association India, also shared personal experiences of sexism as a woman. Another for Multicultural Counseling and Development (ACMD, 1992). These presenter, an African-American male raised in the United States, organizations focus on the development of multicultural competence represented racism and how it continues to affect how societies view in professional counseling organizations. The conference presentations people of color (Lodge, 2010). served as a way to extend the dialogue of multicultural competence from the unique perspective of individual counselors from around the world.

Barriers and challenges The need for cultural competence became more evident during the These studies noted that to become culturally competent, it is imperative 20th century when the American population tripled. This rapid growth to have cultural knowledge that is perceived as a coalition of theoretical was due to an increase in immigration (Urban and Orbe, 2010) and the concepts and life experiences (Kiselica and Maben, 1999). Therefore, birthrates of racial/ethnic groups currently present in U.S. communities. counselors from another culture must make genuine efforts to integrate During this time it was noted that there were barriers and challenges their knowledge of culture and life experiences from their country and faced by counselors who belong to a minority community. Some the United States. Knowledge about two cultures and the experiences counselors described a feeling of culture shock and inadequacy. The from living in both cultures provided scope for reflection and promoted challenges and struggles indicated that they were not adequately counselor self- awareness (Zalaquett, 2011). prepared to assimilate into the white culture. The next important ingredient for multicultural competence, Counselors often sought to consult colleagues, books and research according to the research, was cultural skills. A skilled counselor literature. Many counselors found that while there was a strong uses interventions that are client-based and serve client needs focus on the challenges faced by counselors with clients from ethnic (Chung and Bemak, 2002). This study discussed the significance of backgrounds different from theirs, there was less focus on the updating knowledge about various counseling techniques, becoming challenges that a minority counselor faces in meeting the needs of more knowledgeable about the indications and contraindications clients who are culturally different (Consoli, Kim, and Meyer, 2008). of the techniques, and emphasized the significance of establishing collaborative relationships between the counselor and the client. According to Pederson (1997), the main features of cultural competence are counselor self-awareness, knowledge about culture, In multicultural counseling, the counselor and the client need to and skills. This belief is consistent with the multicultural counseling discuss which techniques will be beneficial to the client. While competencies developed by Sue, Arrendondo, and McDavis (1994). adhering to the normal counseling and ethical practices in multicultural

Page 63 SocialWork.EliteCME.com counseling, counselors need to be more aware of the limitations in While being cognizant of one’s own culture, beliefs and values, it is their counseling skills in the multicultural context. It is vital to have crucial that counselors do not become culturally encapsulated. Cultural cultural skills in order to serve multicultural populations in the most encapsulation puts counselors at risk of using stereotypes, becoming productive way to facilitate rapport. judgmental, and imposing their values on their client. Being culturally aware and recognizing how culture will affect the Counselors are encouraged to respect and accept their clients and their counseling process helps counselors develop empathetic understanding lifestyles, receiving them as who they are, non-judgmentally. However, toward clients (Pederson, 1991). Ridley (2002) stresses the importance immigrant counselors are faced with many challenges. They must of empathic understanding in multicultural counseling based on self- first educate themselves about the new culture and learn more about experiences, self-awareness and knowledge of culture. Cross-cultural the beliefs and values of the people around them. Counselors might awareness facilitates the counselor’s knowledge, understanding and need to ask clients to better educate them about their cultures. It is respect for culturally diverse clientele (Fukuyama and Niemeyer, 1985). especially important for counselors to establish trust with clients and to demonstrate unconditional positive regard (Zalaquett, 2011).

Stereotypes and perception of other groups Stereotypes, perceptions and beliefs that counselors hold about groups Perceiving clients from other cultures in a negative way might lead that are culturally different could hinder their ability to form helpful and clients to believe that the counselor is superior to them, impairing effective relationships. Collaborative relationships might be difficult the collaborative relationship between the counselor and the client. to form in the presence of such hindrances. Counselor educators must A sincere effort must be made by counselors to remove the “invisible prepare counselors to become culturally competent through: veil” (Sue, 2004). People are all products of cultural conditioning, ●● Revamping training programs. and their beliefs, values and worldview represent the invisible veil ●● Developing multicultural competencies as core standards for the that operates outside the level of consciousness. As a result, people profession. assume that everyone, regardless of race, culture, ethnicity or gender, ●● Providing continuing education for current service providers. shares the nature of reality and truth. This universal assumption is Culturally competent counselors do not see their group’s cultural erroneous, but it is seldom questioned because it is firmly ingrained in heritage, history, values, language, tradition or parts as superior to the individual’s worldview. Counselors must make a sincere effort to that of others. Culturally competent counselors are open to the values, remove that invisible veil (Sue, 2004). norms and cultural heritage of clients, and do not impose their values or beliefs on clients (Sue and Sue, 2007).

Qualities of a multicultural counselor There are several common qualities seen in multicultural competent making and reporting a diagnosis that they believe would cause counselors, not unlike those listed in the section above on the harm to the client or others. universally shared view of counselor competence. The qualities below ●● Proper assessment. Counselors must be cautious when selecting have a particular focus on recognition of aspects of multiculturalism assessment instruments for culturally diverse populations so they (Zalaquett, 2011; Ahmed, 2011): avoid the use of instruments that lack appropriate psychometric ●● Credibility, which may be defined as the constellation of properties for the client population. Counselors should seek characteristics that makes one appear worthy of belief, capable, techniques that represent the norms of the population similar to entitled to confidence, reliable and trustworthy. those of a client. They must recognize a client’s culture during test ●● Competence, which includes credentials and qualifications and administration and interpretation, and place test results in proper on how well informed, capable or intelligent others perceive the perspective with other relevant factors (ACA, 2005). person to be. Mental health professionals practice within their areas ●● Nondiscrimination (see next page). of competence and develop and enhance their professional expertise. ●● Commitment to clients. All mental health practitioners’ primary They continually strive to increase their professional knowledge and responsibility is to promote the well-being of clients, which skills and apply them in practice. In addition, they should aspire to includes respecting cultural diversity. contribute to the knowledge base of their profession. ●● Self-determination. Mental health practitioners must respect and ●● Trustworthiness/integrity, which is confidence clients hold in promote the right of clients to self-determination and help them a counselor’s ability to make valid assertions. All mental health identify and clarify goals and cultural perspectives that may impact practitioners must act honestly and responsibly and promote their goals. ethical practices on the part of the organizations with which they ●● Privacy, confidentiality and informed consent. Mental health are affiliated. practitioners should use clear and understandable language to ●● Awareness and sensitivity, which includes cultural meanings inform clients of the purpose of their service, risks related to of confidentiality and privacy. Counselors must respect differing service, limits to service, costs, the client’s right to refuse or views toward disclosure of information and have ongoing withdraw consent, and the HIPAA Privacy Rules that govern discussions with clients on how, when and with whom information sharing of information. Mental health practitioners must respect is to be shared. Sensitivity also includes recognition that culture the client’s right to privacy. Once private information is shared, affects the manner in which clients’ problems are defined. Clients’ standards of confidentiality apply; therapists may disclose socioeconomic and cultural experiences should be considered confidential information when appropriate, with valid consent from when diagnosing mental disorders. Counselors should recognize the client or a person legally authorized to consent on behalf of the that historical and social prejudices can lead to the misdiagnosis client. When providing counseling services to families, couples or of certain individuals and groups, and that mental health groups, they should seek agreement among the parties involved on professionals may play a role in perpetuating these prejudices each individual’s right to confidentiality. The culture and language through diagnosis and treatment. Counselors may refrain from

SocialWork.EliteCME.com Page 64 of the client may dictate how counselors convey these aspects of multicultural competence.

How can counselors provide validation for others and for themselves? In the context of multicultural counseling, validation can mean cultural backgrounds similar to our own (Gamez, 2009). Validation has confirming what another person says. It can also mean having respect nothing to do with agreeing with others, just letting others know that for other another person’s communication by acknowledging the what they have conveyed has meaning. experiences, opinions and thoughts of that person as legitimate. These In reviewing many studies of ethnic and racial minorities in counseling definitions describe validation as the confirming and affirming action, services, it becomes clear that there are many other reasons why but convey nothing about being right or wrong. There are many ways disparities exist. One reason is that some racial and ethnic minorities to use validation with clients to let them know their counselor respects spend less time in psychotherapy, for example, in the case of European what they are saying. American human service workers who perceive a lack of validation. Validation is vital to gaining respect and increasing the therapeutic Perhaps outcomes would improve if human service workers learned alliance between mental health service professionals and their clients. how to employ the awareness, knowledge and skills of multicultural When clients affirm that the validation process is working, counselors competence (Zalaquett, 2011). also feel validated for their efforts to positively connect with the It is also important to apply the multicultural competences when social client’s lives, feelings, struggles and thoughts. issues arise. In fact, many people do not react to situations that are The validation process is viewed as a way of allowing clients to help damaging to clients and peers alike because of: their counselors gain confidence and growth through the clients’ verbal ●● Fear of isolation. or nonverbal communication of “a job well-done” (Wilson, 2006). It ●● Not knowing what to do to advocate. may be less complicated to validate situations with people who have ●● Fear of lost wages, a job, or both.

Evaluating and expanding multicultural competences Validating justice when speaking out against injustice is about collaboration and teamwork. A counselor’s validation of clients’ affirming and confirming action, not about being right or wrong. When feelings and perceptions will benefit the clients’ self-efficacy and self- people do not feel validated in their workplaces, they struggle with low confidence (Cormier, Nurius, and Osburn, 2009). levels of self-confidence. This low self-confidence negatively impacts Studies of multicultural competency are often grouped into several the counseling process as well as their personal lives. Learning to identified themes. These themes are discrimination, validation, become more culturally competent is an active process; it requires less multicultural competence, and the sharing of knowledge. lecture and more active involvement in the learning process including

Discrimination ●● Counselors must not condone or engage in discrimination based on knowledge and resources. They should be advocates for programs age, culture, disability, ethnicity, race, religion/spirituality, gender, and institutions that demonstrate cultural competence, and gender identity, sexual orientation, marital status, partnership, promote policies that safeguard the rights of and confirm equity language preference, socio-economic status or any other basis and social justice for all people. The organization concludes that prescribed by law (ACA, 2005). social workers should act to prevent and eliminate domination ●● Counselors must not discriminate against clients, students, of, exploitation of, and discrimination against any person, group employees, supervisees or research participants (ACA, 2005). or class on the basis of race, national origin, color, sex, sexual ●● The Ethical Standards for School Counselors states that counselors orientation, gender identity or expression, age, marital status, must respect students’ values, beliefs and cultural background political beliefs, religion, immigration status, or mental or physical and not impose their personal values on students or their families disability (NASW, 2008). (2010). In addition, it notes that school counselors must develop Although overt discrimination has diminished, it has been replaced by competencies and understand how prejudice, power and various a more subtle discrimination called micro-aggression that is often hard forms of oppression – disability, age, class, familiarity, gender, to identify and address. Micro-aggressions are insults to people who gender identity, immigration status, language, racism and religion are not in the” dominant” group (Constantine, 2007) and are many – affect them, students and all stakeholders. times unconscious. Is vital that counselors work as a profession to ●● The National Association of Social Workers (2008) states spearhead community change designed to eliminate this in society. that social workers should not practice, condone, facilitate or collaborate with any form of discrimination on the basis of race, Mental health professionals often have to address micro-aggression in ethnicity, national origin, color, sex, sexual orientation, gender advocacy work in the community. Helping non-diverse communities identity or expression, age, marital status, political beliefs, become more open and embracing of difference and supportive of religion, immigration status, or mental or physical disability. change can be challenging, but is essential. Reducing micro-aggression ●● Social workers should promote conditions that encourage respect is a collective responsibility of counseling professionals. Counseling for cultural and social diversity within the United States and professionals might better address social environmental issues, such globally. This includes promoting policies and practices that as sexism and racism, that bring many counselors to counseling, by demonstrate respect for difference and the expansion of cultural increasing public awareness and by changing work cultures to be more inclusive (Zalaquett, 2011).

Page 65 SocialWork.EliteCME.com Multicultural awareness ●● Multicultural competent counselors are culturally self-aware, aware of ●● Multicultural competent counselors do not judge clients by their clients’ culture, and willing to bring culture into the discussion during own values and their own core cultural beliefs, and do not engage interaction with clients (Sue, Arrendondo, and McDavis, 1994). in negative stereotyping. ●● They are open to listening to and helping clients with goals and Being culturally competent is an ongoing process. It is having the objectives without imposing their own cultural values on clients. awareness that no one can know everything, so counselors are always ●● They are respectful of the counselor-client relationship and of the engaged in becoming more competent. The counselor’s focus is to be a client’s uniqueness, and meet clients where they are, go on the true advocate for the client. journey with them, and provide them with the assistance they seek.

Sharing knowledge ●● Multi-culturally competent counselors must be prepared to teach ●● Counselors must seek to become sensitive to and help clients their peers and students about the importance of multicultural become aware of family, work and community differences, and competence and willing to stand up to their colleagues and speak factor those in their decision-making. Counselors must develop the out against micro-aggression. ability to hear and understand the basis for client goals and their ●● They must ask important questions and encourage open discussion values and concerns, and offer alternatives in ways that support about why some people hesitate to take a stand, allowing subtle and respect clients’ cultural values. aggressions to continue. Much work is needed to encourage more ●● Counselors must learn to speak in the language of their clients and therapists and counselors to become more open-minded in their significant others in the therapeutic relationship. They must help professional and personal lives. To become a truly multicultural clients engage their family, friends and colleagues in constructive competent counselor means a person must want to help all conversations to build positive relationships. mankind. To do so, counselors must challenge the “I” centeredness ●● Counselors must be as concerned with the wellness of the of their society and the assumptions or myths that breed fear and environment as they are about their own well-being. They must a sense of self-preservation over others, and assert regard and ask open-ended questions upfront, reflective questions about respect for all mankind (Ahmed, 2011). tradition, spiritual centering and other aspects of their own as well ●● Technology offers counselors new and exciting ways to challenge as the client’s personal cultures to help clients focus on issues and their centeredness by increasing communication and decreasing solutions in relationship to their culture (Arrendondo, et al., 1996). isolation to learn about one another and adopt a more global focus.

Promoting the balance of power and mutual respect Boundaries in a dual relationship A boundary can be visualized as a frame or membrane surrounding or more roles, either concurrently or sequentially, with the help-seeker the therapeutic process that identifies a set of roles for those involved (Herlihy and Corey, 1997). in the therapy. (Smith and Fitzpatrick, 1995; Kathryn 1991) defined The second role commonly is social, financial, as friend or teacher. boundaries as “limits that promote integrity.” Boundaries protect the Role-blurring ethics charges constitute the majority of ethics complaint well-being of clients when the mental health practitioner assumes two and licensing board action (Bader, 1994; Nuekrug, Milliken and Walden 2001; Sonne, 1994).

Bartering In the past several decades, licensing boards that protect consumers ●● A client who feels mistreated in a financial or social exchange with from therapists’ harm and abuse have more vigorously pursued issues the therapist faces barriers in legal redress because therapists can such as bartering of professional services. California licensing boards, use client-shared secrets to create a defense. for example, sent a pamphlet to all therapists in the state noting that ●● Further, therapists can use diagnostic labels to discredit clients “hiring a client to do work for the therapist or bartering goods or (Pope, 1998). services to pay for therapy” represented “inappropriate behavior and The ACA (2005) Code of Ethics contains a section on bartering that is misuse of power” (California Department of Consumer Affairs, 1990). considered a dual financial relationship. Counselors may barter only A larger power and prestige difference between therapist and if the relationship is not exploitive or harmful and does not place the client exist in dual relationships, and a greater potential for client counselor in an unfair advantage, if the client requested it, and if such exploitation; power is generally assigned to healers in most societies arrangements are an accepted practice among professionals in that (Smith and Fitzpatrick, 1995). Some inherent concerns with multiple- community or culture. role relationships include: Bartering with the client for good or services is not ethically prohibited ●● Dual or multiple relationships can deteriorate the professional but it is not recommended as the customary practice. Therapists nature of the therapeutic bond, which is based on predictable generally enter bartering arrangements with good intentions. They may boundaries. barter to offer services to those with limited finances; however, the ●● The essential professional nature of the therapeutic relationship potential for problems often exists. Often, client services do not equal is altered and compromised when the therapist is also the client’s the monetary value, on an hourly basis, to that of therapy (Kitchener employer, friend or teacher. and Harding, 1990). ●● Dual relationships may establish conflicts of interest, jeopardizing the objectivity and neutrality required for professional judgment. ●● Clients do not have equal power in a business or secondary association because of the nature of the therapist-client relationship.

SocialWork.EliteCME.com Page 66 Case study: Bartering A counselor presented an unemployed farm worker the option of In addition, ACA Code of Ethics contains a section on receiving gifts. doing yard work in exchange for psychotherapy. Bartering was “Counselors understand the challenges of accepting gifts from clients an accepted practice in the client’s home country. The counselor and recognize that in some cultures, small gifts are a token of respect charged $100 per hour and credited the client with $15 an hour, and show gratitude. When determining whether to accept a gift from a thus the client had to work more than six hours for each therapy client, counselors must take into account the therapeutic relationship, session. The client protested to the therapist that the time required the monitory value of the gift, the client’s motivation for giving the for the yard work prevented him from finding full-time employment. gift, and the counselor’s motivation for wanting or declining the gift” The therapist countered that the client could choose to terminate (ACA, 2005). therapy and resume when he could pay the full fee. The American Psychological Association’s (APA) Ethical Principals The therapist calculated a below-fair-market value for the of Psychologists and Code of Ethics 2010 amendments addressed client’s labor. The bartering contract contributed to the client’s bartering as well. dissatisfaction as did his difficulty with the English language “Barter is the acceptance of goods, services, or other nonmonetary and understanding monetary value. The therapist interrupted the remuneration from clients/patients in return for psychological services. agreement and abandoned the client upon hearing the client’s Psychologist may barter only if it is not clinically contraindicated, and the complaint. The client sued the therapist for considerable damages resulting arrangement is not exploitive.” The APA also classifies bartering (Koocher and Keith-Spiegel, 2008). as a multiple relationship that the psychologist should refrain from It should be noted that most professional liability insurance policies entering if the relationship could reasonably be expected to impair the exclude financial and other business relationships with clients. psychologist’s objectivity, competence, effectiveness in performing his or Counselors must consider the cultural implications of bartering, her functions as a psychologist, or otherwise risks exploitation or harm to discuss relevant concerns with clients and document such agreements the person with whom the professional relationship exists (APA, 2010). in a clear written contract.

Attitudes and beliefs Counselors must be open to having leaders in their organizations counselors potentially serve all members of society and must be who represent diverse political viewpoints that may definition social viewed as open to viewpoints held by others. action. No one viewpoint can serve as the dominant viewpoint because

Knowledge Counselors must gain knowledge about many different political one is not aware of others’ views and how they come to hold them. perspectives so they can open a dialogue of mutual respect that Knowledge about the worldviews of others is at the core of the leads to openness and respect of differences. Many counselors hold development of multicultural competent counselors and will form the viewpoints that are not necessarily representative of the public at large. basis for opening up professional organizations to leaders from a wide Is very difficult to serve others and open up leadership positions if variety of backgrounds (Zalaquett, 2011).

Skills ●● Counselors must seek ways to help that do not place values held by ●● Counselors must not try to force one particular viewpoint onto the counselor onto clients, so the clients can find their own way of others, and when others reject that viewpoint, must not label them growth and development. Counselors must seek out opportunities as not supporting multicultural and social justice issues. to gain insight into their own views and motivations as well as the Difference is what leads to compromise, and it is the skill of compromise views and motivations of those they serve. that will lead to the balance of power and mutual respect. Reflecting ●● Counselors must develop new ways to engage in discussions of the on personal growth, one author pointed out that his grandmother once many multicultural and social justice issues that mental health said, “All who care about the welfare of others must first care about professionals and society face. To this end, counselors must familiarize themselves. We cannot help others if we are blind to our own views and themselves with the research on social justice and multicultural the effect they have on others” (Hazier and Wilson, 2010). issues that address the wide spectrum of viewpoints that exist.

Group-specific and multicultural approaches Over the past two decades, the counseling profession has underscored ●● Skills include a counselor’s ability to form rapport with culturally the importance of multicultural counseling training, which has become diverse clients and to implement culturally responsive interventions. an integral part of counselor education (Ridley, Mendoza, and Kanitz, The tripartite model has stimulated research along with the development 1994). Sue and his associates (Sue, Arrendondo, and MacDavis, 1992) of instruments that purport to measure the multicultural counseling proposed a tripartite conceptualization of multicultural counseling competencies (Worthington et al., 2007). While the tripartite model made competencies, which became a major force when multicultural much contribution to the field, it also received criticism. One criticism noted counseling gained significant attention in the field. by some researchers was the lack of empirical support for the model and The tripartite model has three components, awareness, knowledge and almost exclusive focus on for racial and ethnic groups in the U.S.; African- skills: Americans, Asian Americans, Latino Americans, and Native Americans. ●● Awareness refers to the counselor’s awareness of his or her own Constantine, Gloria and Ladany (2002) evaluated the factor structure of worldview and cultural biases. multicultural counseling competency measures and did not find support ●● Multicultural knowledge requires counselors to be knowledgeable for the theoretically proposed three-factor structure. With the exception about various cultural factors that might influence the counseling of the Cross-Cultural Counseling Inventory, Revised (CCCR-I), other process. competency measures use self-report (CCC I-R; LaFramboise et al., 1991).

Page 67 SocialWork.EliteCME.com Content analysis of multicultural counseling competency research noted different oppression systems that interact and intersect each other and a theory-research gap in the multicultural counseling literature, which influence individuals’ social positioning in a given context. It is much led to debate on what cultural aspects should be included in divining like a matrix; for instance, although women’s social proximity may multicultural counseling competencies (Worthington et al., 2007). be close to the context of experiencing sexism, it becomes distant The original multicultural competency model focused exclusively on in the context of dealing with mobility issues if such a woman has racial and ethnic issues (Sue et al., 1982), although the second paper a spinal cord injury. In contrast to the single-dimensional approach in 1992 attempted to define the multicultural counseling competencies to multiculturalism, those views attempt to theorize the impact of more inclusively by considering other diversity factors, including sexual multiple socio-cultural factors on individuals and the interactions orientation, disability, gender, religion and socioeconomic status, but among different socio-cultural factors (Collins, 2002). with the major emphasis still on race and ethnicity. In addition, while the Clinical values of the multidimensional approach to can be supported inclusive approach avoids becoming exclusive, there has been the argument by the data that show a high concentration of risk factors among certain that such an all- inclusive approach obscures the understanding of each socio-cultural groups as well as high co-morbidity rates in clinical factor as a powerful dimension of human experience (Sue and Sue, 2003). populations. For example, because ethnic minorities are less likely to Helms and Cook (1999) argued that such all-inclusive definitions lack receive effective treatment, they bear higher rates of disability burden precise conceptualization to understand the role of race in the counseling than European Americans (DHHS, 2001). Demographic variables, process and its sociopolitical implications on clients’ mental health. With such as having a disability, being a woman, African-American, Latino the emphasis on specificity, Helms and Richardson (1997) suggested American, or having less education, have been associated with an that researchers and professionals address the question of which increased likelihood of living in poverty (Kruse, 1998). competencies work best for what aspects of diversity. Focusing on wide-ranging impacts of poverty, Evans (2004) suggested To emphasize the significance of race, Helms and her associate developed that poverty does not occur in isolation and that it is the accumulation racial identity development models for European Americans and of multiple social and environmental risk factors that make African Americans as well as instruments to measure the racial identity chronic poverty more detrimental to the individual’s physical and statuses. Those racial identity development models generally assume that psychological well-being. The data point to the need for counselors individuals begin developing with a racially unaware state, then going to consider interrelations among physical, psychological and social through racial awakening and psychological dissonance to move toward factors that may affect clients presenting issues. a fuller acceptance and awareness of racial issues. The models lead to a The multidimensional approach can provide more realistic body of research that related racial identity with various psychological conceptualization in practice because it addresses the intersectionality constructs, including defense mechanisms (Utsy and Garnet, 2002), among different socio-cultural factors and the complexity inherent racism (Pope-Davis and Ottavi, 1994), and self-reported multicultural in multicultural counseling. On the other hand, because of the counseling competencies for counselors (Constantine, 2002). complexity, the multi-dimensional approach is less likely to be There are other group-specific models of focus on the identity and research-friendly to quickly generate empirical data (Ishii, 2012). development of specific socio-cultural groups, such as gays and A review of single and multidimensional approaches to multiculturalism lesbians (Cass, 1979) and feminists (McNamara and Rickard, 1989). can be compared with landmark research on the multicultural counseling Group- specific models often provide rich information specific to the competency model (Sue et al., 1992). The single-dimension approach group and a more explicit operational definition of the construct. advanced research and understanding of the impact of specific socio- Group-specific models render themselves suitable for yielding instruments cultural factors on clients. The multidimensional approach provides and large-scale quantitative research. Because of the specificity, the group- clinically useful concepts that help better understand the salience and specific approach produces more research and a better understanding of the intersectionality of different socio-cultural factors for a given client. impact of each socio-cultural factor on people. However, this specificity Given the emphasis on a universal or holistic approach in counseling, approach does not consider salience of group membership for individuals researchers suggest that multicultural counseling research and and the interaction effects of multiple socio-cultural factors. practices use knowledge gained from the group-specific approach and Pederson (1991) emphasized individuals’ multiple identities, such as move toward a multidimensional approach in addressing multicultural a person who is a Latino gay man with a disability, and argued that all issues in counseling (Ishii, 2012). To foster empirical endeavors, counseling relationships are essentially cross- or multiple–cultural. In researchers are encouraged to incorporate a multidimensional nature of highlighting the complexity of multicultural counseling, he asserted social-cultural identity and the interactional effect of different socio- that because such multiple identities within a client are affected by cultural factors in their research. In particular, the development of contextual factors, it is important for counselors to assess which instruments or assessment strategies to measure the multidimensional, identity is more salient for the client in a given context. socio-cultural factors will facilitate much needed research. From a social constructionist perspective, Collins (2000) described Similarly, counselors are encouraged to become confident in addressing the concept of intersectionality that suggests complex and dynamic various socio-cultural issues in counseling, including ethnicity, race, interactions between social oppression and individuals’ identity and gender, disability, sexual orientation, age, socio-economic status and everyday experience. According to conceptualization, different social religion. In addition, counselors must understand the concept of saliency categories, race, social class, gender, sexuality and so forth create and intersectionality to conceptualize socio-culturally diverse clients.

Statistics The need for multicultural competent counselors is increasing as the The Children’s Defense Fund predicted that in the first decade population of various ethnic groups grows. Current and projected 21st following 2000, there would be 5.5 million more Latino children, 2.6 century demographic changes in the United States are a major factor. million more African-American children, 1.5 million more children For example, immigration patterns and increases among racially, of other races and 6.2 million fewer white, non-Latino children in the ethnically, culturally and linguistically diverse populations are rapidly United States (NCCC). Cultural competence can increase the overall changing. A 1997 Census Bureau survey reported that one in every quality of life for everyone and supports best practice in mental health 10 persons in the United States is foreign born. Currently, the U.S. as well as decreases the likelihood of liability and malpractice claims foreign-born population comprises a larger segment than at any time in (NCCC Policy Brief). the past five decades. This trend is expected to continue.

SocialWork.EliteCME.com Page 68 Child discrimination reports Discrimination is the denial of equal treatment. Although improvements 4. Attitudes toward seeking help from health care providers. have occurred, serious problems still exist with children and ●● Meeting legislative, regulatory and accreditation mandates. discrimination. Racial injustice is particularly noted in juvenile justice The federal government has a pivotal role in ensuring culturally systems. Youths of color are treated more harshly than white youths for competent mental health care services. State and federal agencies the same detention processing in juvenile court, transfer to adult criminal increasingly rely on private accreditation entities to set standards court, and sentencing and incarceration in juvenile and adult facilities. and monitor compliance with these standards. Both the Joint Courts commit African American youths with no prior drug offenses to Commission on the Accreditation of Healthcare Organizations, state institutions 48 times as often as white youths with no prior drug which accredits hospitals and other health care institutions, and offenses. African American youths are sentenced 90 days longer for the National Committee for Quality Assurance, which accredits violent offenses than white youths, and Latino youths are incarcerated managed care organizations and the behavioral health managed 150 days longer (Child Welfare League of America, CWLA, 2002). care organizations, support standards that require cultural and In a Child Welfare League of America study in 2002, 48 percent of linguistic competence in health care. children ages 8 to 11 and 67 percent of children 12 to 15 stated that ●● Gaining a competitive edge in the market place. The provision children at their schools were treated badly because they were “different,” of publicly financed health care services is rapidly delegated and that discrimination was a big problem for their peers at school. to the private sector. The potential for improved services lies in state managed-care contracts that can increase retention and As reported in 1999, 7,876 hate crimes were reported in the United access to care, expand recruitment and increase the satisfaction of States. Nearly two-thirds of all known perpetrators were teenagers or individuals seeking health care services. To reach these outcomes, young adults (CWLA, 2002). managed care plans must incorporate culturally competent The National Center for Cultural Competence policy brief, Rationale policies, structures and practices to provide services for people for Cultural Competence in Primary Care, states that there are from diverse ethnic, racial, cultural and linguistic backgrounds. additional compelling reasons to become culturally and linguistically ●● Decreasing the likelihood of liability/malpractice claims. competent. They include: Insensitivity and ignorance about cultural competence could ●● Eliminating long-standing disparities in the mental health create liability under tort principles in several ways. For example, status of people of diverse racial, ethnic and cultural providers may discover they are liable for damages as a result of backgrounds. There are continuing disparities in the incidence treatment in the absence of informed consent. Also, health care of illness and death among African Americans, Latino/Hispanic organizations and programs face potential claims that their failure Americans, Native Americans, Asian Americans, Alaskan natives to understand health beliefs, practices and behavior on the part of and Pacific Islanders as compared with the U.S. population as a providers or patients breaches professional standards of care. In whole (U.S. Department of Health, 1998). some states, failure to follow instructions because they conflict ●● Improving the quality of services and health outcomes. with values and beliefs may raise a presumption of negligence on Fundamental differences among people arise from nationality, the part of the provider. ethnicity and culture in addition to family background and In addition, the ability to communicate well with patients has been shown individual experience. These differences affect the health, beliefs to be effective in reducing the likelihood of malpractice claims. A 1994 and behaviors of both clients and mental health practitioners and study appearing in the Journal of the American Medical Association their interaction. indicates that the patients of physicians who are frequently sued had the ●● Understanding critical factors in the provision of culturally most complaints about communications. Physicians who had never been competent mental health services. These include: sued were likely to be described as concerned, accessible and willing to 1. Knowledge of beliefs, values, traditions and practices of a culture. communicate. Effective communication between providers and patients 2. Culturally defined health-related needs of individuals, families may be even more challenging when there are cultural and linguistic and communities. barriers. Health care organizations and programs must address linguistic 3. Culturally based belief systems of the etiology of illness and competence – ensuring for accurate communication of information in disease and those related to health and healing. languages other than English (National Center for Cultural Competence).

Defining culture, competence and diversity Cultural and linguistic competences are at the base of cultural Culture is dynamic in nature, defining individuals and informing their competence. They are defined here. identity. Everyone has culture influences that affect how they see others. Culture – An integrated pattern of human behavior, which includes: Organizations or systems have distinct cultures that are developed and ●● Thought. communicated by mission and goal statements. Communities represent ●● Communication. diverse cultures influenced by their members, the environment and ●● Languages. socioeconomic conditions. Culture is a framework for making human ●● Beliefs. connections, as individuals see things from their own perspective. ●● Values. Intervening factors that influence culture include: ●● Practices. ●● Level of education. ●● Customs. ●● Level of income. ●● Courtesies. ●● Geographic residence. ●● Rituals. ●● Place of birth. ●● Patterns of interaction. ●● Age. ●● Roles. ●● Gender. ●● Relationships. ●● Identification with community groups. ●● Expected behaviors of a racial, ethnic, religious, social, or political ●● Length of U.S. residency. group, and the ability to transmit the above to succeeding generations. ●● Personal experiences.

Page 69 SocialWork.EliteCME.com Competence – The ability to incorporate values, knowledge, attributes cultures, classes, races, ethnic backgrounds, sexual orientation, and and skill sets in order to work effectively cross-culturally. faiths or religions in a manner that recognizes, affirms and values the Diversity – A range of human perspectives, backgrounds and worth of individuals, families, tribes and communities and protects and experiences reflected in characteristics such as age, class, ethnic origin, preserves the dignity of each. gender, nationality, physical and learning ability, race, religion, sexual Demonstrating cultural competence is an ongoing process that orientation and veteran’s status. Other diversity variables include: emphasizes cultural strengths of others and integrates their unique ●● Education. abilities and perspectives into our lives. It is a vehicle that can be ●● Marital status. used to broaden our understanding of individuals and communities, ●● Employment. and is reflected in how people in a community relate to and interact ●● Geographic background. with mental health providers. Cultural competence addresses how ●● Cultural values, beliefs and practices. to understand cultural implication issues and then integrate this Cultural competence – In general, the ability of individuals and knowledge into an optimal therapeutic interaction (CWLA). systems to respond respectfully and effectively to people of all

Five essential cultural competence elements Five major elements comprise cultural competence. They include witnessed her parents’ fighting, which eventually sent her mother, valuing diversity, conducting cultural self-assessment, managing the Tilda, to the hospital with a concussion and broken arm. Annette’s dynamics of difference, acquiring and integrating cultural knowledge grandmother looked after Annette while her daughter was and adapting to diversity and cultural contexts: recuperating, and when Tilda was released from the hospital, she 1. Valuing diversity embraces behaviors, practices, policies and moved into her mother’s home with Annette. Annette had already attitudes as well as larger systems and structure. been seeing Janet and was soon joined by her mother, engaging in 2. Conducting cultural self-assessments challenges mental health dyadic therapy. professionals to assess for personal as well as professional In subsequent weeks, Annette appeared to be more anxious and proficiency in cultural competence. often argued and fought with her teachers and other students. In 3. Managing the dynamics of diversity occurs within natural, formal counseling sessions, Janet struggled to communicate to Annette’s or informal support, and facilitates networking within clinical and mother that Annette was reenacting her traumatic experience with neighborhood settings, ethnic-social-religious organizations and her teachers and classmates. Tilda, on the other hand, felt that spiritual communities. Annette was being blatantly disobedient. During one session, Janet 4. Acquiring and integrating cultural knowledge prompts mental became “affectively charged” by Tilda’s comments that Annette health practitioners to seek out consultation, coaching and could overcome her behavior through punishment and reprimands. mentoring and from a variety of sources. For example, in some cultures it would be appropriate to request an interview with the Being “affectively charged” causes therapists to stick to a message religious leader before working with the community as a whole. that, at the moment, cannot be heard. The message is usually more 5. Adapting to diversity and cultural contexts challenges mental solution focused rather than strength-based focused. health practitioners to formulate and practice new behaviors and Because Janet felt passionately about trauma and how it affects beliefs that might include: children, she forgot to “check-in” with Tilda and ask about a. Revisiting policies and procedures that are no longer relevant Tilda’s mother’s perception that children could be curbed through and, in fact, could be counterintuitive to providing culturally corporal punishment as well. Janet was unaware that Tilda’s mom competent mental health services. had a powerful influence on her daughter and vicariously used her b. Restructuring systems and methodologies to more to express her own feelings, even though she wasn’t in the session appropriately meet the needs of the people served. room with her daughter or granddaughter. c. Enhancing and adopting different values with the commitment to provide culturally competent, evidence-based practice. Janet was also unaware that even if Tilda felt differently, d. Revising service practice to incorporate culturally sensitive her upbringing taught her not to question her own mother’s mental health protocols. authority. In addition, her guilt about leaving her marriage was e. Applying cultural competence to mental health practice. overwhelming due to her cultural orientation toward marriage. Had Janet asked Tilda about Tilda’s culture and also examined The majority of mental health practitioners are culturally sensitive. her own professional agenda, Janet would have been equipped to When missteps occur, it is usually because there is lack of cultural communicate her message more effectively to her client. awareness, communication, perception or other disconnects between a mental health provider and client, especially when a provider becomes Janet’s orientation toward her role as a child advocate is not unusual. “affectively charged.” The following case study provides an example: Circumstances such as hers often initiate professional discussion of Janet, a licensed clinical social worker, has been seeing 6-year- what is best for children and how to handle seemingly resistant parents old Annette for several weeks. Annette was traumatized when she when they are at odds with the therapist about a child’s health and well-being.

In their own words A lot has been written about cross–cultural environments from the Jürgen from Germany viewpoint of Americans. However, how often have natural-born In the workplace we do not use the word “problem.” There is just a Americans stepped back to appreciate the challenges, frustrations, challenge. The word problem seems to be restricted to life-threatening emotions and sometimes amusing experiences that immigrants have conditions only. faced as they tried to assimilate. The following stories are unique It was difficult to adjust to working in a cubicle with no natural light. experiences of people who came to work and live in the United States. In Germany, it was a law that every permanent office workplace has These stories are in their own words, with few grammatical changes daylight access. (Lindsell-Roberts, 2011):

SocialWork.EliteCME.com Page 70 I had to adjust to women’s liberation. At one time I opened the door families, their children, and their income. It shows that you care about and a woman was walking behind me, so I held the door open for her. them. In the U.S., information like that is very private. People here are She rudely yelled at me, “I can open the door myself.” So I just did much more direct. In China we would not disagree with you to your what I felt like: slamming the door in her face. face because we wouldn’t want to make you feel bad. We try to show Robin from Germany disagreement through body language and in other discrete ways. I found it difficult when I came to America to have a conversation Jianyao from China without having to speak of Nazis. My first challenge was and still is to There are some things you may call cultural differences. For instance, meet as many Americans as possible to talk about my country and let Americans usually offer compliments on what you have done well. The them know that Germans are human beings like everybody else, and Chinese don’t, because there is always room for improvement. We do not in each country there are good and bad people. I met a lot of Jewish jump up and down when the boss tells you “You did a good job” because people who did not like me at the beginning and became good friends he may just mean it is not too bad. In contrast, if someone in Chinese said of mine after long talks and disagreements. I have a few memories of that you could do a much better job you would not be upset. Jewish families I became friendly with through strange circumstances, Another difference is how people address others. Here in the states, and they learned to have a better understanding of Germans. everyone uses first name even if you are the president of the company, a My second challenge was this: Most Americans have always been respected professor, or a grandfather. You don’t do this in China unless aware of Germans being good mechanics, keeping good records, and you are talking to a sibling or friend of the same or younger generation. making sure everything is accurate. When I came to this country, I was Otherwise people will think you are rude and disrespectful. To the older shocked when I read letters and other documents written by Americans generation or to people in higher positions, you better say their title first, and saw numerous mistakes in their writings. In Germany we were then their last name, for example, Uncle Chen, or Manager Chou. taught grammar until it came out of our ears. We disliked our English Aman from India teachers because they were very strict, but after coming to the states, I Having grown up in India I came to the U.S. with a very strong thanked him 1,000 times for making sure we would always speak, talk, English accent and lingo. I tried very hard to lose the accent and the and write correctly. lingo because I wanted to blend in. But I realized I wouldn’t blend in, My third challenge, if you want to call it that, was to learn how to because I look different. I wear a turban. People at work were very smoke and chew gum at the same time. There was a lady in my welcoming, but I noticed that people in my neighborhood didn’t talk to department who was always chewing gum and smoking at the same me, maybe because I was different. time. I thought it was absolutely fascinating the way she made noise My life in the U.S. was good until 9/11 when I became a victim of and blew bubbles at the same time with a cigarette in her mouth. I a hate crime. The perpetrators saw my turban and mistook me for a succeeded after a while, and it drove my family crazy but I was proud Moslem. As they victimized me, they shouted, “Go back to Osama of myself. This was my way of becoming “more of an American.” bin Laden.” As a result, I am now part of an organization based out Ari from Israel of New York called Sikh Coalition. It is a nonprofit organization born I grew up in Israel in an Orthodox Jewish family. I went to an all-boys in the aftermath of the bigotry, violence, and discrimination against school and after my Bar Mitzvah I wasn’t allowed to have any physical New York Sikh population following the terrorist attacks of 9/11. contact with females, except my mother, sisters, grandmother, then We go to schools to help children understand Sikh traditions such as later my wife and daughters. That meant no hugging, kissing, or even why we never cut our hair and why we wear turbans. The goal of the shaking hands. When I moved to the United States, I started my own organization is to teach understanding and tolerance. consulting company. I dressed in regular street clothes but I still wore Simon from England my yarmulke, I found it uncomfortable to shake the hands of women Going out for a “pie and a pint” at lunchtime is somewhat of a because of my religious upbringing. I do shake women’s hands to be tradition during the workday in England. Across the nation many polite but it is very uncomfortable for me. white- and blue-collar workers find themselves in a local pub at Suzie from Taiwan lunchtime downing a pint of their favorite beer. I’m sure there are I would like to share my challenges with you when I came to America. some who follow one pint with the second or even third, no doubt to I’m from Taiwan. The challenges I have faced are as follows: help them slide through the afternoon with ease, though hopefully ●● English – I learned English from my Taiwanese English teacher, not literally! When I joined the ranks of corporate America in San so the pronunciation was way off from standard. I spent so much Francisco I started to navigate my way around the different work time to correct it and I’m still trying. culture to the one I was familiar with in London, England. ●● Religion – Here the churches are all about Jesus. Mine are On my first day at work in the U.S., after my boss took me out for my Confucian and Taoist temples. “welcome lunch,” along with my New York colleagues, I was promptly ●● Background – I was taught the more humble you are the better called in to her office for a “chat.” She told me, in no uncertain terms you are. Here you have to express yourself, speak out, otherwise that drinking alcohol during the workday would not be tolerated, and people won’t understand you or respect you. that the beer I had ordered at lunch not be acceptable under normal ●● Culture – I’ve learned to accept gay marriage, living together, and circumstances! Oh boy, that put away those work afternoons sliding having children without marriage. by with ease, and I wondered what other little cultural gems I was to ●● Dress – Showing your body here is very wild. I’ve been taught the discover. As it turns out, I have never been pulled up on such a cultural more you cover up the safer you will be. nuance again, but working in corporate America has shown some other April from China more painful differences to those I was used to in dear old England. My Chinese name is Chunlin but I adopted the American name April. The most challenging one, that I still struggle with on occasion, is Chunlin means “forest in the spring,” and my parents wanted me to that of the “work-life balance.” The thought of having two weeks of be lively, just like the trees that bloom in the springtime. When I lived vacation a year to reinvigorate and rejuvenate oneself after the stresses in China I got my degree in English language and culture and I taught and strains of 50 weeks of work seems like a tall order. In my native English there. So I was very well prepared to live in the U.S. I did find England, and even across the rest of the European continent, where six some cultural differences and was prepared for most of them. People weeks of vacation is typical, this thought would make people break out here talk very fast and it took me a while to get used to that too. In in a sweat. It would likely incite some to civil unrest. China it is commonplace to ask people personal questions about their

Page 71 SocialWork.EliteCME.com Big issue gets compounded if those 40 hours of work a week, for Marita from Sweden which one is contracted and paid, routinely ends up being closer to 60 I was in for a few shocks when I came from Sweden to work in the hours or more, spilling into evenings and weekends. I have often been U.S. as a graphic designer. My first job was at a small advertising firm asked to work late or finish some work up over the weekend to meet a that had a small in-house staff and a lot of “on-the-road salespeople”. timeline, with no consideration given to other plans I may have. After The owners were very unprofessional, immature, and downright numerous times missing a theater performance, being late for a friend’s mean to people. It was a very stressful place to work. The two owners birthday dinner, or disappointing myself or someone else, as I allowed would brag about how they had reduced someone to tears or how they work time to dictate my personal time, I realized that I had to set had turned down job applications because they weren’t Caucasian or my own boundaries. This has not always been easy, as one can often weren’t good looking enough. I found that if you looked good and be perceived as not being a “team player,” and with the knowledge didn’t oppose anything, then you are less likely to be harassed or fired. that it’s far easier to be fired in the U.S. than the UK, I have seen the Good work ethics were not valued at all, this was something I had a softening of my own boundaries. This is the reason why the U.S. is very hard time understanding. I still don’t understand it and I didn’t one of the wealthiest countries in the world! Americans spend much stay there very long. of their time at work being productive. And when they are not talking I interviewed at a publishing company and I was told that I could about it, even when they are not there, they are often thinking about it. “work with other women and it would be less technical.” That didn’t In England I am not always asked, within a minute or two of meeting sit well with me. I did take the job though, because it was similar someone new, what I do for a living. This extends to social settings to my job in Sweden, but even there I felt that it was a little sexist, also, and trying to use British humor to make light of this invariably starting with my job interview. falls flat. Americans often misunderstand satire. Warning: do not use The overall biggest difference I noticed in the U.S. would be the satire in the workplace! sense of teamwork, or rather, lack of teamwork. It doesn’t seem like Fortunately I enjoy my work so I don’t mind answering those questions employees work together as a team, instead of what can we do together sometimes. I do wonder how easy it ends up being for those of us as a team to make our products and services better. I definitely feel less working in the U.S. to genuinely turn off from our heavily defined work valued as an individual at any of these jobs than I ever felt at any of roles, and turn our attention to the many other rich facets of American my jobs in Sweden. life. Now I know it’s possible with that wonderful American “can-do” Akram from Pakistan attitude that puts many other countries’ work culture to shame. When I arrived here I had a very hard time finding a job. I had a Mohammed from Iran bachelor’s degree in chemistry from Pakistan, and every company I I came to the U.S. from Iran to attend the University. After I got my contacted would not accept my degree. I went to college for four years PhD I got a job at a biotech company and got along well with my in the U.S. and got a degree in chemical engineering. After that I got a colleagues. Then 9/11 hit. A few people started making comments in job quickly. I got an entry-level job with low pay, but over the years I front of me about those “blank, blank Moslems,” and they made other worked my way up to a nice job. comments that made me feel uncomfortable. Things quieted down John from Darfur after a few months, but every time there’s an international terrorist I’m one of the “lost boys of the Sudan.” I saw my mothers and sisters incident, I noticed people looking doubtfully at me. I came here with raped and killed and my brothers and father killed. I was wounded and my family and we all became American citizens. I don’t know why still walk with the bad limp. They thought I was dead or they would people don’t trust my loyalty to this country. I love America. have killed me too. I lived in a camp in Darfur for several years and I Nalini from India changed my name to John. A charity brought me to America and found My biggest challenges were the American accent and colloquialisms. me a place to live with three other boys from my country. After all the Although I knew English, I was unfamiliar with most phrases commonly horrors we went through the black community shunned us. We didn’t used in a work setting including something as simple as “wrapping up a fit in because we were too black. meeting.” Even if I knew the phrases, they meant different things to me. The people from the charity were very nice. Help me get into I also noticed that people would ask questions that did not sound like community college, and I worked in a grocery store stocking shelves questions to me. I often did not realize I was expected to respond until to help pay for my food and clothes. The people are treating me well. people looked at me. I frequently ask people to repeat things they said Many white people have invited me to their homes for Thanksgiving just to understand the accent but I did not have the nerve to ask people and Christmas, and I like that. When I finish my education, I want to to explain colloquialisms. After hearing them a few times, I interpreted move back to Darfur to help the people were still there. Maybe I’ll what they meant by the context. even find some living relatives. I also thought people spoke a lot, not always related to the topic of Tony from Johannesburg discussion. I sometimes struggle with trying to figure out if the speaker I came to the U.S. from South Africa when I was in my 20s and made was saying something important. an easy transition. This happened because English was my first language and students are educated to know that because of ongoing political My communication issues made me feel intimidated and I didn’t strife in South Africa they’ll be leaving the country when they graduate. socialize or talk to anyone much, other than on work issues. I think I came to the U.S., had a family, and became an American citizen. people thought I was unfriendly, but I’m not. It wasn’t until my children were in their teens that I learned I wasn’t Also, time was the problem at first. In India, maybe because the roads “an American.” My son came home from school one day and are so crowded, getting places on time isn’t easy and it isn’t important. announced, “Dad, I’m going to teach you how to be an American. Instead of saying when we’ll arrive, we say when we’ll leave. I had to First, you can’t leave your cars in the garage. The garage has to be full train myself to be places on time because that’s important here. of junk. Second, you can’t be so in the serious about us. We smoke and Keiko from Japan drink, so don’t think we are innocent. American fathers already know I came to the U.S. to work for a pharmaceutical company that my that about their kids.” Then when my son went off to college and my Japanese company purchased. Everyone was very nice to me. A lot of wife and I visited him, he said, “American fathers always empty their the U.S. managers made many trips to Japan and they counted on me pockets before they leave.” So this is what it takes to be an American, to help them understand Japanese customs and traditions, which I’m I wondered? always glad to do.

SocialWork.EliteCME.com Page 72 Claudio from Brazil Many black Americans don’t necessarily feel it’s normal to be black, I trying hard to learn better English and take classes after work. The because throughout the history of the U.S. they have been made to feel people I work with know I’m taking English classes, and one person anything but normal. always correct my English. I get embarrassed, but I guess she’s just trying An example of how an initial impression can be a barrier to seeing the to be helpful. In my country we would stand close together when we real person happened during my diversity class. Our instructor said speak. In the U.S., I found that people like what I learned is called “more that her first impression of me was an intimidating one. Initially she personal space.” That worked for me because I work with someone who said it was because of my height and size but, when we got right down smells of garlic. Now I have a good reason to stand far away from her. to it, her feeling was because of the darkness of my skin. She found Maybe I give her too much personal space, but that’s okay. something about dark brown skin anxiety inducing. Conversely, the Anonymous from the United States instructor didn’t feel intimidated by a fellow African American male I guess because I’m an African-American, a minority, and I’m used student who had lighter skin that I did. to my race being highly visible to myself and others, it just never As a counseling student, I think “good counseling” takes into occurred to me that white Americans wouldn’t be equally aware of consideration the contents of the client’s ethnic background and keeps their race or hardly think of it at all. Many white Americans seem to be them in full view at all times. I think this would be valuable for anyone frustrated and angry that black Americans attribute racial causes as the to do in his or her daily lives. root of a lot of social problems for the African-American population.

Lessons learned Cheryl Lindsell-Robert notes that the United States has always drawn ●● Don’t judge a book by its cover. People may act certain ways its strength and greatness from diversity and a lot can be learned from because of cultural differences and experiences. For example, the challenges and experiences of others. Although the stories told although some people may naturally be shy and reserved, others above are a sampling of people Roberts interviewed, they contain may just feel out of place or intimidated. Some may feel that being many lessons we can learn as we strive to understand others. Some of reserved and quiet is a sign of respect. Counselors must work to those lessons follow: seek them out to and get to know them. ●● Check stereotypes at the door. Many stereotypes have been ●● Avoid humor and jokes. Some people in Western cultures passed on by families and sometimes by the individual themselves. try to build rapport through humor, but this is not universally Stereotypes may seek to create order or systems from observations, appropriate. Many cultures don’t appreciate humor and jokes and but they are destructive because they lead to invalid conclusions may see laughter as a sign of disrespect. and rob people of their individuality. The counselor must always ●● Sequence your message strategically. People from different remember they are communicating with a person, not a stereotype. cultures encode and decode messages differently. This increases ●● Never correct people in English unless they ask you to. People the chances of being misunderstood. Recognizing this, think of a who speak English as a second language are trying to speak logical order in which to present information. correctly, and they are made to feel uncomfortable by correcting ●● Be attuned to timing. People in the U.S. are concerned with them. If they say something offensive because of a problem with schedules and the consequences of arriving late and missing translation, mention it privately. Even people whose primary appointments. People from other cultures may not see or language is English make mistakes. understand the significance of time. ●● Allow for cultural differences. People from different cultures Cultural competence is critical to address disparities in mental health often have challenges in terms of language, etiquette, work services that have been documented throughout the United States. practices, and behavior. These differences must be respected, and Practitioners and clients must be able to communicate and develop the counselor has an obligation to manage communication so that trust despite cultural differences. For mental health services to be the individuals can work together productively and cohesively. effective the practitioner must be aware of all socio-cultural influences ●● Learn about gestures and other body language and all you can that impact the diverse needs of their clients. Organizations and about others’ personal space, cultural norms, eye contact and facial systems for mental health care must be attuned and responsive to the expressions. needs of the multi cultural communities they serve in order to conduct outreach services to increase access to quality care for all.

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(2004) Don’t Play In the Sun: One Woman’s Journey Through the Color ŠŠ Pedersen, P. (1976). The field of intercultural counseling. In R. Pedersen, W.J. Lonner Complex. New York: Doubleday. & J.G. Draguns (Eds.), Counseling Across Cultures (pp.17-44). Honolulu, HI: ŠŠ Good, Tawara D. “Promoting Cultural Competence and Cultural Diversity in Early University Press of Hawaii. Intervention and Early Childhood Settings” (2004), Georgetown University Center for ŠŠ Pedersen, P.B. (1997). The cultural context of the American Counseling Code of Child & Human Development, Washington, D.C. Ethics. Journal of Counseling and Development, 76,23-28. ŠŠ Gordon, D.T. (2001) Rising to the Discipline Challenge. In D.T. Gordon (Ed.) ŠŠ Pinker, S. (1997). How the Mind Works. New York: W.W. Norton & Co. Violence Prevention and Conflict Resolution. pp.3-5.Cambridge, MA: Harvard ŠŠ Pope, K.S. (1998) Dual Relationships: A source of ethical, legal, and clinical Graduate School of Education. problems. Independent Practitioner, 8(1), 17-25. ŠŠ Hadley, R.G. & Mitchell, L.K. (1999). Counseling Research and Program Evaluation. ŠŠ Pope-Davis, D.B., Ottavi, T.M. (1994). The relationship between racism and racial Monterey, CA: Brooks/Cole. identity among White Americans: A replication and extension. Journal of Counseling ŠŠ Hazier, R.J. & Wilson, K.B. (2010) The complex person of the counselor. In S. Niles and Development, 72,293-297. (Ed.), Joining the counseling profession: Developing your Identity as a professional ŠŠ Ridley, C.R., Mendoza, D.W. & Kanitz, B.E. (1994) Multicultural Training: counselor (pp. 365-384). Florence, KY: Lahaska Press. Reexamination, operalization, and integration. The Counseling Psychologist, 22,227-289. ŠŠ Helms, J.E. & Cook, D.A. (1999) Using Race and Culture in counseling and ŠŠ Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic psychotherapy: Theory and process. Needham Heights, MA: Allyn & Bacon. personality change. Journal of Consulting Psychology, 21,95-103. ŠŠ Helms, J.E., & Richardson, T.Q. (1997). How multiculturalism obscures races and ŠŠ Romero, D. (1985). Cross-Cultural Counseling: Brief Reactions for the Practitioner. culture as differential aspects of counseling competency. In D.B. Pope – Davis The Counseling Psychologist.13, 665-671. & H.L.K. Coleman (Eds.), Multicultural Counseling Competencies. (pp.60-79). ŠŠ Scott, D. (2002). Social Competence Electronic Version. In Evaluating the National Thousand Oaks, CA: Sage. Outcomes, Program Outcomes, for Youth. Social Competency. Retrieved February 10, ŠŠ Heppner, P.P., Kilighan, D.M. & Wampold, B.E. (2008). Single Subject Research. 2012, from http://ag.Arizona.edu/fcs/cyfernet/nowg/social_comp.html. Research design in Counseling. pp. 198-223 (3rdEd.). Belmont, CA: Thomas ŠŠ Smart, J.F. & Smart, D.W. (1997). The racial/ethnic demography of disability. Journal Brookes/Cole. of Rehabilitation, 63,9-15,25,336-343. 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Poverty in the United States.2002.Washington appreciation training reduce prejudice among counseling trainees? Journal of Mental D.C. Government Printing Office. Health Counseling, 21(3), 240-255. ŠŠ U.S. Department of Health and Human Services (2001). Mental Health: Culture, ŠŠ Kitchner, K.S.& Harding, S.S. (1990) Dual Relationships. American Association for Race, and Identity A Report of the Surgeon General, Rockville, MD: U.S. Department Counseling and Development. Alexandra: VA. of Health and Human Services. ŠŠ Koocher, G.P. & Keith-Spiegel, P. (2008) Ethics in Psychology and the Mental Health ŠŠ Utsey, S.O., & Gernat, C.A. (2002). White racial identity attitudes and the ego Profession: Standards and Cases (3rd ed.). New York: Oxford University Press. defense mechanisms used by white counselor trainees. Journal of Counseling and ŠŠ Kruse, D.L. (1998). Persons with disabilities: Demographic, income, and health Development, 80,475-483. characteristics. Monthly Labor Review, 121,13-22. ŠŠ Vontress, C.E. (1976). Racial and Ethnic Barriers in Counseling. In Pedersen, W.J. ŠŠ LaFromboise, T.D., Coleman, H.L. & Hernandez, A. (1991). Development and Lonner, & J.Draguns (eds.), Counseling Across Cultures (pp.42-46). Honolulu, HI: factor structure of the Cross Cultural Counseling Inventory –Revised. Professional University Press of Hawaii. Psychology: Research and Practice, 22,380-388. ŠŠ Vontress, C.E. (1981) Racial and Ethnic Barriers in Counseling. In P. Pedersen, W.J. ŠŠ Lauver, P.J. Extending counseling cross-Culturally: Invisible Barriers. Paper presented Lonner, & J.Draguns (2nd ed.) Honolulu, Hawaii: University Press of Hawaii at the annual meeting of the California Association for Counseling and Development, ŠŠ Wohl, J. (1976). Intercultural psychotherapy: Issues, questions, and reflections. In San Francisco, CA.ED 274 937 P.Pedersen, W.J. Lonner, & J.Draguns (Eds.), Counseling Across Cultures (pp.184- ŠŠ Lindsell-Roberts, S (2011) New Rules For Today’s Workplace. NY: Houghton Mifflin 207). Honolulu, Hawaii: University Press of Hawaii. Harcourt. ŠŠ Worthington, R.L., Soth-McNett, A.M., & Moreno, M.V. (2007) Multicultural ŠŠ Lodge, E. (2010). A post-racial president … American Renaissance, 21(3), 1-7. counseling competencies research: A 20-year content analysis. Journal of Counseling Retrieved from http://www.amren.com/ar/2010/03/index.html. Psychology, 54,351-361. ŠŠ McFadden. & Gbekobov, K.H. (1984). Counseling African American Children in the ŠŠ Zalaquett, C.P. (2011) Multicultural Social Justice Leadership Development. Journal United States. Elementary School Guidance and Counseling. 18,225-230. for Social Action in Counseling and Psychology Volume 3, Number 1, Spring 2011.

SocialWork.EliteCME.com Page 74 Cultural Competence in Mental Health Practice Part 1: Principles, Preparation and Priorities for Practice Final Examination Questions Select the best answer for each question and complete your test online at SocialWork.EliteCME.com.

1. Recommendations for knowledge of culture are necessary 7. The ability to incorporate values, knowledge, attributes and skill but not sufficient for effective treatment. Knowledge must sets in order to work effectively cross-culturally refers to the term: be______. a. Multi tasking. a. Sufficient for effective treatment. b. Competence. b. Can be achieved by specific academic courses. c. Effectiveness. c. Must be transformed into concrete operations and strategies. d. Credentialed. d. Acquired in the language and customs of every client. 8. A range of human perspectives, backgrounds and experiences 2. The definition of multicultural competence means in part to _____. reflected in characteristics such as age, class, ethnic origin, a. Approach the counseling process from your competency base. gender, nationality, physical and learning ability, race, b. Approach the counseling process from the context of the religion, sexual orientation and veteran’s status refers to the personal culture of the client. term______: c. Use an approach acceptable to the community. a. Sociology. d. Create an approach that follows organizational guidelines b. Diversity. regardless of client culture. c. Egocentric. d. Cultural identity. 3. Which of the following could hinder counselors in their ability to form helpful and effective relationships with culturally different 9. Being “affectively charged” leads the therapists to: groups? a. Stick to a message that at the moment cannot be heard. a. Ethnicity, educational background. b. Commit to a message that is more strength-based. b. Nationality, language, lack of skill. c. Be objective and focus on the goals of therapy. c. Knowledge, skill, ethnicity. d. Increase their cultural awareness of diverse populations for d. Stereotypes, perceptions and beliefs. effective solutions.

4. Which of the qualities below have a particular focus on recognition 10. People from different cultures encode and decode messages of aspects of multiculturalism? differently. This increases the chances of being misunderstood. a. Cultural similarity and gender. When presenting information you should______. b. Ability to handle dual relationships. a. Think of a logical order in which to present information and c. Credibility, trustworthiness and integrity. sequence your message strategically. d. Advanced, specialized education. b. Speak slowly and loudly. 5. Studies of multicultural competency are often grouped into several c. Use hand gestures. identified themes. These themes are ______. d. Use only a few simple words. a. Discrimination, validation, multicultural competence, and the sharing of knowledge. b. Language, ethics, education, and ethnicity. c. Gender, sexual orientation, age, and race. d. Privacy, advocacy, competency, and trust.

6. An integrated pattern of human behavior, which includes thought, communication, languages, beliefs, values, and practices, is called ______. a. Society. b. Customs. c. Culture. d. Community.

SWFL03CP17

Page 75 SocialWork.EliteCME.com Chapter 6: The Heroin Abuse Epidemic in America: Identification, Treatment and Prevention 4 CE Hours

By: Deborah Converse, MA, NBPTS

Learning objectives Upon completion of this course, the student will master the following ŠŠ Describe two categories of signs and symptoms of heroin use and objectives: give four examples of each. ŠŠ Discuss the composition and properties of three types of heroin ŠŠ Explain the differences between the psychological and physical and the effect of the drug on the brain. effects of short-term and chronic heroin use, and give four ŠŠ Identify three ways heroin is introduced into the body and compare examples of each. and contrast the effects of the three types of transmission. ŠŠ Discuss immediate and long-term treatment methods and including three evidence-based therapies to treat heroin use.

Introduction The purpose of this course is to familiarize professionals with basic background information and statistics on the escalation of heroin information concerning heroin addiction, which has reached epidemic addiction in the United States from 1850 to 2014 including causative proportions in the United States and around the globe. This includes factors. The review includes evidence-based treatment and prevention facts about heroin and addiction, effects on the brain, progression programs, as well as the current trends in progress to advance of the disease, psychological and physical effects of short-term and prevention and treatment of the disease. chronic use, screening, treatment, and prevention. The course covers

Background Addiction to opiates, in the form of opium, became a significant problem methadone was introduced to address heroin addiction. Methadone was in the United States during the 1850s. Morphine was introduced as a also developed in Germany in 1937 as an anesthesia for surgery and was replacement because it was thought to be weaker and non-addictive. exported to the United States in 1947 under the name “Dolophine”1. Soon, morphine addiction became an even larger problem, and the Methadone was later used to treat heroin addiction but brought with it solution was the introduction of heroin. Heroin, also thought to be non- a new set of problems if not managed properly. Heroin rapidly became addictive, was developed in 1898 by the Bayer pharmaceutical company a significant health problem in the United States, and over the next in Germany as a treatment for tuberculosis and to address morphine 150 years, the death rate due to heroin addiction has soared to 20 times addiction1. The addiction cycle continued because heroin turned higher than the drug-free population. out to be even more addictive than morphine. Continuing the cycle,

What is heroin and how does addiction happen? Heroin is part of the class of drugs called opioids. The name relates to opiate painkillers, or anesthesia-like xylocaine. Users think that their the heroin molecule that binds to the opioid receptors in the body. The numbness and “high” is coming from high quality heroin, when in fact, it term “opiates” refers to natural, or semi-natural opioids, and heroin has is due to the combination of an adulterant. Sometimes adulterants produce the chemical name diacetylmorphine. Heroin is derived from morphine the opposite effects to heroin, such as cocaine or other stimulants, and which occurs naturally in the latex sap of the seed pod of opium poppy this combination can cause lethal effects on the central nervous system. plants, which grow in Mexico, Columbia, Turkey, Asia, Afghanistan, Other adulterants, such as fentanyl, can be lethal because it is 200 times and parts of Europe2. more potent than heroin. In March 2014, 22 people in Pennsylvania died Heroin and morphine bind to the opioid receptors in the brain and due to overdose, in which stamp-sized bags of heroin were mixed with 7. Fentanyl is a synthetic opioid that binds to the body but heroin binds more effectively, enhancing pain relief and prescription fentanyl opioid receptors in the brain, and when combined with heroin, produces euphoria in the addict. Heroin and morphine, along with codeine, a deadly high3. The danger is that users will take the same dose of heroin hydrocodone, oxycodone, and oxymorphone are similar in structure as usual, but the effects may be enough to stop their breathing or heart due because they all bind to the opioid receptor. Many substances can to central nervous system depression. Other dangerous adulterants, such as be used to cut heroin, including sugar, caffeine, flour, baby powder, levamisole accelerate the heart rate and destroy the immune system, which starch, powdered milk, quinine, strychnine, other poisons and drugs leads to life-threatening infections throughout the body3. which increase the likelihood of death. Strychnine, rat poisoning, is deadly and if ingested, the person will show behavioral effects similar Not only do the addicts buying heroin on the street not know what to other drug-induced behaviors, but marked physical symptoms substances are used to cut the drug, they also do not know the potency include muscle tightness, pain, spasms in the muscles and jaw, rigidity of the drug. The purity or the heroin can increase the chance of overdose of the arms and legs, and arching of the neck and back2. and death. Street heroin is sold in different forms including black tar, Heroin may be adulterated with compounds that are added to cheaply brown powder, and white powder heroin. The purest form is a white enhance the euphoric effects. Examples of adulterants are acetaminophen, powder that may be rose or gray depending on which diluting substances are used to “cut” the heroin to increase the bulk, weight, and profit.

SocialWork.EliteCME.com Page 76 Black tar heroin is identified as a ball or chunk of hard, sticky, black or When injected, heroin enters blood stream and the effects are felt brown material, which is the cheapest and easiest form to make because within seconds, as opposed to snorting or smoking the drug, in which it it is incompletely processed from opium1. The next level of processing may take the user ten to fifteen minutes to feel the effects. Immediately uses lactose as a diluting agent, which produces brown powder heroin. following the heroin injection, users often describe feeling a strong Some darker colored heroin contains dirt, ground-up brown paper, and euphoric “rush” or a sensation of exhilaration, euphoria, extroversion, black shoe polish as fillers. Contaminants and bacteria in black tar heroin enhanced sensations, increased social and communication skills, have been known to carry allergens, botulism spores, and necrotizing heightened sexual performance, and a general feeling of well-being1. bacteria causing poisoning, tissue damage, toxic shock, and death2. Less pleasant are the dry mouth; warm, flushed skin; heavy arms and Death may also occur because these contaminants may not dissolve, legs; and confused mental state. After the euphoria, users experience thus blocking arteries and veins, which cut off blood and oxygen supply feeling alternately drowsy and awake, often described as being “on the causing a deadly aneurism, stroke, or heart attack. Decreased blood flow nod”.2 When the drug is smoked or snorted the initial powerful rush of due to contaminants may also lead to damage, infection, and ultimately euphoria may absent but the later effects will be the same. Users often failure of vital organs, as well as convulsions and death. start by smoking or snorting heroin but progress to injecting to get the enhanced rush. When heroin enters the body and crosses the blood- Street heroin can range from highly potent to forms that are mostly brain barrier, it is changed to morphine and binds to opioid receptors fillers, adulterants, and garden-variety contaminants, but all forms of that are located throughout the brain and body3. Opioid receptors heroin are dangerous, especially when injected. During the process transmit nerve signals in the brain centers involved in signaling pain/ of manufacturing heroin, a number of chemicals may be left behind, pleasure perception, motivation, and reward. Heroin initially increases including calcium oxide, ammonia, chloroform, hydrochloric acid, pleasurable feelings, decreases pain, and motivates the user to seek the and acetic anhydride, which are all lethal ingredients2. White powder “reward” of another heroin high. Opioid receptors located in the brain heroin is a salt form known as diacetylmorphine hydrochloride, and stem control nervous system function that signal critical processes even though white heroin is the purest form, it will still contain lethal such as blood pressure and respiration8. Heroin overdose often contaminants. The purer the heroin, the whiter and shiner it appears, involves a suppression of breathing, due to the effects of heroin that while the more heavily cut heroin will appear duller in color2. cancel the signal for the body to breathe, often with deadly results.

Tolerance and dependence Over time with chronic heroin use, the structure and function of the need to use the drug to avoid withdrawal symptoms known as drug brain changes. These changes cause individuals to develop tolerance sickness. Psychological dependence follows in which users believe to the drug, requiring increasingly larger amounts to reach a high. The they cannot live without heroin and drug-seeking behaviors motivate next progressive stage is physical heroin dependence and individuals their every action.

Withdrawal Severe withdrawal symptoms occur if individuals try to taper or hyper movements, and severe drug cravings8. It is very difficult and stop their heroin use. In a few hours after the last heroin dose, the medically dangerous for the individual to go through withdrawal person will begin to feel withdrawal symptoms which may include without medical assistance, and individuals will likely relapse to avoid vomiting, anxiety, insomnia, diarrhea, chills, muscle spasms, panic, the sickness of withdrawal.

Definitions The following definitions are included in the National Institute for ●● Co-morbidity: The occurrence of two disorders or illnesses in Drug Addiction (NIDA) publication on the Science of Drug Abuse and the same person, either at the same time (co-occurring co-morbid Addiction3. conditions) or with a time difference between the initial occurrence ●● Addiction: A chronic, relapsing disease, characterized by of one and the initial occurrence of the other (sequentially co- compulsive drug seeking and use accompanied by neurochemical morbid conditions). and molecular changes in the brain. (See below.) ●● Conduct disorder: A repetitive and persistent pattern of behavior ●● Agonist: A chemical compound that mimics the action of a natural in children or adolescents in which the basic rights of others or neurotransmitter and binds to the same receptor on nerve cells to major age-appropriate societal norms or rules are violated. produce a biological response. ●● Craving: A powerful, often uncontrollable desire for drugs. ●● Antagonist: A drug that binds to the same nerve cell receptor as ●● Depression: A disorder marked by sadness, inactivity, difficulty with the natural neurotransmitter but does not activate the receptor, thinking and concentration, significant increase or decrease in appetite instead blocking the effects of another drug. and time spent sleeping, feelings of dejection and hopelessness, and, ●● Anxiety disorders: Varied disorders that involve excessive or sometimes, suicidal thoughts or an attempt to commit suicide. inappropriate feelings of anxiety or worry. Examples are panic ●● Detoxification: A process of allowing the body to rid itself of a disorder, post-traumatic stress disorder, social phobia, and others. drug while managing the symptoms of withdrawal; often the first ●● Attention-deficit hyperactivity disorder: (ADHD): A disorder step in a drug treatment program. that typically presents in early childhood, characterized by ●● Dopamine: A brain chemical classified as a neurotransmitter, inattention, hyperactivity, and impulsivity. found in regions of the brain that regulate movement, emotion, ●● Anxiety disorders: Varied disorders that involve excessive or motivation, and pleasure. inappropriate feelings of anxiety or worry. Examples are panic disorder, ●● Dual diagnosis/mentally ill chemical abuser (MICA): Other post-traumatic stress disorder (PTSD), social phobia, and others. terms used to describe the co-morbidity of a drug use disorder and ●● Buprenorphine: A partial opioid agonist for the treatment of another mental illness. opioid addiction that relieves drug cravings without producing the ●● Major depressive disorder: A mood disorder having a clinical “high” or dangerous side effects of other opioids. course of one or more serious depression episodes that last two ●● Bipolar disorder: A mood disorder characterized by alternating or more weeks. Episodes are characterized by a loss of interest or episodes of depression and mania or hypomania. pleasure in almost all activities; disturbances in appetite, sleep, or psychomotor functioning; a decrease in energy; difficulties in

Page 77 SocialWork.EliteCME.com thinking or making decisions; loss of self-esteem or feelings of cognitive, behavioral, and physiological symptoms as defined by guilt; and suicidal thoughts or attempts. the new Diagnostic and Statistical Manual of Mental Disorders, ●● Mania: A mood disorder characterized by abnormally and 5th edition (DSM-V) criteria. Diagnosis of an opioid use disorder persistently elevated, expansive, or irritable mood; mental and can be mild, moderate, or severe depending on the number physical hyperactivity; and/or disorganization of behavior. of symptoms a person experiences. Tolerance or withdrawal ●● Mental disorder: A mental condition marked primarily by symptoms that occur during medically supervised treatment are sufficient disorganization of personality, mind, and emotions specifically excluded from an opioid use disorder diagnosis. to seriously impair the normal psychological or behavioral ●● Partial agonist: A substance that binds to and activates the same functioning of the individual. Addiction is a mental disorder. nerve cell receptor as a natural neurotransmitter but produces a ●● Methadone: A long-acting opioid agonist medication shown to be diminished biological response. effective in treating heroin addiction. ●● Physical dependence: An adaptive physiological state that occurs ●● Naloxone: An opioid receptor antagonist that rapidly binds to opioid with regular drug use and results in a withdrawal syndrome when receptors, blocking heroin from activating them. An appropriate dose drug use stops. of naloxone acts in less than two minutes and completely eliminates ●● Post-traumatic stress disorder (PTSD): A disorder that develops all signs of opioid intoxication to reverse an opioid overdose. after exposure to a highly stressful event (e.g., wartime combat, ●● Naltrexone: An opioid antagonist medication that can only be physical violence, or natural disaster). Symptoms include sleeping used after a patient has completed detoxification. Naltrexone is not difficulties, hyper-vigilance, avoiding reminders of the event, and re- addictive or sedating and does not result in physical dependence; experiencing the trauma through flashbacks or recurrent nightmares. however, poor patient compliance limits effectiveness. A new, ●● Psychosis: A mental disorder (e.g., schizophrenia) characterized long-acting form of naltrexone called Vivitrol® is now available by delusional or disordered thinking detached from reality; that is injected once per month, eliminating the need for daily symptoms often include hallucinations. dosing, improving patient compliance. ●● Schizophrenia: A psychotic disorder characterized by symptoms ●● Neonatal abstinence syndrome (NAS): NAS occurs when heroin that fall into two categories: (1) positive symptoms, such as from the mother passes through the placenta into the baby’s distortions in thoughts (delusions), perception (hallucinations), and bloodstream during pregnancy, allowing the baby to become language and thinking; and (2) negative symptoms, such as flattened addicted along with the mother. NAS requires hospitalization emotional responses and decreased goal-directed behavior. and treatment with medication (often a morphine taper) to relieve ●● Self-medication: The use of a substance to lessen the negative symptoms until the baby adjusts to becoming opioid-free. effects of stress, anxiety, or other mental disorders (or side effects ●● Neurotransmitter: A chemical produced by neurons to carry of their pharmacotherapy). Self-medication may lead to addiction messages from one nerve cell to another. and other drug- or alcohol-related problems. ●● Opioid: A natural or synthetic psychoactive chemical that binds ●● Rush: A surge of euphoric pleasure that rapidly follows to opioid receptors in the brain and body. Natural opioids include administration of a drug. morphine and heroin (derived from the opium poppy) as well ●● Tolerance: A condition in which higher doses of a drug are as opioids produced by the human body (e.g., endorphins); required to produce the same effect as during initial use; often semi-synthetic or synthetic opioids include analgesics such as leads to physical dependence. oxycodone, hydrocodone, and fentanyl. ●● Withdrawal: A variety of symptoms that occur after use of an ●● Opioid use disorder: A problematic pattern of opioid drug use, addictive drug is reduced or stopped. leading to clinically significant impairment or distress that includes

The definition of addiction It is well documented that heroin is a highly addictive substance and ○○ Impairment in cognitive functioning. addiction can occur with only one use. In order to fully understand ○○ Craving. the process of addiction, professionals must first understand heroin ○○ Diminished recognition of significant problems with one’s addiction, treatment, and prevention. The American Society for behaviors and interpersonal relationships. Addiction Medicine in their Public Policy Statement included the ○○ Dysfunctional emotional response. following short definition addiction4: ○○ Cycles of relapse and remission. Addiction is a primary, chronic disease of brain reward, motivation, ○○ Progression that can result in disability or premature death. memory and related circuitry. Dysfunction in these circuits leads As each stage of tolerance, dependence, and addiction progresses, to characteristic biological, psychological, social and spiritual the user requires increasing amounts of heroin to feel pleasure and manifestations. This is reflected in an individual pathologically combat the pain and sickness that now occurs as the body goes through pursuing reward and/or relief by substance use and other behaviors. withdrawal. This class of drugs is known by the name opioids or Addiction is characterized by4: opiates. As defined by the DEA, heroin is a Schedule 1 substance ○○ Inability to consistently abstain. under the Controlled Substances Act, which means it has high potential ○○ Impairment in behavioral control. for abuse, no accepted medical use for treatment in the United States, and lacks accepted safety for use even under medical supervision7.

Today’s heroin epidemic Heroin was formerly viewed as a drug only found in back alleys of The most alarming statistics show heroin addiction among youth is large urban areas. Today heroin addiction is found in every corner of increasing in children as young as nine6. A number of factors contribute the country and affects people of all ages in every socio-economic to this epidemic by making the drug inexpensive and readily available. group in epidemic proportions. Heroin addiction still carries the stigma As the use of heroin became more widespread in contemporary culture, that it is a behavior or character flaw, though it affects a wide cross- it became more accepted among certain segments of society. Rock stars, section of America. No one is spared, from movie stars, such as Philip actors, fashion models, photographers, and other celebrities in popular Seymour Hoffman who died from a heroin overdose after 20 years, to culture abuse heroin, and their deaths are almost commonplace today. teenagers in suburbia and the homeless on inner-city streets. In fact, the “heroin look” became popular in the fashion world in the mid 90’s and was characterized by a thin, pale, emaciated appearance,

SocialWork.EliteCME.com Page 78 blank expression, dark sunken eyes, dirty hair, and disheveled clothing. Families, schools, health agencies, local, state and federal agencies Popular music and advertising campaigns included references to heroin across the country are now focused on addressing the epidemic rates of abuse and death had the effect of making the drug seem safe, exciting, addiction and death caused by heroin. glamorous, and mainstream in the eyes of impressionable youth. Young Heroin today is very different from the drug initially developed and people who would never inject a drug can now find heroin that can be can be found in many multiple drug combinations. With continued smoked or inhaled. This makes heroine seem easier, safer, and more use, these euphoric feelings become more difficult for users to reach, 7. Many youth desirable, thus increasing their willingness to try the drug and over time, the body tries to adjust to the damage caused by the have become addicted, comatose, or have died after only one dose of drug. Individuals become addicted to heroin quickly and their immune heroin. If individuals survive the first dose and continues to use heroin, and body systems are damaged, leaving the individual weak, sick, they quickly develop a tolerance to the previous amount used and malnourished, thin, and if untreated, they will die. One addict reported must have increasing amounts of the drug to replicate the high they from the time she started using heroin she never stopped, and in a experienced the first time. When the high from smoking and snorting week she went from snorting it to injecting and was addicted in a is no longer enough, as tolerance develops, users may inject the drug month.5 To support her habit, she sold everything she had, stole all she to enhance the rush and get the most they can from the amount they could from her family, ran her credit cards to the limit, sold her car, have. As the amount used and the frequency of use escalates, so does lost her job and house and became homeless. While living on the street the danger of overdose. Similarly, if drug use is curtailed through she was raped, robbed, beaten, sick, and in constant fear for her life incarceration or time in rehabilitation, users may overdose and die when and desperate for her next heroin hit. She realized she would die and they return to using heroin at the previous level. Sadly, another factor in felt that living as a junkie was worse than death, so she sought help the increasing number of deaths from heroin abuse is that those around from a local agency and continues to struggle to end her addiction. them are unable or unwilling to summon help when problems occur. Death usually occurs due to the drug’s suppressive effects on the Research into treatment and prevention programs around the world automatic breathing response of the victim, which can be easily reversed produced promising results, but it has not kept pace with the rampant through mechanical measures or medication to restore breathing3. addiction and death caused by heroin. The frequency of overdose among youth has increased so drastically that some states now allow family members to administer antidotal drugs in cases of near death that were previously only used by medical personnel.

Why heroin, why today? Heroin abuse and addiction has replaced other high-priced, commonly drug of choice for street gangs,” says Riley, and he noted the increase abused opiates and became the drug of choice in the United States, started about three years ago, when Mexico’s Sinaloa Cartel began increasing rapidly since 20106. The general public was largely unaware importing heroin through Chicago. “We are seeing it in places like of the epidemic until recent widespread media attention brought heroin Indianapolis, Madison, and Milwaukee, places where traditionally we addiction and death to the forefront and demands for solutions came from really did not see an uptick in heroin7.” “The ability to smoke and snort Vermont to California. The war against heroin must be fought on many today’s pure form of heroine has made it accessible and acceptable to fronts, and medical and mental health personnel must lead the charge. people who normally wouldn’t come near it for fear of the needle,” says Riley. “That’s why it is spreading.” Riley continues, “I’ve been Typically the drug is supplied by Mexican cartels, for just $10 a hit doing this for 30 years in virtually every corner of this country and if called a “stamp bag,” and has gone up 600 percent in the last 10 years anything can be likened to a weapon of mass destruction on a family, across the country7. As the United States cracks down on the sale of opiates such as Oxycodone by closing down pill mills throughout the on a community, on society, it’s heroin.” “I just don’t understand country, an 80 milligram Oxycontin dose now costs $100, which makes why people across the board don’t see its danger. Social services are 7 overwhelmed, our healthcare services are overwhelmed, yet Mexican heroine cheaper and easier to obtain . Manufacturers are also making 7 opiates and other prescription drugs in formulas that are more difficult organized crime and street gangs make billions from it .” for users to snort or dissolve to inject. Another reason heroin use is Many youth come from suburban areas around Chicago and other large thought to have doubled in five years relates to the high rate of addiction urban areas to buy the drug, and they may spend hundreds of dollars a to prescription opiate painkillers now replaced by heroin, which is a day to feed their habit. The streets of Chicago are filled with stories of natural opiate. Approximately 34,000 12-17-year-olds experiment with ruined lives caused by heroin addiction, including one from a college heroin each year due to lower costs of the drug and its availability6. student who went from shooting up between classes to living homeless Even though heroin abuse exists throughout the United States, large on the street, turning to prostitution to survive and stay high. In another cities are reporting dramatic increases in the rates of heroin addiction tragic instance, a suburban high school girl tried it once, overdosed, and and death. In large cities like Chicago, heroin can be found on the died. These stories are not unique to Chicago or large urban areas, but west side, often sold on the streets in plain sight. Addicts know where they are echoed through the farmlands of Wisconsin and Vermont. they can go to in any city, and with a phone call, they can receive Illinois is not alone in its fight against the heroin epidemic that has the drug in a few minutes. Local police are aware of the problem but plagued that state. Over one weekend in February 2014, a drug raid in seem unable to get it under control. Addicts can be seen shooting up the New York City Bronx area resulted in seizure of $8 million worth on the street, bleeding from their injuries as they attempt to find a of heroin. “Heroin is pummeling the northeast, leaving addiction, vein. Special Agent Jack Riley, Regional Representative of the Drug overdoses, and fear in its wake,” said James Hunt, acting special agent Enforcement Agency (DEA) and Special Agent in charge of the DEA’s in charge of the DEA’s New York office7. DEA heroin investigations in Chicago Field Division, is familiar with the addicts on Lower Wacker suburban Rockland County have doubled, and agents note that use is Drive, a notorious drug-infested part of the community. Many addicts increasing in all age groups and across all socioeconomic levels. The congregate under the overpass, injecting drugs or sleeping them off. Long Island Council on Alcoholism and Drug Dependence found an Riley reports that the Mexican cartels supply 70 percent of the drugs increase in families seeking assistance over the last five years from 100 used on Chicago’s streets and that statistic is mirrored nationwide7. to 850, and 80 percent of those were due to heroin addiction7. One of the addicts he encountered first took heroin as young as eleven Dr. Wilson Compton, deputy director of the National Institute on Drug years old and now lives on the street with two young children. Riley Abuse (NIDA), described heroin addiction as consuming the user. states,” heroin addiction is probably at its all time high.” “Heroin is the “The most common and important outcome of using heroin is that it

Page 79 SocialWork.EliteCME.com can cause an addiction where people organize their lives around the 19.8 percent were less than 21 years of age, which is much younder drug,” Dr. Compton said. “They use it to the exclusion of all other than those testing positive for cocaine and methamphetamine, aspects of their lives. It just becomes about scoring the next hit8.” according to the Arrestee Drug Abuse Monitoring Report. ●● In March 2014, Maryland, Vermont, New York, and Florida each The following NIDA statistics describe a nationwide problem6: reported an unprecedented number of deaths, according to the ●● In Maryland, state health officials believe that heroin combined National Institute on Drug Abuse, which is still determining the with other drugs is responsible for 30 or more deaths in the six numbers. NIDA reports these numbers could be the highest ever. months prior to March of 2014. They also note the number of ●● In 2012, New Jersey saw more than 800 opioid overdoses, and half deaths attributed to heroin rose 54 percent from 2011 to 2012 involved heroin. totaling 378 deaths. ●● The DEA reports that drug seizures in New York comprise 20 ●● The U.S. Drug Enforcement Agency (DEA) notes that Baltimore percent of the total heroin confiscated each year. The amount seized has the highest per capita heroin addiction rate in the country. In by the DEA in New York City has increased 67 percent over the past a city of 645,000, the Baltimore Department of Health estimates five years because heroin is now mass-produced in city apartments.7 there are 60,000 drug addicts, with as many as 48,000 of them ●● The New York City Department of Health notes fatal heroin-related hooked on heroin. A federal report released last month puts the overdoses increased 84 percent between 2010 and 2012, and 2012 number of heroin addicts alone at 60,0007. showed a higher rate of heroin overdose deaths at 52 percent over ●● Virginia officials note 91 heroin deaths in the first nine months of deaths involving any other substance. The problem is particularly bad 2012, up from 90 for all of 2011 and 70 for 2010. on Staten Island, where the death rate from overdoses is almost three ●● Vermont Governor Peter Shumlin spent his entire 34-minute times higher than the rest of New York City, according to the agency.7 State of the State address this year discussing a “full-blown ●● Heroin is the most commonly found illicit substance in drug heroin crisis.” Heroin-related deaths in Vermont doubled in 2013 intoxication deaths in Philadelphia, PA. In 2011, 251 intoxication according to the governor, and there were twice as many federal deaths involved heroin/morphine, a significant increase from 138 in indictments against heroin dealers than in the prior two years. Per 2010. Heroin is also the most commonly found substance in mortality capita, the heroin use in Vermont is second in the nation. cases where illicit drugs are present, with 32.4 percent in 2011. ●● Heroin overdose deaths in the Minneapolis/St. Paul metro area nearly ●● Dr. Karen Simone from the Northern New England Poison Center tripled from 2010 to 2011, increasing from 16 to 46 deaths, and these said the number of heroin-related calls doubled from 2007 to 2012. new heroin users were considerably younger. In Minneapolis, for ●● Only 20 percent of the estimated 810,000 heroin addicts seek or example, arrestees testing positive for heroin were much younger: receive any form of treatment for their addiction.

Street names for heroin It is important to know the street names of the drugs to help identify ●● H&C. the user’s drug of choice. There are many street names for heroin, ●● Murder one, One and one. including the following7: ●● Smoking gun. ●● Big H, H. ●● Whiz bang. ●● White, White lady, China white. Heroin and methamphetamine ●● Mexican mud. ●● Meth Speedball. ●● Scag, Skag. ●● Black tar, Tar. Heroin and marijuana ●● Brown crystal, Brown sugar. ●● Canade. ●● Nod. ●● Woolie. ●● Negra. ●● Woola. ●● Chiba, Chiva. Heroin, cocaine, methamphetamine, rohypnol, and alcohol ●● Snowball. ●● The Five Way. ●● Black pearl. ●● Junk. Heroin and fentanyl ●● Smack. ●● Theraflu. ●● Hell dust. ●● Bud ice. ●● Nose drops. Heroin, cocaine and tobacco ●● Thunder. ●● Flamethrowers. ●● Horse. ●● Dragon (smoking heroin is called “Chasing the Dragon”). Heroin and cold medicine ●● Dope. ●● Cheese. Heroin combinations Cheese heroin is a combination of Mexican black tar heroin and cold Heroin is often used in combination with other drugs that are known medicine obtained over the counter. It is a highly addictive substance, by specific names as follows: which is very inexpensive, only a few dollars, so it is often targeted at young people. Children as young as nine years old have been identified Heroin and cocaine in emergency rooms with addiction, overdose, and withdrawal to this ●● Speedball, Snowball. form of heroine which suppresses the central nervous system causing ●● Belushi. breathing and heartbeat to slow or stop. Since 2004, 40 deaths in North ●● Boy-Girl. Texas are attributed to cheese heroin7.

SocialWork.EliteCME.com Page 80 Facts and figures of increased heroin addiction, overdose and death Statistics from the United States Government Substance Abuse Mexican traffickers expanding into white powder heroin markets in and Mental Health Services Administration (SAMHSA) noted the the eastern and Midwest United States.” Previous to 2012, heroin from following statistics:9 Mexico was predominantly west of the Mississippi River with heroin ●● Nearly a half million Americans are addicted to heroin, and this from Asia coming through the major airports east of the Mississippi number is thought to be the highest in history. River. Some heroin from South America is smuggled through Mexico ●● In 2011, 4.2 million Americans aged 12 or older (or 1.6 percent) to the United States. The DEA report noted a steady decrease in cocaine had used heroin at least once in their lives. It is estimated that trafficking from Mexico to the U.S. during this time period and theorizes about 23 percent of individuals who use heroin become dependent. that the increase in heroin trafficking may be a push by the Mexican ●● NSDUH reports the number of new heroin users increased from TCOs to make up for the loss of cocaine profits. The DEA 2013 National 142,000 in 2010 to 178,000 in 2011. Both numbers are a sizeable Drug Threat Assessment Report includes the following7: increase from the average annual estimates of 2002 to 2008 ●● The availability of white powder heroin continued to increase (ranging from 91,000 to 118,000). in 2012 due to an increase in Mexican heroin production and ●● In 2012, there were 156,000 persons aged 12 or older who had trafficking which expanded into the Eastern and Midwest markets. used heroin for the first time within the past 12 months. ●● There was an increased level of smuggling of both Mexican- ●● A SAMHSA study from August of 2012 found that persons aged 12 produced heroin and South-American-produced heroin, which was to 49 who abused prescription pain killers were 19 times more likely smuggled through Mexico into the United States in 2012. to try heroin than those who abused pain killers in the previous year. ●● According to National Seizure System (NSS) data from January ●● In 2011, the average age at first use among heroin abusers aged 12 15, 2013, the amount of heroin seized each year at the Southwest to 49 was 22.1 years and in 2010 it was 21.4 years, significantly Border increased 232 percent from 2008 (558.8 kilograms) to 2012 lower than the 2009 estimate of 25.5 years. (1,855 kilograms). ●● The 2012 average age at first use among recent heroin initiates ●● The increase in Southwest Border seizures appears to correspond aged 12 to 49 was 23.0 years, which was similar to the 2011 with increasing levels of production of Mexican heroin and the estimate (22.1 years). expansion of Mexican heroin traffickers into new US markets. ●● The annual Monitoring the Future survey of teens reported in 2012 ●● Heroin-related overdoses and deaths are increasing in certain areas, that 20 percent of high school seniors felt that heroin was “easily possibly due to high-purity heroin on the streets and increasing available.” numbers of heroin abusers at a younger age because it can be ●● From 2007 to 2012, the number of Americans using heroin nearly smoked or inhaled. Inexperienced abusers, such as teens, college doubled, from 373,000 to 669,000, according to the federal students, and those who would normally not inject a substance start government’s most recent National Survey on Drug Use and by smoking or inhaling. Law enforcement officials reported an Health, released fall 2013. increase of high-purity heroin available at the street level. ●● One out of every four people who try heroin become addicted. ●● People are switching from abusing prescription drugs to abusing ●● The number of people meeting Diagnostic and Statistical Manual of heroin. Law enforcement and treatment officials throughout the Mental Disorders, 4th edition (DSM-IV) criteria for dependence or country report that many heroin abusers began using the drug after abuse of heroin doubled from 214,000 in 2002 to 467,000 in 201210. having first abused prescription opioids. These abusers turned to ●● When teens were surveyed to find out why they started using drugs heroin because it was cheaper and/or more easily obtained than in the first place, 55 percent replied that it was due to pressure prescription drugs and because heroin provides a high similar to from their friends. They wanted to be cool and popular. that of prescription opioids. ●● Heroin accounts for 18 percent of the admissions for drug and ●● According to treatment providers, many opioid addicts will use alcohol treatment in the United States. whichever drug is cheaper and/or available to them at the time. ●● An estimated 9.2 million-use heroin worldwide. Several treatment providers report the majority of opioid addicts will The U.S. Drug Enforcement Agency (DEA) 2013 National Drug eventually end up abusing heroin and will not switch back to another Threat Assessment Summary found that heroin smuggling is increasing drug, because heroin is highly addictive, relatively inexpensive, and across the United States border from Mexico and Mexican cartels, more readily available. Those abusers who have recently switched to called Transnational Criminal Organizations (TCOs) by the DEA7. heroin are at higher risk for accidental overdose. The summary noted, “The availability of heroin continued to increase ●● Unlike prescription drugs, heroin purity and dosage amounts vary, in 2012, likely due to high levels of heroin production in Mexico and and heroin is often cut with other substances, all of which could cause inexperienced abusers to accidentally overdose.

Etiology of heroin addiction: Physical effects on the brain The thorough study of the effects of heroin on the brain would require mental, and behavioral response to stimuli that drives individuals’ a separate course, but it is important to include an outline of the drug cravings and drug-related behaviors. These behaviors may effects of heroin on the brain that lead to addiction. Whether heroin include lack of judgment and impulse control, inability to delay is smoked, snorted, or injected, it is rapidly absorbed and crosses the gratification, poor decision-making and repeated inability to react blood brain barrier. Addiction occurs due to specific effects on the appropriately despite patterns of repeated negative consequences. brain caused by the drug that interfere with normal brain function in ●● Addictive behaviors are exacerbated when younger individuals, the following ways4: whose brain systems have not fully matured, use heroin. ●● Addiction affects the transmission of neurons within the parts of ●● Addiction causes changes in brain chemistry and function, which the brain that control motivation and reward. These parts include results in physical changes to the nerve cells that transmit messages the basal forebrain amygdala and the anterior cingulate cortex. in the brain. Damage to neuron transmission in the nerve cells may This part of the brain affects the individual’s ability to conduct disrupt signals and cues that communicate a variety of messages routine behaviors related to healthcare, motivation, and normal affecting learning, perception, memory, impulse control, motivation, reward-seeking behavior. pleasure/pain sensations, and more critically, central nervous system ●● Addiction interferes with cortical and hippocampal interactions function that controls breathing responses and heart rate. that affect reward; memory of reward; and control of physical,

Page 81 SocialWork.EliteCME.com Factors influencing addiction Psychological factors an addictive disorder may be an indicator that the individual addicted to Individuals may have psychological disorders or mental illness that heroin has a genetic predisposition. Social and environmental influences interfere with their ability to function normally. They may use heroin may determine the impact of genetic factors on addiction. The individual’s and other substances to deal with their psychological issues, which sense of security, stability, personality, motivation, emotional and mental may be the only coping mechanism they know. Their self-medication well-being are influenced by their role models, early experiences, culture, to escape their negative feelings turns to addiction, which may mask health and behavior patterns as they mature. These factors can influence an undiagnosed mental disorder. As the heroin addiction progresses, whether genetic indicators of addiction come into play. the underlying issues will be complicated by increasing psychological Environmental factors and physical changes cause by the damaging effects of the drug. Environmental factors include a complex set of interacting variables and Genetic factors may be difficult to measure initially. Issues related to the individual’s Though genetics factors do not cause an addiction to heroin, they can upbringing, family dynamics, belief systems, educational level, peer group indicate addictive behavior and were found to be significant in about 50 influences, cultural or religious beliefs, stress, trauma, community values, percent of addictions.8 One or more immediate family members with and group affiliations may influence an individual’s decision to try heroin. Screening The two main ways to identify the presence of heroin is in either can be done in house and one version can deliver results in 11 minutes the blood or urine of a user. The analytical methods used are with 98 percent accuracy when compared with GC-MS. The Supreme gas chromatography-mass spectrometry (GC-MS) and liquid Court has approved this test as defensible technology11. 11. Both methods do the chromatography-mass spectrometry (LC-MS) In addition to the tests above, medical history, criminal records, and same thing, which is to separate a mixture of compounds present in physical health/appearance typically identify chronic users. Chronic the sample prepared from the urine or blood, followed by the detection heroin abusers commonly have a lengthy arrest record for drug of those compounds. The separation step allows for detection of any possession or theft; they may have overdosed one or more times and substance that has been used in combination with heroin. The urine is were brought to the hospital; and they will typically have “track marks” screened for 6-acetylmorphine (6-AM) by immunoassay and confirming over the veins in their arms, which are small areas of contusions from the results by GC-MS analysis, which can take four to five days to injecting the drugs; along with other indicators of chronic use. Track complete. Heroin can be detected for one to two days after use. Heroin marks may be found on any part of the body if larger veins are destroyed metabolizes into 6-AM, and this differentiates the use of heroin from by repeated injection. A very lengthy, expensive way to identify chronic other drugs such as codeine, morphine, and other prescription opiate users would be hair analysis for the accumulation of small amounts of drugs. Since October 1, 2010, the Substance Abuse and Mental Health the drug. Extracting drugs from hair is extremely expensive and time Services Administration (SAMHSA) established mandatory guidelines consuming. The low amounts of the drugs that are present in the hair that require 6-AM screening as part of the required screening for all require highly sensitive instrumentation, and those techniques would federally mandated drug testing in the workplace12. The 6-AM screening typically not be done by a lab13. Signs and symptoms of heroin addiction No two individuals who are addicted to heroin will present with the Physical indicators same signs and symptoms, which will vary due to the method of use, ●● Cuts, contusions, bruises, and needle marks on the body, not just arms. level of tolerance, dependency, addiction, frequency of use, form of ●● Weight loss. the drug, and secondary illness and disease. HIV/AIDS is often the ●● Scabs or bruises as the result of picking at the skin. consequence of injecting heroin. Common signs and symptoms of ●● Decreased attention to personal hygiene and appearance. heroin use can be divided into the following categories8: ●● Shortness of breath. Psychological indicators ●● Frequent respiratory infections. ●● Hallucinations, delusions. ●● Dry mouth, loss of teeth. ●● Paranoia. ●● Skin infections and abscesses. ●● Depression. ●● Warm, flushed skin. ●● Disorientation. ●● Drooping heavy extremities. ●● Sudden changes in behavior. ●● Constricted pupils. ●● Slurred, forced, or incoherent speech. ●● Hyperactivity or hyper alertness followed by lethargy. ●● Negative school or work performance. ●● Extreme itching. ●● Distractibility. ●● Loss of menstruation. ●● Frequent comments indicating low self-esteem, negativity. ●● Miscarriage. ●● Insomnia or excessive sleep. Other indicators7 ●● Euphoria. ●● Possession of burned spoons. ●● Blaming others for their issues. ●● Needles or syringes. ●● Withdrawal from friends and family, association with new, ●● Items to use as tourniquet such as a shoelaces or rubber bands. unknown friends. ●● Evidence of drug residue in baggies or foil. ●● Constant runny nose or bloody nose. ●● Foil, straws or gum wrappers with burn marks. ●● Avoiding eye contact. ●● Glass pipes or water pipes. ●● Mood swings. ●● Wearing long pants and shirts, even in warm weather. ●● Anxiety. ●● Repeated borrowing of money, missing valuable items. ●● Apathy, lack of motivation in interests and regular activities. ●● Criminal activity. ●● Fatigue/exhaustion. ●● Hostility toward others, agitation, and irritability. ●● Lying about drug use. ●● Stealing. ●● Avoiding loved ones and others.

SocialWork.EliteCME.com Page 82 Short-term effects of heroin Every addict will present with different side effects due to the type, ●● Nausea. amount, and frequency of heroin use, other substances used, co- ●● Breathing that is slow, shallow, or irregular. existing physical and mental disorders, and pre-existing conditions. ●● Slurred speech. In addition to the initial “rush” or feeling of euphoria, short-term side ●● “Nodding out,” “crashing,” lethargy, sleep/alert cycles. effects of heroin use include3: ●● Confused cognition. ●● Dry mouth. ●● Decreased sensations of pain, physical and emotional “numbness.” ●● Flushed skin. ●● Constipation. ●● Poisoning due to contaminants or adulterants. ●● Stomach cramps. ●● Vomiting. ●● Overdose/death. ●● Itching externally and feeling itchy sensation internally, picking at skin.

Long-term effects of heroin Chronic abuse of heroin leads to severe medical complications, many ●● Seizures. irreversible, and may lead to death3: ●● Miscarriage. ●● Heart problems such as infection of heart lining, infection of the ●● Birth defects.* heart’s surface called endocarditis, valve prolapse, blockage, ●● Diseases and infections from sharing needles. myocardial infarction and arrhythmia, congestive heart failure. ●● Overdose/death. ●● Infectious diseases transmitted through needles (HIV/AIDS and In addition to miscarriage, babies born to mothers using heroin suffer Hepatitis B and C). problems associated with malnutrition, drug toxicity, infection. These ●● Chronic pneumonia, pulmonary diseases. problems include low birth weight, developmental delays, prematurity, ●● Collapsed veins, vascular blockages, clots, resulting tissue death birth defects, failure to thrive, drug dependence, or addiction known due to lack of blood supply. as neonatal abstinence syndrome (NAS). NAS is drug withdrawal that ●● Bacterial infections. the baby must endure under strict medical care in the hospital. Studies ●● Liver and kidney disease. have shown that pregnant mothers with heroin addiction can be treated ●● Immune disorders. in the hospital with the drug buprenorphine, which treats the mother ●● Pulmonary edema. and baby and reduces their withdrawal symptoms. Heroin addicted ●● Coma. mothers will often lose custody of their baby and many are charged ●● Paralysis. with child neglect or abuse. Addicted mothers often abandon their ●● Cognitive disorder. babies after birth.

Heroin withdrawal Heroin withdrawal symptoms can occur within an hour after the last ●● Edema. drug dose, based on the level of abuse. Withdrawal symptoms may ●● Chills. include4: ●● Runny nose. ●● Severe heroin cravings. ●● Diarrhea. ●● Sweating. ●● Fever. ●● Severe muscle and bone aches. ●● Death. ●● Nausea and vomiting. Addicts facing withdrawal must receive medical care in a clinic, ●● Heavy extremities. rehabilitation facility, or hospital from providers who are specifically ●● Muscle cramping. trained to treat patients for heroin withdrawal. They should never ●● Crying. attempt withdrawal alone. ●● Insomnia.

Signs and symptoms of multiple substance abuse Among persons with heroin addiction, multiple substance addiction is ●● Screening instruments: MAST, DAST, CAGE-AID, AUDIT. common. Cocaine and alcohol are the substances most often abused ●● Clinical assessments using interview with the patient, family of with heroin14. A trained professional should assess for abuse of other significant others. substances and determine the effects of the overlapping substances. ●● Structured interviews: DSM-V SCID-1, Structured Clinical The American Psychiatric Association (APA) suggests the following Interview for DSM-V Axis 1 Disorders. four approaches for assessing heroin dependent people for other ●● Laboratory tests: Urine samples done onsite for immediate substances: results that can be addressed with the patient.

Heroin addiction and co-occurring disorders As with other substance abuse addictions, individuals with harm tendencies, which are often part of the heroin addict’s coping heroin addiction often have co-occurring mental disorders. Since or escape mechanism. The following co-occurring mental disorders psychological and emotional causative factors for heroin addiction are commonly seen among heroin addicts on the street and those in exist, it may be critical to determine the primary and secondary rehabilitation programs4: disorder in planning a long-term treatment plan. Of course, chronic ●● Depressive and/or anxiety disorder. addiction to heroin and the physical ravages of the disease must ●● Addiction to other drugs and/or alcohol. be addressed immediately, which will require medical care and ●● Personality disorder. monitoring. Patients must be screened for suicide ideation and self- ●● Cutting, self-harm behaviors.

Page 83 SocialWork.EliteCME.com ●● Bipolar disorder. ●● Schizophrenia. ●● Eating disorders. ●● Conduct disorder. ●● Post traumatic stress disorder. ●● Psychosis.

Treating heroin overdose A new and controversial medication to reverse the effects of heroin Evzio works like an Epipen, which counteracts anaphylactic shock, overdose has been approved and released for sale by prescription by and can go into the muscle or the skin. New Jersey has approved the Federal Food and Drug Administration (FDA) in April 201415. the use of naloxone for law enforcement officers. “We think greater Naxalone comes in the form of a hand-held device, injection, or nasal availability of immediate treatments like naloxone are important as spray, and is being hailed by government and health care leaders as New Jersey confronts this crisis in heroin and opioid overdoses,” a ground-breaking tool to address the epidemic of heroin overdoses said Aline Holmes, a registered nurse and senior vice president of across the nation. The states of New York and New Jersey are already clinical affairs at the New Jersey Hospital Association16. In May 2013, mandating its use by first responders, and after training, the drug was New Jersey signed the Overdose Protection Act, which gives legal saving lives in the first weeks of use. immunity to anyone using the drug to save a life. The drug, also known as Narcan, is marketed under the name of The state of New York has also approved the use of the drug by all law Evzio15. A single dose of the drug, which acts as an antidote to heroin, enforcement agents, and 17 other states have followed suit, with some has been successful in bringing back overdose victims from death due allowing prescriptions to family and friends of the addict. It comes in a to respiratory failure and lack of blood pressure. Naloxone works by nasal spray or injectable form and can be used by anyone without advanced reversing the suppressive effects of heroin on the opioid receptors that training in an emergency situation. It is suggested for use after calling 911 signal respiration to bring back consciousness and normal breathing. The and checking for breathing, though additional training is advisable. drug is not new and has been used by emergency medical personnel One drawback of the drug is that if the heroin is adulterated with fentanyl, on the street and in the hospital for over 40 years in injectable form. patients will need a larger dose over a longer period of time to combat The release of the drug is controversial, because some, like Maine longer-acting drug combinations, which may cause them to sink back into Governor Paul LePage, believe it will give addicts a false sense of respiratory distress. Patients will also require emergency medical care and/ confidence that they can continue to use much heroin as they want and or hospitalization despite receiving the drug and being revived. the drug will save them from death from overdose. Many also object on the grounds that it will drive up insurance costs. Proponents of the drug The CDC reports local and state health departments fund the drug and do not believe addicts will purposely take enough drugs to overdose provide it to hospitals and community-based clinics free of charge22. just because the drug is available and feel the FDA has addressed a life San Francisco’s Drug Overdose Prevention and Education Project and threatening public health crisis that has reached epidemic proportions. Massachusetts’ Overdose Education and Naloxone Distribution Program are examples of two community-based programs using the drug15.

Moving from withdrawal to treatment The American Society for Addiction Medicine (ASAM) provides a periods of relapse which will vary by frequency, duration or amount of wealth of information about the changes faced by the person who is use but ASAM points out that, “the return to drug use or pathological withdrawing or has withdrawn from addiction. Addiction by definition pursuit of reward is not inevitable4.” They provide the following includes periods of withdrawal and relapse, and the journey will be information about the recovery process: different for each individual. It is important to remember that unlike ●● Clinical interventions can help to alter the course of addiction. the feelings of early heroin use, as time goes by, the euphoria, pleasure ●● Close monitoring of the behaviors of the individual and contingency or “reward” felt when the individual gets high does not continue to management, sometimes including behavioral consequences for escalate with each subsequent use. As outlined previously, users need relapse behaviors, can contribute to positive clinical outcomes. more heroin to achieve the same high and actually builds tolerance ●● Engagement in health promotion activities that encourage personal to the “high.” However, they continue to experience deeper and more responsibility and accountability, connection with others, and painful “lows” as their addiction progresses. As explained by ASAM4: personal growth also contribute to recovery. Persons with addiction compulsively use even though it may not ●● The patient must be monitored and managed over time to decrease make them feel good and in some cases long after the pursuit of the frequency and intensity of relapses, to sustain remission and “rewards” is not resulting in pleasurable feelings. Although people optimize functioning, and to minimize episodes of relapse and from any culture may choose to “get high” from one or another their impact. activity, it is important to appreciate that addiction is not solely a ●● Medication management can improve treatment outcomes. function of choice. Simply put, addiction is not a desired condition. Integration of psychosocial rehabilitation and ongoing care with Addiction is classified as a chronic brain disorder or disease and evidence-based pharmacological therapy provides the best results. not a behavioral one, which is important to remember when working ●● Recovery is best achieved through a combination of with a person in recovery. As in any chronic disease there will be self-management, mutual support, and professional care provided by trained and certified professionals.

Treatment and recovery The ultimate goal of treatment is recovery, because the person their treatment team. According to the Substance Abuse and Mental addicted to heroin has so many levels of life that have been damaged Health Services Administration (SAMHSA), “Recovery from Mental or destroyed. Some individuals have co-occurring mental disorders Disorders and Substance Use Disorders” is a process of change that may have preceded the addiction or occurred during drug use. through which individuals improve their health and wellness, live a Knowing that the individual is ready to enter treatment to move toward self-directed life, and strive to reach their full potential17. SAMHSA recovery, and developing a treatment plan to support them in reaching has delineated four major dimensions that support a life in recovery: their goal are the first steps in the process. The recovering patients may ●● Health: Overcoming or managing one’s disease(s) as well as face unresolved issues that initially led to their drug use. Therefore, living in a physically and emotionally healthy way. patients may need to make total life changes with the assistance from ●● Home: A stable and safe place to live.

SocialWork.EliteCME.com Page 84 ●● Purpose: Meaningful daily activities, such as a job, school, ●● Patients’ treatment and services plan must be assessed continually and volunteerism, family caretaking, or creative endeavors, and the modified as necessary to ensure that it meets their changing needs. independence, income, and resources to participate in society. ●● Many drug-addicted individuals also have other mental disorders, ●● Community: Relationships and social networks that provide which must be addressed. support, friendship, love, and hope. ●● Medically assisted detoxification is only the first stage of addiction Heroin addiction is a chronic disease that cannot be treated easily or treatment and by itself does little to change long-term drug abuse. quickly since it has been prevalent since the late 1880s . Scientific ●● Treatment does not need to be voluntary to be effective. research and treatment trials conducted over decades have yielded the ●● Drug use during treatment must be monitored continuously, as following guiding principals for treatment18: lapses during treatment do occur. ●● Addiction is a complex but treatable disease that affects brain ●● Treatment programs should assess patients for the presence of function and behavior. HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious ●● No single treatment works for everyone. diseases, as well as provide targeted risk-reduction counseling to ●● Treatment needs to be readily available. help patients modify or change behaviors that place them at risk ●● Effective treatment attends to multiple needs of patients, not just for contracting or spreading infectious diseases. their drug abuse. After the patient is stabilized and makes the decision to enter treatment, ●● Remaining in treatment for an adequate period of time is critical, a long-term treatment plan is developed. There is no single method that sometimes continuing for years. works for all individuals, but practitioners need to review a variety of ●● Counseling, individual and/or group, along with behavioral therapies programs available in the vicinity of the patient and match the program are the most commonly used forms of drug abuse treatment. to the patient’s needs. This course outlines some current programs and ●● Medications are an important element of treatment for many provides resources for free training materials and program guides. patients, especially when combined with counseling and other behavioral therapies.

Therapeutic communities for residential treatment For individuals with severe drug and addiction problems, therapeutic communication and family issues. Specialized centers can accommodate communities (TC) are the next step after hospital or medical pregnant women, children, and adolescents. The goal of the therapeutic management of their withdrawal symptoms.18 These programs provide community is to provide the treatment and skills necessary for a highly structured, strictly monitored program to meet the medical individuals to return to the community as healthy, drug-free individuals and psychological needs of patients. Patients may live in the facility who can successfully when re-enter society and live productive lives. for up to a year and receive treatment for their addiction as well as other After care will continue through outpatient or support services in the therapy and services needed for recovery. They receive support and community following successful release from residential care. treatment to address behavior issues, including criminal behavior, social,

Pharmacological treatment Heroin addiction changes the structure and function of specific parts no euphoria or side effects when taken orally. The FDA approved of the brain, so for medication to be effective, it must work despite buprenorphine in 2002 for prescription by certified physicians changes that occur in the short and long term. In the beginning stages in their office, which extends the availability of this drug to a of withdrawal, medication must curb the strong cravings for heroin and wider population of patients and makes it more accessible. Some lessen the painful side effects of withdrawal to avoid a relapse. In later critics theorize that the ease of obtaining this drug will encourage stages of recovery, individuals need medication to help them think more individuals to enter and stay in pharmacologic treatment. clearly, gain control, make decisions, and focus on goals and skills for In 2013, the FDA approved two generic forms of Suboxone, a healthy new life. which is buprenorphine that contains naloxone, in 201315. This drug prevents attempts to get high by causing severe withdrawal Pharmacological treatment of heroin addiction has proven to be symptoms if injected but no negative effects when taken orally successful by increasing time in treatment, decreasing rates of as directed. Buprenorphine can be used effectively with prisoners relapse, and reducing rates of infectious disease and illegal drug- and could be implemented through collaboration with health seeking behaviors. Medications such as buprenorphine, methadone, professionals and the juvenile justice system. and naltrexone can help people to escape the grip of heroin, because it reduces their cravings by blocking the euphoric effect. The Many governmental agencies are working together to address the medications used in this treatment work in the same manner as heroin heroin addiction epidemic. An example of one partnership, known by impacting the opioid receptors, but they do not cause the dangerous as the Blending Initiative20, combines the efforts of SAMHSA and side effects or lead to addiction. The three types of medications NIDA to fund and conduct research and clinical trials on a variety interact with the opioid receptors in different ways as follows19: of therapies that can effectively treat heroin addiction. Currently, 1. Agonist medication such as Methadone, also known as Dolophine they are developing and disseminating protocols to educate and Methadose, activates receptors by gradually reaching the multidisciplinary treatment professionals about buprenorphine. brain slowly, preventing the euphoric feeling, and preventing Information can be found at (http://www.ctndisseminationlibrary. withdrawal symptoms. These drugs are appropriate for use by org/display/85.htm). This information contains the following goals: certified physicians in outpatient treatment programs and are given Blending teams of NIDA researchers, treatment practitioners, and to the patient orally each day. An estimated 200,000 people in trainers have completed two buprenorphine training packets21: correctional facilities each year are addicted to heroin. Therapy such ■■ To increase overall awareness of buprenorphine therapy. as methadone maintenance treatment has been effective in prison ■■ To instruct physicians and treatment practitioners in populations and shown to increase time in treatment and diminish implementing a 13-day detoxification intervention for criminal activity if continued in the community upon release, opiate-dependent patients. because it eliminates the need to commit crime to buy heroin. ■■ To change the mindset of many community treatment 2. Partial agonists, such as Buprenorphine, also called Subutex, providers previously unwilling to consider the use of produce a small response in the brain, which relieves cravings with medications to treat drug addiction.

Page 85 SocialWork.EliteCME.com ■■ To expand the programs now regularly use buprenorphine to suppress all drug craving, and many patients cannot remain assist in opiate detoxification and treatment maintenance. abstinent and relapse in six months. According to Dr. George22, ■■ To work with SAMHSA’s Addiction Technology Transfer “Drug abusers are notoriously ambivalent and just because they Centers (ATTC), State Directors, and other stakeholders, to decide to quit using heroin one week doesn’t mean they’ll be spread the word about buprenorphine to more proactively motivated to quit a week later.” Extended-release forms like Vivitrol address the urgent needs of drug addiction. can provide long-lasting protection over time, which can help ■■ To continue clinical tests on the safety and efficacy of patients in their resolve to stay drug-free. Patients taking a daily oral buprenorphine in other affected populations, including dose of naltrexone must make a daily decision to remain drug-free. pregnant women, adolescents, and patients addicted to Patients using Vivitrol will receive a sustained dose each month, opiate analgesics. so they have more time in treatment and recovery between doses ■■ To increase the use of this and other addiction medications and do not face a daily decision to use heroin when the naltrexone in different settings and locales, including in the U.S. tapers every 24 hours. Clinical trials are being conducted on patients criminal justice system and in countries where injection in Russia with extended release implants that last up to two months drug use is still a primary mode of HIV transmission21. and can be refilled without having to be removed22. Early trials of Additional information on buprenorphine can be found at these implants are proving to be three times more effective in some http://www.ctndisseminationlibrary.org/ display/85.htm patients than the daily dose pill in preventing relapse. Dr. Woody 3. Antagonists, such as Naltrexone, also known as Depade and Revia, continues, “Methadone and buprenorphine have helped hundreds of block opioid receptors that send pleasure signals, thus blocking the thousands of people around the world who are drug dependent, and “high.” They doo not cause dependence, addiction, or sedation. they have helped reduce the spread of HIV.” “The new injectable Patients must take this drug daily, but the FDA recently approved and implantable naltrexone formulations are really the new kids on a long-acting form called Vivitrol that can be administered once the block, but they’re offering us more options in an area where we a month, which may increase compliance. Naltrexone does not really need a lot of help.”

Urine testing for compliance Treatment programs that include medication are only effective if If the results are negative, the therapist can immediately address they include strict monitoring to make sure patients comply with the the issue with the person. In both cases, the samples may have to program and have not relapsed. This is done through urine testing, be confirmed off site depending on the lab, and additional tests patient interview, observation, and input from family and other may be required if the result is negative. Off-site testing allows significant parties in the patient’s life. Drug treatment programs for more comprehensive testing; a higher level of expertise that are administered through outpatient or doctor’s office settings among personnel, which may yield higher rates of accuracy; and may have limited contact with the patient and must rely on tightly admissibility in court. controlled drug monitoring protocols. These testing protocols must ●● Type of test contain the following components12: Different types of tests provide different levels of information. ●● Location Immunoassay can test for heroin and other natural opioids, and A decision must be made about whether testing will be on site or it provides almost immediate results. Methadone is a synthetic off site. opioid but specific immunoassay tests have been developed for There are advantages to each setting, depending on the person’s this drug. Immunoassay tests will not detect the presence of other needs. On- site testing will give immediate, affirming results if synthetic opioids, like fentanyl and buprenorphine, so it is not as positive. The sample will require less handling, and the patient comprehensive as other tests. Laboratory tests such, as GS-MS, 11. may feel this testing is more confidential because it is kept on site. will detect all types of opioids but take four to five days

Current research in pharmacology new medications NIDA is committed to new treatments for heroin addiction, which called Probuphine is producing positive results in clinical trials. It is a include improved medication and other forms of therapy. When long-acting form of buprenorphine that is administered as an implant combined, they have proven to raise recovery rates. The NIDA is under the skin to provide medication over a six-month period23. This working to improve treatment for heroin addiction that they can drug is more convenient for the patient and eliminates daily dosing implement to large numbers of patients across the country. A new drug which increases adherence to treatment goals.

The heroin vaccine Another exciting NIDA clinical trial currently underway is vaccine Two parts must be present in the vaccine to accomplish this action24. The research that can effectively block addiction to heroin and other drugs. first is a protein that causes the immune system to produce sufficient Dr. Ronald Crystal and Dr. George Koob and Dr. Kim Janda are among antibodies to overtake the total molecules in the amount of heroin taken the many researchers around the world conducting research and clinical so they do not reach the brain. The second part of the drug, hapten, trials to develop a vaccine to address heroin addiction24. The vaccine has molecules that are similar to heroin in structure. Hapten serves as acts to combat the effects of heroin as it enters the bloodstream before the schematic for the development of the antibodies that identify and it reaches the brain and the opioid receptors so the euphoric or reward combine with the heroin molecules. Each person’s immune system sensation is not released. The medication would be part of a treatment responds differently, and the system is often compromised from heroin plan that would increase the chance of recovery by lowering the risk addiction. The drug trials focus on identifying the effective combinations of relapse. The vaccine works by interfering with the immune system’s of the parts of the vaccine to illicit the immune response necessary to ability to conduct the action of heroin on the brain. The antibodies in block the action of the heroin in the bloodstream. the vaccine identify and attach to molecules of heroin and the together Several concurrent trials are underway for the vaccine, which are they are too big to cross the blood brain barrier to enter the brain. When in the early stages of development and have not yet been tested on the drug does not enter the brain, it cannot reach the opioid receptor and humans. Researchers agree that vaccine treatment should be part of a signal the pleasurable sensation that drivers the need for the drug. comprehensive therapy plan.24 Dr. Janda and Dr. Crystal note, “People

SocialWork.EliteCME.com Page 86 have the misconception that a single vaccine can protect patients from in weak moments.” “The vaccine approach provides an alternative substance abuse, that’s not true.” Dr. Crystal states, “A patient who strategy for treating drug addiction,” says Dr. Nora Chiang of NIDA’s has attained abstinence could be vaccinated to block the effects of the Division of Pharmacotherapies and Medical Consequences of Drug drug, thereby preventing relapse. Dr. Janda notes, “Our vaccine will Abuse. “There is much more work to be done on these vaccines, but not alleviate craving, but it could help patients maintain abstinence the results so far are promising25.”

Treatment for adolescents Many biological factors, such as immature brain development in the with the adolescent and parent to develop behavior goals, treatment plans, frontal cortex, social and environmental factors, influence drug abuse behavior strategies, and treatment interventions. The therapist writes a and addiction in adolescents. Government health agencies, through contact based on the goals and treatment plan, with contingencies based their initiatives to blend the fields of study that research addiction, on measurable behaviors. The adolescent and parent work together to have combined neurobiology and social sciences to develop prevention practice new behaviors and skills in the home, school, and community. and treatment programs that address the multiple and overlapping Therapists and adolescents review the contract on a schedule that is factors that influence heroin addiction in adolescents. NIDA explains appropriate for the child’s age and maturity level to motivate and reinforce this process as follows: behavior. Professionals should reinforce appropriate behavior and goal The resulting social neuroscience initiative will help us better mastery frequently in order for the program to work effectively. understand how neurobiological mechanisms and responses, genetic, Functional family therapy (FFT) hormonal, and physiological, underlie, motivate, and guide social FFT is based on the premise that problem behaviors stem from behaviors related to abuse and addiction. This perspective may help dysfunctional family interactions. Therapy uses behavioral strategies us understand adolescents’ heightened sensitivity to social influences to resolve conflict by improving skills for parenting, communication, and decreased sensitivity to negative consequences, for example, and problem solving within the family involving all family members. 20. that make them particularly vulnerable to drug abuse Program goals include engaging and motivating all family members Pharmacology to work together to change their patterns of interaction through None of the medications used with adults to treat addiction have been techniques of behavior therapy. approved by the FDA for use with children and adolescents. At this Multidimensional family therapy (MDFT) time, clinical trials for additional medications are in development. The MDFT approach combines treatment components from all programs Behavioral treatment addicted youths encounters as a result of their addiction or conduct. Behavioral therapies are effective with children and adolescents and At-risk or addicted youths can benefit from techniques of family therapy follow the same procedures noted in the section on therapy for adults. combined with treatment at school, juvenile justice, child protective Contingencies and incentives help to motivate youth, and cognitive services, clinics, family court, or other community agencies involved behavioral strategies work effectively when they are structured to in their treatment plans. Often adolescents abusing drugs exhibited meet the child’s needs, age, developmental and maturity level. Any at-risk behavior, conduct disorder, family problems, or illegal behavior healthcare provider trained and certified to provide services to young in the past that brought them in contact with special services in a clients can deliver behavioral treatment. number of organizations. MDFT goals work toward pooling resources Family therapy and developing consistency and collaboration among all agencies Children and adolescents can benefit from treatment using family therapy involved in the child’s care. Representatives from these agencies meet approaches, which include all significant people in their lives, including together with the adolescent and family to plan and implement goals parents, guardians, mentors, siblings, and peers. Family therapy can address and strategies consistently and hold the young person accountable on all all areas of children’s lives and increase communication and address fronts. According to NIDA, the MDFT program has been effective with problems in family dynamics, which may add to the stress of recovery. severe substance-use disorders and can facilitate the reintegration of Therapy can build a wide circle of support for adolescents and help them juvenile detainees into the community. gain confidence and self-esteem as they fight their addiction. Involving the Multisystemic therapy (MST) family is a critical part of adolescent substance abuse treatment. Similar to MDFT, this therapy uses a multidimensional approach that The following evidence-based family treatments programs work combines family therapy approaches with treatment strategies from effectively to treat adolescent substance abuse26. a variety of treatment programs in the community. This approach is a natural out-growth of treatment for adolescents involved in Brief strategic family therapy (BSFT) severe drug addictions, violent behavior, and illegal activity. MST BSFT focuses on unhealthy family interactions that contribute to focuses on adolescents’ personality, attitude, behavior, emotions, and the young person’s drug problem. The therapist works to establish peer influences related to their addiction and behavior. The second rapport with each family member, while observing how each member component includes a review of family interactions such as discipline, interacts, to identify problem areas and strategies. During the course of parenting skills, communication, and history of substance abuse 12–16 sessions, the therapist will work to address problems and guide among family members, and attitudes and values that influence them. the family members to work together to resolve them. This approach The last variable looks to adolescents’ performance and attitudes in can target any family issue and can be conducted in any setting. the community at school, on the street, and membership in gangs or Family behavior therapy (FBT) other groups in the community. The therapist works with the youth FBT includes strategies from behavioral therapy, including behavior individually, with the family and youth together, and they coordinate contracts that include contingencies to motivate the young person, and and lead meetings with community agencies to coordinate services and build impulse control and appropriate behaviors. The therapist works build program consistency.

Recovery support for adolescents If addiction treatment and recovery programs work effectively, there trials show promise in supporting recovery and lowering relapse must be support services for aftercare to avoid relapse and support among adolescent addicts26. adolescents as they develop and apply skills to maintain a healthy, Assertive continuing care (ACC). ACC is a home-based continuing- drug-free lifestyle. NIDA notes the following programs in clinical care approach delivered by trained clinicians to prevent relapse, and

Page 87 SocialWork.EliteCME.com is typically used after an adolescent completes therapy utilizing the importantly, these services can provide new social connections so the Adolescent Community Reinforcement Approach (A-CRA). ACC adolescent can build positive social interactions with sober peers. combines A-CRA, behavior therapy, and assertive case management Recovery high schools. Recovery high schools can take different forms, services using a multidisciplinary team of professionals, round-the-clock but they are designed to meet the specific needs of students recovering coverage, and assertive outreach to help adolescents and their caregivers from drug abuse. Students may attend a separate school or be part of a acquire the skills needed to engage in positive social activities. community school, but initially, they attend classes in a separate area Peer recovery support services. Peer recovery support services connect with students who share their specific experiences and needs. The high youth with groups and individuals who have experienced addiction and school program may run concurrently with other treatment programs. recovery and act as peer mentors. They help individuals, based on their Students benefit from specially trained teachers and counselors who specific needs, support and coach the individual through treatment, and support their treatment plan, which may address mental disorders as help them connect with community support groups and resources. More well as substance abuse. Students participate with peers who have experienced similar issues in a structured setting that promotes recovery.

Behavioral therapies Outpatient behavioral treatment provides therapy through individual long-term recovery and health. Behavior therapy uses strategies to and group settings based on the program that best meets the needs address unwanted behaviors using learning theory, conditioning, and of the person. It can be designed to meet the needs of youth and reinforcement with the focus on the present and addicts’ ownership and adults and is often combines with pharmacological treatment to responsibility for their behavior. Therapy focuses on targeted behaviors increase efficacy. The NIDA outlines the following types of outpatient to change and strategies to identify the triggers, or antecedents, and behavioral treatment programs27: consequences of the behavior. The addict identifies behavior patterns ●● Cognitive–behavioral therapy aims to help patients recognize, to change and works toward healthy replacement behaviors. The avoid, and cope with the situations in which they are most likely to therapist and client work to identify goals and barriers to those goals that abuse drugs. may include habits, obsessions, compulsions, denial, procrastination, ●● Motivational interviewing capitalizes on the readiness of fear, depression, anxiety, dysfunctional inter-personal relationships, individuals to change their behavior and enter treatment. communication issues, and any other negative thought and behavior ●● Motivational incentives and contingency management uses patterns. They work through these barriers together to build the client’s positive reinforcement to encourage abstinence from drugs. awareness of the former thoughts, feelings, and behaviors that have a Contingency programs and cognitive-behavioral therapy are commonly negative impact on recovery and must be changed. Behavior therapy used forms of therapy to help patients take control and responsibility has been around for decades, and many forms have proven effective for their behavior and build coping and life skills to move toward with addiction. In the case of heroin addiction, this therapy works best when combined with pharmacological therapy.

Motivational incentives for enhanced drug abuse recovery: Promoting awareness of motivational incentives The National Institute on Drug Abuse (NIDA) a division of the Substance resources along with suggestions for implementation, data collection, Abuse and Mental Health Services Administration (SAMHSA) noted the training and replication of the program and includes a video, Successful challenge of helping patients avoid relapse while in a treatment program. Treatment Outcomes Using Motivational Incentives. They conducted research and clinical trials to develop an evidence-based The NIDA31 reported data showing that approximately 25 percent of approach called Promoting Awareness of Motivational Incentives (PAMI) samples from both study groups tested negative for stimulants and to train other organizations to use incentive techniques, sometimes alcohol at the first study visit. Overall, participants in the incentive called contingencies, in programs to maintain abstinence from drug group (54.4 percent) were significantly more likely to submit target 30. After testing the program, they developed a package and alcohol use drug-negative samples than were participants in the usual care group of tools and training resources to replicate the program and share (38.7 percent). evidence-based research data behind the clinical use of motivational incentives. The strategies of the approach used low-cost incentives with The motivational incentives and interviewing techniques address patients that were successful in maintaining abstinence and program patients’ feelings and barriers about stopping drug use. Motivational compliance to avoid relapse during treatment. PAMI is based on positive interviewing is a therapeutic approach to help patients in recovery, research outcomes from the NIDA Clinical Trials Network (CTN) and the incentives help patients modify and change specific behaviors. study, Motivational Incentives for Enhanced Drug Abuse Recovery The incentives acted as a supplement to therapy were effective in the (MIEDAR), and uses strategies from Dr. Nancy Petry’s Fishbowl treatment of substance-use disorders. The study noted that the incentives Method of incentives31. “We use rewards as a clinical tool not as by improved therapeutic climate because they were based on positive, bribery but for recognition; the really profound will come later.” affirming, and celebratory strategies. Positive reinforcement incentives will be effective if they are valuable to the person and motivate them to The researchers used motivational incentives because they lead to work to change target behaviors. Patients received a menu of incentives higher rates of retention in treatment and abstinence from drug abuse. to choose from, and therapists were consistent in the distribution of the They found incentives that were motivating, low cost, and supported incentives earned. Intermittent schedules of reinforcement were the the patient’s treatment plan included prices, vouchers, and clinic most powerful, and the Fishbowl Method used this schedule to deliver privileges. The patients earned reinforcers on the results of their on- low or no-cost incentives, such as coupons, vouchers, and privileges. site urine screening and completion of treatment goals. The study noted Patients had a chance to earn and win prizes when they drew from the that patients who participated in incentive programs were more likely fishbowl. Target behaviors must be observable and measurable, and they to submit urine samples that were negative than patients not receiving should include abstinence and the successful completion of goals from incentives. The average cost of incentives was $120 per patient32. PAMI the patient’s treatment plan. The PAMI program outlines seven core is designed to build awareness of motivational incentives as a research- principles of motivational incentive programs30. based therapeutic strategy for addiction treatment. The package, which is free of charge, reviews the research, provides support materials and

SocialWork.EliteCME.com Page 88 Seven core principles of motivational incentive programs: The PAMI program materials include all the information needed to 1. Identification of target behavior. replicate the program and include supplemental software to track 2. Choice of target population. information about patients’ participation and progress in the program. 3. Choice of reinforcer. Information on these programs, and others to address the heroin 4. Incentive magnitude. addiction epidemic, can be obtained from the Motivational Incentives 5. Frequency of incentive distribution. Web-Portal: www.bettertxoutcomes.org; National Institute on Drug 6. Timing of the incentive. Abuse: http://www.drugabuse.gov/blending-initiative; and SAMHSA 7. Duration of the incentive. ATTC: http://www.attcnetwork.org/blendinginitiative

Prevention Prevention programs to address heroin addiction have been researched audience in a way they can understand; therefore, the programs must for over 20 years, which is not very long, considering the heroin encompass all languages, cultures, and educational levels. Community addiction goes back to the late 1800s. education for prevention must also address the relationship between To find a solution to the complex, epidemic disease of heroin at-risk behavior, addiction and the spread of HIV/AIDS, which is part addiction, the process must include the following components: of the heroin addiction epidemic. ●● Identification and definition of heroin addiction. The NIDA and other federal research organizations have included ●● Determine the scope of the problem, sequence of events and prevention as a primary goal. The principles outlined in this section focus factors that lead to addiction. on numerous, long-term, evidence-based studies of addiction behavior ●● Review evidence-based programs proven to effectively break the and combined concepts from many successful prevention programs. cycle of addiction including prevention and treatment. The prevention principles target children through young adults across ●● Matching prevention and treatment programs to the individual the country with the goal of implementation at the community level. needs of the individual and community. Prevention programs are geared to specific settings and specific needs of There is a rush to implement these steps because of the public’s awareness the participants and address the needs of all youth, whether they are drug- of the problem of heroin addiction and the number of overdose deaths free, at-risk, or already experimenting with drugs. These principles can be in every community, large or small. For those in the field of medical implemented at home, school, community or all three. and mental health, the work to eradicate this complex problem has The entire list and specific details on each principle, including research been in progress for decades. It is clear to all who work in this field information, can be obtained on the NIDA website Prevention section that there is no easy and quick solution because the predictors or heroin at http://www.drugabuse.gov/publications/preventing-drug-use-among- addiction are varied and there is no definitive “test” to determine who children-adolescents. The following information and principles can will become addicted. Instead, many factors overlap to increase the guide the development of prevention programs for children and youth:35 chance that a person will become addicted. Biology, genetics, age NIDA’s prevention research program focuses on risks for drug at onset of use, environment, personality, and social influences are a abuse and other problem behaviors that occur throughout a child’s few of the factors that contribute to addiction but are impossible to development, from pregnancy through young adulthood. Research unravel or measure. Researchers, therapists, medical personnel, school funded by NIDA and other federal research organizations – such as staff, and families know that addiction to the substance may take hold the National Institute of Mental Health and the Centers for Disease quickly, but addiction is a developmental disease that begins long before Control and Prevention – shows that early intervention can prevent the person becomes addicted to heroin. NIDA research shows that in many adolescent risk behaviors. some cases, the signs were there in childhood and adolescence while the brain is rapidly developing and changing. Brain research shows that the Principle 1 - Prevention programs should enhance protective factors prefrontal cortex develops last, and that is the part of the brain that controls and reverse or reduce risk factors. The risk of becoming a drug abuser decisions and judgments, which explains why adolescents often engage involves the relationship among the number and type of risk factors, in at risk behaviors. These factors correlate with statistics that show deviant attitudes and behaviors, and protective factors. Specific risk heroin addiction is rising among young people because they are open to and protective factors change with age and stage of development. experimentation with drugs, and therefore, vulnerable to heroin addiction. For example, risk factors within the family have greater impact on a younger child, while association with drug-abusing peers may be a These facts, established from evidence-based research, conclude that more significant risk factor for an adolescent. Early intervention with for prevention programs to work, they must begin early in order to risk factors, such as aggressive behavior and poor self-control, often address all the factors that lead to addiction, which often begin in has a greater impact than later intervention by changing a child’s childhood. NIDA identifies the following factors that can be addresses life path away from problems and toward positive behaviors. These 33 to prevent addiction at an early age : factors can have a different effect depending on a person’s age, gender, ●● Mental illness. ethnicity, culture, and environment. ●● Neurobiology. ●● Physical or sexual abuse. Principle 2 - Prevention programs should address all forms of drug ●● Aggressive behavior. abuse, alone or in combination, including the underage use of legal ●● Academic problems. drugs and substances and the use of illegal drugs. ●● Poor social skills. Principle 3 - Prevention programs should address the type of drug ●● Lack of motivation. abuse problem in the local community, target modifiable risk factors, ●● Peer influences. and strengthen identified protective factors. ●● Poor parent-child relations. Principle 4 - Prevention programs should address risks specific Effective prevention programs must have a multidimensional approach to population or audience characteristics, such as age, gender, and involving family, school staff, community health agencies, media, ethnicity, to improve program effectiveness. and other social and cultural modes of communicating prevention Principle 5 - Family-based prevention programs should enhance family education, information, and early intervention. Because heroin bonding and relationships including parenting skills and training in addiction crosses all boundaries and excludes no one, community drug education and information. Family bonding is the bedrock of prevention outreach programs must speak directly to the intended the relationship between parents and children. Family bonding can

Page 89 SocialWork.EliteCME.com strengthen through skills training on parent supportiveness of children, Principle 9 - Prevention programs aimed at general populations at key parent-child communication, and parental involvement. Parental transition points, such as the transition to middle school, can produce monitoring and supervision are critical for drug abuse prevention. beneficial effects even among high-risk families and children. Training on rule-setting; techniques for monitoring activities; praise for Principle 10 - Community prevention programs that combine two appropriate behavior; and moderate, consistent discipline that enforces or more effective programs, such as family-based and school-based defined family rules should be included. Drug education and information programs, can be more effective than a single program. for parents or caregivers reinforces what children learn about the effects of drugs and opens opportunities for family discussions about the abuse Principle 11 - Community prevention programs reaching populations of legal and illegal substances. Brief, family-focused interventions for in multiple settings such as schools, clubs, faith-based organizations, the general population can positively change specific parenting behavior and the media, are most effective when they present consistent, and reduce children’s later risks of drug abuse. community-wide messages in each setting. Principle 6 - Prevention programs can be designed to intervene Principle 12 - When communities adapt intervention programs as early as infancy to address risk factors for drug abuse, such as to match their needs, community norms, or differing cultural aggressive behavior, poor social skills, and academic difficulties. requirements, they should retain core elements, which include the structure, content, and delivery of the program. Principle 7 - Prevention programs for elementary school children should target academic and social-emotional skills to address risk Principle 13 - Prevention programs should be long-term with repeated factors for drug abuse. Education should focus on the following skills: interventions to reinforce the original prevention goals. Benefits ●● Self-control. from middle school prevention programs diminish without follow-up ●● Emotional awareness. programs in high school. ●● Communication. Principle 14 - Prevention programs should include teacher training on ●● Social problem solving. good classroom management practices, such as rewarding appropriate ●● Academic support, especially in reading. student behavior to foster students’ positive behavior, achievement, Principle 8 - Prevention programs for middle or junior high and high academic motivation, and school bonding. school students should increase academic and social competence with Principle 15 - Prevention programs work most effectively when they the following skills: use interactive techniques, such as peer discussion groups and parent ●● Study habits and academic support. role-playing. ●● Communication. ●● Peer relationships. Principle 16 - Research-based prevention programs can be cost- ●● Self-efficacy and assertiveness. effective. Research shows that for each dollar invested in prevention, a 28 ●● Drug resistance skills. savings of up to $10 in treatment for alcohol or other substance abuse . ●● Reinforcement of anti-drug attitudes. ●● Strengthening of personal commitments against drug abuse.

The community youth development study This NIDA program offers assessment tools and technical trainings to allows communities to select appropriate evidence-based prevention communities so they can more accurately identify risk and protective programs based on their particular needs29. factors for youth drug use and related behavior problems. This system

Future trends In addition to the pharmacological and therapeutic models in clinical Initiative of 200120 was to address this problem of disseminating trials previously reviewed, additional research studies may prove research-based addiction treatment information so that it could be effective in the identification, prevention, and treatment of heroin implemented in clinical practice. NIDA explains the process as follow: addiction. NIDA and the Substance Abuse and Mental Health Services Administration (SAMHSA) joined together to create the Blending High-resolution mapping of targeted brain areas. Initiative in 2001 to reduce the gap that exists between the Research is currently underway that will increase knowledge of publication of research results and impact on treatment delivery. the brain systems and pathways taken by drugs and their effects on This initiative incorporates collaboration between clinicians, centers of the brain that influence drug-related behaviors involved in scientists, and experienced trainers to catalyze the creation of motivation, impulse control, pleasure, reward, compulsions, addiction, user-friendly treatment tools and products and facilitate the and relapse34. With this information, advances can be made to identify medications that interfere and block these drug behaviors to prevent adoption of research-based interventions into front-line clinical drug addiction in persons at risk or assist in recovery and relapse settings. Through this initiative, NIDA and SAMHSA’s Addiction prevention. Technology Transfer Centers (ATTC) disseminate treatment and training products based on results from studies conducted by the Blending initiative National Drug Abuse Clinical Trials Network (CTN) as well as Research and clinical trials are of no use if the results languish in a other NIDA-supported research. government publication and remain unused. The goal of the Blending

Conclusion It is the responsibility of all health care professional to advocate for many diseases, such as HIV/AIDS, heroin addiction causes fear and is their clients and promote access to health care for everyone. The disease widely misunderstood in the community. Scientists and researchers are of heroin addiction impacts all ages in all communities, so health collaborating on better screening, treatment, and prevention techniques, professionals today must work to bring heroin addiction out of the health professionals and the general public should be educated about shadows. They must educate others to remove the stigma and address what they can do in their daily lives to prevent heroin addiction from heroin addiction as a brain disease that can affect anyone. As with spreading. This course points to the need for a multiple disciplinary

SocialWork.EliteCME.com Page 90 approach that must start early in life to address the complex factors and offer services to young people and adults at risk, educating the public that lead to at-risk behaviors that may lead to drug experimentation. about the disease, and working with the media to develop effective Environmental, social, genetic, physical, and mental health factors campaigns to combat negative cultural influences. that contribute to addiction have been identified and are critical in By moving forward through a multi-disciplinary approach, health care developing effective treatment and prevention programs. Addressing professionals can close the heroin treatment gap and increase prevention these factors among youth at an early age may be the only way to efforts. As advocates, health professionals, government agencies, and control the epidemic, while law enforcement tries to eradicate the source politicians must collaborate to write policies and increase funding of the drug from Mexico, South America, and Asia. for heroin addiction prevention and treatment to stop the escalating Prevention begins by educating parents, teachers, and healthcare staff cycle of addiction and relapse. NIDA research has demonstrated that about early identification of risk factors in childhood as well as the early prevention is cost effective in lowering expenditure in areas such as the signs and symptoms of drug use. Health care professionals, school residential treatment, hospital and health care, incarceration, crime, and staff, and community resource agencies can identify and refer at-risk the justice system. Funds are necessary to increase the accessibility and individuals and struggling families to social services for prevention and ease of treatment to encourage families and individuals to seek help to treatment programs. Once identified, these families can benefit from early stop the cycle of addiction and prevent it in the future. There is no way intervention programs, including, health care, counseling, assistance with to put a price on the mounting death toll from this epidemic, and health parenting, and discipline to support healthy family interaction. Health care professionals are the front line of defense. The epidemic of heroin care professionals must participate in prevention and treatment programs addiction is a massive problem that requires effort on the part of every in the community through fundraising activities, lobbying local officials health care professional to identify what they can do today to break the and state legislators, conducting community outreach activities to identify cycle of addiction in their community.

Resources ŠŠ Addiction Severity Index. Provides a structured clinical interview designed to collect information ŠŠ NIDA DrugFacts: Treatment Approaches for Drug Addiction (Revised 2009). This is a fact sheet about substance use and functioning in life areas from adult clients seeking drug abuse treatment. covering research findings on effective treatment approaches for drug abuse and addiction. Available triweb.tresearch.org/index.php/tools/download-asiinstruments-manuals. online at drugabuse.gov/publications/drugfacts/treatment-approaches-drugaddiction. ŠŠ Blending Teams Web site at nida.nih.gov/blending. drugabuse.gov/blending-initiative. ŠŠ NIDA DrugPubs Research Dissemination Center. NIDA publications and treatment materials are ŠŠ Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services available from this information source. Staff provide assistance in English and Spanish, and have (SAMHSA) TTY/TDD capability. Phone: 877-NIDA-NIH (877-643-2644); TTY/TDD: 240-645-0228; fax: 240- ŠŠ Center for Substance Abuse Treatment; Substance Abuse and Mental Health Services 645-0227; e-mail: [email protected]; Web site: drugpubs.drugabuse.gov. Administration( SAMHSA). www.samhsa.gov/about/csat.aspx. http://www.samhsa.gov/data/ ŠŠ Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm. Treatment Educators, and Community Leaders– Second Edition. This booklet lists over 20 examples of Locator: 1-800-662-HELP or search www.findtreatment.samhsa.gov. SAMHSA’s Store has a wide effective research-based drug abuse prevention programs and is available free on NIDA’s website. range of products Web site: store.samhsa.gov ŠŠ Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide. NIH ŠŠ Clinical Trials. For more information on federally and privately supported clinical trials, please visit Publication No.: 11-5316. Available online at nida.nih.gov/PODAT_CJ. clinicaltrials.gov. ŠŠ Research Report Series: Therapeutic Community This report provides information on the role of ŠŠ Drugs, Brains, and Behavior: The Science of Addiction (Reprinted 2010). This publication provides residential drug-free settings and their role in the treatment process. NIH Publication #02-4877. an overview of the science behind the disease of addiction. Publication #NIH 10-5605. Available Available online at NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) online at drugabuse.gov/publications/science-addiction. drugabuse.gov/CTN/Index.htm. ŠŠ Complete NSDUH findings are available at National Institute for DrugAddiction drugabuse.gov. ŠŠ Seeking Drug Abuse Treatment: Know What To Ask NIDA Publication #12-7764. Available online ŠŠ National Institute of Drug Addiction. Web site: www.drugabuse.gov NIDA Public Information at drugabuse.gov/publications/seeking-drug-abuse-treatment. Office: 301-443-1124. ŠŠ The “Find A Physician” feature on the American Society of Addiction Medicine (ASAM) Web site: ŠŠ The National Institute of Justice. The research agency of the Department of Justice. For information http://community.asam.org/search/default.asp?m=basic Patient Referral Program on the American contact the National Criminal Justice Reference Service at 800-851-3420 or 301-519-5500; or visit Academy of Addiction Psychiatry Web site: http://www.aaap.org/patient-referral-program. www.nij.gov. ŠŠ The Child and Adolescent Psychiatrist Finder on the American Academy of Child and Adolescent ŠŠ National Institute of Mental Health nimh.nih.gov. Psychiatry Web site: http://www.aacap.org/cs/root/child_and_adolescent_psychiatrist_finder/ ŠŠ The National Registry of Evidence-Based Programs and Practices. This database of interventions for child_and_adolescent_psychiatrist_finder the prevention and treatment of mental and substance use disorders is maintained by SAMHSA and can be accessed at nrepp.samhsa.gov. References 1. Foundation for a Drug-Free World. (2014). Retrieved from http://www.drugfreeworld.org/drugfacts/ 17. SAMHSA Announces a Working Definition of “Recovery” from Mental Disorders and Substance Use heroin.html Disorders. Retrieved from http://www.samhsa.gov/newsroom/advisories/1112223420.aspx 2. What is Heroin and What is it For? (2014). Retrieved from http://www.drugabuse.gov/publications/ 18. Principles of Drug Addiction Treatment: A Research-Based Guide, Third Edition (2012). Retrieved research-reports/heroin/what-heroin from http://www.drugabuse.gov/publications/principles-drug-addiction-treatment 3. Drugs, Brains, and Behavior: The Science of Addiction (2014). Retrieved from http://www. 19. Neuropsychopharmacology. (2012) 2012 Apr; 37(5): 1083-91. doi: 10.1038/npp.2011.200. Epub 2011 drugabuse.gov/publications/science-addiction Sep 14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21918504. 4. The Definition of Addiction (2011). Retrieved from http://www.asam.org/advocacy/find-a-policy- 20. Topics in Brief: NIDA’s Blending Initiative: Accelerating Research-Based Treatments into Practice statement/view-policy-statement/public-policy-statements/2011/12/15/the-definition-of-addiction (2007). Retrieved from http://www.drugabuse.gov/publications/topics-in-brief/nidas-blending- 5. Panell, I. (2014). The Horrific Toll of America’s Heroin Epidemic. BBC News Magazine. Chicago. initiative-accelerating-research-based-treatments-practice Retrieved from http://www.bbc.com/news/magazine-26672422 21. National Institute on Drug Abuse(2006) Buprenorphine: Treatment for Opiate Addiction Right 6. National Survey on Drug Use and Health: Summary of National Findings (2012). Retrieved from in the Doctor’s Office Retrieved from http://www.drugabuse.gov/publications/topics-in-brief/ http://www.drugabuse.gov/publications/research-reports/heroin/scope-heroin-use-in-united-states buprenorphine-treatment-opiate-addiction-right-in-doctors-office 7. The U.S. Drug Enforcement Administration (2012) National Drug Threat Assessment Report (FULL) 22. Krupitsky, E.; Zvartau, E.; Blokhina, E.; Verbitskaya, E.; Wahlgren, V.; Tsoy-Podosenin, M.; Bushara, Retrieved from http://www.justice.gov/dea/resource-center/DIR-017-13%20NDTA%20Summary%20 N.; Burakov, A.; Masalov, D.; Romanova, T.; Tyurina, A.; Palatkin, V.; Slavina, T.; Pecoraro, A.; final.pdf Woody, G. E. (2013). Naltrexone Implant Outperforms Daily Pill in Russian Trial: Randomized 8. Heroin Addiction. (2013). Retrieved from http://report.nih.gov/nihfactsheets/viewfactsheet. Trial of Long-Acting Naltrexone Implant vs Oral Naltrexone or Placebo for Preventing Relapse to aspx?csid=123 Opioid Dependence. Archives of General Psychiatry 69(9): 973–981, 2012. Retrieved from http:// 9. Data, Outcomes and Quality (2012). Retrieved from http://www.samhsa.gov/data/ www.drugabuse.gov/news-events/nida-notes/2013/11/naltrexone-implant-outperforms-daily-pill-in- 10. American Psychiatric Association (2013). Substance-Related and Addictive Disorders, in Diagnostic russian-trial and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC: American Psychiatric 23. CDC (2002). Methadone Maintenance Treatment. Retrieved from http://www.cdc.gov/idu/facts/ Publishing, 540–550, and 2013. MethadoneFin.pdf 11. Mardis, C. (2011). Increased Opiate Use and the Need for Onsite Heroin Screening. Retrieved from 24. Substance Abuse and Mental Health Services Administration, Results from the 2011 National http://www.nadcp.org/sites/default/files/nadcp/Final%206AM%20Brief.pdf Survey on Drug Use and Health: Summary of National Findings (2012) NSDUH Series H-44, HHS 12. Department of Health and Human Services (2010). Mandatory Guidelines for Federal Workplace Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Drug Testing Programs. Retrieved from http://www.gpo.gov/fdsys/pkg/FR-2010-04-30/pdf/2010- Administration, 2012. Retrieved from http://www.drugabuse.gov/publications/research-reports/ 10118.pdf heroin/scope-heroin-use-in-united-states 13. Harrison, L .D., Martin, S. S., Enev, T., Harrington, D. (2007). Comparing Drug Testing and Self- 25. Wee, S., Hicks MJ, De BP, Rosenberg JB, Moreno AY, Kaminsky SM, Janda KD, Crystal RG, Report of Drug Use among Youths and Young Adults in the General Population Department of Health Koob GF. (2011). Novel Cocaine Vaccine Linked to a Disrupted Adenovirus Transfer Vector Blocks and Human Services Substance Abuse and Mental Health Services Administration Office of Applied Cocaine Psychostimulant and Reinforcing Effects. Neuropsychopharmacology. Retrieved from http:// Studies. Retrieved from http://www.samhsa.gov/data/nsduh/drugtest.pdf www.ncbi.nlm.nih.gov/pubmed/21918504 14. Symptoms and Signs of Poly-substance Abuse (2014). Retrieved from http://www.buppractice.com/ 26. Division of Pharmacotherapies and Medical Consequences of Drug Abuse (DPMCDA) howto/screen/polysubstance (2011). Retrieved from http://www.drugabuse.gov/about-nida/organization/divisions/division- 15. U.S. Foods and Drug Administration (2014). FDA Approves New Hand-Held Auto-Injector to pharmacotherapies-medical-consequences-drug-abuse-dpmcda/research-programs#ATDP Reverse Opioid Overdose. FDA News Release. April 3, 2014. Retrieved from http://www.fda.gov/ 27. Family Based Approach (2014). Retrieved from http://www.drugabuse.gov/publications/principles- NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm. adolescent-substance-use-disorder-treatment-research-based-guide/evidence-based-approaches-to- 16. O’Brien, R. (2014) FDA Approves Potential Lifesaver in Heroin Epidemic: April 4, 2014. 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Page 91 SocialWork.EliteCME.com 29. Mark TL, Woody GE, Juday T, Kleber HD. (2001) The Economic Costs of Heroin Addiction in the Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment, 28, 57–65. United States. Drug Alcohol Dependency. 2001; 61:195–206. Retrieved from http://www.ncbi.nlm. Retrieved from http://www.drugabuse.gov/sites/default/files/files/MI-PRESTO_Factsheet.pdf nih.gov/pubmed/11137285 34. Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide (2014). 30. Community Youth Development Study (2009). Retrieved from www.drugabuse.gov/sites/default/ Retrieved from http://www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder- files/nnvol23n4.pdf treatment-research-based-guide/principles-adolescent-substance-use-disorder-treatment 31. Promoting Awareness of Motivational Incentives NIDA (2006). Retrieved from http://www. 35. High Resolution Brain Spectrum Imaging in a Clinical Substance Abuse Practice (2010). Retrieved drugabuse.gov/sites/default/files/files/PAMI_Factsheet.pdf from http://www.ncbi.nlm.nih.gov/pubmed/20648911 J Psychoactive Drugs. 2010 Jun; 42(2): 153-60. 32. Petry, N. M., & Bohn, M. J. (2003). Fishbowls and candy bars: Using low-cost incentives to increase 36. National Institute on Drug Abuse Preventing Drug Use among Children and Adolescents: A Research- treatment retention. NIDA Science & Practice Perspectives, 2(1), 55–61. PDF] Successful Treatment Based Guide for Parents, Educators, and Community Leaders, Second Edition booklet. (2003). NIH Outcomes Motivational Incentives: Positive Reinforces to Enhance http://www.drugabuse.gov/sites/ Pub Number: 04-4212(A) Published: January 1997Revised: October 2003: Retrieved from http:// default/files/files/MI-PRESTO_Factsheet.pdf www.drugabuse.gov/publications/preventing-drug-use-among-children-adolescents 33. Kellogg, S. H., Burns, M., Coleman, P., Stitzer, M., Wale, J. B., & Kreek, M. J. (2005). Something of Value: The Introduction of Contingency Management Interventions into the New York City The Heroin ABUSE Epidemic in America: Identification, Treatment and Prevention Final Examination Questions Select the best answer for each question and proceed to SocialWork.EliteCME.com to complete your final examination.

1. Heroin and morphine, along with codeine, hydrocodone, 6. Severe muscle and bone aches may indicate which of the oxycodone, and oxymorphone are similar in structure because of following? the following: a. Over exertion. a. They all bind to the opioid receptor. b. A withdrawal symptom. b. They are all benzodiazepines. c. Hepatitis. c. They are inexpensive. d. An elderly client and not related to drug use. d. They are easily accessible 7. Which is correct about treatment of heroine addiction? 2. A chronic, relapsing disease, characterized by compulsive drug a. Medication does not work in these cases for long term positive seeking and use accompanied by neurochemical and molecular outcomes. changes in the brain is the definition of which term below? b. Only behavioral therapy will work to provide lasting results. a. Dependence. c. There is no effective treatment known. b. Tolerance. d. Integration of psychosocial rehabilitation and ongoing care c. Addiction. with evidence-based pharmacological therapy provides the d. Drug abuse. best results.

3. An opioid receptor antagonist that rapidly binds to opioid, 8. Partial agonists, such as buprenorphine, also called Subutex, blocking heroin from activating them is which of the following? produce which of the following? a. Morphine. a. A large response in the brain to stop cravings when injected. b. Methadone. b. A small response in the brain, which relieves cravings with no c. Naloxone. euphoria or side effects when taken orally. d. Oxycodone. c. A slow response that causes minimal euphoria that can be diminished over time. 4. A combination of Mexican black tar heroin and cold medicine d. A quick response that is unpleasant but stops cravings. obtained over the counter is called which of the following? a. Cold tar. 9. NIDA identifies the following factors that can be addresses to b. Cheese heroin. prevent addiction at an early age: c. Brown heroin. a. Neurobiology. d. China jade. b. Culture. c. IQ. 5. Though genetics factors do not cause an addiction to heroin, they d. Ethnicity. can indicate which of the following? a. The person is prone to alcoholism. 10. The Blending Initiative of 2001 was developed to ______. b. Addictive behavior and were found to be significant in about a. Blend all therapeutic efforts together in therapy. 50 percent of addictions. b. Educate the public to work together to stop addiction. c. Addiction is 85% likely to occur. c. Reduce the gap that exists between the publication of research d. Addiction occurs more often in certain minority groups. results and impact on treatment delivery. d. To blend mental health and law enforcement efforts to stop addiction.

SWFL04HE17

SocialWork.EliteCME.com Page 92 Chapter 7: Medication Management of Opioid Dependence

5 CE Hours

By: Kathryn Brohl, MA, LMFT

Learning objectives ŠŠ Define opioid dependence. ŠŠ Understand why methadone provides effective medical ŠŠ Understand the diagnosis of opioid dependence. management for opioid dependence. ŠŠ Describe opioid withdrawal. ŠŠ Understand why methadone can be used with pregnant women. ŠŠ Understand the history of opioid use in the United States and ŠŠ Understand how buprenorphine is used with opioid dependence. related legal implications. ŠŠ Understand different research that validates medical management ŠŠ Understand what opioid-dependent populations benefit from for opioid dependence. methadone and buprenorphine medical management. ŠŠ Provide treatment information in early recovery with health care and counseling professionals.

Jeff’s story Jeff was the third child born to professionals who adored their that Jeff had taken all of the money out of his savings account, son. A rambunctious and curious child from birth, Jeff was not an but not before he began to behave erratically. Jeff’s folks had a A-student, but he was exceedingly bright, with interests in music difficult time thinking that their son could have a drug problem and literature as well as a love for baseball. Sports came easily because they thought they had done everything to prevent it from to him, and at the age of 10 he was the lead pitcher on a traveling occurring. They watched him carefully throughout his childhood baseball team. Jeff’s dream was to get into the Major League and and adolescence, and never failed to mention the danger of using play for the Mets. His parents were diligent supporters and often drugs. traveled with the team, lending their support and encouragement. Yet, the idea of pain medication as an addiction had never entered Sadly, a shoulder injury sidelined the young man at age 16, and their minds. Didn’t young people generally smoke marijuana, he was told an operation could fix the problem. Jeff, with his drink alcohol, or take ecstasy, they wondered? usual straight-ahead attitude, went for it. The operation proved After several days and much questioning, Jeff finally admitted to to be more painful than the teen had anticipated, but the doctor his addiction/dependence, and with even greater trepidation, his prescribed pain medication, OxyContin, and it greatly helped Jeff’s parents guiltily admitted him into a detox unit at local hospital. discomfort. As a matter of fact, it actually made Jeff feel good, so But while Jeff was getting medical attention and counseling good, in fact, that when it came time to wean himself off the meds, during this time, his parents and he still had to decide what he he was not willing. He’d never experienced this feeling before, and was going to do when he was released from detox. The physician while he told his parents he’d stopped his use, it continued after he at the facility suggested that Jeff might have a very difficult time returned to playing baseball. in early recovery without some form of medication management, Jeff didn’t have any trouble getting the painkillers; there were coupled with counseling, and a suggested methadone maintenance plenty of people selling them. The once well-intended, benign use regimen. He also referred him to a licensed mental health to relieve pain began to turn into abuse and then an addiction/ professional. dependence. Jeff became more concerned about getting the At this point, Jeff and his parents thought that this would simply medication than getting to school on time, or practicing baseball, extend his addiction, but the doctor told them that with careful and he felt terribly guilty. A couple times he tried to stop, but then supervision and counseling, Jeff’s chances of sobriety long-term he would get sick, and sought the pills to feel better. were good. His addiction was turning into a nightmare, and he was ashamed to tell his parents. They came upon the truth when they learned

Introduction In recent years, opiate dependence has become a catastrophic problem Drug abuse and addiction/dependence changes the way the brain in the United States, causing thousands, especially younger people, works, resulting in compulsive behavior focused on drug seeking and to lose their lives, and leaving loved ones behind to question these use, despite often devastating consequence. These behaviors are the senseless losses. People included in this grave epidemic come from the essence of addiction. Consequently, drug abuse/addiction treatment full spectrum of socio-economic backgrounds. Sadly, approximately 9 must address these brain changes, both in the short and long term. percent of the population is believed to misuse opiates over the course When people addicted to opioids first stop, they undergo withdrawal of their lifetimes, including illegal drugs like heroin and prescription symptoms, which may be severe pain, diarrhea, nausea and vomiting. pain medications such as Oxycontin. (Opiate drugs include heroin, (Note: Throughout this course, “ addiction” and “dependence” will be morphine, codeine, Oxycontin, Dilaudid, methadone, and others.) It is used interchangeably to describe the same condition.) an addiction, where, truly, no one gets left behind.

Page 93 SocialWork.EliteCME.com Prescription and OTC drugs and the brain Taken as intended, prescription and OTC drugs safely treat specific Medications developed to treat opioid addiction work through the mental or physical symptoms. But when taken in different quantities or same receptors as the addictive drug, but are safer and less likely to when such symptoms aren’t present, they may affect the brain in ways produce the harmful behaviors that characterize addiction. very similar to illicit drugs. For example, stimulants such as Ritalin Three types include: increase alertness, attention, and energy the same way cocaine does – 1. Agonists that activate opioid receptors. by boosting the amount of the neurotransmitter dopamine. 2. Partial agonists that also activate opioid receptors but produce a Opioid pain relievers like OxyContin attach to the same cell receptors diminished response. targeted by illegal opioids like heroin. Prescription depressants produce 3. Antagonists that block the receptor and interfere with the sedating or calming effects in the same manner as the club drugs rewarding effects of opioids. GHB and rohypnol by enhancing the actions of the neurotransmitter Physicians prescribe a particular medication based on a patient’s GABA (gamma-aminobutyric acid). When taken in very high doses, specific medical needs and other factors. Effective medications dextromethorphan acts on the same glutamate receptors as PCP or include: ketamine, producing similar out-of-body experiences. ●● Methadone (Dolophine or Methadose), a slow-acting, opioid When abused, all of these classes of drugs directly or indirectly cause agonist. Methadone is taken orally, so that it reaches the brain a pleasurable increase in the amount of dopamine in the brain’s reward slowly, dampening the “high” that occurs with other routes of pathway. Repeatedly seeking to experience that feeling can lead to administration while preventing withdrawal symptoms. Methadone addiction. has been in use since the 1960s to treat heroin addiction and is still Opioids can produce drowsiness, cause constipation, and depending an excellent treatment option, particularly for patients who do not upon the amount taken, depress breathing. The latter effect makes respond well to other medications; however, it is only available opioids particularly dangerous, especially when they are snorted or through approved outpatient treatment programs, where it is injected or combined with other drugs or alcohol. dispensed to patients on a daily basis. ●● Buprenorphine (Subutex, Suboxone), a partial opioid agonist. CNS depressants slow down brain activity and can cause sleepiness and Buprenorphine relieves drug cravings without producing the loss of coordination. Continued use can lead to physical dependence and “high” or dangerous side effects of other opioids. Suboxone is a withdrawal symptoms if discontinuing use. Dextromethorphan can cause novel formulation taken orally that combines buprenorphine with impaired motor function, numbness, nausea or vomiting, and increased naloxone (an opioid antagonist) to ward off attempts to get high heart rate and blood pressure. On rare occasions, hypoxic brain damage by injecting the medication. If an addicted patient were to inject – caused by severe respiratory depression and a lack of oxygen to the Suboxone, the naloxone would induce withdrawal symptoms, brain – has occurred from the combination of dextromethorphan with which are averted when taken orally as prescribed. The FDA decongestants often found in the medication. approved buprenorphine in 2002, making it the first medication Deaths from opioid pain relievers exceed those from illegal drugs. eligible to be prescribed by certified physicians through the Drug Opioid pain relievers have the potential for addiction, and this risk is Addiction Treatment Act. This approval eliminates the need to visit amplified when they are abused. Also, as with other drugs, abuse of specialized treatment clinics, expanding treatment access. prescription and OTC drugs can alter a person’s judgment and decision ●● Naltrexone (Depade, Revia) an opioid antagonist. Naltrexone making, leading to dangerous behaviors such as unsafe sex and is not addictive or sedating and does not result in physical drugged driving. dependence; however, poor patient compliance has limited its effectiveness. Recently an injectable long-acting formulation of Medications can be helpful in this detoxification stage to ease craving naltrexone called Vivitrol received FDA approval for treating and other physical symptoms, which often prompt relapse. However, opioid addiction. Given as a monthly injection, Vivitrol should this is just the first step in treatment. Medications may also become an improve compliance by eliminating the need for daily dosing. To essential component of an ongoing treatment plan, enabling opioid- avoid withdrawal symptoms, Vivitrol should be used only after a addicted persons to regain control of their health and their lives. patient has undergone detoxification. Vivitrol provides an effective alternative for individuals who are unable to or choose not to engage in agonist-assisted treatment.

Benefits of medication-assisted treatment Scientific research has established that medication-assisted treatment Through the New York State Department of Substance Abuse Services, of opioid addiction increases patient retention and decreases drug use, NIDA researchers have estimated the yearly costs to maintain an infectious disease transmission, and criminal activity. For example, opioid addict in New York are: studies among criminal offenders, many of whom enter the prison ●● Untreated and on the street ($43,000). system with drug abuse problems, showed that methadone treatment ●● In prison ($34,000). begun in prison and continued in the community upon release ●● In a residential drug-free program ($11,000). extended the time parolees remained in treatment, reduced further drug ●● In methadone maintenance treatment ($2,400). use, and produced a three-fold reduction in criminal activity. (New York State Committee of Methadone Program Research has also demonstrated that methadone maintenance Administrators, 1991.) treatment is beneficial to society, cost-effective, and pays for itself As early as the 1960s, methadone gained recognition as an effective in basic economic terms. A study of the cost benefits of methadone treatment for heroin addiction. Naltrexone, an opioid receptor blocker, maintenance treatment showed that the costs to society of the criminal joined the medications treatment inventory in 1984. It proved to be activities related to active heroin use can run as high as four times highly effective in reversing the effects of opiate overdose, but poor more than the costs for methadone maintenance treatment (Harwood et treatment adherence has hampered its utility to promote abstinence. al., 1988). Buprenorphine, the newest medication, is a long-acting partial agonist that acts on the same receptors as heroin and morphine, relieving drug cravings without producing the same intense “high” or dangerous side

SocialWork.EliteCME.com Page 94 effects. These medications, along with effective behavioral treatments This course will focus on medication maintenance treatment for and outreach efforts, have not only reduced injection drug use in this substance abuse and addiction, as well as its medication management country, but have also helped reduce the spread of HIV/AIDS from a and treatment implications. Related, validating research on its use for peak of more than 25,000 new cases in 1993 to fewer than 10,000 cases opioid addiction will further be described. An additional section of the in 2003. course will explain why methadone is used successfully with pregnant women, a seemingly counter-intuitive medication management intervention.

UNDERSTANDING THE CLASS OF DRUGS KNOWN AS OPIOIDS Heroin, morphine, and some prescription painkillers (e.g., OxyContin, significant abuse liability. Currently, approximately 1 million people Vicodin, and Fentanyl) belong to the class of drugs known as opiates. in the United States are addicted to heroin (Office of National Drug They act on specific (opiate) receptors in the brain, which also Control Policy, 2000), and more than 3 million people over the age interact with naturally produced substances known as endorphins or of 12 have used heroin at least once (National Survey on Drug Use enkephalins, which are important in regulating pain and emotion. and Health, NSDUH, 2004). And an estimated 1.4 million people are And while prescription painkillers are highly beneficial medications dependent on or abusing other opiate drugs, including prescription when used as prescribed, opiates as a general class of drugs have painkillers (NSDUH, Ibid).

Opioid dependence Opioid dependence falls under the DSM-IV-TR Criteria for Substance ●● A strong desire or sense of compulsion to take the substance. Dependence (American Psychiatric Association, 2000). ●● Difficulties in controlling substance-taking behavior in terms of its DSM-IV-TR onset, termination, or levels of use. It is a maladaptive pattern of substance use, leading to clinically ●● A physiological withdrawal state when substance use has ceased significant impairment or distress, as manifested by three (or more) of or been reduced, as evidenced by the characteristic withdrawal the following, occurring at any time in the same 12-month period: syndrome for the substance or use of the same (or closely related) 1. Tolerance, as defined by either of the following: substance with the intention of relieving or avoiding withdrawal a. A need for markedly increased amounts of the substance to symptoms. achieve intoxication or desired effect. ●● Evidence of tolerance, such that increased doses of the b. Markedly diminished effect with continued use of the same psychoactive substance are required in order to achieve effects amount of the substance. originally produced by lower doses (clear examples of this are 2. Withdrawal, as manifested by either of the following: found in alcohol- and opiate-dependent individuals who may take a. The characteristic withdrawal syndrome for the substance daily doses sufficient to incapacitate or kill non-tolerant users). (refer to Criteria A and B of the criteria sets for withdrawal ●● Progressive neglect of alternative pleasures or interests because from the specific substances). of psychoactive substance use and increased amount of time b. The same (or a closely related) substance is taken to relieve or necessary to obtain or take the substance or to recover from its avoid withdrawal symptoms. effects. 3. The substance is often taken in larger amounts or over a longer ●● Persisting with substance use despite clear evidence of overtly period than was intended. harmful consequences, such as harm to the liver through excessive 4. There is a persistent desire or unsuccessful efforts to cut down or drinking, depressive mood states consequent to periods of control substance use. heavy substance use, or drug-related impairment of cognitive 5. A great deal of time is spent in activities necessary to obtain the functioning; efforts should be made to determine that the user was substance (e.g., visiting multiple doctors or driving long distances), actually, or could be expected to be, aware of the nature and extent use the substance (e.g., chain-smoking), or recover from its effects. of the harm. 6. Important social, occupational, or recreational activities are given ICD-10 Diagnostic Criteria for Research (World Health up or reduced because of substance use. Organization, 2006) 7. The substance use is continued despite knowledge of having a Three or more of the following manifestations should have occurred persistent or recurrent physical or psychological problem that is together for at least one month or, if persisting for periods of less likely to have been caused or exacerbated by the substance (e.g., than one month, should have occurred together repeatedly within a current cocaine use despite recognition of cocaine-induced 12-month period: depression, or continued drinking despite recognition that an ulcer ●● A strong desire or sense of compulsion to take the substance. was made worse by alcohol consumption). ●● Impaired capacity to control substance-taking behavior in terms ICD-10 Clinical Description (World Health Organization, 2006) of its onset, termination, or levels of use, as evidenced by the A cluster of physiological, behavioral, and cognitive phenomena in substance often being taken in larger amounts or over a longer which the use of a substance or a class of substances takes on a much period than intended, or by a persistent desire or unsuccessful higher priority for a given individual than other behaviors that once efforts to reduce or control substance use. had greater value. A central descriptive characteristic of the dependence ●● A physiological withdrawal state when substance use is reduced syndrome is the desire (often strong, sometimes overpowering) to or ceased, as evidenced by the characteristic withdrawal syndrome take psychoactive drugs (which may or may not have been medically for the substance or by use of the same (or closely related) prescribed), alcohol, or tobacco. There may be evidence that return substance with the intention of relieving or avoiding withdrawal to substance use after a period of abstinence leads to a more rapid symptoms. reappearance of other features of the syndrome than occurs with ●● Evidence of tolerance to the effects of the substance, such that nondependent individuals (World Health Organization, 2006). there is a need for significantly increased amounts of the substance to achieve intoxication or the desired effect, or a markedly A definite diagnosis of dependence should usually be made only if diminished effect with continued use of the same amount of the three or more of the following have been present together at some time substance. during the previous year:

Page 95 SocialWork.EliteCME.com ●● Preoccupation with substance use, as manifested by important alternative pleasures or interests being given up or reduced The spectrum of prescription drug because of substance use; or a great deal of time being spent in abuse includes: activities necessary to obtain, take, or recover from the effects of 1. Taking someone else’s prescription the substance. to self-medicate. ●● Persistent substance use despite clear evidence of harmful 2. Taking a prescription medication in a consequences, as evidenced by continued use when the individual way other than prescribed. is actually aware, or may be expected to be aware, of the nature 3. Taking a medication to get high. and extent of harm.

A brief history of opioid addiction 1860-1910 – Although opioids have been used as pain medications 1950-Present – Intravenous use of heroin intensified in the United and anti-anxiety drugs throughout recorded history, it was not until States after WWII, reaching epidemic proportions in urban centers the U.S. Civil War of 1861-1865 that widespread prevalence of opioid during the 1950s and 1960s (Joseph, Stancliff, and Langrod, 2000). addiction was documented in the United States (Hentoff, 1965). The In 1967, the National Survey on Drug Use and Health (NSDUH) synthesis of heroin in 1874 and its commercial marketing as a “wonder began collecting data on heroin use. The survey documents dramatic drug” contributed to a pattern of iatrogenic addiction that continued increases in the initiation of heroin use during the early 1970s and into the early 1900s, with physicians, pharmacists, and patent medicine between 1995 and 2002 (Substance Abuse and Mental Health Services salesmen dispensing narcotics freely to patients who were primarily Administration, 2005), when the annual number of new heroin users middle-aged, middle-class women (Courtwright, 1992; United Nations ranged from 121,000 to 164,000. The National Institute on Drug Abuse Department of Social Affairs, 1953; Acker, 2002). The Institute of (NIDA) reports that, during this period, most new users were age 18 or Medicine estimated that by 1900, perhaps 300,000 Americans were older (on average, 75 percent) and most were male (National Institute addicted to opiates (Courtwright, 1992). on Drug Abuse, 2005a). The 2003 NSDUH found that an estimated 1910-1950 – Between 1910 and 1950, opioid addiction was rarely 3.7 million Americans had used heroin at some time in their lives prevalent among U.S. patients inadvertently addicted to a medical cure. and 314,000 in the past year. The group that represented the highest The Institute of Medicine describes how successive waves of immigration number of those users was age 26 or older (National Institute on Drug and urbanization contributed to a population of opioid abusers who were Abuse, 2005a). NIDA also reports that heroin use in 2003 was stable at in their teens or early 20s, unmarried, poor, primarily male, ethnic low levels (National Institute on Drug Abuse, 2005b). minorities who experimented with drugs for nonmedical purposes (Courtwright, 1992).

Opiates create physical dependence People rely on the drug to prevent symptoms of withdrawal. Over time, greater amounts of the drug become necessary to produce the Opioid intoxication same effect. And the time it takes to become physically dependent Opioid intoxication is a condition caused by use varies with each individual. of opioid-based drugs, which include morphine, Prescription and OTC drugs may be abused in one or more of the heroin, oxycodone, and the synthetic opioid narcotics. following ways: Prescription opioids are used to treat pain. Intoxication ●● Taking a medication that has been prescribed for somebody or overdose can lead to a loss of alertness, or else. Unaware of the dangers of sharing medications, people often unconsciousness. Symptoms of opioid intoxication can unknowingly contribute to this form of abuse by sharing their include breathing problems, and breathing may stop; unused pain relievers with their family members. Most teenagers extreme sleepiness or loss of alertness, and small pupils. who abuse prescription drugs are given them for free by a friend or relative. Some people even withdraw from opiates after being given such drugs ●● Taking a drug in a higher quantity or in another manner for pain while in the hospital without realizing what is happening to than prescribed. Most prescription drugs are dispensed orally in them. They think they have the flu, and because they don’t know that tablets, but abusers sometimes crush the tablets and snort or inject opiates would fix the problem, they don’t crave the drugs. the powder. This hastens the entry of the drug into the bloodstream and the brain and amplifies its effects. The opioid-dependent person generally uses opioids several times each ●● Taking a drug for another purpose than prescribed. All of the day. Each use causes an elevation in mood, and the user feels “high.” drug types mentioned can produce pleasurable effects at sufficient This high is followed by a rapid decline in mood and functional state. quantities, so taking them for the purpose of getting high is one of The user no longer feels high and may begin to feel sick. At the end of the main reasons people abuse them. ADHD drugs like Adderall the day, or in the morning, the user feels quite sick as a result of opioid are also often abused by students for their effects in promoting withdrawal. alertness and concentration. Overall, a typical day includes several cycles of elevated and depressed mood and function state. As an opioid dependent person uses opioids for a period of time – weeks or months – the person’s level of physical dependence makes it less likely that he or she will experience the “high.” Continued drug use results from a desire to avoid the depressions and physical symptoms associated with opioid withdrawal. In the story shared earlier about Jeff, he was literally unable to stop his opioid use on his own because of this withdrawal cycle.

SocialWork.EliteCME.com Page 96 Opiate withdrawal refers to the wide range of symptoms that occur ●● Runny nose. after stopping or dramatically reducing opiate drugs after heavy and ●● Sweating. prolonged use (several weeks or more). When the person stops taking ●● Yawning. the drugs, the body needs time to recover, and withdrawal symptoms ●● Agitation. result. Withdrawal from opiates can occur whenever any chronic use is Late symptoms of withdrawal include: discontinued or reduced. ●● Abdominal cramping. Early symptoms of withdrawal include: ●● Diarrhea. ●● Anxiety. ●● Dilated pupils. ●● Muscle aches. ●● Goose bumps. ●● Increased tearing. ●● Nausea. ●● Insomnia. ●● Vomiting.

Prescription opioids (abuse): Hydrocodone, oxycodone, codeine

Health effects

Acute. Pain relief, drowsiness, nausea, constipation, euphoria in some. When taken by routes other than as prescribed (e.g., snorted, injected), increased risk of depressed respiration, leading to coma, death. CDC reports marked increases in unintentional poisoning deaths since late the 1990s, due mainly to opioid pain reliever overdose (often in combination with alcohol or other drugs).

Long-term. Tolerance, addiction.

In combination with alcohol. Dangerous slowing of heart rate and respiration, coma, or death.

Withdrawal symptoms. Restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold turkey”), and leg movements.

Associated special vulnerabilities/populations

Youth. 8-10 percent of high school seniors have used Vicodin non-medically in the past year; ~5 percent have abused OxyContin.

Pregnancy. Spontaneous abortions; low birth weight.

Older adults. The higher prevalence of pain in this population renders a greater number of prescriptions written for opioid medications. Unintentional misuse or abuse could have more serious health consequences for elderly patients because of comorbid illnesses (and multiple prescriptions), potential for drug interactions, and age- related changes in drug metabolism.

Treatment options

Medications. ●● Methadone. ●● Buprenorphine. ●● Naltrexone (short and long-acting).

Behavioral therapies. Behavioral therapies that have proven effective for treating addiction to illicit opioid drugs, such as heroin, may be useful in addressing prescription opioid addiction.

Opioid withdrawal reactions are very uncomfortable but are not, in ●● Social/family functioning. general, life-threatening. Symptoms usually start within 12 hours of ●● Legal problems. last heroin usage and within 30 hours of last methadone exposure. In addition to patient self-report, urine testing can be a useful practice The Addiction Severity Index (ASI) (McLellan, Kushner, Metzger, et in monitoring patient progress in treatment. In some countries, urine al., 1992) is an instrument designed to assess the impact of a patient’s testing is mandated as part of the treatment plan. addiction on his or her function. Although this instrument is typically used in research, it has been adapted for clinical use and illustrates A variety of substances can be detected in urine testing. Testing can the various aspects of a patient’s life that should be assessed at each occur for naturally occurring opioids (e.g., codeine, morphine) or patient visit to determine the impact of active addiction or the benefits synthetic or semi-synthetic opioids (e.g., oxycodone, methadone). of abstinence. Testing also can occur for benzodiazepines, cocaine, marijuana, or other drugs that are used and abused by the patient population. The ASI evaluates patient function in the areas of: The period of detection of each of these substances varies with the ●● Drug use. laboratory technique that is used, and the extent of drug use and can ●● Alcohol use. range from days to weeks. ●● Psychiatric function. ●● Medical function. ●● Employment.

Page 97 SocialWork.EliteCME.com METHADONE MAINTENANCE TREATMENT

U.S. opiate addiction regulations and methadone maintenance treatment U.S. regulations about treatment for heroin addiction have evolved 1924-1960: Criminalization of narcotics use - Between 1924 and 1960, from strict prohibition of medical prescription of heroin to treat the United States approved a series of progressively stiffer narcotics addiction, which began in 1914 and continued into the 1960s. Initial policies, first establishing mandatory sentences for possession and sale pilot studies testing methadone maintenance treatment for heroin of opioids in 1951 (Courtwright, 1992). Internationally, the United addiction began in 1964, and methadone maintenance treatment was States was a signatory to two more international treaties to limit the formally approved in 1972. Scientific advances prompted major manufacture of narcotics: the Geneva Convention of 1925 and the reviews of Federal regulations by the Institute of Medicine in 1995 Limitation Convention of 1931 (United Nations Department of Social (Substance Abuse and Mental Health Services Administration, 2000b) Affairs, 1953). made significant changes in U.S. regulations about treatment for heroin 1960-Present: Combined medical-criminal approach - Scientific addiction, reducing Federal regulations and paving the way for new advances in the 20th century revolutionized our understanding of pharmacotherapies to treat heroin addiction. addiction and contributed to a medical approach to drug abuse treatment 1860-1909: Minimal government involvement - The Institute of coupled with criminal sanctions for drug traffickers. The 1962 White Medicine documents U.S. narcotics policies from the 19th century House Conference on Narcotic Drug Abuse first recommended more through 1992, (Courtwright, 1992). In the first years following flexible sentencing, wider latitude in medical treatment, and more widespread use of heroin in the United States, there were no Federal emphasis on rehabilitation and research. By 1971, the Special Action regulations about the manufacture, distribution, or use of heroin, Office of Drug Abuse Prevention (SAODAP), established within the and the few State or municipal laws that existed were enforced White House, was responsible for drug treatment and rehabilitation, sporadically. Physicians, pharmacists, and opportunists were free to prevention, education, training, and research. prescribe opioids–and treat subsequent opioid addiction–in whatever Currently, heroin is regulated under the Controlled Substances Act. manner they chose, which contributed to widespread addiction and Federal policies and regulations about heroin are coordinated by the sometimes unscrupulous practices. Inadvertent addiction to early following agencies: over-the-counter medications prompted enactment of the 1906 Pure ●● The Office of National Drug Control Policy (ONDCP) operates Food and Drug Act, which first authorized Federal regulations on any within the White House to establish policies, priorities, and medication. objectives for the Nation’s drug control program. 1909-1924: Increasing federal government role - In the United ●● The U.S. Department of Health and Human Services to promote States, heroin was first placed under Federal control by the 1914 and regulate addiction treatment services. Harrison Narcotic Act, which required anyone who sold or distributed ●● The Drug Enforcement Administration (DEA) operates within narcotics–importers, manufacturers, wholesale and retail druggists, the Department of Justice to prevent diversion and illicit use of and physicians–to register with the Federal Government and pay controlled substances and administer criminal sanctions for drug an excise tax. The United Nations Bulletin on Narcotics documents traffickers. early international efforts to address opioid addiction (United Nations In 2004, the World Health Organization (WHO), the United Nations Department of Social Affairs, 1953). The United States was among the Office on Drugs and Crime (UNODC), and the Joint United Nations organizers of the 1909 International Opium Commission in Shanghai, Program on HIV/AIDS (UNAIDS) adopted a joint position paper China, and a signatory of the 1912 Hague Opium Convention, the first on substitution maintenance therapy for opioid dependence, calling international treaty to make heroin a controlled substance. substitution maintenance therapy one of the most effective treatment options.

Law and methadone maintenance From 1914 through 1972, although heroin became a controlled treatment programs, which also were subject to additional State or substance under the Harrison Act of 1914, the law did not expressly local rules. prohibit the medical prescription of heroin to treat addiction. The U.S. Methadone was approved for office-based dispensing by the Food Government concluded that the Harrison Act intended to prohibit such and Drug Administration in 2002. Administered daily, methadone medical uses of controlled substances, prosecuting individual doctors treatment is currently regulated so that only specialized clinics can who prescribed the drugs. In 1919, the U.S. Supreme Court upheld the provide it. Government’s position in Webb v. United States. In response, about 40 localities opened municipal narcotic clinics to treat addiction using Methadone maintenance programs must go through an accreditation a variety of methods, including medical prescription of narcotics, but process in order to operate. The Substance Abuse and Mental Health by the mid-1920s, these clinics had all been closed by the Federal Services Administration address each critical legal, clinical, safety, and Government (Joseph, Stancliff, and Langrod, 2000). After 1972 until program management area related to the treatment of patients using 2000, Methadone maintenance treatment for heroin addiction was first methadone maintenance therapy. approved by the U.S. Food and Drug Administration in 1972, subject All accredited methadone programs operate under the authority of to three levels of Federal regulation: the Drug Enforcement Agency (DEA) regulations that govern the ●● Food and Drug Administration rules that pertained to all dispensing of controlled substances. The DEA regulations (www. prescription drugs. deadiversion.usdoj.gov/pubs/manuals/narcotic/narcotic.pdf) stipulate ●● Drug Enforcement Administration rules that governed all requirements for the type of registration required, qualifications for controlled substances. physicians who dispense methadone, and rules for physician record- ●● Unique Department of Health and Human Services rules limiting keeping. methadone maintenance treatment to strictly controlled opioid

SocialWork.EliteCME.com Page 98 Methadone treatment dosage Patients’ illicit opioid use declines, often dramatically, during judgment of the program physician and careful observation of the methadone maintenance treatment. However, adequate methadone patient, dosing can go up to 60 mg a day prior to stabilization (http:// dosage and basic psychosocial services are essential for treatment dpt.samhsa.gov/pdf/draft_accred_guidelines.pdf) (267KB). effectiveness. In the Ball and Ross studies (1991), patients reduced their use of Methadone is provided in various forms, including diskettes, injected heroin by 71 percent compared with preadmission levels. tablets, oral solution, liquid concentrate, and powder. In the United Illicit opioid use was directly related to methadone dosage: in patients States, methadone used in medically assisted treatment is almost on doses above 71 mg per day, no heroin use was detected, whereas always administered orally in liquid form. Parenteral administration patients on doses below 46 mg per day were 5.16 times more likely to is prohibited in opioid treatment programs. Parenteral abuse of use heroin than those receiving higher doses. methadone is not widespread, and people rarely inject the methadone The impact of methadone dose has been demonstrated consistently dispensed in U.S. programs because it is mixed with substances across studies and countries. Higher (e.g., greater than 50 mg) doses of (e.g., flavored drinks) that make injection unattractive (Treatment methadone are associated with better treatment retention and decreased Improvement Protocol 43, Chapter 3: http://www.ncbi.nlm.nih.gov/ illicit drug use (Faggiano, Vigna-Taglianti, Versino, et al., 2003). books/NBK25695/#A82783). A meta-analysis (Faggiano et al., 2003) of 21 studies concluded that The acceptable initial dose for methadone treatment is 30 mg daily, methadone dosages ranging from 60 to 100 mg per day were more unless a reason for a higher dose can be evidenced, which could effective than lower dosages in retaining patients and in reducing use increase the initial dose to no more than 40 mg a day. Based on the of heroin and cocaine during treatment.

Research and methadone treatment Methadone is a rigorously well-tested medication that has been safely be effective in improving treatment retention, criminal activity, and used to treat opioid addiction in the United States for more than 40 heroin use (Marsch, 1998). years. Methadone: ●● An overview of 5 meta-analyses and systematic reviews, ●● Suppresses the symptoms of opioid withdrawal for 24 to 36 hours. summarizing results from 52 studies and 12,075 opioid-dependent ●● Blocks the effects of administered heroin. participants, found that when methadone maintenance treatment ●● Does not cause euphoria, intoxication, or sedation. was compared with methadone detoxification treatment, no ●● Blocks the craving for opioids that is a major factor in relapse. treatment, different dosages of methadone, buprenorphine For 40 years, methadone maintenance treatment has been used maintenance treatment, heroin maintenance treatment, and L-a- successfully to treat heroin addiction in the United States. From the acetylmethadol (LAAM) maintenance treatment, methadone first pilot project in 1964, when Drs. Vincent P. Dole and Marie E. maintenance treatment was more effective than detoxification, no Nyswander established that methadone maintenance treatment was an treatment, buprenorphine, LAAM, and heroin plus methadone. effective medical intervention for heroin addiction, rigorous scientific High doses of methadone are more effective than medium and low research has documented the safety and effectiveness of methadone doses (Amato, Davoli, Perucci, et al., 2005). maintenance to treat heroin addiction. Through the extensive research ●● Patients receiving methadone maintenance treatment exhibit grant programs administered by the National Institutes of Health, the reductions in illicit opioid use that are directly related to Federal Government funds most major medical research conducted methadone dose, the amount of psychosocial counseling, and the in the United States, including research on methadone maintenance period of time that patients stay in treatment. Patients receiving treatment. In addition, some of the research on methadone methadone doses of 80 to 100 mg have improved treatment maintenance treatment has been conducted by the Federal Government retention and decreased illicit drug use compared with patients itself at research facilities like the U.S. Public Health Service Hospital receiving 50 mg of methadone (Simpson, 1993). in Lexington, Kentucky, where methadone was first shown to be ●● A systematic review conducted on 28 studies involving 7,900 effective in treating the symptoms of heroin withdrawal. patients has demonstrated significant reductions in HIV risk behaviors in patients receiving methadone maintenance (Metzger, Research has demonstrated that methadone maintenance treatment is Woody, McLellan, et al., 1993). an effective treatment for heroin and prescription narcotic addiction ●● A randomized clinical trial in Bangkok, Thailand, included 240 when measured by: heroin-dependent patients, all of whom had previously undergone ●● Reduction in the use of illicit drugs. at least 6 detoxification episodes. The patients were randomly ●● Reduction in criminal activity. assigned to methadone maintenance versus 45-day methadone ●● Reduction in needle sharing. detoxification. The study found that the methadone maintenance ●● Reduction in HIV infection rates and transmission. patients were more likely to complete 45 days of treatment, less ●● Cost-effectiveness. likely to have used heroin during treatment, and less likely to have ●● Reduction in commercial sex work. used heroin on the 45th day of treatment (Vanichseni, Wongsuwan, ●● Reduction in the number of reports of multiple sex partners. Choopanya, et al., 1991). ●● Improvements in social health and productivity. ●● In the Treatment Outcome Prospective Study (TOPS), methadone ●● Improvements in health conditions. maintenance patients who remained in treatment for at least 3 ●● Retention in addiction treatment. months experienced dramatic improvements during treatment with ●● Reduction in suicide. regard to daily illicit opioid use, cocaine use, and predatory crime. ●● Reduction in lethal overdose. These improvements persisted for 3 to 5 years following treatment, For example the following research demonstrates the efficacy but at reduced levels (Hubbard, Marsden, Rachal, et al., 1989). methadone treatment: ●● In a study of 933 heroin-dependent patients in methadone ●● Recent meta-analyses have supported the efficacy of methadone maintenance treatment programs, during episodes of methadone for the treatment of opioid dependence. These studies have maintenance, there were (1) decreases in narcotic use, arrests, demonstrated across countries and populations that methadone can criminality, and drug dealing; (2) increases employment and marriage; and (3) diminished improvements in areas such as

Page 99 SocialWork.EliteCME.com narcotic use, arrest, criminality, drug dealing, and employment for demonstrated that methadone maintenance resulted in greater patients who relapsed (Powers and Anglin, 1993). treatment retention (median, 438.5 vs. 174.0 days) and lower ●● In a 2.5-year follow up study of 150 opioid-dependent patients, heroin use rates than did detoxification. Methadone maintenance participation in methadone maintenance treatment resulted in a therapy resulted in a lower rate of drug-related (mean [SD] at substantial improvement along several relatively independent 12 months, 2.17 [3.88] vs. 3.73 [6.86]) but not sex-related HIV dimensions, including medical, social, psychological, legal, and risk behaviors and a lower score in legal status (mean [SD] at 12 employment problems (Kosten, Rounsaville, and Kleber, 1987). months, 0.05 [0.13] vs. 0.13 [0.19]) (Sees, Delucchi, Masson, et ●● A study that compared ongoing methadone maintenance with 6 al., 2000). months of methadone maintenance followed by detoxification

Patient status before and after methadone maintenance treatment A study by McGlothlin and Anglin (1981) examined patients from maintenance treatment. The percentage of days the patient was three methadone maintenance treatment programs. All three program involved in crime decreased after methadone maintenance treatment. results illustrate that methadone maintenance treatment is effective in The percentage of time dealing drugs decreased after methadone improving patients’; lives in terms of time spent (1) using narcotics maintenance treatment. The percentage of time incarcerated decreased daily, (2) unemployed, (3) involved in crime, (4) dealing drugs, and after methadone maintenance treatment (McGlothlin and Anglin, (5) incarcerated. The percentage of time using daily narcotics was 1981). A single oral dose of methadone in the morning promotes a much greater before methadone maintenance treatment than after. relatively steady state of mood and function. The percentage of time unemployed decreased after methadone

Treatment duration and outcomes There is a relationship between reduction in illicit opioid use in drug use and needle sharing by most heroin addicts. Of 388 patients recovery and treatment duration. And there is a relationship between who remained in treatment for 1 year or more, 71 percent had stopped how long patients remain in treatment and how well they function injection drug use. Conversely, 82 percent of the 105 patients who left after treatment. The length of treatment is, in general, associated with treatment relapsed rapidly to injection drug use (Ball et al., 1988). abstinence from illicit drug use and an absence of crime. The longer In one study, 82 percent of 105 patients who discontinued methadone patients stay in treatment, the more likely they are to remain crime relapsed to intravenous drug use within 12 months (Payte and free. For example, those who remained in methadone maintenance Khuri, 1993). And, Drug abuse reduction program studies of opioid- treatment for the entire 18-month study period, 3.5 percent became dependent patients 12 years following admission to treatment showed infected with HIV. However, among those who remained out of that illicit opioid use declined progressively over time until year 6, treatment, 22 percent became infected with HIV (Metzger et al., 1993). when it stabilized at about 40 percent for “any” use and 25 percent for In a 3-year field study of methadone maintenance treatment programs “daily” use (Simpson, Joe, Lehman, et al., 1986). In studies, of long in New York, NY, Philadelphia, PA, and Baltimore, MD, methadone treatment duration was the strongest predictor of reduced heroin use maintenance treatment was found to be effective in reducing injection among methadone maintenance patients.

HIV and methadone maintenance The daily oral administration of adequate dosages of methadone small-to-moderate effect in reducing HIV risk behaviors (Marsch, reduces the need for opioid-dependent individuals to inject drugs. By 1998). decreasing injection drug use, methadone maintenance treatment helps ●● A study that evaluated HIV risk behavior in patients receiving reduce the spread of diseases transmitted through needle sharing, such ongoing methadone maintenance compared with patients receiving as human immunodeficiency virus (HIV) infection, hepatitis C virus 6 months of methadone maintenance followed by detoxification (HCV), and other bloodborne infections (Sullivan, Metzger, Fudala, et demonstrated that those patients who received ongoing methadone al., 2005; Gowing, Farrell, Bornemann, et al., in press). maintenance treatment reported lower HIV drug (but not sex) risk Research demonstrates decreased in HIV risk behaviors among behaviors after 6 and 12 months of treatment (Sees, Delucchi, methadone maintenance patients Masson, et al., 2000). A systematic review of 23 studies of 7,900 patients in diverse countries ●● In New Haven, CT, 107 methadone-maintained injection drug and settings reported significant decreases in the following HIV risk users who were not in treatment were surveyed regarding their behaviors among patients receiving methadone maintenance treatment: risk behaviors. The frequency of injections was found to be 50 to (1) the proportion of opioid-dependent injection drugs, (2) the reported 65 percent (p < .001) higher among the out-of-treatment subjects frequency of injection, (3) levels of sharing of injection equipment, (4) (Meandzija, O’Connor, Fitzgerald, et al., 1994). illicit opioid use, (5) reduction in the proportion of opioid-dependent ●● In a 3-year field study of methadone maintenance treatment injection drug users reporting multiple sex partners or exchanges of programs in New York, NY, Philadelphia, PA, and Baltimore, MD, sex for drugs or money, and (6) reductions in cases of HIV infection treatment was found to be effective in reducing injection drug among opioid-dependent injection drug users. However, it should use and needle sharing by most heroin addicts. Of 388 patients be noted that methadone treatment had little or no effect on the use who remained in treatment for 1 year or more, 71 percent had of condoms. The authors concluded that the provision of agonist stopped injection drug use. Conversely, 82 percent of patients who treatment for opioid dependence should be supported in countries with left treatment relapsed rapidly to injection drug use (Ball, Lang, emerging HIV and injection drug use problems as well as in countries Meyers, et al., 1988). with established populations of injection drug users (Gowing, Farrell, ●● Abdul-Quader, Friedman, Des Jarlais, et al. (1987) reported that Bornemann, et al., 2004). both the frequency of drug injection and the frequency of drug injection in shooting galleries were significantly reduced by the These results support an earlier meta-analysis of 11 studies that found amount of time spent in methadone maintenance treatment. a consistent, statistically significant relationship between methadone ●● A study by Serpelloni, Carrieri, Rezza, et al. (1994) examined maintenance treatment and the reduction of HIV risk behaviors. This the effect of methadone maintenance treatment on HIV infection meta-analysis found that methadone maintenance treatment had a incidence among injection drug users. The study found that the

SocialWork.EliteCME.com Page 100 amount of time spent in methadone maintenance treatment was ●● At entry into this study, 18 percent of the out-of-treatment subjects the major determinant in remaining HIV-free, which confirms the and 11 percent of the methadone-maintained clients tested positive effectiveness of long-term programs in reducing the risk of HIV for antibodies to HIV. After 18 months of study, 33 percent of the infection. Indeed, the risk of HIV infection increased 1.5 times out-of-treatment cohort were infected, whereas 15 percent of the for every 3 months spent out of methadone treatment in the past methadone clients tested positive (p < 0.01). The incidence of new 12 months immediately preceding seroconversion. The study infection was strongly associated with the level of participation in noted that higher daily methadone doses were associated with a methadone treatment. Among those who remained in methadone reduction in HIV infection. treatment for the entire 18-month study period, 3.5 percent became ●● A study by Weber, Ledergerber, Opravil, et al. (1990) examined infected. Among those who remained out of treatment, 22 percent the role of methadone maintenance treatment in reducing the became infected with HIV (Metzger, Woody, McLellan, et al., progression of HIV infection among 297 current and former 1993). injection drug users with asymptomatic HIV infection. The study ●● Another study of HIV seroconversion followed 56 patients who showed that HIV infection progresses significantly more slowly were continuously enrolled in methadone maintenance and in those who receive methadone maintenance treatment and those compared them with 42 patients who had intermittent methadone who are drug free than in active injection drug users. treatment. Subjects in continuous treatment had a seroconversion ●● In Philadelphia, PA, a longitudinal study of HIV infection and rate of 0.7 per 100 person years (95 percent CI = 0.1, 5.3), and risk behaviors among 152 injection drug users in methadone those with interrupted treatment had a rate of 4.3 per 100 person maintenance treatment and 103 out-of-treatment injection drug years (95 percent CI = 2.2, 8.6) (Williams, McNelly, Williams, et users found significantly lower rates of risk behavior, including al., 1992). needle sharing, injection frequency, shooting gallery use, and visits ●● A relatively short-term study of methadone maintenance versus to crack houses among the methadone-maintained users. While control in a prison system in Australia found reductions in opioid 70 percent of the out-of-treatment cohort reported sharing needles use but no changes in HIV or HCV incidence (Dolan, Shearer, during the 6 months before entry into the study, only 30 percent MacDonald, 2003). of those in treatment reported sharing needles during this same interval.

Methadone maintenance and criminal activity Patients are less likely to become involved in criminal activity while in dealing decreased during episodes of methadone maintenance methadone maintenance treatment. treatment when compared with addicts not in treatment. ●● Patients who remain in methadone maintenance treatment for long ●● In the National Treatment Outcome Research Study, acquisitive periods of time are less likely to be involved in criminal activity criminal behavior decreased in the majority of the 333 patients than patients in treatment for short periods. except those (n = 88) who were felt to have a poor treatment ●● The availability of methadone maintenance treatment in a response. In these patients, there was no change in this type of community is associated with a decrease in that community’s criminal activity (Gossop, Marsden, Stewart, et al., 2000). criminal activity, particularly theft. ●● The meta-analysis by Mattick, Breen, Kimber, et al. (2003) Research revealed that criminal activity declined in consort with reductions ●● In a meta-analysis of 24 studies, results indicate an overall small- in heroin use, although the advantage for methadone beyond to-medium effect of r = -0.25 (un-weighted) of the impact of control in reducing criminal activity was not statistically methadone maintenance on criminal activity. A large effect size of significant (3 studies, 363 patients: RR = 0.39, 95 percent CI: 0.12- r = 0.70 (un-weighted) was seen in those studies that investigated 1.25). the efficacy of methadone maintenance treatment in reducing drug- The effects of methadone maintenance treatment on crime-days related criminal behaviors. A small-to-moderate effect of r = 0.23 Ball and Ross study (1991) of 617 patients demonstrated that (un-weighted) was obtained when both drug and property-related methadone maintenance treatment is associated with a dramatic criminal activities were evaluated. Finally, a small effect of r = decline in the average number of crime-days per year. The study 0.17 (un-weighted) was demonstrated when drug- and nondrug- revealed that the average number of crime days per year before related criminal behaviors were combined (Marsch, 1998). treatment was 237. During the 4-month initial methadone maintenance ●● In the Treatment Outcome Perspective Study (TOPS), 32 percent treatment, the average number of crime days per years was 69. This of the methadone maintenance patients acknowledged committing represents about a 71 percent decline. The decline was followed one or more predatory crimes in the year before treatment, but by continuing, but less dramatic, declines in the average number of only 10 percent continued these activities during treatment. By 3 crime days among those in methadone maintenance treatment for to 5 years after leaving treatment, only 16 percent of the patients one to three years. Patients who remained in methadone maintenance reported predatory criminal activity–a reduction of one-half the treatment for 6 or more years reported only 14.5 crime days per year, pretreatment level (Hubbard, Marsden, Rachal, et al., 1989). representing a 94 percent decline in average number of crime days. ●● Among the 617 patients studied by Ball and Ross (1991), there Ball and Ross (1991) also found a dramatic decline in crime when was a 70.8-percent decline in crime-days within the 4-month comparing pretreatment crime-days per year and the number of methadone maintenance treatment period. This decline was crime-days per year after 6 months or more in methadone maintenance followed by continuing, but less dramatic, declines in mean crime- treatment. Although there are differences among programs, the days among those in treatment for 1 to 3 years. Those in treatment dramatic decrease in crime days before and during methadone for 6 or more years had the lowest rate of crime-days per year maintenance treatment occurs for all six programs. The average (14.5). reduction in crime for those in methadone maintenance treatment was ●● The Powers and Anglin (1993) retrospective study of 933 heroin just over 91 percent. addicts demonstrated that rates of criminality, arrests, and drug

Page 101 SocialWork.EliteCME.com Methadone maintenance and employment Methadone maintenance has been associated with significant increases than those who were in treatment for less than 1 year (mean of 35 in full-time employment. months) (Maddux and Desmond, 1992). Research ●● The Powers and Anglin (1993) study of 933 heroin addicts in ●● In an early study of 100 chronic heroin users who were admitted to methadone maintenance treatment demonstrated that rates of methadone maintenance treatment, the employment rate increased employment (and marriage) increased during treatment. from 21 percent at admission to 65 percent 1 year later (Maddux ●● Methadone maintenance patients in the Treatment Outcome and Desmond, 1979). Perspective Studies (TOPS) had small changes in employment ●● A study of 92 males admitted to methadone maintenance treatment rates during and following treatment compared with pretreatment programs from 1971 through 1973 demonstrated that, following rates. Although 24 percent of the patients reported full-time methadone maintenance treatment, employment increased about employment in the year before admission, this rate did not increase 18 percent (Harlow and Anglin, 1984). significantly during treatment. It declined abruptly in the 3 months ●● In a 10-year followup study, 95 chronic opioid users who spent following discharge, improved to 29 percent by year 2, and at least 1 cumulative year in methadone maintenance treatment dropped off again to less than pretreatment rates by years 3 to 5 were compared with 77 chronic opioid users who spent less than following treatment (Hubbard, Marsden, Rachal, et al., 1989). 1 cumulative year in methadone maintenance treatment. Those ●● In a study that compared ongoing methadone maintenance with 6 who were on methadone maintenance treatment for more than 1 months of methadone maintenance followed by detoxification, no year had a higher average time employed (mean of 42 months) difference was seen in employment, although nearly 50 percent of patients were employed at entry into the study (McLellan, Arndt, Metzger, et al., 1993).

Methadone maintenance treatment and general drug abuse Research outcomes are mixed regarding the effect of methadone Among three cohorts of new-admission patients in methadone maintenance treatment on the use of illicit drugs other than opioids. maintenance treatment, Ball and Ross (1991) found that the use of all In other words, some research indicates that methadone maintenance illicit drugs, except marijuana, decreased markedly in relation to time treatment is associated with decreases in the use of alcohol, cocaine, in treatment. These three cohorts had been in treatment 6 months, 4.5 and marijuana; other research indicates increases in the use of these years, or more than 4.5 years. drugs. It is important to note that the medication methadone has no In the Treatment Outcome Perspective Study (TOPS), 90 percent direct effect and is not intended to have an effect on rates of alcohol of methadone maintenance treatment patients who reported drug and other drug use. Patients receiving methadone maintenance who use at intake reported a reduction in use during the first 3 months of disengage from interactions with others who are actively using drugs treatment. For 80 percent, this reduction is large. In the year before are less likely to engage in these behaviors. treatment, less than 10 percent of methadone maintenance treatment In addition, reductions in alcohol and drug use result from the patients were minimal drug users. During treatment, more than 50 counseling services included in methadone maintenance treatment. percent of the patients were minimal drug users. During the 3 to 5 When these services are specifically designed to reduce alcohol and years after discharge, less than 32.5 percent were minimal drug users other drug use, such reductions are likely. (Hubbard, Marsden, Rachal, et al., 1989). Research In the National Treatment Outcome Research Study (NTORS), ●● In the Drug Abuse Reporting Program (DARP) studies, there were of 333 patients receiving methadone maintenance in the United reductions in non-opioid drug use (except marijuana) among 895 Kingdom, overall declines were seen in the use of heroin, barbiturates, methadone maintenance patients, comparing the 2-month period amphetamines, cocaine, and crack cocaine among patients receiving before admission and the year following discharge. The reduction methadone maintenance. Alcohol use, however, did not change over in non-opioid use was 13 percent–from 54 percent of patients time (Gossop, Marsden, Stewart, et al., 2000). who reported any use before admission to 41 percent at the 1-year In another evaluation of 513 heroin users in methadone treatment in follow-up point (Simpson and Sells, 1982). TOPS, a decline was observed in the use of cocaine, amphetamines, ●● In the 12-year DARP follow-up study, “heavy drinking” was illegal methadone, tranquilizers, and marijuana, but not alcohol reported by 21 percent of the sample in the month before (Fairbank, Dunteman, and Condelli, 1993). treatment; it rose to 31 percent during the first year afterward and then declined to 22 percent by year 12. One-half of the patients The Powers and Anglin study (1993) of 933 heroin addicts in reported substituting alcohol for opioids after stopping daily illicit methadone maintenance programs demonstrated that during episodes opioid use (Lehman, Barrett, and Simpson, 1990). of methadone maintenance treatment, illicit opioid use decreased, ●● In a study comparing buprenorphine maintenance with methadone but alcohol and marijuana levels increased moderately. Kreek (1991) maintenance for patients with opioid dependence and cocaine observed that by 1990, alcoholism was identified in 40 or 50 percent abuse, both treatments resulted in significant declines in opioid of new admissions to methadone maintenance treatment programs, use but were indistinguishable in terms of their effect on comorbid and cocaine abuse was found in 70 to 90 percent. She also estimated cocaine use (Schottenfeld, Pakes, Oliveto, et al., 1997). that 20 to 46 percent of patients in effective methadone maintenance treatment programs continue using cocaine, and 15 to 20 percent of methadone maintenance treatment patients regularly inject cocaine.

Methadone maintenance treatment and cocaine use Among the TOPS patients who remained in methadone maintenance patients who regularly used cocaine before treatment and stayed in treatment at least 3 months, 26.4 percent had used cocaine regularly treatment for at least 3 months abstained from cocaine use in the year the year before treatment. This rate fell to 10 percent during the first after treatment (Hubbard et al., 1989). 3 months of treatment but returned to 16 percent by 3 to 5 years after In the TOPS studies, although 70 percent of heroin abusers had discharge. Altogether, 40 percent of methadone maintenance treatment frequently used cocaine the year before treatment, it was the primary

SocialWork.EliteCME.com Page 102 drug of choice for only 2 percent of methadone maintenance treatment percent vs. 62.4 percent and 67.1 percent, respectively; p < 0.05) patients (Hubbard et al., 1989). (Strain, Stitzer, Liebson, et al., 1993). In the new admissions group of a six-program study (n = 345), 46.8 A systematic review examined the impact of methadone dose on percent of 126 patients had used cocaine in the past 30 days. Among cocaine use and found three studies that addressed the question. the average-stay group (up to 4.5 years in treatment), 27.5 percent still Results from the one study in which cocaine use was based on self- used cocaine; this rate dropped to 17.2 percent among the long-term reported use showed no significant excess of use of cocaine among group of 146 patients who had been in continuous treatment for more subjects treated with higher doses compared with subjects treated than 4.5 years (Ball and Ross, 1991). with lower doses. Pooled results from the two studies that used urine A study evaluating the effect of methadone dose on treatment analysis and looked at an abstinence period longer than 3 weeks outcomes noted that patients receiving 50 mg of methadone, compared showed that higher methadone doses increased the probability that with those receiving 20 mg or 0 mg, had a reduced rate of opioid- patients would stay abstinent from cocaine, compared with lower positive urine samples (56.4 percent vs. 67.6 percent and 73.6 percent, doses (RR = 1.81 [1.15, 2.85]) (Faggiano, Vigna-Taglianti, Versino, et respectively; p < 0.05) and cocaine-positive urine samples (52.6 al., 2003).

Methadone maintenance and marijuana use Among TOPS subjects, marijuana use was common: 55 percent of Ball and Ross (1991) found that marijuana continued to be used quite methadone maintenance patients who stayed in treatment for 3 months regularly (an average of 13 to 16 days per month) by high percentages reported regular use in the year before admission. This decreased of all patient groups in methadone maintenance treatment: 48.4 percent to 47 percent during the first 3 months of treatment, continued to of the new admissions, 47.7 percent of the average-stay group, and decline immediately posttreatment, and decreased even more to 36.4 37.2 percent of the patients in treatment more than 4.5 years. percent in the 3- to 5-year period after discharge. However, marijuana In one study of 132 opioid addicts participating in methadone use appeared more resistant to change than other illicit substances maintenance treatment programs, it was noted that during episodes of (Hubbard et al., 1989). It should be considered that the treatment methadone maintenance treatment, levels of alcohol and marijuana use programs likely did not clinically address marijuana or other drug use. increased modestly (Powers and Anglin, 1993).

Methadone maintenance and the non-medical use of prescription drugs In the TOPS studies, the regular nonmedical use of psychoactive 2000). In the TOPS studies, nonmedical prescription drug use declined prescription drugs by methadone maintenance treatment patients during methadone maintenance treatment, increased immediately during the first post-treatment year decreased by one-third from following discharge, and declined again to 10 percent of patients 3 to 5 the pretreatment period. Although 30.3 percent of this methadone years following discharge (Hubbard et al., 1989). maintenance group reported regular nonmedical use of prescription Ball and Ross (1991) found that although the nonmedical use of drugs (i.e., barbiturates, amphetamines, tranquilizers, sedatives, and sedatives other than barbiturates was acknowledged by 31.8 percent of hypnotics), nonmedical prescription drug use was a primary problem new admissions to methadone maintenance treatment, the percentage for only 1.9 percent of these patients at admission (Hubbard et al., of sedative-using patients who had been in treatment for more than 1989). 4.5 years was less than half that of the new admission group (14.5 In the NTORS study, a decline was seen in the use of benzodiazepines percent). among patients receiving methadone maintenance (Gossop et al.,

Methadone maintenance treatment and alcohol and other drug use In the TOPS studies, improvements in the use of illicit and marijuana use, and 4. Alcohol abuse. (Hubbard et al., 1989) “Any nonprescription drugs follow a pattern of (1) a dramatic reduction opioid use” declined from 63 percent pretreatment to 17 percent 1 year during treatment, (2) a sharp increase immediately after discharge, post-treatment. This was the most dramatic decline. “Any cocaine use” and (3) a leveling off at an impressively reduced rate for up to 5 years declined from 26 percent to 18 percent. “ Any marijuana use” declined of follow-up contacts (Hubbard et al., 1989). In the TOPS study of from 55 percent pretreatment to 46 percent 1 year post-treatment. 4,184 patients, methadone maintenance treatment was associated Alcohol abuse remained almost steady, declining slightly from 25 with reductions in: 1. Any illicit opioid use 2. Any cocaine use 3. Any percent to 24 percent.

Women and methadone maintenance Since the earliest methadone maintenance treatment programs in the ●● Have different psychological, counseling, and vocational training United States, women have been treated successfully with methadone needs. through all phases of their lives, including pregnancy. There is ●● Have difficulty with transportation to treatment. consensus that the major outcomes of the effectiveness of methadone Research maintenance treatment, especially cessation of illicit drug use and ●● In the past, little emphasis was placed on gender-specific bio- lifestyle stabilization, apply to both men and women. However, psychosocial problems in drug treatment. One reason was the gender-specific issues, which are often related to the social status of predominance of drug-addicted men, estimated in the United women, are important to treatment effectiveness for female injection States to be three males to every female. Although mild forms drug users. of psychoactive substance use show converging usage rates and Compared with men, women are more likely to: patterns for males and females, opioid addiction and other forms ●● Have total responsibility for child care. of chemical dependency continue to show a male predominance ●● Have lower socioeconomic status. (Kandel, 1992). ●● Encounter greater barriers to treatment entry, retention in ●● Drug Abuse Reporting Program (DARP) studies showed that 19 treatment, and economic independence. to 28 percent of admissions to drug treatment programs from 1969 to 1973 were women. In 12 years of follow-up of 84 females and

Page 103 SocialWork.EliteCME.com 91 males in methadone maintenance, there were no differences A systematic review revealed that randomized controlled studies between men and women in overall reduction of opioid use. of methadone treatment in pregnancy demonstrate an approximate Women required more government financial assistance and had threefold reduction in heroin use and a threefold increase in retention lower rates of employment than men. Compared with men, women in treatment relative to non-pharmacologic treatment (Rayburn and were more likely to enter treatment for health reasons (Marsh and Bogenschutz, 2004). Simpson, 1986). ●● All drug-using women are considered to be at higher-than-normal ●● A study of 567 methadone-maintained patients in California found risk for medical and obstetrical complications. Methadone- overall shorter duration of time from first entry to first discharge maintained women show a far greater improvement in obstetrical from treatment for women compared with men (Murphy and health than untreated women. Hepatitis types A, B, and C and Irwin, 1992). other sexually transmitted diseases; bacterial endocarditis; ●● A study of white, Latina, and African American women in septicemia; and cellulites are common among active injection drug methadone maintenance found that, in general, Latinas were more users, particularly those who share needles. Women maintained on likely to report familial influences and to display evidence of low methadone who have stopped illicit drug use and injection before self-esteem and self-efficacy, inconsistent condom use, and high- pregnancy are less likely to experience these and other medical risk injection behavior. White women reported the highest levels complications during pregnancy. Obstetrical complications of regular condom use at follow-up; however, they were the least such as spontaneous abortion, placental insufficiency, and other likely to report safer injection practices. African American women conditions also occur at a lower rate among methadone-maintained expressed the highest levels of self-esteem, yet they reported more women than among opioid-dependent women not enrolled in alcohol use at intake and crack cocaine use both before and after treatment. When compared with opioid-addicted women not in treatment entry. African American women showed the greatest treatment, women in methadone maintenance treatment have gains in adopting safer injection practices and were the least been observed to maintain better overall health and nutritional likely to report multiple sex partners after treatment entry (Grella, status during pregnancy because of stability provided through Annon, and Anglin, 1995). treatment. In addition, methadone clinics can provide onsite ●● Drug-using women are likely to experience clinical depression, prenatal services or link patients to these services in nearby clinics, anxiety disorders, and low self-esteem to a much greater degree coordinating addiction treatment and prenatal care to optimize than their male counterparts. Women entering treatment have both (Kaltenbach, Silverman, and Wapner, 1993). experienced unique gender-specific life events. In particular, ●● Some women in methadone maintenance treatment are infected female drug users often have been abused physically, sexually, with HIV before pregnancy. Treatment programs that link women and emotionally. Experiences of sexual violence, especially to appropriate medical care during pregnancy may reduce the during childhood, have profound, lifelong psychological effects burden of illness suffered by HIV-infected women. In a study of and often underlie addiction, complicating successful recovery. 191 methadone-maintained women in a New York City clinic with Methadone maintenance treatment of women requires awareness extensive medical linkages, medical and obstetrical complications of these issues and appropriate counseling. Confrontational styles did not differ among women with and without HIV infection. of therapy and counseling are not effective for most women in HIV infection occurred among 37 percent of women, most of treatment (Hartel, 1989/1990). Therefore, key treatment issues whom were asymptomatic for HIV disease and AIDS before include: pregnancy. Adverse birth outcomes were relatively infrequent and ○○ Social isolation. occurred at approximately the same rates as observed in studies of ○○ Poor self esteem. methadone-maintained women before the HIV epidemic (Selwyn, ○○ Clinical depression and anxiety disorders. Schoenbaum, Davenny, et al., 1989). ○○ Physical and sexual abuse. ●● U.S. research in the 1970s demonstrated that methadone does cross the placenta. Passive exposure to methadone in utero can There is a strong need for: result in neonatal abstinence syndrome among exposed infants. ●● Child care. The syndrome varies considerably and depends on a number ●● Transportation to treatment. of factors, including the use of other drugs during pregnancy, ●● Non-confrontational therapy and counseling. anesthesia during delivery, the maturational and nutritional status ●● Vocational job skills training and education designed specifically of the infant, and other aspects of maternal health that affect the for women. fetal environment. The relationship of maternal methadone dose In research conducted in New York, NY, among 452 methadone- in the last trimester of pregnancy has been explored in a number recruited injection drug users early in the HIV epidemic, having an of studies, but results have not consistently delineated a dose- injection drug user as a sex partner was associated with HIV infection response relationship between maternal dose and severity of infant status independent of or in addition to injection risk behavior. In this abstinence syndrome. For those neonates experiencing withdrawal, same study, women reported a higher level of sexual risk behavior the length and severity of the withdrawal vary greatly; however, than men: 57 percent of women compared with 45 percent of men pharmacotherapy for neonatal methadone abstinence syndrome is reported one or more injection drug users as sex partners since 1978. simple and effective. Methadone maintenance treatment affords In addition, women were more likely than men to have engaged in protection of the fetus from erratic maternal opioid levels and sex work: 23 percent of women compared with 5 percent of men repeated episodes of withdrawal typically seen in users of illicit (Schoenbaum, Hartel, Selwyn, et al., 1989). opioids (Finnegan, 1991). ●● The majority of infants exposed to methadone in utero are healthy Research and have fewer adverse outcomes than infants exposed to heroin Since the early 1970s, methadone maintenance treatment has been and other illicit drugs. Methadone maintenance treatment for used successfully with pregnant women. There is consensus that pregnant women can reduce in utero growth retardation and methadone can be safely administered during pregnancy with little neonatal morbidity and mortality, in comparison with women not risk to mother and infant. Maintenance on methadone is necessary to in treatment (Kaltenbach and Finnegan, 1984). prevent relapse to illicit opioid use and thus to maintain optimal health during pregnancy. A review of the literature on methadone and lactation reveals that the amount of methadone in breast milk is very small and depends

SocialWork.EliteCME.com Page 104 on the dose of methadone that a mother is receiving. The amount a mother is receiving methadone, her infant may require additional of methadone received by an infant from breast milk is not enough opiate treatment of neonatal abstinence syndrome (Jansson, Velez, and to prevent neonatal abstinence syndrome. Therefore, even though Harrow, 2004).

Methadone safety for pregnant women and their infants Methadone for pregnant women and their infants: maternal dose have been effectively administered during the last ●● Reduces adverse pregnancy outcomes. stage of pregnancy. However, many women in treatment have ●● Reduces adverse birth outcomes. been successfully maintained on a constant dose and, in some ●● Infant withdrawal is treatable. cases, on an increased dose to keep blood levels stable throughout ●● Shows no long-term adverse neurobehavioral consequences to in pregnancy (Finnegan, 1991). utero exposure. ●● Some women in treatment experience decreased blood levels of Women have been safely maintained on stable methadone dosage methadone during pregnancy, causing withdrawal symptoms. during pregnancy without adverse long-term effects on their health This decrease in blood levels of methadone during pregnancy and the health of their infants. Withdrawal of medication during can be accounted for by an increased fluid space, a large tissue pregnancy leads to opioid abstinence syndrome, which is harmful to reservoir that can store methadone, and drug metabolism by both the pregnancy and often leads to relapse to illicit drug use. Dosage the placenta and the fetus. Pregnant women in treatment with low change in pregnancy must be carefully evaluated on an individual blood levels of methadone frequently experience a high level of basis. Some women experience lowered blood levels of the methadone discomfort, withdrawal symptoms, and drug craving and anxiety during pregnancy and may need an increase in dosage or split (e.g., and may be at high risk of relapse to opioid use and treatment twice daily) dosing. It is important to determine the relapse risk for dropout. Determination of methadone blood levels and possibly each woman when considering a dosage change because a woman raising the methadone dosage to maintain sufficient blood levels steadily maintained on methadone is more likely to have a healthy may be warranted in such cases but must be carefully evaluated. pregnancy and infant than a woman who uses alcohol and other drugs. Dosages should be evaluated in conjunction with ongoing medical The intermittent periods of withdrawal that typically occur with monitoring of the pregnancy. Since the greatest risks to maternal illicit opioid use and can adversely affect the fetus do not occur when and infant health occur when women in treatment relapse to illicit methadone is individually determined and properly administered. drug use, it is important to promote methadone dosage stability during and after pregnancy to optimize both maternal and child Research health (Kreek, Schecter, Gutjahr, et al., 1974; Pond, Kreek, Tong, ●● Optimal methadone dosage for pregnant women in methadone et al., 1985). maintenance treatment should be based on careful consideration of risks and benefits to both mother and fetus on an individual Methadone dosage adjustment during pregnancy basis. Individual dose should be evaluated, taking into account Three main considerations regarding dosage for pregnant women in the stage of pregnancy, the relapse risk potential of the mother, methadone maintenance treatment: pre-pregnancy methadone dose, previous experience with ●● Pregnancy can lower methadone blood levels. methadone, and history of addiction recovery. When the mother ●● Lower blood methadone levels can increase relapse-risk. does not relapse to illicit drug use, short-term reductions in ●● Dosage levels should be evaluated and individually tailored to reduce risk of relapse and to stabilize both mother and fetus.

Long-term administration of methadone Studies of the long-term administration of methadone confirm that it is sleep abnormalities (insomnia and nightmares), and altered a medically safe drug. Long-term methadone maintenance treatment at appetite (mild anorexia, weight gain) (Kreek, 1979). A study of 92 doses of 80 to 120 mg per day is not toxic or dangerous to any organ methadone-maintained patients found that the rate of global sexual system after continuous treatment for 10 to 14 years in adults and 5 to dysfunction in methadone-treated men was similar to the general 7 years in adolescents. population but that orgasm dysfunction may respond to methadone Research dose reduction. ●● Methadone has few adverse biological effects. There appear to be ●● Although euphoria and drowsiness, with occasional nausea no dangerous or troubling psychological effects from long-term and vomiting, can occur before tolerance develops, these side administration (Verdejo, Toribio, Orozco, et al., 2005). effects are most noticeable when doses are increased too rapidly. ●● Methadone sometimes causes minor side effects, such as sweating, Conversely, if a heroin habit has been particularly heavy, initial constipation, temporary skin rashes, weight gain, water retention, methadone doses may be too low to prevent the onset of early and changes in sleep and appetite (Lowinson et al., 1992). withdrawal symptoms (Kreek, 1979). ●● Methadone prescribed in high doses for a long period of time has ●● Life-threatening interactions of methadone with other drugs no toxic effects and only minimal side effects for adult patients have not been identified. Drugs found to affect the metabolism maintained in treatment for up to 14 years and for adolescent of methadone include phenytoin (Dilantin) and rifampin. Opioid patients treated for up to 5 years (Kreek, 1978). antagonists such as pentazocine (Talwin) and buprenorphine can ●● Although early studies demonstrated no persisting abnormalities cause withdrawal symptoms in methadone patients and should not directly attributable to methadone in the functioning of five organ be prescribed (Kreek, 1978). systems (pulmonary, cardiovascular, renal, ophthalmologic, and Methadone maintenance patients, in the early stages of treatment, liver) (Krantz, Lewkowiez, Hays, et al., 2002). can experience several minor side effects that include: constipations, ●● Patients maintained on methadone have no impairment in driving organism abnormalities, alternations of sexual interest, alternations and have no more frequent motor vehicle accidents than people not of sleep and appetite, nausea, drowsiness, nervousness, headaches, receiving methadone maintenance treatment (Schindler, Ortner, body aches and pains, and chills. Many of these side effects almost Peternell, et al., 2004). disappear with long-term, high-dose methadone maintenance treatment ●● The most common and enduring complaints after 6 months (Hartel, 1989/1990). to 3 years of continuous methadone treatment are sweating, constipation, abnormalities in libido and sexual functioning,

Page 105 SocialWork.EliteCME.com Patient characteristics associated with treatment success include the ●● Emotional health. following: ●● Psychiatric health. ●● Age. ●● Social health. ●● Age of first heroin use. ●● Vocational stability. ●● Overall drug-use history. ●● Criminal history. ●● Severity and duration of drug use.

Methadone maintenance retention in treatment Retention in methadone is related to the dose of methadone but methadone maintenance treatment (being forced to attend treatment not the provision of ancillary services. In a study of 351 daily or by the criminal justice system) is as effective as voluntary treatment. weekly heroin users who were admitted to 1 of 17 publicly funded Patients who are legally coerced into methadone maintenance methadone treatment programs, predictors of retention in methadone treatment experience treatment success at about the same rate as maintenance treatment programs included (1) positive patient patients who participate voluntarily in treatment. evaluations of the quality of social services received during the first A study by 36) had moderate legal pressure to participate in methadone month after admission (e.g., family, legal, educational, employment, maintenance treatment (medium coercion). A third group had mild financial services); (2) positive patient ratings of how easily accessible legal pressure to participate in methadone maintenance treatment (low the program was; and (3) participation in programs that informed coercion). patients of their methadone dosage levels (Condelli, 1993). Mandated

Methadone abuse Methadone can be diverted for oral or intravenous use (Fiellin and Both methadone and buprenorphine can be diverted from their Lintzeris, 2003; Green, James, Gilbert, et al., 2000). Some diverted intended recipients. This diversion occurs in countries that provide methadone can result in fatal overdoses; however, the rate of overdose these medications via supervised dispensing (e.g., pharmacies) and among patients enrolled in methadone maintenance is low. A meta- by prescription. Oftentimes, this diversion is by individuals who analysis revealed a relative risk of death of 0.25 (95 percent CI: 0.19- are seeking a therapeutic benefit (e.g., unobserved treatment). Other 0.33) for patients receiving methadone maintenance (Capelhorn et al., times, this diversion results in abuse. The extent of these two types 1996). A study of nearly 10,000 individuals inducted onto methadone of diversion varies, although most studies note that the benefits of determined that the mortality rate was 7.1 deaths per 10,000 providing the treatment outweigh the risks associated with diversion. inductions (95 percent CI: 1.8± 12.4). In this same study, 51 percent of For instance, the efficacy of methadone has been demonstrated methadone-related deaths occurred in people who were not registered over the past 40 years (O’Connor and Fiellin, 2000). The provision in methadone maintenance (Zador and Sunjic, 2002). of methadone and buprenorphine treatment was associated with a In addition, while methadone may be detected in drug-related deaths, 75-percent decrease in fatal heroin overdoses in France (Lepere, it is often not the causative agent. In one study in the west of Scotland, Gourarier, Sanchez, et al., 2001; Auriacombe, Fatseas, Dubernet, et al., during the period 1991–2001, methadone alone was judged to be 2004). the causative agent in only 29 percent (56) of drug-related deaths In studies that have compared death rates from heroin overdose among (Seymour, Black, Jay, et al., 2003). those who are untreated and those who receive methadone, deaths are Similarly, with the increased use of methadone as a treatment for higher among untreated opioid-dependent individuals (Capelhorn, chronic pain, the majority of methadone-related deaths in Australia Dalton, Haldar, et al., 1996,; Zanis and Woody, 1998). and the United States are believed to be associated with the use of this medication for pain treatment instead of treatment of opioid dependence (Center for Substance Abuse Treatment, 2004).

BUPRENOrPHINE AND BUPRENOrPHINE/NALOXONE MEDICATION MANAGEMENT NIDA-supported basic and clinical research led to the development of buprenorphine, which culminated in a large NIDA-sponsored, Buprenorphine and multisite clinical trial demonstrating its effectiveness. The trial Buprenorphine/Naloxone Help showed that, alone or in combination with naloxone, buprenorphine Patients Quit Opiate Abuse significantly reduced opiate drug abuse and cravings and was a safe and acceptable addiction treatment (figure). 25% 20.7 20 17.8

15

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0 Bup Bup/Nal Placebo Treatment Group

Fudala, et al. New England J Medicine 349(10):949-958, 2003.

SocialWork.EliteCME.com Page 106 While these products were being developed in concert with industry Patients receiving buprenorphine can be either (1) discontinued partners, Congress passed the Drug Addiction Treatment Act (DATA without significant withdrawal, (2) maintained, or (3) transferred 2000) permitting qualified physicians to prescribe narcotic medications to opioid antagonist treatment, such as naltrexone. Patients with a (Schedules III to V) for the treatment of opioid addiction. This higher level of physical dependence and whose needs cannot be met legislation created a major paradigm shift by allowing access to by buprenorphine can be transferred to an opioid agonist, such as opiate treatment in a medical setting rather than limiting it to federally methadone or L-alpha-acetyl-methadol, (LAAM). approved Opioid Treatment Programs. Research The FDA approved Subutex (buprenorphine) and Suboxone tablets ●● Mello and Mendelson showed that buprenorphine suppresses (buprenorphine/naloxone) in October 2002, making them the first heroin self-administration by opioid-dependent primates and medications to be eligible for prescribing under the DATA 2000. humans (Mello, Bree, and Mendelson, 1983). To date, nearly 10,000 physicians have taken the training needed to ●● Findings from a subsequent dose-ranging study at the Los Angeles prescribe these two medications, and nearly 7,000 have registered as Addiction Treatment Research Center (LAATRC) suggest that the potential providers. median doses of buprenorphine for adequate clinical stabilization Buprenorphine is approved for use in the treatment of opioid may be in the 12- to 16-mg range (Compton, Ling, Charuvastra, et dependence in a large number of countries, including Australia, al., in press). Belgium, Canada, Croatia, Germany, Iran, England, France, the United ●● A NIDA-sponsored, 12-site LAATRC/Veterans Administration/ Kingdom, and the United States. Buprenorphine is a partial agonist at NIDA multicenter study compared doses of 1, 4, 8, and 16 mg of the opioid receptor, as opposed to a full agonist such as methadone or buprenorphine in 631 patients. The primary comparison between heroin. This means that buprenorphine has a unique pharmacologic the 8-mg and the 1-mg groups shows that the 8-mg group used profile leading to a lower likelihood of overdose or respiratory fewer illicit opioids and remained in treatment longer (Ling, depression. Like methadone, buprenorphine has the ability to suppress Charvastra, Collins, et al., 1998). opioid craving and withdrawal, block the effects of self-administered ●● A clinical trial comparing buprenorphine, the buprenorphine/ opioids, retain patients in treatment, and decrease illicit opioid use. naloxone combination, and placebo was terminated early because Because it is a partial agonist, buprenorphine maintains patients in a buprenorphine and naloxone in combination and buprenorphine milder degree of physical dependence and is associated with milder alone were found to have greater efficacy than placebo. Opioid- withdrawal syndrome following cessation. negative urine samples were found more frequently in the buprenorphine and buprenorphine/naloxone groups (17.8 percent Clinical trials comparing the efficacy of buprenorphine to methadone and 20.7 percent, respectively) than in the placebo group (5.8 on the outcomes of retention and illicit opioid use have demonstrated percent, p < 0.001 for both comparisons) (Fudala, Bridge, Herbert, similar results when compared with low doses of methadone (20 to 30 et al., 2003). mg) (Kosten, Schottenfeld, Ziedonis, et al., 1993).

Potential benefits of buprenorphine Research on buprenorphine has shown that it has the potential to be a ●● Low abuse potential. feasible alternative to methadone maintenance treatment. One potential ●● Relatively mild withdrawal symptoms. benefit of buprenorphine compared with methadone that needs further ●● May facilitate transfer to opioid antagonist treatment. investigation is a lower prevalence of medication interactions between ●● High safety profile. buprenorphine and highly active antiretroviral treatment used to treat ●● May attract broader range of addicts. patients with HIV. Potential benefits of buprenorphine include:

Buprenorphine abuse As a partial agonist, buprenorphine has less potential for abuse than patients who are receiving a full opioid agonist (Mendelson, Jones, most full agonists. However, there is a reinforcing effect that subjects Welm, et al., 1999). can experience with buprenorphine administration, especially via the When the buprenorphine/naloxone combination tablet is taken injection route. This reinforcement is less likely if the subject has sublingually, as prescribed, naloxone is poorly absorbed, and recently used a full agonist compound; in fact, buprenorphine can the patient receives a buprenorphine effect. However, if the lead to a painful and uncomfortable precipitated withdrawal under tablet is dissolved and injected, the naloxone will antagonize the this scenario. In addition, the development of a tablet that combines buprenorphine, resulting in a range of reactions, including blockade buprenorphine with naloxone, in a 4 to 1 ratio, has demonstrated of opioid effects and precipitation of an immediate withdrawal. In this decreased abuse potential and the ability to precipitate withdrawal in way, the combination gives the therapeutic benefit but greatly reduces opportunities for abuse by injection.

Buprenorphine’s pioneering contributions to addiction treatment ●● Buprenorphine’s novel formulation with naloxone, an opioid physicians’ offices gives opiate-addicted patients more medical antagonist, limits abuse and diversion potential. Scientific options and extends the reach of addiction medication to remote breakthroughs led to this formulation, which produces severe populations. Its accessibility may even prompt earlier attempts to withdrawal symptoms in those who inject it to get “high” but no obtain treatment. adverse effects when taken orally, as prescribed. ●● Buprenorphine represents a health services delivery innovation. The development of buprenorphine and its authorized use in

Page 107 SocialWork.EliteCME.com Outreach SAMHSA, NIDA is developing and disseminating protocols to ●● To instruct physicians and treatment practitioners in implementing educate multidisciplinary treatment professionals about buprenorphine a 13-day detoxification intervention for opiate-dependent patients. (http://www.ctndisseminationlibrary.org/ display/85.htmExternal Through these efforts, buprenorphine has helped change the mindset of link, please review our disclaimer.). Blending Teams of NIDA many community treatment providers previously unwilling to consider researchers, treatment practitioners, and trainers have completed two the use of medications to treat drug addiction. Some of these programs buprenorphine training packets: now regularly use buprenorphine to assist in opiate detoxification and ●● To increase overall awareness of buprenorphine therapy; and treatment maintenance.

Next steps ●● NIDA will continue to test the safety and efficacy of in different settings and locales, including in the U.S. criminal buprenorphine in other affected populations, including pregnant justice system and in countries where injection drug use is still a women, adolescents, and patients addicted to opiate analgesics. primary mode of HIV transmission. ●● Working with SAMHSA’s Addiction Technology Transfer Centers NIDA continues to be committed to supporting research to improve (ATTCs), State Directors, and other stakeholders, these agencies opioid addiction treatment, including behavioral therapies, which can are continuing to spread the word about buprenorphine to more be an important component of long-term recovery. Equally important proactively address the urgent needs of drug addiction. They are is ensuring that these improvements reach all affected communities. striving to increase the use of this and other addiction medications

Improved medications Probuphine is a long-acting version of buprenorphine that is showing Vivitrol, it aims to prevent abuse and diversion and increase treatment promise in clinical trials. An implant inserted under the skin, adherence by eliminating the need for daily dosing. Probuphine can deliver medication continuously for 6 months. Like

Vaccine research Vaccines are being developed to help combat a variety of addictions This brief intervention gives patients a chance to learn about their drug including heroin. A heroin vaccine, currently under development, use – especially as it pertains to their health – from an objective third would corral heroin in the bloodstream and prevent it from reaching party with medical training. It relies on the premise that advice from the brain and exerting its euphoric effects. This approach could guard an expert has been shown to promote change. against relapse and be an effective addition to a comprehensive treatment plan for heroin addiction.

TREATMENT Research validates the use of both health care and counseling predicts been examined by a health care provider and started the medication better outcomes for sustaining sobriety and engagement with long- induction process. Often, the first contact will include a brief term recovery. introduction and handing the client written information pertaining to The mental health professional will, in general, first meet their opioid recovery treatment. prospective opioid dependent client, shortly after he or she has

The role of the health care provider The health care provider will measure and monitor the patient’s vital UniversityExternal link, please review our disclaimer. found that signs, including temperature, pulse, breathing rate, and blood pressure. both assignment to ICM and the presence of high levels of depression Symptoms will be treated as appropriate. The patient may receive: symptoms independently enhanced participants’ likelihood of ●● Breathing support. engaging in substance abuse treatment and attending more treatment ●● Tube placed through the mouth into the lungs (endotracheal sessions during the 2-year study. Surprisingly, ICM proved to be more intubation). effective among depressed participants than among non-depressed ●● Medicine called naloxone, which helps block the effect of the drug ones in improving two outcomes: treatment engagement and reducing on the central nervous system (such medicine is called a narcotic alcohol consumption. A higher level of depression symptoms at the antagonist). start of the study also predicted more days of abstinence over a 2-year ●● Toxicology screening. period. The researchers had hypothesized that ICM would be less, In most cases, the health care team will monitor the patient for 4 to 6 rather than more, effective for depressed women, as it did not include hours in the emergency room, although the optimal observation time any specialized focus on comorbid psychiatric disorders. To explain after opioid intoxication has not been defined for most opioids.Those their contrary findings, the researchers note previous research that with moderate-to-severe intoxications will likely be admitted to the showed that depression increases readiness to change. They suggest hospital for 24 to 48 hours. that ICM participants’ copious ongoing contact with case managers and help in overcoming practical barriers to treatment capitalizes on The health care provider may also indicate a psychiatric evaluation such readiness. is needed for all exposures with suicidal intent. For example, a new analysis of data from a trial in which “intensive case management” Complications from withdrawal include vomiting and breathing in or (ICM) outperformed usual care among women receiving welfare stomach contents into the lungs. This is called aspiration, and can indicates that comorbid depression played a significant role in cause lung infection. Vomiting and diarrhea can cause dehydration and the outcomes. Dr. Alexis Kuerbis and colleagues at Columbia body chemical and mineral (electrolyte) disturbances.

SocialWork.EliteCME.com Page 108 The biggest complication is return to drug use. Most opiate overdose just gone through withdrawal can overdose on a much smaller dose deaths occur in people who have just withdrawn or detoxed. Because than they used to take. withdrawal reduces a person’s tolerance to the drug, those who have

Exams, tests and long-term health care maintenance A doctor can often diagnose opiate withdrawal after performing a Patient progress should be monitored via clinical evaluation (e.g., physical exam and asking questions about your medical history and patient self-report) and objective measures (e.g., urine toxicology drug use. testing). Urine or blood tests to screen for drugs will be utilized. The Addiction Severity Index (ASI) (McLellan, Kushner, Metzger, Treatment involves supportive care and medications. The most et al., 1992), mentioned earlier in this course, is an instrument commonly used medication, clonidine, primarily reduces anxiety, designed to assess the impact of a patient’s addiction on his or her agitation, muscle aches, sweating, runny nose, and cramping. function. Although this instrument is typically used in research, it has been adapted for clinical use and illustrates the various aspects of a Other medications can treat vomiting and diarrhea. Buprenorphine patient’s life that should be assessed at each patient visit to determine (Subutex) has been shown to work better than other medications for the impact of active addiction or the benefits of abstinence. The ASI treating withdrawal from opiates, and it can shorten the length of evaluates patient function in the areas of: detox. It may also be used for long-term maintenance like methadone. ●● Drug use. People withdrawing from methadone may be placed on long- ●● Alcohol use. term maintenance. This involves slowly decreasing the dosage of ●● Psychiatric function. methadone over time. This helps reduce the intensity of withdrawal ●● Medical function. symptoms. ●● Employment. ●● Social/family functioning. Some drug treatment programs have widely advertised treatments ●● Legal problems. for opiate withdrawal called detox under anesthesia or rapid opiate detox. Such programs involve placing you under anesthesia and Stated earlier, in addition to patient self-report, urine testing can be a injecting large doses of opiate-blocking drugs, with hopes that this useful practice in monitoring patient progress in treatment. In some will speed up the return the body to normal opioid system function. countries, urine testing is mandated as part of the treatment plan. A There is no evidence that these programs actually reduce the time variety of substances can be detected in urine testing. Testing can spent in withdrawal. In some cases, they may reduce the intensity of occur for naturally occurring opioids (e.g., codeine, morphine) or symptoms. However, there have been several deaths associated with synthetic or semi-synthetic opioids (e.g., oxycodone, methadone). the procedures, particularly when it is done outside a hospital. Because Testing also can occur for benzodiazepines, cocaine, marijuana, or opiate withdrawal produces vomiting, and vomiting during anesthesia other drugs that are used and/or abused by the patient population. significantly increases death risk, many specialists think the risks of The period of detection of each of these substances varies with the this procedure significantly outweigh the potential (and unproven) laboratory technique that is used and the extent of drug use and can benefits. range from days to weeks.

Mental health professional intervention The mental health professional’s role, often includes “case a therapeutic alliance. The professional wears many hats during this management” jobs, and in general, includes: process by utilizing the ASI, checking in with the client’s healthcare ●● Advising the client about drug use. professional, and informing clients about medical management, and ●● Assessing client’s readiness to quit. possible side effects, and normal withdrawal cycles. ●● Facilitating client changes. It is important to establish rapport by: ●● Arranging other types of treatment or follow-up care. ●● Avoiding a tone that your client might think is judgmental or confrontational. Providers should be aware that many states mandate reporting ●● Show an interest in your client’s life. of drug use during pregnancy and that failure to do so may be a ●● Acknowledge your client’s current view of his/her drug use. prosecutable offense. ●● Signal to the client that having mixed feelings about a drug use problem is normal. Mental health professionals, during the course of their initial sessions ●● Highlight client’s confidentiality (and its limitations). will assess their clients’ readiness to quit opioid use while establishing

Utilizing the ASI results

When administering and reporting on the ASI results begin by Reminder: The ASI screen is only one indicator of a client’s reviewing screening results with the client by: potential drug use problem. It is not a substitute for clinical ●● Asking permission to have a short discussion about the screening judgment, which you should use to determine when an intervention results. is warranted. ●● Report back the types and amounts of use reported: ○○ Allow the client to correct omissions so you get the full picture When appropriate, educate clients on the following: of use. ○○ Use of even small amounts of drugs or tobacco may negatively ○○ Prompt the patient: “Tell me more about your use of drug X impact health and performance (e.g., driving or operating and Y” (for each drug the patient reported). machinery). ○○ Because drug intoxication can lead to impaired judgment and risky behaviors, refer all sexually active clients for confidential testing for HIV and other sexually transmitted diseases or provide an onsite testing opportunity, if they do not know their

Page 109 SocialWork.EliteCME.com status or have not been tested recently. Encourage all clients to Lower risk - Consider having a discussion about acceptable levels practice safe sex. of use and the potential for future problems. You may begin the ○○ Refer all clients with past or current injection drug use for HIV discussion by saying, “Your screening results show you are unlikely and Hepatitis B/C testing if they have not been tested twice to have a substance use disorder. However, people with any history over a 6-month span following their last injection. of substance use can be at some risk of adverse consequences and ●● Make referrals to evaluate suspected co-occurring conditions (e.g., developing a disorder especially in times of stress or if they have just psychiatric consultation for depressed, inattentive, or anxious started to use recently. It is impossible to know in advance whether clients or pain specialist consultation for patients seeking narcotic or not a person will become addicted. As your physician I encourage prescriptions for chronic nonmalignant pain). you to only use alcohol moderately and responsibly and to avoid using ●● Provide recommendations based on risk level that includes: other substances.” High risk - A strong recommendation to change substance use ●● Intervention duration may be minimal. is essential. Consider making a statement such as: “Based on the ●● Use your clinical judgment based on the medical status of the screening results, you are at high risk of having or developing a patient and drug being used. For example, pregnant women,* substance use disorder. It is medically in your best interest to stop your youth, people with histories of substance use disorders, and others use of (insert specific drugs here). I am concerned that if you do not for whom any drug use could potentially pose a serious risk may make a change quickly, the consequences to your health and well- benefit from a complete intervention regardless of apparent risk being may be serious.” Include a referral for additional assessment level. (the NIDA-Modified ASSIST provides a risk level, but not a diagnosis At follow-up, make targeted recommendations to moderate-, high- and of abuse or dependence). Let the client know that the assessment select lower-risk clients accordingly: will determine whether they have a diagnosis of substance abuse or High risk – targeted recommendations: dependence and if substance abuse treatment is indicated. Whether to ●● Determine whether the client followed through with the referral. attend treatment will be the patient’s decision. ●● Offer additional brief intervention for clients who did not attend ●● Specific examples of harm for different problem drug categories the referral. may be helpful. ●● Make additional referrals for clients who missed referral. ●● Emphasize that there are many ways to change substance use ●● Obtain records of assessment and/or treatment for clients who behavior (e.g., community treatment programs, self-help groups, attended referral and/or treatment. medications, etc.). ●● Discuss ways to help support recommendations of referral source. ●● Emphasize that treatment is often on an outpatient basis and programs are often accommodating of concerns like maintaining Moderate risk – targeted recommendations: employment, insurance reimbursement, child care, etc., depending ●● Determine whether the client reduced or abstained from use. on the patient’s concerns. ●● For clients who did not make progress with change efforts, acknowledge change is hard, repeat brief intervention, and discuss Moderate risk - Consider beginning the discussion by saying, additional ways to support the clients’ efforts. “Based on the screening results, you are at moderate risk of having ●● For clients who have made changes, reinforce efforts and or developing a substance use disorder. It is medically in your best encourage additional goal-setting. interest to change your use of (insert specific drugs here).” ●● Follow up at subsequent visits. ●● Add information that is specific to the drugs the client uses. ●● Express your concern about specific ways drugs might negatively Lower risk – targeted recommendations: impact your patient’s life (e.g., health, relationships, work, etc.). ●● If the client indicated that he/she wanted to make a change, ask ●● Emphasize that there are many ways to change substance use what, if anything, the client decided to do about substance use. behavior (e.g., community treatment programs, self-help groups, ●● Encourage abstinence from tobacco and illicit drugs and advise medications, etc.). low-risk alcohol users to remain within acceptable drinking levels. ●● On evidence of escalation of use, conduct brief intervention.

Assessing client’s readiness to quit When assessing your client’s readiness to quite consider these revisit the issue at future visits and have resources available when suggestions: he/she decides to pursue making a change. ●● Have a conversation about whether the client is ready to quit. For ●● If the client is ready to quit, reinforce current efforts and then example, you might say something like, “Given what we’ve talked assist client in their efforts to make changes that will help them about, do you want to change your drug use?” reduce and/or quit their drug use. ●● If the client is unwilling to quit, raise awareness about drugs as a health problem. Let clients who are not ready know that you will

Facilitating your client’s change ●● Jointly complete a progress note form with the client to document may need to start again with a fresh copy during their second the screening results and create a follow-up plan. session. ●● Help set concrete (and reasonable) goals for making a change: ○○ For clients not interested in completing a change plan, ○○ Ask interested clients to complete a change plan during encourage them to set a few brief change goals (e.g., cutting session. back, trying a self-help group); record the goals to check ○○ Make a copy without their name or the name of your office on progress at the next visit. it, give it to them to take home, and tell them you will check in Longer-term treatment is recommended for most people following on their progress at the next visit. withdrawal. This can include self-help groups, like Narcotics ○○ For clients who do not complete a change plan, schedule a Anonymous or SMART Recovery, outpatient counseling, intensive second appointment to continue the discussion and to complete outpatient treatment (day hospitalization), or inpatient treatment. the change plan. You may provide a blank copy for them to take home and ask them to return with it, but some clients

SocialWork.EliteCME.com Page 110 Professional counseling is strongly recommended, particularly in Treatment goals should be discussed with the patient and early recovery. Those withdrawing from opiates should be checked for recommendations for care made accordingly. If a person continues depression and other mental illnesses. Appropriate treatment of such to withdraw repeatedly, methadone maintenance is strongly disorders can reduce the risk of relapse. Antidepressant medications recommended. should NOT be withheld under the assumption that the depression is only related to withdrawal, and not a pre-existing condition.

Follow-up As a licensed mental health professional it is necessary to evaluate judgment to determine whether additional assessment is necessary. your strengths when counseling substance abuse clients; specifically Use SAMHSA’s treatment locator (see additional resources, http:// opioid dependent persons. Continue to assess your client for need for findtreatment.samhsa.gov/) or NIDA’s National Drug Abuse additional services such as specialty assessments, residential drug Treatment Clinical Trials Network List of Associated Community treatment, and long-term care. Treatment Programs (see additional resources, www.drugabuse. Remember to: gov/about-nida/organization/cctn/ctn) to locate assessment ●● Refer clients as appropriate. resources. ○○ If nearby treatment resources are not available, consider Support groups - Support groups, such as Narcotics providing support group contact information and self-change Anonymous and SMART Recovery, can be enormously materials, as well as other counseling resources – clergy or helpful to people addicted to opiates. mental couples counselors. ○○ Obtain a written information release to send the screening ●● Schedule follow-up on a consistent basis. results to all providers who will receive referrals. ●● Offer continuing support at follow-up with regard to additional ●● Schedule a follow-up session within 1–2 weeks for moderate and book recommendations, materials, blogs, etc. high-risk clients and low-risk clients in certain groups. ●● Because the screening does not provide a diagnosis of abuse or ●● Offer continuing support at follow-up sessions. dependence, refer high-risk clients for a full assessment. For ○○ Annual rescreening is indicated for clients who report any drug moderate-risk clients and low-risk patients with special concerns use at baseline (even with scores of 0–3) and for any other (e.g., pregnant women, past injection drug users), use clinical clients about whom you remain concerned. For moderate- and high-risk patients, rescreen at next appointment.

Treatment benefits Many benefits of medication management combined with counseling When interviewed after 24 months, 47 percent of the women receiving for opioid dependence have been discussed in this course. But in ICM had been abstinent from drugs for the past 30 days, compared addition, intensive case management (ICM) can help substance- with 24 percent of those in the usual care group. At that same time, 22 abusing women who receive welfare benefits stay off drugs and make percent of the women in the ICM group – but only 9 percent of those strides in employment, report Dr. Jon Morgenstern and colleagues in the usual care group – were employed full-time. For comparison, the at Columbia University. In a study of 302 applicants for Temporary full-time employment rate was 34 percent among 150 female welfare Assistance for Needy Families in New Jersey, the researchers assigned recipients who did not abuse drugs. roughly half to an ICM intervention that included weekly visits from The researchers are now conducting a cost-benefit analysis of ICM. a case manager, help in overcoming treatment barriers, assistance If their promising results are replicated in future evaluations, welfare in identifying and meeting other patient service needs, and voucher agencies may have an effective tool to help some of their most incentives for remaining in treatment. The rest of the trial participants vulnerable clients. (American Journal of Public Health 28(53):14372– received the care welfare agencies typically provide to substance- 14378, 2008 (AbstractExternal link, please review our disclaimer.)) abusing clients, which consists of screening and referral for treatment.

Preventing opioid dependence in the future Healthcare providers have long wrestled with how best to treat patients abuse or mental illness. Monitoring patients for signs of abuse is who suffer from chronic pain, roughly 116 million in this country. also crucial, and yet some indicators can signify multiple conditions, Their dilemma stems from the potential risks involved with long- making accurate assessment challenging. Early or frequent requests term treatment, such as the development of drug tolerance (and the for prescription pain medication refills, for example, could represent need for escalating doses), hyperalgesia (increased pain sensitivity), illness progression, the development of drug tolerance, or the and addiction. Patients themselves may even be reluctant to take an emergence of a drug problem. opioid medication prescribed to them for fear of becoming addicted. The development of effective, non-addicting pain medications is a Estimates of addiction among chronic pain patients vary widely - public health priority. A growing elderly population and an increasing from about 3 percent to 40 percent. This variability is the result of number of injured military only add to the urgency of this issue. differences in treatment duration, insufficient research on long-term Researchers are exploring alternative medications that can alleviate outcomes, and disparate study populations and measures used to assess pain but have less abuse potential. More research is needed to better abuse or addiction. understand effective chronic pain management, including identifying To mitigate addiction risk, physicians should screen patients for factors that predispose some patients to addiction and developing potential risk factors, including personal or family history of drug measures to prevent abuse.

Summary Taken as intended, prescription and OTC drugs safely treat specific very similar to illicit drugs. For example, stimulants such as Ritalin mental or physical symptoms. But when taken in different quantities or increase alertness, attention, and energy the same way cocaine does – when such symptoms aren’t present, they may affect the brain in ways by boosting the amount of the neurotransmitter dopamine.

Page 111 SocialWork.EliteCME.com Drug abuse and dependence changes the way the brain works, dampening the “high” that occurs with other routes of administration resulting in compulsive behavior focused on drug seeking and use, while preventing withdrawal symptoms. Since the earliest methadone despite often devastating consequence. These behaviors are the maintenance treatment programs in the United States, women have essence of addiction. Consequently, drug abuse/addiction treatment been treated successfully with methadone through all phases of their must address these brain changes, both in the short and long term. lives, including pregnancy. When people addicted to opioids first stop, they undergo withdrawal Buprenorphine (Subutex, Suboxone), a partial opioid agonist. symptoms, which may be severe pain, diarrhea, nausea and vomiting. Buprenorphine relieves drug cravings without producing the “high” Medications can be helpful in this detoxification stage to ease craving or dangerous side effects of other opioids. Suboxone is a novel and other physical symptoms, which often prompt relapse. However, formulation, taken orally, that combines buprenorphine with naloxone this is just the first step in treatment. Medications may also become an (an opioid antagonist) to ward off attempts to get high by injecting the essential component of an ongoing treatment plan, enabling opioid- medication. addicted persons to regain control of their health and their lives. Naltrexone (Depade, Revia) an opioid antagonist. Naltrexone is not Physicians prescribe a particular medication based on a patient’s addictive or sedating and does not result in physical dependence; specific medical needs and other factors. Effective medications however, poor patient compliance has limited its effectiveness. include: Research validates the use of both health care and counseling predicts Methadone (Dolophine or Methadose), a slow-acting, opioid better outcomes for sustaining sobriety and engagement with long-term agonist. Methadone is taken orally, so that it reaches the brain slowly, recovery with opioid dependent persons.

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Page 113 SocialWork.EliteCME.com Medication Management of Opioid Dependence Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your final examination. 1. Approximately ______of the population is believed to misuse 10. Opioid intoxication is a condition caused by: opiates over the course of their lifetime. a. Use of Xanax. a. 25 percent. b. Taking more than 10 mg. a day. b. 9 percent. c. Drinking alcohol. c. 2 percent. d. Use of opioid-based drugs. d. 35 percent. 11. Opiate withdrawal refers to the wide range of symptoms that occur 2. Opiate drugs include: after stopping or dramatically reducing opiate drugs after: a. Benzos, Xanax, anti-anxiety medications. a. Heavy short term use. b. Aspirin, non-prescription medication, inhalents. b. Heavy and prolonged use. c. B and d. c. Moderate use. d. Heroin, morphine, codeine, methadone. d. Prolonged light use.

3. Taken as intended, prescription and OTC drugs: 12. Methadone was approved for office-based dispensing by the Food a. Safely treat specific mental or physical symptoms. and Drug Administration in: b. Rarely treat mental or physical symptoms. a. 1978. c. Occasionally treat mental or physical symptoms. b. 2010. d. Have been known to treat mental or physical symptoms. c. 1995. d. 2002. 4. Repeatedly seeking to experience that “high” feeling can lead to: a. Addiction. 13. Opioid withdrawal reactions are very uncomfortable but are not, in b. Vomiting. general: c. Loss of sleep. a. Addictive. d. Feelings of depression. b. Benign. c. Blatant. 5. As early as the ______methadone gained recognition as an d. Life threatening. effective treatment for heroin addiction. a. 1930’s. 14. Methadone maintenance has been associated with significant b. 1940’s. increases in: c. 1960’s. a. Unemployment rates. d. 1970’s. b. Costly over-time. c. Full-time employment. 6. Deaths from opioid pain relievers exceed those: d. A decrease in worker productivity. a. From illegal drugs. b. From excessive drug use. 15. The daily oral administration of adequate dosages of methadone c. Car accidents. reduces the need for opioid-dependent individuals: d. Heart disease. a. Take vitamins. b. To inject drugs. 7. Scientific research has established that medication-assisted c. To release sugar into their systems. treatment of opioid addiction: d. To take methadone for long period of time. a. Suppresses patient retention. b. Interrupts patient retention. 16. Ball and Ross study (1991) of 617 patients demonstrated that c. Increases patient retention. methadone maintenance treatment is associated with a dramatic d. Decreases patient retention. decline in the average number of: a. Days missed at work per year. 8. Methadone (Dolophine or Methadose), is: b. Crime-days per year. a. Neural inhibitor. c. Employee complaints. b. A slow-acting, opioid agonist. d. Days in treatment. c. A fast-acting opioid agonist. d. A partial opioid agonist. 17. Since the early 1970s, methadone maintenance treatment has been used successfully with: 9. Buprenorphine (Subutex, Suboxone), is: a. The elder population. a. A partial opioid agonist. b. Adolescents. b. A slow-acting opioid agonist. c. Athletes. c. A fast-acting opioid. d. Pregnant women. d. None of the above.

SocialWork.EliteCME.com Page 114 18. The longer patients stay in treatment, the more likely they are to remain: a. Free from heart disease. b. Crime free. c. Lacking in energy. d. Physically fit.

19. The ASI screen is: a. The only proven indicator of a client’s potential drug use problem. b. Still being tested as a viable assessment instrument. c. A very long assessment instrument that takes several hours to complete. d. Only one indicator of a client’s potential drug use problem.

20. Providers should be aware that many states mandate reporting of drug use during pregnancy and that failure to do so may be: a. A sign of future problems for the mother and child. b. A problematic issue for the states. c. An ethics issue. d. A prosecutable offense.

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Page 115 SocialWork.EliteCME.com Chapter 8: Understanding Neurotransmission and the Disease of Addiction 4 CE Hours

By: Kathryn Brohl, MA, LMFT

Learning objectives This workshop is designed to help you: ŠŠ Describe neurotransmitters and the drugs that affect them. ŠŠ Assess neurotransmission in the context of drug use and research. ŠŠ Apply changes to the Criteria for Substance Dependence and ŠŠ Describe the neurotransmitter – neurotransmission interaction. Abuse in the new DSM-5. ŠŠ Apply different research methodologies. ŠŠ Assess the long term effects of drug use. ŠŠ Analyze certain medication and behavioral management interventions.

Introduction The National Institute of Alcohol Abuse and Alcoholism (2013), During recent decades, the accumulation of research has enlightened nearly 88,000 people (approximately 62,000 men and 26,000 women) the addictions field, while it has also provided patients/clients, die from alcohol related causes annually, making it the third leading validation with regard to their physical and mental cravings, and preventable cause of death in the United States. In 2006, alcohol relapse triggers following their withdrawal from drugs or alcohol. In misuse problems cost the United States $223.5 billion. addition it has given interventionists a deeper understanding about ●● Adults (ages 18+): Approximately 17 million adults ages 18 and the disease of addiction, and enhances medication management and older (7.2 percent of this age group) had an Alcohol use disorder psychotherapy approaches, to the benefit of their patients/clients. (AUD) in 2012. This includes 11.2 million men (9.9 percent of Overall, the field of addiction has gathered a substantial body of men in this age group) and 5.7 million women (4.6 percent of research that has identified specific drugs’ effects on neurotransmission, women in this age group). establishing that drug dependence and addiction are elements of organic ○○ About 1.4 million adults received treatment for an AUD at a brain disease. By altering neurotransmission, addictive drugs produce specialized facility in 2012 (8.4 percent of adults in need). This effects that make people want to continue to abuse them, and induce included 416,000 women (7.3 percent of women in need) and health problems that can be penetrating and long term. 1.0 million men (8.9 percent of men in need). ●● Youth (ages 12–17): In 2012, an estimated 855,000 adolescents Notably, these effects are drug specific, and disrupt particular ages 12–17 (3.4 percent of this age group) had an AUD. This neurotransmitters in specific ways. However, some relevant effects, number includes 444,000 females (3.6 percent) and 411,000 males such as initial pleasurable feelings, subsequent dependence and (3.2 percent). addiction, are shared by all. The end result is a disruption of the ○○ An estimated 76,000 adolescents received treatment for an AUD dopamine neurotransmitter system. at a specialized facility in 2012 (8.9 percent of adolescents in When neuroscientists seek to better understand why a drug is abused need). This included 28,000 females (6.3 percent of adolescent and the subsequent consequences of this abuse, they ask: females in need) and 48,000 males (11.7 percent of adolescent 1. Which neurotransmitter or neurotransmitters does the drug affect? males in need). 2. How does the drug alter transmission? Drug and alcohol dependence continues to challenge mental health In this course, learners will gain further understanding about the professionals as they partner with responsible addictionologists interaction between neurotransmitters and addictive substances, (medical doctors who are board-eligible or certified by the American and how they alter neurotransmission, and subsequent thinking and Society of Addiction Medicine) to utilize a two pronged approach to behaviors. Learners will also gain a deeper awareness about research providing medical intervention/management and psychotherapeutic methodologies about neurotransmission and drug interaction, as well as treatment for their patients/clients. recent scientific findings. Abused drugs affect the way people think, feel, and behave. The long term effects ultimately interface with our overall society as well; at great emotional and financial cost to those affected.

Long-term effects of drugs on the brain A normal question is to ask why drugs are bad. After all, the “high” or synapses may form, or existing synapses may get stronger. Other “rush” only lasts a little while, right? What else could be happening synapses may disappear. in the drug abuser’s brain? However, one must consider that the brain When a person takes drugs repeatedly, the experience literally changes is continuously changing, and learning occurs because neurons are the brain. If a person takes drugs and then stops, he or she will forming new synapses. Scientists say that the brain has plasticity. It “crave” the drug. In other words, the individual will have a strong does not mean the brain is made of a chemical plastic, but it refers to desire to take more of the drug. Scientists can actually see evidence of the brain’s ability to modify connections in response to experience. cravings in the brain. For example, if a cocaine addict sees pictures of When a person learns something or has new experiences, some new drug paraphernalia: PET scans show that the part of the brain that is important for memory (called the amygdala) is activated. If the addict

SocialWork.EliteCME.com Page 116 sees a video with mountains, trees, and animals, the amygdala is not have abnormally high regrowth of the neurons. Either way, the neurons stimulated. Thus, just seeing pictures of drugs or things associated are not normal. Studies have not yet been able to determine if MDMA with drugs can trigger an uncontrollable urge for drugs. has this same effect on humans, but some preliminary evidence After taking drugs for a period of time, a person may need to take a indicates that MDMA may kill serotonin neurons in humans. higher dose to have the same feeling or “rush” that he or she did when Cocaine also changes the brain in ways that may last for a long first taking the drug. This is called tolerance. The brain has adapted period of time. PET scans of human brains have shown that glucose to having a certain amount of drug present and does not respond the metabolism is reduced even three months after the last use of cocaine. same way it did initially. For this reason, drug abusers and addicts Remember, that glucose metabolism is an indicator of how active take increasingly higher amounts of an abused drug. Tolerance may the brain cells are. If the neurons are using less glucose, they are not develop because the body may become more efficient at eliminating as active. The changes that cocaine causes in the brain last much the chemical from the body, or because the cells of the body and brain longer than the pleasurable feelings it produces. Other drugs cause become less responsive to the effect of the drug. similar decreases in brain activity. Even two years after the last use of Drugs can also change the structure of the brain. Perhaps one of the amphetamines, PET images show that the drug abuser’s brain is less most dramatic long-term effects of a drug is to kill neurons. Many active than the person who never used drugs. people have heard that drinking alcohol will kill brain cells, and it’s While scientific studies have clearly shown that certain drugs can cause true. If alcohol is abused over a period of time, neurons in the brain dramatic changes in the brain, not all questions have been answered. can die. Some neurons in the brain are more sensitive to alcohol than Scientists, for many reasons, don’t know all of the effects that a drug others. Neurons that make up the mammillary bodies, areas in the may have. First, the brain is such a complicated organ that, despite brain that are important for memory, are more vulnerable to the effects great scientific advances, understanding all that it does, will take many of alcohol than are some other neurons in the brain. The neurons in the more years. Second, individuals may respond differently to drugs cerebral cortex, the part of the brain that controls most of our mental due to genetic differences among people. Third, many drug abusers functions and endows us with consciousness, may also die if a person abuse more than one drug. Many individuals who take cocaine, for frequently abuses alcohol in high doses. example, also drink alcohol. The combination of the drugs makes it Another drug that is toxic to neurons is an amphetamine derivative difficult to determine what the effect of one drug alone may be. Another called MDMA, or ecstasy. In rats and non-human primates, MDMA complication is drug addicts may have other health problems, in addition appears to kill neurons that produce serotonin. In some parts of the to their drug problem. Heroin addicts, for example, spend most of their brain, the axons of some of these neurons may regenerate (or re-grow) energy and activity trying to get their next “fix.” Consequently, they do after drug use is stopped, but the new growth of the neurons is not not eat well and may have impaired immune systems. Also, drug addicts normal. Some areas are not reinnervated (nerve fibers do not grow often suffer from mental illnesses, such as depression. The changes that back into the area) as they were before the drug abuse and some areas occur in the brain because of mental illness make it difficult to determine what changes the drugs have caused.

Understanding diagnosis criteria Developed and published by the American Psychiatric Association the more severe manifestation. In practice, the abuse criteria were (APA), the Diagnostic and Statistical Manual of Mental Disorders sometimes quite severe. The revised substance use disorder, a single (DSM) is the manual used by clinicians and researchers to diagnose diagnosis, may result in a better match the symptoms that patients and classify mental disorders. experience. According to the APA (2013), within the fifth edition of the Diagnostic Previously, the diagnosis of dependence caused much confusion. Most and Statistical Manual of Mental Disorders (DSM-5), the revised people link dependence with “addiction” when in fact dependence can chapter of “Substance-Related and Addictive Disorders” includes be a normal body response to a substance. substantive changes to the disorders grouped there plus changes to the Substance use disorders span a wide variety of problems arising from criteria of certain conditions. substance use, and cover 11 different criteria: Substance use disorder 1. Taking the substance in larger amounts or for longer than the you While the DSM-IV utilized two separate diagnoses of “Dependence” meant to. and “Abuse,” substance use disorder in DSM-5 combines the DSM-IV 2. Wanting to cut down or stop using the substance but not managing to. categories of substance abuse and substance dependence into a single 3. Spending a lot of time getting, using, or recovering from use of the disorder measured on a continuum from mild to severe. Each specific substance. substance (other than caffeine, which cannot be diagnosed as a substance 4. Cravings and urges to use the substance. use disorder) is addressed as a separate use disorder (e.g., alcohol use 5. Not managing to do what you should at work, home or school, disorder, stimulant use disorder, etc.), but nearly all substances are because of substance use. diagnosed based on the same overarching criteria. In this overarching 6. Continuing to use, even when it causes problems in relationships. disorder, the criteria have not only been combined, but strengthened. 7. Giving up important social, occupational or recreational activities Whereas a diagnosis of substance abuse previously required only because of substance use. one symptom, mild substance use disorder in DSM-5 requires two to 8. Using substances again and again, even when it puts the you in three symptoms from a list of 11. Drug craving has also been added danger. to the list, and the criteria detailing “problems with law enforcement” 9. Continuing to use, even when you know you have a physical or have been eliminated because of cultural considerations that make the psychological problem that could have been caused or made worse criteria difficult to apply internationally. by the substance. 10. Needing more of the substance to get the effect you want (tolerance). In DSM-IV, the distinction between abuse and dependence was based 11. Development of withdrawal symptoms, which can be relieved by on the concept of abuse as a mild or early phase and dependence as taking more of the substance.

Page 117 SocialWork.EliteCME.com Addictive disorders The chapter also includes gambling disorder as the sole condition in While gambling disorder is the only addictive disorder included in a new category on behavioral addictions. DSM-IV listed pathological DSM-5 as a diagnosable condition, Internet gaming disorder will be gambling but in a different chapter. This new term and its location included in Section III of the manual. Disorders listed there require in the new manual reflect research findings that gambling disorder further research before their consideration as formal disorders. This is similar to substance-related disorders in clinical expression, brain condition is included to reflect the scientific literature on persistent origin, comorbidity, physiology, and treatment. and recurrent use of Internet games, and a preoccupation with them, Recognition of these commonalities will help people with gambling can result in clinically significant impairment or distress. Much of this disorder get the treatment and services they need, and others may literature comes from studies in Asian countries. The condition criteria better understand the challenges that individuals face in overcoming do not include general use of the Internet, gambling, or social media at this disorder. this time.

Additional DSM-5 information DSM-5 no longer includes caffeine use disorder, although research research on the impact of this condition, caffeine use disorder is shows that as little as two to three cups of coffee can trigger a included in Section III of DSM-5. withdrawal effect marked by tiredness or sleepiness. There is sufficient Additionally, the DSM-5 eliminated “legal problems” as a criterion for evidence to support this as a condition, however it is not yet clear to both substance use disorder and addictive disorders. what extent it is a clinically significant disorder. To encourage further

Defining neurotransmission as a communicator Simply put, the process of communication between brains cells is These interactions are an essential component of the brain’s response called neurotransmission. Information is relayed from cell to cell to to experience and the environment. regions that process and attach meaning and memory, taking the form, Communication between neurons is the foundation for brain when within the cell, of an electrical signal. function. Understanding how neurotransmission occurs is crucial to Consequently, in order to cross the tiny intercellular gap that separates understanding how the brain processes and integrates information, as one cell from the next, the information takes the form of a chemical it interacts with drugs. Interruption of neural communication causes signal. The specialized chemicals that carry the signals across the changes in cognitive processes and behavior. intercellular gaps, or synapses, are, thus, called neurotransmitters.

The brain is made up of nerve cells and glial cells The brain of an adult human weighs about three pounds and contains axon is the part of the neuron that is specialized to carry messages away billions of cells. The two distinct classes of cells in the nervous system from the cell body and to relay messages to other cells. Some large are neurons (nerve cells) and glia (glial cells). axons are surrounded by a fatty insulating material, called myelin, which The basic signaling unit of the nervous system is the neuron. The brain enables the electrical signals to travel down the axon at higher speeds. contains billions of neurons. The interactions between neurons enable Near its end, the axon divides into many fine branches that have people to think, move, maintain homeostasis, and feel emotions. A specialized swellings called presynaptic terminals. These presynaptic neuron is a specialized cell that can produce different actions because terminals end in close proximity to the dendrites of another neuron. of its precise connections with other neurons, sensory receptors, The dendrite of one neuron receives the message sent from the and muscle cells. A typical neuron has four morphologically defined presynaptic terminal of another neuron. regions: the cell body, dendrites, axons, and presynaptic terminals.

Post-synaptic Neuron Presynaptic Terminals

Neuron - The neuron, or nerve cell, is the functional unit of the nervous system. The cell body, also called the soma, is the metabolic Presynaptic Neuron center of the neuron. The nucleus is located in the cell body and most of the cell’s protein synthesis occurs in the cell body. The site where a presynaptic terminal ends in close proximity to a receiving dendrite is called the synapse. The cell that sends out A neuron usually has multiple processes, or fibers, called dendrites information is called the presynaptic neuron, and the cell that receives that extend from the cell body. These processes usually branch out the information is called the post-synaptic neuron. It is important to somewhat like tree branches and serve as the main apparatus for note that the synapse is not a physical connection between the two receiving input into the neuron from other nerve cells. neurons; there is no cytoplasmic continuity between the two neurons. The cell body also gives rise to the axon. Axons can be very long processes; in some cases, they may be up to one meter in length. The

SocialWork.EliteCME.com Page 118 The intercellular space between the presynaptic and postsynaptic oligodendrocytes, astrocytes, and Schwann cells. The oligodendrocytes neurons is called the synaptic space or synaptic cleft. and Schwann cells form the myelin sheaths that insulate axons and Researchers originally thought that electrical impulses jumped these gaps, enhance conduction of electrical signals along the axons. like electricity jumps across the gap in a spark plug. Now scientists know Scientists know less about the functions of glial cells than they do this is false. Chemicals-not electrical impulses- travel across the gap. about the functions of neurons. However, they do know that glial cells An average neuron forms approximately 1,000 synapses with other fulfill a variety of functions including: neurons. It has been estimated that there are more synapses in the ●● Glial cells function as supporting elements in the nervous system human brain than there are stars in our galaxy. Furthermore, synaptic to provide structure and to separate and insulate groups of neurons. connections are not static. Neurons form new synapses or strengthen ●● Oligodendrocytes in the central nervous system and Schwann synaptic connections in response to life experiences. cells in the peripheral nervous system form myelin, the sheath that wraps around certain axons. The synapse is the site where chemicals pass between neurons. ●● Some glial cells are scavengers that remove debris after injury or Neurotransmitters are released from the presynaptic neuron terminals neuronal death. into the extracellular space called the synaptic cleft or synaptic space. ●● Some glial cells buffer the potassium ion (K+) concentration in The released neurotransmitter molecules can then bind to specific the extracellular space, while some glial cells take up and remove receptors on the postsynaptic neuron membrane to elicit a response. chemical neurotransmitters from the extracellular space after Glial cells - The brain contains another class of cells called glia. There synaptic transmission. are as many as ten to fifty times more glial cells than neurons in the central ●● Some glial cells guide the migration of neurons and direct the nervous system. Glial cells are categorized as microglia or macroglia. outgrowth of axons during development. ●● Some glial cells induce formation of impermeable tight junctions Microglia are phagocytic cells that are mobilized after injury, infection in endothelial cells that line the capillaries and venules of the brain or disease. They are derived from macrophages and are unrelated to to form the blood-brain barrier. other cell types in the nervous system. The three types of macroglia are ●● Glial cells may serve nutritive functions for nerve cells.

Neurons continued… Neurons use electrical and chemical signals to transmit information. The However, the influx of Na+ ions in one area of the neuron fiber starts a billions of neurons that make up the brain coordinate thought, behavior, similar change in the adjoining segment and the impulse moves from homeostasis, and more. The following information paints a more specific one end of the neuronal fiber to the other. Action potentials are an picture about how all these neurons pass and receive information. all-or-none phenomenon. Regardless of the stimuli, the amplitude and Neurons convey information by transmitting messages to other neurons duration of an action potential are the same. The action potential either or other types of cells, such as muscles. For example, neurons employ occurs or it doesn’t. The response of the neuron to an action potential electrical signals to relay information from one part of the neuron to depends on how many action potentials it transmits and the time another. The neuron converts the electrical signal to a chemical signal in interval between them. order to pass the information to another neuron. The target neuron then Stated previously, electrical signals carry information within a converts the message back to an electrical impulse to continue the process. single neuron. Again, communication between neurons (with a few In some ways, neurons act like computers. That is, they receive exceptions in mammals) is a chemical process. When the neuron is messages, process their message, and send out the results as new stimulated, the electrical signal (action potential) travels down the messages to other cells. In the case of neurons, the message consists axon to the axon terminals. When the electrical signal reaches the end of chemicals that interact with the outer surface of the cell membrane. of the axon, it triggers a series of chemical changes in the neuron. This chemical interaction with the cell membrane causes chemical Calcium ions (Ca++) flow into the neuron. The increased Ca++ in the changes within the receiving neuron. axon terminal then initiates the release of neurotransmitter. Remember, a neurotransmitter is a molecule that is released from a neuron to relay Within a single neuron, information is conducted via electrical information to another cell. Neurotransmitter molecules are stored in signaling. When a neuron is stimulated, an electrical impulse, called membranous sacs called vesicles in the axon terminal. Each vesicle an “action potential”, moves along the neuron axon or dendrite. Action contains thousands of molecules of a neurotransmitter. potentials enable signals to travel very rapidly along the neuron fiber. Action potentials last less than 2 milliseconds (1 millisecond = 0.001 For neurons to release their neurotransmitter, the vesicles fuse second) and the fastest action potentials can travel the length of a with the neuronal membrane and then release their contents, the football field in one second. Action potentials result from the flow of neurotransmitter, via exocytosis. The neurotransmitter molecules are ions across the neuronal cell membrane. released into the synaptic space and diffuse across the synaptic space to the postsynaptic neuron. A neurotransmitter molecule can then bind Neurons, like all cells, maintain a balance of ions inside the cell that to a special receptor on the membrane of the postsynaptic neuron. differs from the balance outside of the cell. This uneven distribution Receptors are membrane proteins that are able to bind a specific of ions creates an electrical potential across the cell membrane. This is chemical substance, such as a neurotransmitter. For example, the called the resting membrane potential. In humans, the resting membrane dopamine receptor binds the neurotransmitter dopamine, but does not potential ranges from -40 millivolts (mV) to -80 mV with –65 mV as bind other neurotransmitters such as serotonin. an average resting membrane potential. The resting membrane potential is assigned a negative number because the inside of the neuron is more The interaction of a receptor and neurotransmitter can be thought of as negatively charged than the outside environment of the neuron. a lock-and-key for regulating neuronal function. Just as a key fits only a specific lock, a neurotransmitter binds only to a specific receptor. The A stimulus occurring at the end of a nerve fiber starts an electrical change chemical binding of neurotransmitter and receptor initiates changes that travels like a wave over the length of the neuron. This electrical in the postsynaptic neuron that may generate an action potential in change, the action potential, results from a change in the permeability the postsynaptic neuron. If it does trigger an action potential, the of the neuronal membrane. Sodium ions rush into the neuron, and communication process continues. the inside of the cell becomes more positive. The Na+-K+ pump then restores the balance of sodium and potassium to resting levels. After a neurotransmitter molecule binds to its receptor on the postsynaptic neuron, it comes off of (releases from) the receptor and

Page 119 SocialWork.EliteCME.com diffuses back into the synaptic space. The released neurotransmitter, sending neuron. In this way, the original impulse is conducted through the as well as any neurotransmitter that did not bind to a receptor, is either sending neuron -and through the rest of the neurons in a nerve pathway. degraded by enzymes in the synaptic cleft, or it may be taken back Eventually, the impulse reaches its final destination, such as muscle, gland up into the presynaptic axon terminal by active transport through or organ. The result is a change in the way we think, feel or behave. a transporter or reuptake pump. Once the neurotransmitter is back The chemical reactions inside the receiving neuron are called second inside the axon terminal, it is either destroyed or repackaged into new messengers. Second messengers pass along the original message from vesicles that may be released the next time the neuron is stimulated. the neurotransmitter. And, neurotransmitters are sometimes called first Different neurotransmitters are inactivated in different ways. messengers. Binding causes a set of chemical reactions within the receiving neuron. Those reactions start up the same kind of impulse that was fired in the

Neurotransmission and drugs To review, the task in neurotransmission is to convey a signal are chemicals that carry signals across intercellular gaps – synapses.) from a sending cell to a receiving cell across an open space known The volume of these signals and their routes through the organ as a synapse. (Communication) All brain cells accomplish this determine how humans thinking, feel, and do. Brain cells respond with in approximately the same way. The sending cell manufactures greater versatility to more types of input than semi-conductors, as they neurotransmitter molecules and stores them in packets called vesicles. change, grow, and reconfigure their own circuits. When stimulated appropriately, the cell generates an electric signal Neurotransmitters can be excitatory or inhibitory - Different and causes some vesicles to migrate to the cell membrane, merge neurotransmitters fulfill different functions in the brain. Some with it, open it up, and release their contents into the synapse. Some neurotransmitters act to stimulate the firing of a postsynaptic molecules drift across the synapse and link up, lock and key fashion, neuron. Neurotransmitters that act this way are called excitatory with molecules called receptors on the surface of the receiving cell. neurotransmitters because they lead to changes that generate an action Receptors bridge the receiving cell’s membrane. For example, they potential in the responding neuron. Other neurotransmitters, called have one facet on the outside, and one on the inside of the cell. inhibitory neurotransmitters, tend to block the changes that cause an When the neurotransmitter links up with the exterior facet, the interior action potential to be generated in the responding cell. Each neuron facet brings on an electrical response in the cell membrane or inside generally synthesizes and releases a single type of neurotransmitter. the cell. The result may be increased production of a particular cell (Neurons may contain other signaling chemicals, such as product and or a repeat of the process, so that the message gets neurohormones, in addition to their neurotransmitter.) relayed to the next cell in the circuit; completing the cell-to-cell The postsynaptic neuron often receives both excitatory and inhibitory communication. The neurotransmitter molecules drop off the receptors. messages. The response of the postsynaptic cell depends on which Loose again in the synapse, they can: message is stronger. Keep in mind that a single neurotransmitter molecule 1. Be broken apart by an enzyme. cannot cause an action potential in the responding neuron. An action 2. Reenter the sending cell through a special pathway through the potential occurs when many neurotransmitter molecules bind to and axon membrane, called a transporter, and once inside the cell are activate their receptors. Each interaction contributes to the membrane available for re-release for addition neurotransmission. permeability changes that generate the resultant action potential. 3. Attach to another receptor. Some examples of antagonist (drugs that bind but don’t stimulate dopamine receptors) drug actions include the following: ●● Dopamine antagonists are traditionally used to treat schizophrenia and related mental disorders. A person with schizophrenia may have an overactive dopamine system. Dopamine antagonists can help regulate this system by “turning down” dopamine activity. ●● Cocaine and other drugs of abuse can alter dopamine function. Such drugs may have very different actions. The specific action depends on which dopamine receptors the drugs stimulate or block, and how well they mimic dopamine. Drugs can act directly or indirectly on dopamine receptors. Drugs such as cocaine and amphetamine produce their effects by changing the flow of neurotransmitters. These drugs are defined as indirect acting because they depend on the activity of neurons. In contrast, some drugs bypass neurotransmitters altogether and act directly on receptors. Under normal circumstances, when drugs are not present, the cycle Such drugs are direct acting. of breakup, re-entry, or release is stable and maintains the amount of neurotransmitter in the synapse, and, within certain limits, Use of these two types of drugs can lead to very different results neurotransmission. However, when an abused drug enters the brain, in in treating the same disease. As mentioned earlier, people with most instances, it causes neurotransmission to dramatically increase or Parkinson’s disease lose neurons that contain dopamine. To decrease beyond those limits. compensate for this loss, the body produces more dopamine receptors on other neurons. Indirect agonists (drugs that bind to dopamine To describe neurotransmission further, Author Carl Sherman, receptors in place of dopamine and directly stimulate those receptors) (Sherman, 2007), compares the brain to a computer. A computer are not very effective in treating the disease since they depend on the consists of basic units or semi-conductors that are organized into presence of dopamine neurons. In contrast, direct agonists are more circuits; it processes information by relaying electric current from effective because they stimulate dopamine receptors, even when unit to unit; the amount of current and its route through the circuitry dopamine neurons are missing. determines the final output. In comparison, the brain’s corresponding basic units are the neurons. The brain relays information from neuron Once returned to the sending neuron by the reuptake system, dopamine to neuron using electricity and neurotransmitters. (Neurotransmitters is subject to an enzyme named monoamine oxidase (MAO). MAO also

SocialWork.EliteCME.com Page 120 affects dopamine levels. MAO usually breaks down dopamine. If no dopamine. So, these drugs with similar effects produce their actions other factors were at work, MAO would keep the amount of “used” through entirely different processes. In turn, addiction to the two drugs dopamine, fairly low. However, dopamine taken back into the nerve may call for somewhat different types of treatment. ending can return to the vesicle for storage. Once inside the vesicle, In addition, neurons can become sensitized or desensitized to dopamine is protected from MAO. dopamine. One important aspect of drug addiction is how cells adapt A drug named reserpine prevents the reuptake of dopamine and some to previous drug exposure. For example, long-term treatment with other neurotransmitters. Administering reserpine causes dopamine dopamine antagonists increases the number of dopamine receptors. to remain exposed within the cell and broken down by MAO. This This happens as the nervous system tries to make up for less profoundly reduces the available dopamine. stimulation of the receptors by dopamine itself. Likewise, the receptors Changing the action of MAO can help physicians treat diseases that themselves become more sensitive to dopamine. Both are examples of involve dopamine transmission. For instance, the drug deprenyl the same process, called sensitization. inhibits MAO. This increases the stores of dopamine and slows the An opposite effect occurs after dopamine or dopamine agonists progression of Parkinson’s disease. In higher doses, deprenyl enhances repeatedly stimulate dopamine receptors. Here, overstimulation the effects of dopamine on behavior. decreases the number of receptors, and the remaining receptors Interestingly, one form of MAO actually protects dopamine. This become less sensitive to dopamine. This process is called form of MAO, found in dopamine neurons, acts on substances in desensitization. the neuron other than dopamine. Here MAO protects the “purity” Tolerance reflects the actions of the nervous system to maintain of neurotransmission by breaking down other neurotransmitters. homeostasis, a constant degree of cell activity, in spite of major Inhibiting this form of MAO can increase levels of neurotransmitters changes in receptor stimulation. The nervous system maintains this such as serotonin, which seems to help people diagnosed with constant level in an attempt to keep the body in a state of equilibrium, depression. even when foreign chemicals are present. Drugs affect dopamine levels. Dopamine binds to its receptors quickly. It is a myth that sensitization and desensitization take place only after This neurotransmitter is also quickly removed from its receptors, as long-term under-stimulation or overstimulation of dopamine receptors. long as dopamine levels in the synapse are sufficiently high. However, Both sensitization and desensitization can occur after only a single drugs can affect dopamine levels. Some drugs increase dopamine by exposure to a drug. In fact, they may develop within a few minutes. preventing dopamine reuptake, leaving more dopamine in the synapse. Drugs can produce faulty sensitization. Sensitization or desensitization An example is the widely abused stimulant drug, cocaine. Another is normally occurs with drug exposure. However, addiction or mental methylphenidate, used illness can tamper with the reuptake system. This disrupts the therapeutically to treat normal levels of neurotransmitters in the brain and can lead to faulty childhood hyperkinesis, desensitization or sensitization. If this happens in a region of the brain and symptoms of that serves emotion or motivation, the individual can suffer severe schizophrenia. consequences. Amphetamine and For example, cocaine prevents dopamine reuptake by binding to cocaine use affect proteins that normally transport dopamine. Not only does cocaine behavior and heart “bully” dopamine out of the way, it hangs on to the transport proteins function in similar much longer than dopamine does. As a result, more dopamine remains ways. Furthermore, to stimulate neurons, which causes prolonged feelings of pleasure both drugs increase the and excitement. Amphetamine also increases dopamine levels. Again, amount of dopamine the result is over-stimulation of these pleasure-pathway nerves in the in the synapse. However, cocaine achieves this action by preventing brain. dopamine reuptake, while amphetamine helps to release more

More about major neurotransmitters Dopamine - One of the neurotransmitters playing a major role In contrast to dopamine agonists, dopamine antagonists are drugs in addiction is dopamine. Yet, many of the concepts that apply to that bind but don’t stimulate dopamine receptors. Antagonists can dopamine apply to other neurotransmitters, as well. As a chemical prevent or reverse the actions of dopamine by keeping dopamine from messenger, dopamine is similar to adrenaline. Dopamine affects brain attaching to receptors. processes that control movement, emotional response, and ability to Pivotal studies and dopamine experience pleasure and pain. Since their introduction in the 1960s, drugs categorized as Regulation of dopamine plays a crucial role in our mental and benzodiazepines, which include diazepam (Valium) and alprazolam physical health. Neurons containing the neurotransmitter dopamine (Xanax), have been widely prescribed to treat anxiety and insomnia, are clustered in the midbrain in an area called the substantia nigra. In alcohol withdrawal, and other conditions. Although they are highly Parkinson’s disease, the dopamine- transmitting neurons in this area effective for their intended uses, these medications must be prescribed die. As a result, the brains of people with Parkinson’s disease contain with caution because they can be addictive. almost no dopamine. To help relieve their symptoms, these individuals Recently, work by NIDA-funded researchers has established that are given L-DOPA, a drug that can be converted in the brain to benzodiazepines cause addiction in a way similar to that of opioids, dopamine. cannabinoids, and the club drug gamma-hydroxybutyrate (GHB). Drugs can stimulate, or fail to stimulate, dopamine receptors. Some The discovery opens the door to designing new benzodiazepines that drugs are known as dopamine agonists. These drugs bind to dopamine counteract anxiety but are not addictive. receptors in place of dopamine and directly stimulate those receptors. Dr. Christian Lüscher and colleagues at the University of Geneva, Some dopamine agonists are currently used to treat Parkinson’s Switzerland, studied benzodiazepines as part of a larger project, to disease. These drugs can stimulate dopamine receptors even in identify the point of convergence for all neurobiological pathways someone without dopamine neurons. to drug addiction. Their findings strongly suggest that this juncture

Page 121 SocialWork.EliteCME.com occurs when dopamine surges, in response to drug taking, to initiate mice with benzodiazepine-insensitive alpha-1 GABAA receptors did a change in synaptic plasticity in dopamine-producing cells. From not. Recordings of intracellular electrical currents confirmed synaptic receptor activation to dopamine surge, the pleasurable sensations, that changes of dopamine-producing neurons in the normal mice and not make addictive drugs disastrously attractive for vulnerable individuals, the altered mice. To pin down the relationship further, the researchers occur when dopamine levels in the brain’s reward area abruptly injected mice with two other compounds, one (zolpidem) that surge. Researchers had worked out how most addictive drugs, but not preferentially activates only the alpha-1 GABAA receptors, and one benzodiazepines, precipitate these surges. (L-838417) that antagonizes these receptors. GluA2-lacking AMPA receptors were expressed in dopamine-producing neurons following a Dr. Lüscher and colleagues have now demonstrated that treatment with zolpidem, but not with L-838417. benzodiazepines weaken the influence of a group of cells, called inhibitory interneurons, in the brain’s ventral tegmental area (VTA). Proof: The Swiss researchers hypothesize that although different These neurons normally help prevent excessive dopamine levels by addictive drugs produce dopamine surges by various mechanisms, the down-regulating the firing rates of dopamine-producing neurons. subsequent chain of effects is the same. Consistent with this idea, they Two negatives make a positive, so when benzodiazepines limit the showed that even in the absence of any drug, artificial stimulation of interneurons’ restraining sway; the dopamine-producing neurons the dopamine-producing neurons is sufficient to induce the appearance release more dopamine. of GluA2-lacking AMPA receptors. The Swiss researchers traced benzodiazepines’ effect on VTA In this experiment, the researchers introduced a virus containing interneurons to the drugs’ activation of a subset of GABAA (gamma- a light-activated protein, channelrhodopsin, into the dopamine- aminobutyric acid type-A) receptors on the interneurons. Although producing cells of mice. When exposed to light pulses from an optical benzodiazepines typically activate multiple subtypes of GABAA fiber inserted into the animals’ VTA, the channelrhodopsin stimulated receptors, their activation of the alpha-1 subtype is decisive for their neuron firing in bursts similar to those produced by addictive drugs. impact on VTA interneuron behavior. These interneurons are highly The result was an increase in GluA2-lacking AMPA receptors sensitive to such activation because they carry abundant numbers of comparable to that seen following exposure to addictive drugs. “This these receptors. By staining brain tissue, the researchers showed that was a nail-in-the-coffin study to show that activity of dopaminergic

81 percent of VTA interneurons carry GABAA receptors that contain neurons leads to synaptic adaptation that is involved in addiction,” the alpha-1 subunit. says Dr. Lüscher. “This is why addiction is so difficult to treat. Even if you clear the drug from the body, there are long-lasting changes in To prove that activation of alpha-1 GABAA receptors underlies benzodiazepines’ dopamine effect, the researchers administered a brain architecture.” typical benzodiazepine, midazolam, to two groups of mice. The results Looking forward to better benzodiazepines: Taken all together, the supported the researchers’ proposed mechanism: In normal animals, data from the studies, show that the activation of alpha-1-containing the firing rate of interneurons decreased in response to the drug, GABAA receptors, by benzodiazepines calms inhibitory interneurons, while that of dopamine-producing neurons increased. In contrast, in and increases dopaminergic neuron firing, and leads to strengthening animals that were genetically altered to prevent benzodiazepines from of excitatory synapses that favor addictions. Dr. Roger Sorensen of potentiating alpha-1 GABAA receptors, the drug had little or no impact NIDA’s Functional Neuroscience Research Branch says, “This is on neuron firing. the first demonstration that acute benzodiazepine use can increase A behavioral finding completed the chain of proof linking dopamine release, supporting its addictive potential.” benzodiazepines’ stimulation of alpha-1 GABAA receptors to their “Now that we know that it’s the alpha-1-containing GABAA receptor rewarding effects. When given the option of drinking sugar water or that is responsible for benzodiazepine addiction, we can design a sweetened solution of midazolam, normal mice imbibed roughly benzodiazepines that do not touch those particular receptors,” says Dr. three times as much drug-laced as drug-free liquid. Mice with altered Lüscher. Drugs that bind only to alpha-2-containing GABAA receptors, alpha-1 GABAA receptors, however, drank equal amounts of each, he adds, might relieve anxiety non-addictively. “Such substances thereby exhibiting no evidence of finding one drink more rewarding already exist for research purposes,” Dr. Lüscher says. “It’s possible than the other. When benzodiazepines limit the interneurons’ that we can also create them for clinical use” (NIDA notes, 2012). restraining influence, the dopamine-producing neurons release more Serotonin - Serotonin plays a major role in emotional disorders such dopamine. Benzodiazepines’ newly discovered mechanism for as depression, suicide, impulsive behavior, and aggression. Neurons producing reward is comparable to those of opiates, cannabinoids, using serotonin as a neurotransmitter are found in the brain, primarily and GHB. Each of the four drugs reduce an inhibitory influence on in a cluster of cells called the pons. dopamine-producing cells, thereby promoting dopamine spikes. Serotonin is normally involved in temperature regulation, sensory Here is where it gets interesting; from surge to addiction. - Dopamine perception, and mood control. The hallucinogenic drug LSD acts on surges are transient events, but addictive drugs cause long-lasting serotonin receptors; so do some antidepressant drugs. changes in the reward system. Among the earliest of these along the path from voluntary to compulsive drug use and addiction, is the Mentioned earlier, neurotransmitters usually bind and stimulate their migration of certain AMPA receptors (i.e., GluA2-lacking receptors) receptors, then travel back to their sending neurons. These are the from the interior to the surface of the dopamine-producing neurons. normal events in the reuptake system. Reuptake occurs in order to These receptors render the cell more susceptible to stimulation by keep neurotransmitter levels steady and maintain homeostasis. In the excitatory neurotransmitter glutamate, and as a result, the cells effect, the receiving neuron says “That’s enough!” to the sending respond to future drug exposures with larger dopamine surges that neuron that has been releasing neurotransmitters. The sending neuron produce even more intense pleasure. Scientists also have evidence that quickly picks up the leftover neurotransmitters and stops releasing new these special AMPA receptors initiate a series of changes in neural ones. This is an example of negative feedback. transmission that cumulatively give rise to the range of addictive Prozac and some of the other drugs used to treat severe depression symptoms. prevent the normal reuptake of serotonin. As a result, there is more Dr. Lüscher and colleagues showed that benzodiazepines induce serotonin floating around to grab on to receptors and trigger impulses in receiving neurons. This leads to increased stimulation of serotonin AMPA receptor migration via the alpha-1 GABAA receptors. In these experiments, brain tissue from normal mice exhibited GluA2-lacking neurons in depressed people, who find that the drugs help to relieve AMPA receptors after a single injection of midazolam, but tissue from their symptoms.

SocialWork.EliteCME.com Page 122 Norepinephrine - Norepinephrine, also called noradrenaline, is a gamma-amino butyric acid (GABA). Glutamate strongly excites neurotransmitter that doubles part-time as a hormone. (Hormones neurons, while GABA strongly inhibits neurons. are chemicals that regulate many body functions, including growth, Glutamate and GABA are unique in several ways. The number of digestion, and fluid balance.) As a neurotransmitter, norepinephrine synapses using glutamate and GABA is much greater than those using helps to regulate arousal, dreaming, and moods. As a hormone, all other types of neurotransmitters, combined. Glutamate and GABA norepinephrine acts to increase blood pressure, constrict blood vessels, neurons are found in many brain regions. As a result, glutamate and and increase heart rate - responses that occur when we feel stress. GABA work all over the brain, while other neurotransmitters do not. Acetylcholine - Another major neurotransmitter named acetylcholine Both glutamate and GABA have important functions in the body excites neurons in the brain and many other parts of the body, in addition to their role as neurotransmitters. For example, they are including muscle tissues and glands. Acetylcholine is released needed by our body’s metabolism to break down food and make where nerves meet muscles and is therefore responsible for muscle energy-rich molecules in cells. contraction. The fact that GABA and glutamate are so widely present makes it After acetylcholine stimulates its receptors, it is quickly inactivated likely that they will be altered during drug addiction. This fact also and destroyed by an enzyme. Drugs that keep this enzyme from makes it difficult to treat addiction with drug therapy. Say that a drug working are used to treat myasthenia gravis, a disease of muscle affects GABA and glutamate in a way that relieves craving. Because weakness and fatigue. These drugs lead to an excess of acetylcholine GABA and glutamate are so widely present, these drugs could in synapses and overstimulation of the muscles. The result in patients produce a mess of side effects, as well. If there were drugs that could with extreme muscle weakness is normal muscle contraction. selectively stimulate or block certain receptors, then it would be easier Glutamate and gamma-amino butyric acid (GABA) - Certain to treat addiction and avoid doing more harm than good. amino acids also act as neurotransmitters, including glutamate and

Drugs interfere with neurotransmission Drugs can interfere with almost every step in the work of ●● Bind to receptors in place of neurotransmitters. neurotransmitters. To further understand, consider an analogy. In ●● Prevent neurotransmitters from returning to their sending neuron your apartment you perform various tasks: working on a computer, (the reuptake system). watching television, listening to music on a stereo system, and more. ●● Interfere with second messengers, the chemical and electrical When you leave your apartment, you make sure the door is locked. changes that take place in a receiving neuron. You would hate for people to get a key so similar to yours, that they Mentioned previously, one example of drug interference is the effect of could somehow jimmy your door open and break in. Once in your cocaine. In other words, this type of drug can damage your intellectual apartment, they could vandalize your property, take your computer and property by blocking nerve impulses, preventing neurotransmitters VCR, break your TV, bust out your lights, or drop your stereo. You from getting where they’re supposed to be, or producing too many could then no longer perform your daily tasks. or too little neurotransmitters. As a result of using cocaine, neurons Something like this can happen in your brain. Remember that each may be overstimulated or not stimulated at all, crippling the nervous receptor is designed to bind only to a certain neurotransmitter. A drug system’s ability to carry out its functions. of abuse that is structurally similar to a neurotransmitter could be a In each of these ways, and more yet to be identified, cocaine and other “key” that fits into a receptor’s “lock.” In this way, the drug could drugs can damage and vandalize the complicated circuit of nerve disrupt neuron activity in the same way that an intruder disrupts your pathways in one’s body. Treatment for drug addiction stops this cycle apartment and damages your property. of neuro-exploitation. A network of so intricately designed to reason, More specifically, drugs can: imagine, compute, remember, and dream is truly incredible, and not ●● Stop the chemical reactions that create neurotransmitters. something to be tampered with. Central to treatment is the idea that ●● Empty neurotransmitters from the vesicles where they’re normally the vast network of neurons in our bodies should be treated with care stored and protected from breakdown by enzymes. and respect. First, however, research has had to play a large role in ●● Block neurotransmitters from entering or leaving vesicles. identifying how to treat the disease of addiction.

Research methodologies Research continues to uncover and enlighten all who work within the to nicotine in utero had fewer nicotine receptors in the reward system field of addictions. When researchers begin their processes, in order than unexposed rates (NIDA Notes). to determine how a drug affects a particular neurotransmitter, they A second experimental method using removed brain tissue – in vitro, will typically compare subjects who have a history of drug exposure literally, in glass, a historical term referring to the containers for the with others who do not. For example, if researchers are investigating tissue and solution enables researchers to view a drug’s effects on links between a drug’s impact on neurotransmission and a drug-related neurotransmission in action. Scientists place the tissue in a laboratory behavior or symptom, they may compare subjects who exhibit the solution of nutrients that enables the cells to continue to carry out behavior or symptom with others who do not. The subjects in these some of their living functions. The researchers may then, for instance, experiments may be animals or people. In the case of animals, drug add the drug being investigated to the solution, and monitor whether exposure often takes place under laboratory conditions designed to the cells respond by increasing their release of neurotransmitters. mimic human drug consumption. Studies can be divided into those in Alternatively, they may measure cell membrane or electrical properties which measurements are made in living animals or people, and those that stimulate or inhibit the release of neurotransmitters. in which animal brain tissue is removed and examined. In both, in vitro experiments and in living animals, the techniques for Using chemical assays (analysis) researchers quantify the presence measuring neurotransmitter quantities and fluctuations include micro of neurotransmitter, receptor, or other structure of interest. In a more dialysis and fast-scan cyclic voltammetry (FSCV). Microanalysis recent experiment, scientists assayed brained tissue from brain tissue involves taking a series of samples of the intercellular fluid containing from 35-day-old rat pups and found that those that had been exposed the neurotransmitter through a microscopic tube inserted into the tissue or living brain. FSCV recently developed by NIDA-funded

Page 123 SocialWork.EliteCME.com scientists, monitors neurotransmitter fluctuations at tenth of second those experiments. Although scientists strive to develop non-animal intervals by measuring electrical changes related to neurotransmitter models for research, these models often do not duplicate the complex concentrations. animal or human body. Continued progress toward a more complete Studies with live animals or people are important for typing drugs’ understanding of human and animal health depends on the use of effects on neurotransmitters to behaviors and/or symptoms. living animals. Animals as research models: Why do scientists study the brains of A common design for experiments with either animals or people is to non-human animals? Scientists use animals in research studies because give study subjects a chemical that has a known effect on a particular the use of humans is either impossible or unethical. For example, when neurotransmitter, and then observe the impact on their behavior. scientists investigate the effects of drugs of abuse on brain function, The chemical is usually, either an agonist (promoter) or antagonist either the question they are asking cannot be answered in a living (blocker) of signaling by the neurotransmitter. human, or it would be inappropriate to give drugs to them. In a more recent experiment, for instance, a research team The use of animals as subjects in scientific research has contributed administered a glutamate agonist to rats and showed that the to many important advances in scientific and medical knowledge. resulting increased their levels of the neurotransmitter correlated Scientists must analyze the goals of their experiments in order to with a reduction in the animals’ cocaine seeking. Another team select an animal species that is appropriate. Scientists often use fruit using the same strategy implicated glutamate in nicotine withdrawal. flies (Drosophila melanogaster) when they want to learn more about (NIDA Notes, 2012) Such studies are a staple of testing compounds genetics. However, fruit flies are not a very good model if a scientist (combinations) to identify medication classes with potential for is investigating muscle physiology; a mouse may be a better model for treating abuse or addiction.

Building effective vaccines NIDA supported vaccine developers have achieved promising structures simultaneously, allowing the immune system to generate preclinical results with novel formulations against cocaine and heroin. antibodies to not only heroin but also its psychoactive metabolites Laboratory animals treated with the new vaccines produced high 6-acetylmorphine (6AM) and morphine (mor). blood concentrations of anti-drug antibodies and exhibited sharply Vaccine fundamentals - The goal of an anti-drug vaccine is to induce reduced behavioral responses to the drugs. Dr. Ronald Crystal of Weill the immune system to block the psychoactive effects of its target Cornell Medical College and Drs. George Koob and Dr. Kim Janda of drug. When an anti-drug antibody encounters a molecule of the drug, the Scripps Research Institute are among the many scientists who are the two combine to form a complex that is too large to pass from the striving to create vaccines that can protect against nicotine, cocaine, bloodstream into the brain. Locked out of the brain, the drug cannot methamphetamine, and opiates. In 2009, NIDA-supported researchers produce the rewarding effects that motivate continued use. at Baylor College of Medicine reported partial success in the first clinical trial of an anti-cocaine vaccine. Some recipients generated Both, the group including Drs. Crystal and Koob, and the one led by strong antibody responses and reduced their cocaine intake, but others Dr. Janda, employed the same two-component strategy to construct did not. Those results affirmed that antidrug vaccines can protect their vaccines. The first component is a carrier protein, selected to be against drugs’ psychoactive and behavioral effects, and invigorated the highly immunogenic: Its function is to stimulate the immune system search for other and improved formulations. to produce enough antibodies to intercept the millions of molecules in a dose of the target drug before they reach the brain. The second Anti-drug vaccination strategies train the immune system to attack component, called a hapten, is a molecule that shares some key molecules it would not otherwise recognize. Because addictive structural features with the target drug: It provides the immune system drugs are small molecules, the immune system, on its own, does not with a template for the formation of antibodies that recognize and target them. “During my team’s research on human gene therapy, we attach to the target drug. observed that particular adenoviruses, some of which can cause the common cold, are potent inducers of antibodies,” says Dr. Crystal. The The efficacy of vaccines of this type depends on the precise selection researchers hypothesized that coupling a molecule similar to cocaine, and configuration of the carrier protein and hapten. Because of the to one of these potent stimulators of the immune system, could provide complexity and intricacy of immune responses, the search for an ideal the basis for an anti-cocaine vaccine. Dr. Crystal and colleagues combination is largely a process of trial and refinement. identified a way to hook a cocaine-like molecule onto the inactivated Cocaine and the common cold - Dr. Crystal and colleagues employed adenovirus’ protein coat. a carrier protein whose potent immunogenicity is all too familiar: The anti-cocaine vaccine comprises a cocaine analog – an inactive, an adenovirus, agent of the common cold. The researchers disabled cocaine-like molecule – attached to a robust stimulator of the immune a protein (the adenovirus 5 gene transfer vector) from the virus’ system – an adenovirus with hexon and fiber components. The infectious apparatus and linked it to a hapten termed GNE, an amide- resulting vaccine induces the body to generate a high level of cocaine cocaine-memetic that was designed and synthesized by Dr. Janda’s antibodies, which prevent the drug from entering the brain for several group at Scripps. This combination, given in an initial vaccination months. followed by booster injections after 3 and 5 weeks, produced high blood concentrations (500,000 to 1,000,000 titer units) of anti-cocaine Heroin introduces an additional challenge. Because its two major antibodies that persisted for 3 months in rats. metabolites also contribute to heroin abuse, an effective vaccine must keep all three compounds from acting in the brain. Dr. Janda explains, To determine whether the vaccine prevented cocaine from moving “Countering the effects of heroin is like peeling back layers of an from the blood into the brain, the researchers administered onion – heroin is the first layer, but the metabolites are second and radiolabeled drug to vaccinated and control rats. Assays found that third layers. Our vaccine degrades slowly to expose these metabolites, 2 minutes after the administration, vaccinated animals had 3.5 times so that they stimulate the immune system to produce antibodies that as much drug in their blood as compared to control animals, and 66 keep each of them out of the brain.” percent less in brain tissue. The anti-heroin vaccine comprises an inactive, heroin-like hapten With less cocaine reaching their brain, vaccinated rats exhibited linked to a carrier protein (keyhole limpet hemocyanin, KLH) and an weakened behavioral responses to the drug. Although they displayed adjuvant (Alum). This dynamic vaccine displays multiple haptenic typical reactions of hyperactivity and increased locomotor activity,

SocialWork.EliteCME.com Page 124 following a series of cocaine injections, they did so, only 20 percent and Janda agree vaccine treatments for addiction should be part of a as intensely, as control animals. Similarly, vaccinated rats retained comprehensive therapy. motivation to press a lever to self-administer cocaine intravenously, “People have the misconception that a single vaccine can protect but they did not work as hard for the drug as control animals: In a patients from substance abuse, and that’s not true,” says Dr. Janda. progressive ratio protocol, which multiplies the number of presses However, the results suggest that vaccines are a promising adjunct required for delivery of each successive infusion, vaccinated rats quit therapy to accompany drug counseling. For example, Dr. Crystal says, at a cost, or ratio, of 12 presses per injection, whereas controls would “a patient who has attained abstinence could be vaccinated to block the keep pressing up to 32 presses per injection. effects of the drug, thereby preventing relapse. Dr. Janda notes, “Our Another experiment had direct application to the vaccine’s primary vaccine will not alleviate craving, but it could help patients maintain proposed clinical use: to shield abstinent individuals who lapse from abstinence in weak moments.” He adds that by fighting addiction, a experiencing cocaine effects that can precipitate extended relapses. heroin vaccine may help to combat HIV in countries where injection The researchers gave a small priming dose of cocaine to rats that of the drug contributes to spread of the virus. “The vaccine approach had previously established steady cocaine self-administration but provides an alternative strategy for treating drug addiction,” says Dr. had stopped seeking the drug during a period of extinction. The new Nora Chiang of NIDA’s Division of Pharmacotherapies and Medical exposure to the drug prompted the control rats, but not the vaccinated Consequences of Drug Abuse. “There is much more work to be done rats, to return to drug-seeking – pressing the lever that had initially on these vaccines, but the results so far is promising” (NIDA notes, yielded cocaine, but no longer did so. 2012). Overcoming an immunological challenge - In designing their heroin Imaging the brain: Scientists, continue to use newer technologies vaccine, Dr. Janda and colleagues noted that antibodies to heroin alone that enhance their learning about how the brain works, and how drugs would still permit production of the drug’s psychoactive metabolites. of abuse, changes neurotransmission. Historically, scientists could Therefore, they varied the basic vaccine strategy to employ what they examine brains only after death, but new imaging procedures enable call a dynamic vaccine. A single hapten coupled to a carrier protein scientists to study the brain in living animals, including humans. Brain slowly morphed itself into multiple haptens paralleling heroin’s scans or brain imaging techniques enable neuroscientists to directly degradation pathway, thus allowing the immune system to sample and assess neurotransmission in people and living animals. make antibodies, to not only heroin, but its important metabolites, One of the most extensively used techniques to study brain activity such as 6-acetylmorphines. The Scripps team achieved its results by and the effects of drugs on the brain is positron emission tomography binding haptens to a commonly used carrier protein, keyhole limpet (PET). PET measures the spatial distribution and movement of hemocyanin, and the adjuvant alum, a chemical salt that restricts radioisotopes in tissues of living subjects. Because the patient is enzymatic access. With reduced exposure to enzymes, breakdown of awake, the technique can be used to investigate the relationship the haptens occurs more slowly, affording the immune system more between behavioral and physiological effects, and changes in brain opportunity to detect the resulting metabolites and form antibodies to activity. them. PET scans can detect nanomolar concentrations of tracer molecules The researchers observed significant antibody titers 14 days after and achieve spatial resolution of about 4 millimeters. In addition, initial vaccination. Antibody levels rose to a maximum (1:122,000) computers can reconstruct images obtained from a PET scan in two or 53 days after the initial vaccination and after two boosters. The levels three dimensions. PET requires the use of compounds that are labeled remained potentially protective (at 1:50,000) 105 days after the initial with positron-emitting isotopes. A cyclotron accelerates protons into vaccination and after a third booster. the nucleus of nitrogen, carbon, oxygen, or fluorine to generate these To test how successfully the vaccine blocked the drug from entering isotopes. The additional proton makes the isotope unstable. To become the brain, initially the researchers, in collaboration with the Koob stable again, the proton must break down into a neutron and a positron. group, assessed its impact on heroin analgesia. This test can be used as The unstable positron travels away from the site of generation and a first screen because if the drug does not reach the brain, it will lose dissipates energy along the way. Eventually, the positron collides with its analgesic, as well as its rewarding effects. The researchers injected an electron leading to the emission of two gamma rays at 180 degrees rats with heroin and placed them on a plate that was hot enough to from one another. cause mild pain, but not injury. Control rats took 30 seconds to lift The gamma rays reach a pair of detectors that record the event. their paws off the plate. Vaccinated rats evinced sufficient discomfort Because the detectors respond only to simultaneous emissions, to do so, after just 10 seconds, no different from the response of scientists can precisely map the location where the gamma rays were animals not treated with heroin. Most remarkable, was the vaccine’s generated. The labeled isotopes are very short-lived. The half-life (the specificity for heroin: In parallel experiments, it did not lessen the time for half of the radioactive label to disintegrate) of the commonly analgesic effects of the closely related and commonly prescribed drug used radioisotopes ranges from approximately two minutes to less Oxycodone. than two hours, depending on the specific compound. Because a PET Vaccinated rats also demonstrated less inclination than controls to self- scan requires only small amounts (a few micrograms) of short-lived administer heroin intravenously. Over 10 sessions in which animals radioisotopes, negative pharmacological effects are imperceptible. had access to a lever that delivered infusions of the drug, all seven PET scans can answer a variety of questions about brain function, control animals pressed the lever three or more times during any of including the activity of neurons. Scientists use different radio-labeled three consecutive sessions, whereas only three of the seven vaccinated compounds to investigate different biological questions. For example, rats did so. radiolabeled glucose can identify parts of the brain that become more Additional ammunition - It is always challenging to transfer new active in response to a specific stimulus. Active neurons metabolize vaccine technology to people. Dr. Crystal stated, “Our team will more glucose than inactive neurons. Active neurons will emit more need to demonstrate that, from patient to patient, the cocaine vaccine positrons. This will show as red or yellow on PET scans compared to consistently induces a high level of antibodies with strong affinity to blue or purple in areas where the neurons are not highly active. PET cocaine for a long duration.” “The only way to do that is to conduct a also helps scientists investigate how drugs affect the brain by enabling clinical trial.” If the technology needs tweaking, Dr. Koob continues, them to: “There are ways to make vaccines more compatible with humans, ●● Determine the distribution of a drug in the body. for example, using carriers other than the adenovirus.” Drs. Crystal ●● Measure the local concentration of a drug at binding sites.

Page 125 SocialWork.EliteCME.com ●● Estimate receptor occupancy based on competitive binding assays. Brain imaging correlated the reductions in craving with altered activity ●● Evaluate the effects of drugs on other neurotransmitter systems. levels in regions associated with emotional regulation and reward. ●● Investigate the activity of enzymes that metabolize the drug. The cue-induced craving was roughly twice as strong after 35 days With positron emission topography (PET), researchers can compare of abstinence, as it was after 1 week. Moreover, the craving increased groups of drug-abusing and non-abusing individuals, quantifying over this period even though the smokers’ urges to light up in the differences in their levels of a particular neurotransmitter molecule absence of cues steadily weakened, dropping by more than 25 percent (e.g., dopamine) or neurotransmission component (e.g., a receptor or over 5 weeks. transporter). With PET, researchers are also able to correlate a drug’s The participants were 21 men and women who had smoked for 10 transit through the brain with fluctuations in a target neurotransmitter. years, on average, and were not trying to quit. In preparation for the They can elicit a drug-related behavior or symptom (e.g., craving) and study, the participants practiced turning their thoughts to rewarding relate neurotransmitter fluctuations to the rise and fall in its intensity. effects of cigarettes or high-fat food consumption when given the Another more recent PET study, for instance, showed that smokers instruction “NOW” and to negative effects when given the instruction have less of the neurotransmitter degrading enzyme monoamine “LATER.” In the study itself, the researchers gave each participant oxidase B (MAO-B) throughout their bodies than non-smoking 100 such instructions, in random order, each followed by a 6-second persons. The relative deficit of MAO-B may help explain why exposure to a screen image of either cigarettes or food. Then, after a smokers are at higher risk for hypertension and other chronic diseases. 3-second delay with the screen blank, the participant reported how Researchers use both PET and functional magnetic resonance imaging much he or she desired to smoke or eat, on a scale of 1 (not at all) to 5 (MRI) to monitor metabolic activity in selected regions of the brain. (very much). And, because each neurotransmitter has a unique distribution among The power of thinking about negative effects proved to be the regions of the brain, information on locations of heightened or considerable. The participants reported 34 percent less intense urges decreased activity provides clues to which neurotransmitter is affected to smoke and 30 percent less intense food cravings after the LATER under the conditions of a study. instruction, compared with the NOW instruction. Similar to PET, single-photon emission computed tomography Brain scans, taken during the experiment, showed how concentrating (SPECT) imaging uses radioactive tracers and a scanner to record data on long-term negative consequences alters brain activity to reduce that a computer constructs into two- or three-dimensional images of craving. Functional magnetic resonance imaging (fMRI) of the active brain regions. Because the tracers used in SPECT take longer participants’ whole brain revealed increased activity levels in areas, the to deteriorate than those for PET, longer periods of time between tests dorsomedial, dorsolateral, and ventrolateral regions of the prefrontal are required for SPECT. While PET is more versatile than SPECT and cortex (PFC), which supports cognitive control functions, such as produces more detailed images with a higher degree of resolution, focusing, shifting attention, and controlling emotions. SPECT is much less expensive than PET, and can address many of the Activity decreased in regions that previous studies have linked same drug abuse research questions. with craving. These areas include the ventral striatum and ventral MRI uses magnetic fields and radio waves to produce high-quality tegmental area, which are parts of the reward circuit; the amygdala; two- or three-dimensional images of brain structures without injecting and the subgenual cingulate. Individual participants who reported radioactive tracers. In this procedure, a large cylindrical magnet larger reductions in craving exhibited these changes to a more marked creates a magnetic field around the research volunteer’s head, and degree. A specialized mediation analysis of the images found that radio waves are sent through the magnetic field. Sensors read the the increase in PFC activity drove the decrease in ventral striatum signals and a computer uses the information to construct an image. activity, which, in turn, fully accounted for the reduction in craving. Using MRI, scientists can image both surface and deep brain structures “These results show that a craving-control technique, from behavioral with a high degree of anatomical detail, and they can detect minute treatment, influences a particular brain circuit, just as medications changes in these structures over time. affect other pathways,” says Dr. Steven Grant, of NIDA’s Division of A modification of this technique, called functional MRI (fMRI), Clinical Neuroscience and Behavioral Research. enables scientists to see images of blood flow in the brain as it occurs. The researchers noted that the study participants reduced their fMRI provides superior image clarity along with the ability to assess smoking and food cravings to the same extent, even though smoking blood flow and brain functions in just a few seconds. However, PET cravings were, initially, more intense. This finding suggests that retains the advantage of being able to identify which brain receptors calling undesirable consequences to mind has potential to help people are being activated by neurotransmitters, abused drugs, and potential overcome a variety of unhealthy urges. treatment compounds. When study participants thought of the long-term negative EEG uses electrodes placed on the scalp to detect and measure patterns consequences of cigarette consumption (after receiving the instruction of electrical activity in the brain. The greatest advantage of EEG is “LATER”), rather than short-term pleasures (“NOW”), they reduced speed. It can record complex patterns of neural activity occurring their craving. Brain scans showed increased activity in the dorsolateral within fractions of a second after a stimulus has been administered. prefrontal cortex, a region critical to setting goals, planning, and The drawback to EEG is it does not provide the spatial resolution controlling behavior, which, in turn, inhibited the ventral striatum, part of fMRI or PET. Researchers often combine EEG images of brain of the reward pathway that generates craving. electrical activity with MRI scans to localize brain activity more “The mediation analysis that Dr. Ochsner and colleagues conducted precisely. is unique among imaging studies and is a particular strength to the Brain imaging reveals changes when smokers focus on long-term research,” says Dr. Grant. “Because the researchers examined the consequences of their tobacco use. interaction of brain regions, the results provide a perspective on the Cognitive behavioral programs are generally effective, but, until neural circuits involved in cognitive control of craving.” Dr. Grant now, researchers have shed little light on the neurological basis for suggest two important next steps in this area of research: identifying their efficacy. In a study led by Dr. Kevin N. Ochsner of the Social why some people have more problems than others in controlling the Cognitive Neuroscience Laboratory at Columbia University, smokers desire for cigarettes, and determining whether brain activity predicts reported milder cigarette cravings when they thought about smoking’s the ability to quit smoking (Kober, 2010). harmful effects while viewing smoking cues, than when they focused on its pleasures.

SocialWork.EliteCME.com Page 126 Studying gene regulation and glucocorticoid receptors: recognize the importance of early developmental changes and how, Overexpression of the glucocorticoid gene in the first weeks after birth because the brain is in such a plastic mode during this early period, increased anxiety and response to cocaine in adulthood. Researchers these changes can critically set the path for life.” investigating how stressful experiences early in life promote later Research and exercise: Exercise also decreases neural change linked drug abuse have homed in on the glucocorticoid receptor (GR). In with drug seeking during abstinence. For example, studies indicate that experiments with mice, augmenting GRs in the forebrain during the aerobic exercise might help cocaine abusers establish and maintain early postnatal period increased animals’ anxiety and sensitivity to abstinence, recent NIDA-funded animal research suggests. cocaine as adults. In two independent studies, running on an exercise wheel reduced The GR plays a pivotal role in producing the physiological response rats’ cocaine seeking during forced abstinence, and their eagerness to to stress. NIDA-supported research suggests that GR levels, during resume cocaine seeking following the abstinence. One study indicated early brain development, also affect the hard wiring of neural circuits that exercise may produce these effects in part by lowering brain levels that shape an individual’s basic emotional makeup. Increasing mouse of a protein that has been linked to drug craving. The research teams, GRs prior to the animals’ weaning was associated with alterations in one led by Dr. Marilyn Carroll at the University of Minnesota and the the expression of more than 5,000 genes in the nucleus accumbens and other by Dr. Wendy Lynch at the University of Virginia, examined the hippocampus. impact of exercise on drug seeking with a protocol that researchers Putting mice under pressure: When a mouse or a person confronts often use to test potential addiction medications. Their work highlights a threat, the brain signals the adrenal gland to release glucocorticoid the potential usefulness of such protocols for assessing behavioral hormones. The hormones stimulate GRs on cells throughout the brain approaches to addiction treatment as well. and body. The cells, in turn, alter their activity in ways that produce The research teams varied details of the test protocol, but both stress-related symptoms and behaviors. preserved its basic three-phase structure, which parallels a person’s Dr. Huda AkilExternal link, please review our disclaimer. and acquisition of chronic drug abuse, establishment of abstinence, and colleagues at the University of Michigan, Ann Arbor, have developed a exposure to a relapse trigger: mouse strain that enables them to study the impact of greatly amplified ●● Self-administration: The animal self-administers cocaine GR activity, such as occurs in traumatic stress. The mice have an extra infusions by pressing a lever, ultimately leveling off at a dosage copy of the GR gene that gives them a superabundance of GRs in the that it apparently finds optimal. forebrain. In early experiments, the researchers showed that these GR- ●● Extinction (of the lever-pressing behavior): The researchers augmented mice exhibit behaviors suggestive of heightened anxiety deactivate the lever and observe how rapidly the rat tapers off its and depression, and hypersensitivity to cocaine. To investigate whether lever pressing in the absence of the drug reward. early-life GR levels have lifetime consequences, the researchers ●● Reinstatement: The researchers expose the rat to some strong attached an off-switch to the extra GR gene. They raised male mice reminder of the rewarding sensations produced by the drug – e.g., to the age of weaning with the gene turned on, then turned it off by a priming dose or drug-associated cues – and observe how avidly administering the antibiotic doxycycline. When the animals reached the animal resumes lever pressing. adulthood, the researchers tested their responses to stressful situations In studies with this protocol, researchers administer a potential and cocaine. treatment after the self-administration phase and judge it to be Compared to normal animals, the mice that had early-life GR effective if it results in reduced lever pressing during extinction and/ augmentation responded more fearfully to stress-inducing situations. or reinstatement. Thus, the Virginia and Minnesota teams moved their They were more anxious in adulthood than normal mice, and reluctant animals to cages with exercise wheels after the self-administration to venture out on a narrow beam in the “elevated plus maze” test. They stage. Both found that animals that ran on the wheels tapered off lever also hesitated longer, before emerging from the dark, to explore a pressing faster during extinction and took it up less avidly during brightly lit novel space in “light-dark box” and “defensive withdrawal” reinstatement, compared with control animals placed in cages with tests. locked running wheels. In addition, cocaine sensitizes the mouse brain so re-exposures to In the Minnesota study, female rats that exercised pressed the lever the drug produce more locomotor stimulation than initial doses. The about half as often, on average, during the first 9 days of the 14-day Michigan researchers’ genetically manipulated mice exhibited this extinction phase. Dr. Carroll and colleagues also found that exercise effect more markedly than normal mice. Given two injections of the reduced lever pressing during reinstatement when animals ran on drug 14 days apart, they covered 2.5 times as much distance after the the same day that they received a priming dose of cocaine, but not second, compared to after the first. when there was a delay between receiving the priming dose and being Further experiments indicated that early life is the critical period for introduced to the wheel. GR activation to influence anxiety and drug sensitivity. In behavioral In the Virginia study, male rats that exercised for up to 2 hours tests, compared with control animals with normal GR: a day during a 2-week period of forced abstinence between self- 1. Mice in which GR was augmented from birth to weaning exhibited administration and extinction pressed the lever about 35 percent less increased anxiety and drug sensitivity responses, but continuing often during the extinction phase and about 45 percent less often augmentation after weaning and into adulthood produced no during reinstatement. additional rise. Both studies indicate exercise does more than simply provide an 2. Mice in which GR was not augmented from birth to weaning did alternative activity that reduces the time available for drug seeking, the not exhibit increases in anxiety and drug sensitivity responses, researchers say. The researchers note that both exercise and addictive even when the researchers turned on the extra GR gene, after drugs raise levels of dopamine in the brain’s reward system, and as a weaning. result, exercise may compete with cocaine as a source of pleasurable “These findings demonstrate the critical nature of early development in sensations. In addition, the Virginia researchers found evidence resilience or liability to drug abuse,” says Dr. Akil. Another researcher suggesting exercise may alter levels of the neurotransmitter glutamate weighs in. “Studies that are done at early ages have turned out to be in their rats’ prefrontal cortex (PFC). Such an effect might weaken very critical in our thinking about how addiction occurs and which the progressive intensification (incubation) of craving that takes place changes are most important,” says Dr. Nancy Pilotte, chief of NIDA’s during early abstinence from cocaine, and appears to depend largely on Functional Neuroscience Research Branch. “They’ve forced us to glutamate.

Page 127 SocialWork.EliteCME.com Dr. Lynch and colleagues assayed brain tissue from the PFC of their In a study at the University of Minnesota, female rats that had access animals 1 day after the end of reinstatement. Exercise was associated to a functional running wheel during extinction, pressed the cocaine- with 32- and 42-percent reductions in the activity of two proteins, delivery lever less often during this period, than rats that did not extracellular signal-regulated kinase (ERK) 1 and 2, whose levels are have such access. In response to a priming injection of the drug, rats regulated by both dopamine and glutamate. Previous research has that had access to a running wheel during reinstatement, pressed the established associations between ERK, drug-seeking behavior, and the cocaine-delivery lever less often at this stage than rats with a locked incubation of cocaine craving. wheel or access to a running wheel only during extinction.

More about what drug(s) impacts which neurotransmitter(s) Stated earlier in this course, each individual neuron manufactures dopamine signaling in the nucleus accumbens (NAc), leading to one or more neurotransmitters that can include Dopamine, Serotonin, euphoria and a desire to repeat the experience is an indirect one in Acetylcholine, or any one of several others that scientists continue many cases. to discover. For example, dopamine is highly concentrated in How do drugs alter neurotransmission? regions that regulate motivation and feelings of reward, accounting Identifying the precise step that a drug disrupts, and how it provides for its importance in compulsive behaviors such as drug abuse. A pivotal insight into its impact on abusers, within the neurotransmission neurotransmitter’s impact also depends on whether it stimulates or cyclic process, is essential when identifying and addressing medical dampens activity in its target neurons. Some drugs primarily disrupt and behavioral interventions to inhibit, counter and or reverse one neurotransmitter or class of neurotransmitters. Opioid drug disruption. A cyclic neurotransmission process transpires in several abusers, for instance, experience changes that are similar to, yet more steps as it utilizes specialized components of the sending and receiving pronounced than those changes that accompany normal fluctuations cells. in the brain’s natural opioid-like neurotransmitters, endorphin and encephalin that increased analgesia, decreased alertness, and slowed Opioid drugs such as heroin and OxyContin mimic neurotransmitters. respiration. They chemically resemble the brain’s natural opioids enough to engage and stimulate their specialized receptors. Because heroin Other drugs interact with more than one type of neurotransmitter. For stimulates many more receptors than the brain uses in the normal example, cocaine attaches to structures that regulate dopamine, thereby cycle of endorphin and encephalin release and uptake, the result is producing euphoria. However, cocaine also produces changes in a massive amplification of opioid activity. Marijuana and hashish norepinephrine and glutamate, which are the sources of its stimulant mimic cannabinoid neurotransmitters, the most important of which effects. is anandamide. Nicotine attaches to receptors for acetylcholine, the Cocaine and neurotransmitter activity neurotransmitter for the cholinergic system. ●● A young person’s marked taste for novelty may be an indication Some drugs alter neurotransmission by interacting with molecular that dopamine activity in his or her brain’s reward system is components of the sending and receiving process, other than receptors. especially sensitive to cocaine, and an individual’s attraction to Cocaine, for example, attaches to the dopamine transporter, the cocaine’s dopamine-stimulating effects also may relate to his or molecular conduit that draws free-floating dopamine out of the her social circumstances. synapse and back into the sending cell. As long as cocaine occupies ●● After chronic cocaine abuse dopamine ticks up in the reward the transporter, dopamine cannot reenter the cell by this route. It builds system when the abuser encounters a cue associated with the drug. up in the synapse, stimulating receiving cell receptors more copiously, ●● In living animals with minimal exposure to cocaine, the drug alters and producing much greater dopamine impact on the receiving cells, the dopamine responsiveness for at least a week. than occurs naturally. Cocaine’s dopamine connections enumerates ●● Some studies indicate that the transition from casual cocaine abuse some of cocaine’s interactions with the mechanisms of dopamine to addiction begins with the abuser’s very first doses. A single signaling, and how they motivate abuse and contribute to dependence exposure to cocaine causes some cells in the brain’s reward system and addiction. to increase their responsiveness to subsequent stimulations. ●● Brains usually sprout new neurotransmitter receiving structures Some drugs alter neurotransmission by means other than increasing in the process of turning new experience into learning. Cocaine or decreasing the quantity of receptors stimulated. Benzodiazepines, accelerates this process, which may help account for the drug’s such as diazepam or lorazepam, enhance receiving cells’ responses unusual hold on an addicted individual’s attention. when the neurotransmitter gammaminobutyric acid (GABA) attaches to their receptors. Benzodiazepines’ relaxation effects result from this Secondary impact: Due to a neurotransmitter often stimulating or increased sensitivity to GABA’s inhibitory impact on cellular activity. inhibiting a cell that produces a different neurotransmitter, a drug that alters one can have secondary impacts on another. The key effect all abused drugs seem to have in common is a dramatic increase in

SocialWork.EliteCME.com Page 128 Examples of drug interaction with neurotransmission

Distribution in the central Neurotransmitter Functions affected Drugs that affect it nervous system 1. Serotonin. Midbrain, ventral tegmental area Mood, sleep, sexual desire, MDMA (ecstasy), LSD, cocaine. (VTA) cerebral cortex, hypothalamus. appetite. 2. Dopamine. Midbrain, (VTA), cerebral cortex, Pleasure and reward, movement, Cocaine, methamphetamine, amphetamine. In hypothalamus. attention, memory. addition, virtually all drugs of abuse directly or indirectly augment dopamine in the reward pathway. 3. GABA. Widely distributed in brain. Neuron activity (slowed), anxiety, Sedatives, tranquilizers, alcohol. memory, anesthesia. 4. Norepinephrine. Midbrain, (VTA), cerebral cortex, Sensory processing, movement, Cocaine, methamphetamine, amphetamine. hypothalamus. sleep, mood, memory, anxiety. 5. Glutamate. Widely distributed in brain. Neuron activity (increased rate), Ketamine, phencyclidine, alcohol. learning, cognition, memory. 6. Endogenous. Cerebral cortex, hippocampus, Movement, cognition and Marijuana. thalamus, basal ganglia. memory. 7. Acetylcholine. Hippocampus, cerebral cortex, Memory, arousal, attention, mood. Nicotine. thalamus, basal ganglia, cerebellum. 8. Endogenous Widely distributed in brain but regions Analgesia, sedation, rate of bodily Heroin, morphine, prescription painkillers opioids vary in type of receptors, spinal cord. functions, mood. (oxycodone). (endorphin and enkephalin).

Chronic drug abuse and neurotransmission During the early phase of an individual’s drug experimentation, The drug-related mechanisms producing cumulative changes in neurotransmission normalizes, as intoxication wears off, and the neurotransmission sometimes are genetic in nature. While a drug substance leaves the brain. Eventually, however, drugs wreak cannot change a person’s genes, drugs can prompt some genes to changes in cellular structure and function that lead to long-lasting increase their production of proteins, leading to changes in cell or permanent neurotransmission abnormalities. These alterations function, or even actual reshaping of the physical structure of cells. For underlie drug tolerance, addiction, withdrawal, and other persistent example, cocaine and amphetamine stimulate genes which produce the consequences. Some longer term changes begin as adjustments to proteins used to build dendrites, branch-like cell structures that contain compensate for drug-induced increases in neurotransmitter signaling neurotransmitter receptors. Brains normally sprout new dendrites intensities. For example, drug tolerance typically develops because as they register new learning. The accelerated dendrite formation sending cells reduce the amount of neurotransmitter they produce and stimulants induce may partially account for these drugs’ unusual hold release, or receiving cells withdraw receptors or otherwise dampen of an abuser’s attention. their responsiveness. Scientists have shown that cells, for example, Some drugs are toxic to nerve cells, and the effect accumulates with withdraw opioid receptors into their interiors (where they cannot be repeated exposures. The club drug methylenedioxymethamphetamine stimulated) when exposed to some opioid drugs. When exposed to (MDMA, ecstasy), for instance, damages axons that release serotonin, morphine, however, cells appear instead to make internal adjustments and the result is disruption of serotonin neurotransmission that likely that produce the same effect, which is reduced responsiveness to underlies the long-lasting memory problems that are experienced by opiate drugs and natural opioids. Over time, this and related changes abusers. In addition, methamphetamine, over time, damages enough recalibrate the brain’s responsiveness to opioid stimulation downward dopamine-sending cells to cause significant defects in thinking and to a level where the organ needs the extra stimulation of the drug to motor skills. With abstinence, dopamine function can partially recover, function normally. Therefore, without the drug, withdrawal occurs. but it is not clear whether cognitive and motor capabilities come back as well.

Research outcomes prompt current treatment approaches for addiction Scientific research and clinical practice have yielded a variety of problems. While the biological foundation for drug addiction does not effective approaches to treatment for addiction to certain drugs, such absolve an individual from the responsibility of his or her actions, the as heroin. Continuing research is also yielding new approaches to stigma of drug addiction needs to be lifted so individuals may receive developing medications to treat addiction to other drugs, such as proper medical treatment, similar to that for other chronic diseases. cocaine, for which no medications are currently available. The sad news is that addiction is a recurring chronic disease. No cure Drug abuse and addiction lead to long-term changes in the brain’s is available at this time, but addiction can be effectively treated. Drug chemistry and anatomy. The changes in the brain cause drug addicts, addiction is often viewed as a lapse in moral character. This value not only to lose the ability to control their drug use, but their addiction judgment influences how society deals with the disease, both socially also changes all aspects of their lives. Drug addicts often become and medically. Unfortunately, because people, including physicians, isolated from family and friends and have trouble in school or work. have often viewed addiction as a self-inflicted condition, drug addicts In addition, the compulsive need for drugs can lead to significant legal have not always received the medical treatment common for other

Page 129 SocialWork.EliteCME.com chronic diseases. Treating addiction requires more than a “just say no” A second medication prescribed for heroin addiction is naltrexone. approach. Unlike methadone, naltrexone is an opiate receptor antagonist. Instead Using pharmacological agents: Treatment for addiction is often very of competing with heroin for the opiate receptor, naltrexone prevents effective. Treatment is successful when the addict reduces or abstains heroin from binding to the receptor, thereby preventing heroin from from drug use, improves his or her personal health or social function, eliciting the euphoric high. and becomes less of a threat to public health and safety. Buprenorphine is a prescribed medication with weaker opioid Certain addictions, such as heroin addiction, can be treated with agonist activity than methadone. Buprenorphine is not well absorbed pharmacological agents that include: if taken orally, therefore the usual route of administration in treatment of opioid dependence, is sublingual. With increasing doses of Methadone, the most common pharmacological treatment, prevents buprenorphine, effects reach a plateau. Consequently buprenorphine craving and withdrawal symptoms in heroin addiction. Methadone is less likely, than either methadone or heroin to cause an opioid is an opiate receptor agonist. That is, methadone binds to the opiate overdose condition, even when taken with other opioids, at the receptor just as heroin does. Methadone, however, does not produce same time. The effectiveness of buprenorphine is similar to that of the euphoria or “high” that results from heroin use. methadone at adequate doses, in terms of reduction of illicit opioid Methadone, as dispensed at a methadone maintenance treatment use and improvements in psychosocial functioning, but buprenorphine facility, is a synthetic opioid that is typically administered orally, as a may be associated with lower rates of retention in treatment. liquid. Methadone is the medication that is most commonly used for Buprenorphine is currently more expensive than methadone. Opiate Agonist Pharmacotherapy of opioid dependence. Methadone Suboxone (buprenorphine and naloxone) - Buprenorphine is maintenance treatment is also an extensively researched treatment acceptable to heroin users, has few side effects, and is associated with modality. There is strong evidence, from research and monitoring of a relatively mild withdrawal syndrome. When used in “Opiate Agonist service delivery, that Opiate Agonist Pharmacotherapy maintenance Pharmacotherapy” for pregnant women with opioid dependence, it with methadone (Methadone Maintenance Treatment) is effective appears to be associated with a lower incidence of neonatal withdrawal in reducing illicit drug use, reducing mortality, reducing the risk of syndrome. spread of HIV, improving physical and mental health, improving Dihydrocodeine is used in some countries for detoxification social functioning, and reducing criminal behavior. Higher doses of and “Opiate Agonist Pharmacotherapy.” Tincture of opium methadone are generally associated with greater reductions in heroin (laudanum) is used in some countries in Asia for the management use than either low or moderate doses. of opioid withdrawal and, less commonly, for “Opiate Agonist Methadone Maintenance Treatment is associated with a low Pharmacotherapy”. The various oral preparations of morphine incidence of side-effects and with substantial health improvements. formulated to provide slow release (also called sustained release, Around three-quarters of people who commence “Opiate Agonist controlled release and timed release preparations) are also of potential Pharmacotherapy” with methadone, respond well. However, for value in the treatment of opioid dependence. However, controlled various reasons, methadone does not suit all people with opioid studies of the effectiveness of these preparations for Opiate Agonist dependence. For this group it is important that alternative approaches Pharmacotherapy are yet to be undertaken. are available to encourage their retention in treatment. Some require several episodes of treatment before major progress is achieved.

Pharmacologic and behavioral treatment in combination, work for best outcomes Pharmacological therapies, when available, are not sufficient for succumbing to them. “Cognitive reappraisal, through mentally effective treatment. Behavioral treatment, in combination with changing the meaning of an event or object to lessen its emotional pharmacological treatment, is the most effective way to treat drug impact, and therefore, alter the behaviors it triggers, is a strategy that addiction. Recovering addicts need to address the behavioral and helps a variety of problems,” states researcher, Dr. Ochsner. Cognitive- social consequences of their drug use and learn to cope with the social behavioral therapists train patients to use this approach, among others, and environmental factors that contribute to their illness. Behavioral to cope with negative emotions, stress, and substance cravings. He treatments can occur either individually or as a group. continues, “People may not realize they can control cravings or Relapse is a common event for recovering drug addicts. In many ways, emotions using cognitive strategies. For example, thinking of negative relapse should be thought of as a normal part of the recovery process. consequences, and distracting, and distancing oneself, but patients A recovering drug addict is more likely to experience a relapse if he or can learn these techniques and then must continue to apply them over she also has other psychiatric conditions or lacks the support of family time.” (See previously described study.) and friends. But chances of recovery grow, using both medication Dr. Ochsner adds that there is broad scientific interest in the management and behavioral interventions such as cognitive strategies. neurobiological mechanisms underlying cognitive control over Cognitive strategies: Addiction challenges people to look beyond thoughts and emotions that promote unhealthy behaviors. Such studies immediate gratification, to the longer term consequences of their generally find that although there is some overlap in the regions of actions. Therefore, patients in drug abuse treatment are often coached the PFC engaged when people exert cognitive control, different areas to make and rehearse mental associations between situations that seem to support different strategies for the regulation of emotional trigger drug cravings and the problems that are likely to ensue from responses.

In summary Despite the preconceptions and value judgments many people place The initial choice to use drugs is voluntary, but once addiction on addiction, it is, in many ways, similar to other chronic diseases, develops, drug use is compulsive – not voluntary. Moreover, voluntary such as diabetes and coronary artery disease. Genetic, environmental, choices do contribute to the onset or severity of other chronic diseases, and behavioral components contribute to each of these diseases. Some as well. For example, a person who chooses to eat an unhealthy diet people may argue that drug addiction is different because it is “self- and not exercise, increases his or her risk for coronary heart disease. inflicted.”

SocialWork.EliteCME.com Page 130 Successful treatment for any chronic disease necessitates patient causing changes in the chemistry and function of the brain. Their compliance with the prescribed treatment regimen. Adhering to a discoveries have led to new medications to treat the disease of treatment plan is difficult for those with any chronic disease. For addiction. Scientists continue to work on developing medications example, less than 50 percent of diabetics follow their routine that relieve the cravings experienced during withdrawal. In addition, medication plan, and only 30 percent follow their dietary guidelines. scientific advances may reveal ways to reverse the long-term damage Problems adhering to a treatment plan lead to about 50 percent of to the brain drugs inflict. diabetics needing to be treated again, within one year of diagnosis Scientists must use a variety of experimental tools and methods to and initial treatment. Similar statistics hold true for other chronic study drugs’ effects on neurotransmission. Utilizing both animals diseases. Approximately, 40 percent of patients with hypertension, and people, their findings enhance understanding of the experiences need emergency room treatment for episodes of extreme high blood of drug abusers, the burden of addicts, and lead the way to new pressure, and only about 30 percent of adult asthma sufferers take their behavioral interventions, as well as medication interventions. These medication, as prescribed. findings provide potential bases for prevention strategies and treatment Although treatment for drug addiction statistically is more successful process monitoring. than treatment for other chronic diseases, drug addicts commonly have As a reminder, some important effects, though, are shared by all relapses during treatment and recovery and begin using drugs again. people using drugs, and they include initial pleasurable feelings, and The difficulties in following a treatment plan and coping with the subsequent dependence and addiction resulting from disruption of the stresses of a chronic disease illustrate how difficult changing human dopamine neurotransmitter system. behavior is. By altering neurotransmission, addictive drugs produce effects that make people want to continue to abuse them and induce The brain is a hugely complex organ. Its complexity will prompt health problems that can be recurring and long-lasting, with profound scientists to continue their work for many years. It is anticipated that, consequences. The effects are drug-specific and each drug disrupts at some point, they will answer questions about what happens in the particular neurotransmitters in particular ways. brain to cause addiction, which will then help them understand how to prevent the disease. Scientific research has transformed how drug addiction is treated. Researchers seek to understand how drugs impact neurotransmission

References ŠŠ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ŠŠ The Brain: Understanding Neurobiology Through The Study of Addiction: Neurons, Brain ed.). Arlington, VA: American Psychiatric Publishing. Chemistry and Neurotransmission Lesson 2 (NIDA, 2004) ŠŠ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders ŠŠ The Brain: Understanding Neurobiology Through the Study of Addiction; Lesson 1~ The Brain: (4th ed., text rev.). Washington, DC: Author. What’s Going On In There? (NIDA) 2004, Compiled and edited by: Deborah Shrira Dated: January ŠŠ Biological Psychiatry 69(7):708–711, 2011. http://www.sciencedirect.com/science/article/pii/ 25, 2001, Asst. Editor: Dee Black Updated: March 16, 2012. S0006322310007584 Overexpression of the glucocorticoid gene in the first weeks after birth ŠŠ The Brain: Understanding Neurobiology Through The Study of Addiction Lesson 4~Drug Abuse and increased anxiety and response to cocaine in adulthood. November 29, 2012, Sharon Reynolds, Addiction (NIDA 2004), Compiled and Edited By: D. Shrira Updated: 9 Jan 2007. NIDA Notes Contributing Writer ŠŠ The Brain: Understanding Neurobiology Through The Study of Addiction Lesson 5~Drug Addiction Is ŠŠ Brown, M.T.C., et al. Drug-driven AMPA receptor redistribution mimicked by selective dopamine A Disease So What Do We Do About It? (2) WHO/UNODC/UNAIDS position paper; Substitution neuron stimulation. PLoS One. 5:12: e15870, 2010. http://www.ncbi.nlm.nih.gov/pmc/articles/ Therapy In The Management of Opioid Dependence and HIV/AIDS, NIH/National Institute on Drug PMC3013137/pdf/pone.0015870.pdf, Riegel, A.C., and Kalivas, P.W. Neuroscience: Lack of Abuse 2004, Compiled & Edited By: D. Shrira Dated: January 12, 2007, Asst. Editor: Dee Black inhibition leads to abuse. Nature 463: 743–744, 2010. http://www.nature.com/nature/journal/v463/ Updated: March 16, 2012 n7282/full/463743a.html like opioids and cannabinoids, diazepam and other benzodiazepines take ŠŠ Understanding Addiction (Addiction Science Research and Education, College of Pharmacy, The the brakes off activity of dopamine-producing neurons. April 19, 2012 by NIDA Notes Staff University of Texas ) (Permission Granted). ŠŠ Kober, H., et al. Prefrontal-striatal pathway underlies cognitive regulation of craving. Proceedings ŠŠ The Brain: Understanding Neurobiology Through The Study of Addiction: Neurons, Brain of the National Academy of Sciences 107(33):14811–14816, 2010. http://www.pnas.org/ Chemistry and Neurotransmission~ Lesson 2 (NIDA 2004), Deborah Shrira, Editor 2008 August. content/107/33/14811.full.pdf+html ŠŠ Wee, S., et al. Novel cocaine vaccine linked to a disrupted adenovirus gene transfer vector blocks ŠŠ Kober, H., et al. Regulation of craving by cognitive strategies in cigarette smokers. Drug and cocaine psycho-stimulant and reinforcing effects. Neuropsychopharmacology [Epub ahead of print Alcohol Dependence 106(1):52–55, 2010. September 14, 2011]. ŠŠ Neurons and Neurotransmitters: The “Brains” of The Nervous System (Permission Granted) http:// ŠŠ Wei, Q., et al. Early-life forebrain glucocorticoid receptor overexpression increases anxiety www.utexas.edu/research/asrec/neuron.html. Compiled & Edited By: D. Shrira Dated: 6 January behavior and cocaine sensitization. BiolPsychiatry 2012;71:224–231. http://www.ncbi.nlm.nih.gov/ 2007 pubmed/21872848 ŠŠ Stowe, G.N. et al., A vaccine strategy that induces protective immunity against heroin. Journal of ŠŠ Whitten, Lori, NIDA Notes Staff Writer April 19, 2012, Whitten, Lori, To Block the Effects of Medicinal Chemistry 54(14), 5195–204, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21692508 Abused Drug, NIDA Notes, September 17, 2012. ŠŠ The Brain: Neurotransmitters Send Chemical Messages, Understanding Addiction ( Permission Granted) http://www.utexas.edu/research/asrec/synapse_m.html, Compiled & Edited: D. Shrira Updated: 8 January 2007.

Page 131 SocialWork.EliteCME.com Understanding Neurotransmission and the Disease of Addiction Final Examination Questions Select the best answer for each question and proceed to SocialWork.EliteCME.com to complete your final examination.

1. Alcohol related deaths are the ______leading preventable 7. Addictive drugs cause long-lasting changes in the: cause of death in the United States. a. Limbic system. a. Number one. b. Reward system. b. Second. c. Vertical system. c. Third. d. Vascular system. d. Fourth. 8. Overexpression of the glucocorticoid gene in the first weeks after 2. After taking drugs for a period of time, a person may need to take birth increased: a higher dose to have the same feeling or “rush” that he or she did a. Lethargy and response to smoking in adulthood. when first taking the drug. This is called: b. Anxiety and response to cocaine in adulthood. a. Tolerance. c. Anxiety and response to Xanax in adulthood. b. Craving. d. Lethargy and response to alcohol in adulthood. c. Addiction. d. Dependence. 9. The drug-related mechanisms producing cumulative changes in neurotransmission: 3. Synapses are also called: a. Are always genetic in nature. a. Intercellular gaps. b. Are concentrated in the right brain hemisphere. b. Trackers. c. Are concentrated in the left brain hemisphere. c. Electrical activity. d. Are sometimes genetic in nature. d. Glials. 10. In many ways, relapse should be thought of as: 4. The brain of an adult human contains: a. A normal part of the recovery process. a. Thousands of cells. b. An abnormal part of the recovery process. b. Billions of cells. c. Almost never happening. c. Millions of cells. d. A normal part of life. d. Trillions of cells.

5. The neuron is the functional unit of the: a. Endocrine system. b. Limbic system. c. Nervous system. d. Glial cells.

6. Some drugs increase dopamine by preventing dopamine reuptake, leaving more dopamine in the synapse. An example is the widely abused stimulant drug: a. Cocaine. b. Xanax. c. Benedryl. d. Codeine.

SWFL04UN17

SocialWork.EliteCME.com Page 132 Chapter 9: The Use of the Internet in Therapy: Guidelines and Best Practices 4 CE Hours

By: Leah Walker, Ph.D., LMFT

Learning objectives ŠŠ Define the key areas of controversy over online therapy. suffering through an adjustment disorder, in part triggered by the death ŠŠ List the major types of online therapy modalities. of her mother. Craig has been pleased with Geneva’s progress and ŠŠ Explain the findings of at least two studies on the efficacy of believes her case will soon be closed successfully. online therapy. Bob ŠŠ Identify the findings of two studies comparing outcomes of online Bob is a 36-year-old man on disability for a long history of alcoholism. to face-to-face therapy. Bob has been hospitalized seven times since the age of 18 for suicide ŠŠ List at least two benefits perceived by patients in online therapy attempts and severe depression. He has been noncompliant with settings. several psychiatrists regarding medication over the years, and he ŠŠ Describe two complaints that patients have had about online tends to only go into counseling during times of acute crisis. Bob was therapy. having issues with transportation, as his license is suspended because ŠŠ Discuss two benefits to online therapy as perceived by therapists. of two DUIs. Bob had heard of Craig, a counselor who provided online ŠŠ Explain the biggest frustration that therapists have regarding therapy, and Bob thought that he wanted to try this type of therapy, so online therapy. that he wouldn’t have to hassle with taking the bus to appointments. ŠŠ Define the ways in which distance creates unique ethical In addition, Bob had been feeling suicidal a great deal lately, and had dilemmas. made a plan to overdose on his mother’s pain medication. He wanted ŠŠ List at least three ways therapists can protect clients and to talk to someone about feeling suicidal. themselves in online situations. ŠŠ Be able to define at least three common themes in all the Craig evaluated Bob, and did not agree to provide online therapy professional codes of ethics. to him. Craig felt that Bob’s current suicidal ideations, which ŠŠ Explain two suggestions for practice that can overcome some of included having a plan to kill himself, combined with his history of the inherent issues in online therapy. noncompliance, numerous hospitalizations, and long mental health and substance abuse history, would be better served in face-to-face therapy Geneva in a local clinic specializing in treating dually diagnosed persons and Geneva is a 42-year-old woman who lives in a rural area of Montana. those with long-term psychiatric issues. He arranged to have Bob Geneva has been struggling with what she believes is depression for taken to the local emergency center for an evaluation, based on his several months. She was crying frequently, had trouble sleeping, and concerns about Bob’s suicidal thoughts and plans. Bob was admitted to lost her appetite. Her mother died recently, and this event, combined the local crisis stabilization unit for 3 days, and followed up with the with her divorce 2 years ago, made life harder to manage recently. local clinic. Geneva wanted to talk to a counselor, but the area in which she lives has only one counselor within 100 miles of her home. Her pastor These two cases represent two ends of the possible spectrum of people had counseled her, but felt he is not able to help her further. At his who seek to participate in online therapy. Obviously, they are the types suggestion, Geneva went on the internet and found a social worker of cases in which it is fairly clear if they can be treated through online who offered online counseling. Geneva decided it might be a good services. Many of these cases, however, fall in between these two idea for her to try. She called and scheduled a telephone appointment types of situations, and the appropriateness of participation in online with Craig, a licensed clinical social worker in the state capitol. Craig therapy is less clear. asked her numerous questions, and screened Geneva at length to Overall, the majority of therapists are not providing online services. ensure she was not suicidal. Geneva has been working with Craig in Prabakhar (2012) noted that only about 2% of counseling professionals weekly online sessions, and has also been doing workbooks online for surveyed were providing the service. However 60% of counselors cognitive behavioral therapy (CBT) for depression. Geneva has begun wanted more information about doing this type of work. So while there to feel more in control of her depression over the last few weeks, and is a great interest in online therapy, most providers are unsure of how has recommended Craig to several friends. online therapy works, the effectiveness of the approach, especially Craig felt that Geneva was an ideal candidate for this type of therapy. as compared to face-to-face therapy, the benefits and drawbacks, the After carefully evaluating her for suicidality, psychosis, and other ethical situations involved with this form of therapy, and some of the serious mental health issues, Craig determined that Geneva was best practices in the approach.

Controversy over online therapy It can be argued that Freud offered the first recorded incidence of providing mental health services via email, video conferencing, virtual distance therapy, through his exchanges of letters with patients. As reality technology, chat technology, or any combination of these’’ noted by Prabakar (2012), beginning in the mid-1990s, a handful of (Manhal-Baugus, 2001). therapists began experimenting with the idea of online therapy. Today, Barak, Hen, Boniel-Nissim, and Shapira (2008), published a meta- the definition that seems to fit most appropriately is, online therapy is a analysis of online therapy in which they explained the history and form of service delivery by ‘‘a licensed mental health care professional

Page 133 SocialWork.EliteCME.com practice of online therapy. The authors noted that online therapy quality (Hamburger, et al., 2014). Kingsley and Henning (2015) noted has been described as cybertherapy, telehealth, ehealth, and internet that the unreliability of internet connections could force sessions to be therapy. Some therapy programs are self-help, web-based sites in canceled if the power or the internet was out, which could frustrate and which users can log in and complete exercises and workbooks. upset the client. Other times, a provider and patient may exchange emails. Online It is important to note that some types of clients may also not benefit therapy can be provided asynchronously, which means it occurs in a from email interactions. People with low literacy and those who have delayed fashion, such as a patient sending an email, and a therapist limited access to the internet, such as low-income persons who have to answering the email at a later time. Online therapy can also be use public access services may not have adequate privacy (Finfgeld- provided in real-time, or synchronously, such as in the case of using Connett, 2006). a webcam, or instant messaging type of software program for the patient and therapist to interact. The authors note that historically, the In response to these types of criticisms, other researchers presented implementation of this type of therapy was met with great resistance. counter-arguments. Hamburger et al. (2014), noted that while there is The resistance can be divided into four broad categories: certainly concern for the confidentiality and security of information, 1. Concern over the inability of the therapist to see body language, traditional face-to-face therapy has its own problems in this area, facial expressions and the like, as nonverbal communication was and breaches of confidentiality and improper releases of information considered to be of extreme importance in therapy. occur in these settings as well. Furthermore, in relation to therapeutic 2. Concerns over privacy – including computer hacking of emails, relationships, it is suggested that an online therapeutic setting may webcam transmissions, and websites – that could expose an actually lead to more openness and a faster therapeutic alliance as not individual’s secrets, as well as concerns over the safety of patients having to be face-to-face with a therapist can actually reduce anxiety in crisis. about disclosure (Amichai-Hamburger & Barak, 2009). Hamburger et 3. Concerns that technology was outpacing both the law and the al. note that the assessment and planning of how to handle a patient in ethics of this type of therapy. Without a firm ethical understanding crisis is not that different than it is in traditional settings. The authors of online therapy, licensing and professional boards were argue that with the use of proper assessment, and taking steps to insure concerned as to how to guide therapists into unknown territory, that therapists have client’s location information and information and there were no laws to govern such issues as crossing state lines regarding resources where the client is located, the problem of suicide for service delivery. is not as hard to deal with as some researchers would claim. 4. Concerns over the lack of qualifications and training for therapists In issues of transference, Hamburger et al. (2014) make a persuasive providing online therapy. argument that resistance occurs in online therapy and not just in face- Other researchers voiced additional concerns, noting that the distance to-face therapy. Furthermore, in citing the work of Scharff (2013), involved would make it easier for a client to terminate therapy. they note that transference, countertransference, and other aspects Furthermore, there were beliefs in the therapeutic community of the therapeutic relationship still occur in online settings. “Those that the physical distance would also prevent the formation of welcoming etherapy believe that resistance in psychotherapy via the transference from the client’s unconscious to the therapist, as well internet may take both similar and/or different forms from that of face as countertransference from the therapist to the client (Ragusea & to face psychotherapy. Examples of resistance may be forgetting to go VandeCreek, 2003). Some studies also presented concerns about the online/call, speaking softly, not using a headset, moving away from technology itself, such as having the power going out in the middle the microphone, accepting other calls, and chatting as if on a social of a critical point in a session, or dealing with poor video or audio call, in addition to silence, hesitation, coughing, lateness, nonpayment, displacement, and so on” (p. 289).

How does online therapy work? Barak, Klein, & Proudfoot (2009) attempted to explain the different per week. The authors noted an example of a highly interactive site, types of online therapy. They stated that “web-intervention” is the PTSD Online, which is a CBT program treating those persons with best term to use, as it incorporates a variety of service types. They posttraumatic stress disorder (PTSD) in a format with a high level of described a web-based intervention as, “a primarily self-guided therapist support and multimedia features that are highly interactive. intervention program that is executed by means of a prescriptive The authors cite some recent research that indicates that overall, the online program operated through a website and used by consumers therapist-supported online therapy may be more effective than the seeking health- and mental-health related assistance. The intervention self-guided programs (Barak, Boniel-Nissim, & Shapira, 2008; Spek, program itself attempts to create positive change and or improve/ et al., 2006). enhance knowledge, awareness, and understanding via the provision The approaches vary amongst the various models. For example, in of sound health-related material and use of interactive web-based one program for social phobia, which is self-guided, a user logs in components” (p. 5). They further noted that web-based interventions and is directed to a “contact” module in which the therapist has left can be subdivided into three categories: 1) Self-help, 2) self-guided, information about him/herself and invites the participant to contact and 3) therapist-supported. him/her. The therapist responds within 3 days of receiving the email. Self-guided interventions utilize sophisticated software and some are Therapists were also required to send each client an email each week highly interactive, providing multimedia applications and immediate with motivating messages. Other parts of the program included an feedback. The individualization provided varies depending on the interactive guide with 57 different websites of five pages each. The complexity of the software used. Therapist-supported sites usually progress through the programs is self-guided. The participants are free offer some form of interactive features. Overall, the main focus is on to repeat sessions as they wish. There is also a group area in which direct human interaction, whether it occurs from instant messaging, clients can share experiences with others in the program. It is designed email, Skype, or webcams. The quickness of responses from the to last 10 weeks. therapist can vary from immediate to days, depending on the format Participants are educated about social phobia and asked to complete of the site. Other forms of interaction can include group chat rooms such exercises as ranking how high their anxiety is during various or group bulletin boards where users can post messages and receive activities. For example, if they were to be engaged in public speaking, replies from others as peer support. The amount of time spent how high would their anxiety be on a scale of 1 to 10? Throughout the interacting with the therapist varied from a few minutes to a few hours program, assessment and exercises like these are used and feedback is

SocialWork.EliteCME.com Page 134 given to the participants. The participants also keep a behavioral diary. For anyone who has provided this type of therapy, the steps are very They are encouraged to plan in vivo exposure exercises and follow familiar. The key difference is that it is done at a computer without the through with them. Then participants report about the experience. The therapist sitting in the same room. However, the behavioral diary, the participants are then taught to decrease negative self-talk. Each section change of negative self-talk, and gradual exposure in vivo is the same builds upon the next (Berger, Hohl, & Caspar, 2009). format as regular CBT.

Does online therapy work? Early studies on the efficacy and satisfaction with online therapy Another meta-analysis of internet CBT indicated that the approach was produced mixed results. The authors noted that some studies found that effective in working with anxiety disorders, as well as depression. The online and face-to-face therapy were found to be very comparable in patients reported high levels of satisfaction, and the outcome of the patient satisfaction and outcomes. There were some studies that found reduction of symptoms was significant (Andrews et al., 2010). certain aspects of online therapy, such as the therapeutic alliance, to Online treatment has also been found to be effective with such be inferior to face-to-face therapy. Some patients expressed concerns diverse issues as social phobia. In a study conducted by Berger, over privacy, but liked the convenience of not having to attend Hohl, & Caspar (2009), adults were treated through online treatment appointments. However, Barak et al. (2014) noted that the studies with minimal phone contact provided by a therapist. In comparing varied tremendously in how online therapy was evaluated. They outcomes with the control group, with the control group members observed that many of the studies focused only on one diagnosis, such being placed on a waiting list, those in the participation group had as depression or anxiety, and many studies only examined one specific significantly better outcomes. This does at least show that online type of service delivery. treatment was better than not having treatment. There have been many studies examining the efficacy of online In 2015, the American Psychological Association (APA) noted treatment for a variety of psychiatric diagnoses. One approach, self- that online therapy is available for numerous conditions, including guided CBT, has been studied extensively. Internet CBT has been depression, anxiety, schizophrenia, smoking cessation, diabetes found to be effective in persons with PTSD. Ivaarson et al. (2014) management, panic disorders, health promotion for weight loss, and studied a group of Swedish adults who met the diagnostic criteria adherence with antiretroviral medication. The APA refers consumers to for PTSD. The participants were assessed and provided the internet- the research studies regarding the effectiveness of these treatments and based treatment for PTSD. The participants did show significant cites numerous articles outlining the efficacy of online therapy. improvement over the control group, both immediately after treatment, and at the 6-month follow-up evaluation.

Is face-to-face therapy more effective? The comparison of face-to-face and online therapy is still in the early behavioral health diagnoses. In therapeutic approaches, the authors did stages of research. One of the most comprehensive studies to date, find support that CBT was the most effective form of online therapy. Olthuis, Watt, & Stewart, 2011, argued that there were simply not Furthermore, no differences were found in the efficacy of web-based enough studies to effectively and fairly compare the two forms of interventions versus those approaches that used interactive approaches treatment. However, the studies currently available have not found between patient and therapist. any real differences in the outcomes for patients (Andersson, Cuijpers, However, some recent studies have indicated that periodic phone Carlbring, Riper, & Hedman, 2014). Another study of online CBT had contact with a therapist did not increase the adherence to the online similar findings. In this study, patients were treated for either PTSD treatment in any significant way (Berger et al., 2012). Other studies or depression. The patients followed a manualized treatment program have shown than when used with a specific form of coaching, and aside from an initial telephone screening, they completed their it increased adherence to online treatment and resulted in better assessments and workbooks online, and exchanged emails with their outcomes (Mohr et al., 2013). Mohr and his fellow researchers found therapists. The outcomes over a period of several months were found that in working with persons who had a diagnosis of major depressive to be comparable to another group of participants who received the disorder, their model, called TeleCoach, did show significantly lower same therapy in a clinic face-to-face with a therapist. Overall, about rates of dropout than those not receiving TeleCoach. TeleCoach 80% of patients felt satisfied with the treatment and their therapists, involved having a therapist make a weekly phone call to the program and would recommend the online therapy to a friend. However, participant to develop a supportive relationship, reviewing goals 30% of patients did state that they would have liked to have had for participation in the online program, positively reinforcing using face-to-face contact with the therapist. Andrews et al. (2010) noted the site, and encouraging the participants to stay with their goals. that in comparing online therapy with face-to-face therapy using the Therapists were also allowed to discuss the technical aspects of CBT model for persons with anxiety and depression, there were no using the online program, but were not allowed to do any type of significant differences in outcome or patient satisfaction with the two therapy over the phone to ensure that the actual therapy was only types of treatment (Ruwaard, et al., 2012). occurring online. However, as in the previously cited study by Berger In treating panic disorders, Kiropoulos et al. (2008) found that online et al. (2012), the improvement in symptoms did not differ between therapy was just as effective as face-to-face therapy. O’Reilly et al. participants who had TeleCoach and those who did not. So it appears (2007) also compared video therapy to face-to-face therapy for a group that while there is no difference in effectiveness of the treatment in this of clients with a variety of psychiatric disorders. The study showed approach when the therapist provides telephone support, the program that the two groups were equivalent in both patient satisfaction and participants are more likely to finish their treatment with the telephone clinical outcomes. support. Barak et al. (2007) in their meta-analysis of online therapy, noted that overall, in the numerous studies they reviewed, the effectiveness of online therapy was equal to face-to-face therapy for a variety of

Page 135 SocialWork.EliteCME.com Perceived benefits by patients In addition to measurable outcomes of effectiveness using online (laughs) that there are studies that show that it is not always that big therapy, it is also important to consider the patient’s perceptions of this a difference when you assess it, so it is simply relative, that . . . we form of therapy. Participants often note that convenience of therapy who go for both parts, we might experience a greater difference than was a reason they liked online therapy. They stated that the ease of patients who only experience the one” (p. 475). Another important access made them more able to actually start working on their issues. consideration of patient satisfaction with the online therapeutic bond is One participant noted that in using MoodGym (an online self-help the patient themselves. The type of patients who want to participate in program for depression), “working with MoodGym, the best thing online therapy may be happier with the alliance that forms because the about it all was that I was doing something about it. You know, coming patient selects the online therapy (Bengtsson, Nordic, and Carlbring, to these sessions every week, getting to talk, starting the next chapter. 2015). You know, the things I worked with did not suffice, but I felt good Another plus is easier accessibility to services for clients with physical working with it. I felt sort of like I was getting out from getting back illnesses or disabilities that keep them from being able to leave home to normal.” The researchers noted the ability to start treatment quickly, easily to attend traditional office-based servicesHertlein, Blumer, rather than waiting for an office appointment, also kept participants & Mihaloliakos (2013). The APA also cited this as one of the major motivated once they decided to start treatment (Lillevol et al., 2013). reasons that clients often prefer online therapy, as they do not have to One recent study of college students noted that among the reasons worry about traveling to an office, missing work, and can just log on they liked online therapy was the convenience and accessibility. Some to a computer (APA,2016). Another group of people that prefer to seek admitted that if they had had to go to an office, they would have online services may be those who have trouble leaving the home and missed the sessions due to not wanting to get out of bed and feeling getting to appointments due to their responsibilities with childcare and/ too stressed to leave home. This particular study examined an email- or eldercare (Pollock, 2006). based therapy approach, rather than a website where the participants There is a definite advantage for those who live in rural areas to logged in and thus, the participants developed an ongoing therapeutic participate in online therapy, as they have access to services that would relationship with a provider who exchanged emails with them. In not be available otherwise. As noted by the APA (2016), psychologists addition to convenience, another added benefit for the college students are relatively rare in remote areas, and patients may have to drive was being able to receive ongoing support during spring break and hours to reach the nearest provider, which simply is not feasible for Christmas break when they left campus and would not have been able everyone. In addition, even those who live in more populated areas to have attended therapy in a traditional setting (Mishna, Boggs & may not have easy access to a specialist for their particular clinical Sawyer, 2013). needs, and through online therapy, they have access to specialized Other participants in the Mishna, Boggs and Sawyer study also noted services without having to travel (Rummell & Joyce, 2010). Pollock that they felt more comfortable disclosing certain issues online that (2006) also notes that gay and lesbian couples who live in rural or they might have otherwise have avoided discussing in a face-to-face remote areas may also have difficulty finding a therapist open to setting. Some participants also felt that writing out their emotions and treating gay couples. issues made it more real, noting that they would reread their emails Furthermore, Shaw and Shaw (2006) noted that some who are and this made the situation more real to them, noting that in traditional reluctant to seek mental health services in person are more willing to therapy, they would speak and then forget about their issues after engage in what they perceive as the safety of online therapy. Mishna, the session. One participant was quoted as saying, “cyber was very Boggs, & Sawyer (2013) noted that many of their participants cited profound because it’s one thing to talk about it, but it’s almost like it that having some distance between themselves and the clinician doesn’t exist, it’s hypothetical. But when you’re reading something made it more comfortable to discuss certain issues via email that and it’s either on the screen or on the paper, which almost makes it they otherwise might have not spoken about face-to-face. This is also more legitimate. You can’t run away from it, it’s like in your face kind echoed in the study by Bengtsson, Nordin, and Carlbring (2013) in of thing versus when you’re talking to someone and you can tune out, which a therapist noted in working with patients with social anxiety, you can check out” (p. 174). “I think that many times, for some patients, it can be an advantage that The authors noted that as is common in younger people, college you have not . . . met live because it feels a little more threatening and students may be particularly responsive to online therapy due to revealing to sit face-to-face and tell someone things that are shameful, their constant use and familiarity with the internet and social media. anxious” (p. 475). Likewise, participants in another study noted that Overall, participants stated they felt a strong emotional connection being somewhat anonymous helped increase their disclosure (Beattie, to their therapists, despite not having a face-to-face relationship. Of Shaw, Kaur, & Kessler, 2009). course, as these participants were college students who are more When looking at the perceived benefits of online therapy, it is also comfortable with the internet and are used to communicating with important to note how the expectations of online therapy met the peers via social media and numerous chat applications, this may experiences of those participants. One recent study explored what a predispose them to feel a bond through a media connection. Therefore, patient initially expected of online CBT and how those expectations it is somewhat difficult to assume that older people would feel matched the outcomes of the actual process. A sample of expectations the same way about online therapy, particularly if they do not use was: computers routinely. It may not be possible to generalize these findings a. “I don’t think you would get the same feeling as if you were to older adults who may not be used to such forms of communication one-to-one in a room. You get more, you get to know the other on a routine basis (Mishna, Boggs, & Sawyer, 2013). Indeed, older person, so in a way you would. To me it would be like talking to a people’s frustration with computers was noted in one recent study machine” (P21 Pre, female, 50–59, completer, 10 sessions). (Beattie, Shaw, Karr, & Kessler, 2009). b. “It’s perhaps more difficult for them to offer the right advice The lack of face-to-face contact may not be a problem for some because they’re not seeing you. I see that is perhaps the one participants because of another factor. Bengtsson, Nordin, and disadvantage” (P19 Pre, male, 60–69, completer, 10 sessions). Carlbring (2013) also noted that a reason clients may be happy c. “I don’t know…I’ll be nervous…it’ll be strange…I suppose it’ll be with the therapeutic alliance in online therapy is due to a lack of just like talking to someone you don’t know…Well, people could comparison. A therapist is quoted as saying, “I experience that you not tell, say how they really feel. If you’re with someone one- get a stronger alliance in face-to-face, but at the same time I know to-one, say yeah, like now and I said something and you thought

SocialWork.EliteCME.com Page 136 well, you could tell really if it was bothering me or if, if I just said c. “I don’t honestly think I could have sat down with someone that because I didn’t want to talk about things And maybe you and talked to them face-to-face, I don’t think I’d have had encourage me to talk about it more, whereas maybe on-line I could the confidence to do that. I’d talk to them but I think I’d have just say, ‘Oh, I don’t want to think about that.’ And the person expressed what I express on a computer, having the therapy on on the other end wouldn’t really, really know” (P20 Pre, female, there. So I don’t think it would have worked as well because I 20–29, withdrew from therapy, 2 sessions). wouldn’t have been as honest with them” (P2 Post, male,30–39, d. “There might be some issues of trust, with people feeling, you completer, 9 sessions). know, that they’re not really talking to a psychologist if they can’t d. “I enjoyed the anonymity. You know, I think it was, to start off see them” (P12 Pre, male, 30–39, completer, 10 sessions, no post- with, but come the end, it didn’t worry me. It didn’t worry me, therapy interview). because I, I didn’t feel it was anonymity come the end. I thought e. “I’m actually excited that there might be something that might I knew [psychologist’s name], I thought I knew the lady that I do something for me, that I can actually commit to, because I can was talking to, you know, as if I was talking to her one-to-one, commit to it, if there’s nobody, if I don’t have to face someone face-to-face, that’s what it felt like. I didn’t feel like I was typing then it’s easier to commit to, and it’s easier to be honest as well things on a computer, you know, it didn’t feel like that at all, and because you’re not, you know, if you say something to someone’s I’ve never done that before on a computer; talked to anybody on, face and it’s something really personal that you care about, you on a computer like that and yeah, it was, it was okay” (P16 Post, know, whether you know you’re doing it or not, the way they female, 40–49, completer, 10 sessions). react will probably frame and what you say afterwards. You might e. “I’m not sure there was a relationship. And that, because of that, modify what you’re saying without knowing it” (P4 Pre, female, part of the reason for that was the lacking the face-to face, it’s 40–49, withdrew from therapy, 1 session) (p. 50). like having a telephone conversation isn’t it? You don’t have the After coming in for services, a posttreatment evaluation was same closeness as you would meeting somebody round a table, completed. The participants noted that some of their fears were it’s inevitable. And that, that’s got to impact on the benefit of the unfounded and they developed a relationship with their therapists, therapy…I didn’t build a relationship with him” (P19 Post, male, and others noted that not seeing the therapist made the process easier. 60–69, completer, 10 sessions). However, some quit due to feeling that the process did not feel f. “I didn’t feel comfortable with it. I think that what I need, or comfortable for them and they did not feel a bond with the therapist. what I needed was to talk to someone one-on-one rather than talk a. “After a couple of sessions when it felt dry and then starting through a machine…I could see the idea of it, and I think it’s a to feel that it was fluid, but I don’t think that’s to do with the good idea but I personally didn’t feel comfortable with it…the medium, I think that’s actually just to do with communicating idea I think is good. But it wasn’t for me” (P24 Post, male, 50–59, with someone there…We had built a relationship. It took a while withdrew from therapy, 6 sessions). but yeah, I was pleased with the way things were going at the g. “I don’t know if it would have been the same if I’d been face- end. Yes, it was a bit difficult at first because you know, it’s … to-face with the same person. And that’s nothing against her you’re just communicating with a computer and you don’t know [psychologist] it’s just sometimes you can’t always relate the person at the other end, who you’re communicating with... I to everybody and I don’t know if it was that, or if it was the was emailing, and I had a picture of somebody else in my mind computer, I honestly don’t know” (P20 Post, female, 20–29, and I was convinced I was talking to somebody else, so you know, withdrew from therapy, 2 sessions). you’ve got that potential, sort of trying to get over that sort of not h. “Are they concentrating on what you’re saying? Are they focusing knowing, but I guess, given the constraints and the fact that the really on what you’re saying or are they doing something else… persons not there, it was, it worked I would say, yeah” (P14 Post, are they on the telephone, having a cigarette, maybe not taking me male, 30–39, completer, 10 sessions). seriously” (P5 Post, female, 20–29, withdrew) (p. 51). b. “I was surprised, I felt as though it was flowing quite well, which In these cases, certainly some participants did not feel that online I didn’t think it would. And I warmed to him [psychologist], you therapy was right for them. They were displeased with the process know, straight away, you can do that over the internet…I think and usually chose to quit. So at times, there can be negative outcomes you could build up a good relationship over the internet, I was associated with online therapy. quite surprised” (P1 Post, female, 40–49, withdrew from therapy, 2 sessions).

Negative outcomes The use of online therapy is not recommended for all types of would also have occurred for these patients in a face-to-face treatment patients, and there have been a few studies that have examined setting, based upon their particular needs and issues. Some patients got negative outcomes for those who have participated in online therapy. worse and some had other life events that complicated their treatment, Notably, Rozental, et al. (2015) did find that about 9% of participants but this is no different for online therapy than for any other treatment reported negative experiences with online therapy. Some of the setting. The participants noted that some of their worsening feelings negative feelings about the experiences stemmed from frustration while participating in therapy were caused by various life events, with technology. Failure to be able to easily log in and navigate and they did not ascribe their worsening symptoms or more negative the sites made patients feel incapable of handling a simple task, feelings to the therapy. Some patients in the study also reported which reinforced the negative feelings they had about themselves. frustration with the rigid approach in the manualized treatment and felt Others reported that their negative feelings resulted from not having pressured to complete the assignments too quickly. For some people, therapeutic support adequate for their needs. Some stated that the the pressure may be too much, and as the authors noted, this failure to program did not incorporate enough therapeutic support, and others complete the program in a timely fashion made them feel even more stated that they felt the therapist who provided the support did not do negative about themselves. One participant noted that he knew he an adequate job. could never finish in the allotted number of weeks, and this made him The resulting frustrations resulted in greater feelings of sadness and feel worse about his already problematic procrastination. The authors distress than before beginning the treatment. However, the authors suggested that therapeutic support is a valuable tool to help patients noted that it is impossible to tell if some of these negative feelings feel supported, motivating them and encouraging them to finish if they

Page 137 SocialWork.EliteCME.com were procrastinating, and provided competent technical support to of the therapist to ensure the therapist was really engaged in their ensure clients could navigate the sites without feeling so frustrated. treatment. During the lag time after their emails were sent and were Beattie, Shaw, Karr, and Kessler (2009) also noted that for some being read by the therapist, these patients stated that they wondered depressed persons, some of the inherent issues in online therapy what the therapist was actually doing. They wondered if the therapist actually reinforce their depression, due to their tendency to go quickly was doing something else, or taking a break. Other patients reported into negative self-talk. When these patients could not visually see a that having to wait for a therapist to respond was wasted time and therapist, they felt the therapist was lacking in commitment to their during the lag, they would lose focus or motivation to work on their case. They complained about not being able to read the body language issues.

The therapist’s perspective tost of the research regarding online therapy has been from the automated reminders for clients to complete assignments or email their patient’s point of view. However, the therapist’s perspective is a therapists. Furthermore, the therapists felt they were also able to reach vital aspect of the process. One recent study, Bengtsson, Nordin, and more people and provide more help than they could seeing all the Carlbring (2013), focused specifically on the use of CBT and how patients face-to-face. therapists felt the experience of online therapy compared to doing Furthermore, counselors in other studies had noted that online therapy CBT face-to-face. The therapists in this study provided therapy is easier to do with some patients. For some patients, email and written through email and the use of a manualized CBT approach. The patients communication works better than face-to-face communication, such as they treated had diagnoses including PTSD, eating disorders, and in the case of clients who tend to not be very verbal (Fantus & Mishna, depression. All therapists had extensive experience in CBT, both face- 2013). to-face and online, and were thus well qualified to compare the two types of service delivery. In terms of the negative feelings about online therapy, most of the therapists in the study by Bengtsson, Nordin, and Carlbring (2013) Several themes emerged from the qualitative study. Overall, therapists felt that the therapeutic alliance was not as strong for online therapy found that in some ways, online therapy was less frustrating, because as face-to-face therapy. Their main concern was not being able to read they did not have to deal with clients cancelling sessions, as they did in body language, such as gestures and facial expressions. One therapist face-to-face therapy. In addition, some of the therapists cited that face- described this feeling, “in some way maybe it is easier (to create a to-face therapy often resulted in being more emotionally drained, and working alliance), that is, when you are sitting in the room, because that online therapy freed them somewhat from this potentially negative you have access to the body in some way. And then you have gestures outcome. One therapist noted, “I think that is has been both, well, fun and like . . . yes, but, facial expressions and gaze” (p. 474). and occasionally also very, like, demanding. Similar concerns were cited by other therapists in other studies as You feel very much well. “Yeah, I felt more uncomfortable trying to gain control. Like it less burdened by was harder for me to say, ‘Stop, let’s go back to this.’ I know that I (ICBT) than in regular feel more comfortable saying it face-to-face, because at least I would outpatient care. It does be able to show that I was more interested. But online, you know, that not get as, like . . . could come across that I was upset, or that I was being rude, or that I heavy in the moment, was, you know, just being different” (Haberstroh, et al., 2008, p. 465). as it can get when Despite their feelings that the alliance was not as strong, Bengtsson, you are sitting with Nordin, and Carlbring (2013) noted that the therapists still felt that someone who become online therapy was just as beneficial for their patients. Some expressed like that really sad or surprise that the alliances formed were much stronger than they had really angry or dissatisfied or – you become protected by the screen in originally expected before providing online therapy. some way” (p. 473). Another positive finding in online therapy was the perception by the Other therapists felt that online therapy protected them from burnout therapists that in online work, the focus really remained on the therapy as illustrated in this statement, “I think it is good that you, you are itself. One therapist stated, “There is more focus on me, that is also... protected and you will last a little longer and you do not get tired and uh, could actually be a disadvantage in live therapy, that there is less you will not, like, you will not be negatively impacted. Uh, you do not focus on the therapy. Progress is also attributed more to me as therapist get run down. I think you will last longer as an internet therapist” (p. than to the therapy itself and what the patient does” (p. 473). 474). Mishna, Boggs, and Sawyer (2013) noted in their study that social The reasons given for the preference for online therapy also go beyond workers reported some frustration with the format of online therapy, the positive effects that occur from the therapy itself. Other benefits stating that they felt they missed experiencing certain emotional events of the online format include not having clients getting frustrated by simultaneously with a client, which could cause a disconnect in their having to coordinate hectic schedules, especially for those therapists therapeutic alliance with the patient. One provider noted that she who provide couple or family therapy involving multiple parties. received an email detailing a very positive experience that a client had, Therapists also reported liking the ability to have more control over and while she was happy for the client, she really wished she could their schedules. They noted that the online therapy approach enabled have experienced the client’s feelings of satisfaction and happiness them to choose when they wanted to work. For example, it was easy in the moment with the client, rather than reading about it later. It is to rearrange their schedules as needed and check client’s progress at interesting to note that the social workers in the study were master- different times then they had originally planned. Some of the therapists level interns, and most were quite young, so their experiences might who had family responsibilities noted that it was an advantage over differ from those of more experienced therapists. Even though they face-to-face therapy if a child became ill, so instead of having to lacked the experience of having done much face-to-face therapy and cancel a full day of booked clients, they could just log on later in the are more comfortable with computerized communication, they cited day. The online format also enabled the therapists to easily have a many of the same feelings about not having the face-to-face experience colleague take over cases in the event of an emergency. In addition, as older, more experienced therapists in other studies (Bengtsson, the website did some of the work for the therapists, which included Nordin, and Carlbring, 2013).They did feel they were missing the

SocialWork.EliteCME.com Page 138 chance to view body language and gestures, and worried they were Technology could also prove to be a frustration for therapists. In this missing something in the therapeutic alliance. On the positive side, the same study, a therapist explained her experiences with a patient who social workers liked to be able to reread emails from the patient and had little computer knowledge and experience stating, “It hasn’t gone this helped them think more about which interventions were best, as anywhere. I still feel like we’re on the first session. We had one full well as reread their own responses to the patient. They felt this was a hour, before that it was sporadic. I still feel like we are on the first good learning tool for them as emerging clinicians. Another interesting session. I feel like I really don’t know a lot about her. She called my finding was that while the social workers were concerned they did not cell number to tell me she couldn’t get on, and admitted to trying this feel as emotionally connected to the client, due to not seeing the client project to help get better acquainted with the computer. It has been face-to-face, the client did not feel the same way. very frustrating to be there. Now she’s gone. Will she come back? Therapists in other studies have expressed similar frustrations. In Do I need to wait? I was trying last night to help her. I explained Haberstroh, et al., 2008, a therapist lamented that she could not see her that AOL [America Online Service Provider] was not a good way to patient in person saying, “I thought this was different, obviously, not communicate, that explorer [Microsoft Internet Explorer] was better. to even know what she looks like. Just to have no idea. I mean, I do She did get on for about 15 or so minutes. Got bumped and called know that she is female and that’s about it. That’s all I know. I try to again. We got nowhere” (p. 464). imagine someone I’m talking to. That was really hard, because I don’t Overall, the therapists who were interviewed in these studies did want to do that, because I don’t want to stereotype what they look like. feel a certain disconnect from their patients in the online setting, I challenge myself not to assume anything. I think I have a tendency to and did experience some frustration with technology. However, the assume my client is more like me than different from me, if that makes therapists did feel a decrease in the burnout and stress they often felt sense. I do find myself wondering about her appearance, etc. When in face-to-face therapy, and overall they felt their schedules were more she’s telling her story” (p. 464-465). manageable and they could reach more clients this way.

Online couples and family therapy Most of the information explored thus far pertains to individual communication being written down and read by everyone, creating counseling. Online couples and family counseling is an emerging field. less chance for family members to argue over who said what, as often Pollock (2006) was an early advocate for family and couples therapy occurs in live sessions. Furthermore, she found that practices such as being done online. She noted that one advantage of online therapy email communication through a therapist can be a good alternative to was the ability to bring together geographically separated family live sessions for those who are too hostile to communicate face-to-face members into a therapy session that might be otherwise impossible. but who need to communicate with one another. She cites the example She noted that this can be done through videoconferencing, or through of two parents having custody issues as a situation in which the use of synchronous chat rooms, where all the members participate at once. email can be effective. She also believed that emails can be used effectively, especially with

Ethical concerns with online therapy Janet Michael never thought to verify that clients are really who they say Janet has been a licensed clinical social worker for 18 years. She they are. Today, he received an email from Marissa, who told him began providing services online 5 years ago. Janet carefully screens that she felt guilty about lying to him. Marissa admitted that she was her clients and takes only those cases she feels qualified to treat. Janet only 16 years old and lied to Michael when she said she sought online has clear, written procedures explaining online therapy, its benefits, therapy to avoid revealing her sexual issues to her family, which the potentially negative aspects of online therapy, and confidentiality. she was afraid Michael would do since she was a minor. Marissa is Janet worked with a web-hosting company that ensured her that her completely unaware of how much trouble Michael can now be in for site was HIPAA compliant. Janet counsels her patients via email, providing services to a minor without the informed consent of a parent. instant messaging, and sometimes uses phone support. However, in all Michael is panicking and called his attorney to ask how to proceed. of her technical consultations, no one had ever advised Janet to have a Michael is furious with himself for not thinking to verify the client’s series of passwords set up with clients to ensure the client was indeed identity and believed he had covered all his bases related to ethics and the person on instant messaging or email Today, Janet received an regulations. email from John, a client she has been treating online for 3 months for Jackie an anxiety disorder. John discovered that last week, his wife, who was Jackie is a professional counselor who has been providing online aware of the treatment he had been receiving, logged into his account services for 2 years. She has been a counselor for 5 years. Jackie is 29 and not only read the emails from Janet, but also exchanged instant years old and like many people her age, she is savvy in social media, messages with Janet, posing as him, to obtain more information about having accounts on Twitter, Instagram, and Facebook. Jackie is careful what, if anything, John was saying to Janet about their marriage. John to keep her personal and professional accounts separate and labeled is furious, and is threatening to complain to the state social worker clearly. She has received consultation from IT specialists and feels that about the breach of confidentiality. He is also threatening to sue Janet. her site is confidential and HIPAA compliant. She has taken numerous Michael workshops in the provision of online therapy. She also has clearly Michael is a marriage and family therapist who has been treating written policies and procedures to protect herself and her patients. Marissa, a 19-year-old college student, through online therapy and Jackie has been treating Blake, a 28-year-old female. Despite what phone therapy for 2 months. Marissa is from a very religious family Blake has told her about her history with alcohol being very minimal, and has been struggling with issues of sexual identity and whether Jackie became suspicious that Blake was more of a partier than she or not she is a lesbian. Marissa pays Michael via a Paypal account. was letting on. Jackie decided to look at Blake’s Facebook page, which Michael has been careful to maintain privacy and has worked closely Blake had not set up with privacy controls. Just as she suspected, with a company to ensure his website is secure. He also makes Blake was in numerous pictures holding cocktails and looking clients uses a series of password and images to ensure no one is intoxicated. Of course, Jackie is now faced with dilemma of having posing as his client. Michael has policies and procedures regarding information about a client that she cannot confront her with, and she safety, confidentiality, boundaries, and other important ethical and feels guilty about snooping, acknowledged it was a boundary violation, legal considerations that he has clients electronically sign. However, and promised herself to never do it again. Unfortunately, Jackie did

Page 139 SocialWork.EliteCME.com not know that while scrolling through the Facebook page, she had Boundaries are another issue that vary from online therapy to face- accidentally pushed the “like” button on one of Blake’s pictures. Blake to-face therapy. Fantus and Mishna (2013) noted that due to the noticed this and left Jackie an angry message, asking her why she had nontraditional atmosphere of online therapy, face-to-face boundaries been spying on her. Blake told Jackie that she felt violated. She also of office hours no longer exist. As emails can be answered at any time, asked Jackie if she was “being funny or sarcastic by liking the picture some patients may get upset if the provider does not respond right of me drinking?” Jackie is frantic and is calling her attorney for advice, away, not realizing that even though an email can be sent late at night, but also is deeply worried that she will never be able to rebuild her it does not mean the therapist is working at that time. Boundaries and trust and rapport with Blake and feels really awful about what she did. response times should be covered in the initial discussion between These vignettes illustrate the complexities of online therapy and client and therapist. In addition, providers need to be aware that their potential pitfalls, even for therapists who are being careful and have own information is more accessible than ever before, and patients sought technical and regulatory consultation. As the field develops, may become privy to details about the provider’s personal life there will be unforeseen problems. Technology is rapidly growing and through social media. Not only should providers ensure their accounts often outpaces ethical and regulatory oversight. In 1999, no governing are private, but they also need to accept that patients will discover board had to think about therapists lurking on a patient’s Facebook information about them that they may not be comfortable with page as a boundary issue because there was no Facebook. Guidelines patient’s knowing. The authors note that, “It is argued that practitioners on how to ensure your client is really your client online could never cannot block certain aspects of their lives from patients, and they must have been predicted as a real ethical and legal dilemma in 1985. In learn to adapt to the new world that cyberspace has created” (Gabbard, 1985, therapy could not have been envisioned by most providers as Kassaw, and Perez-Garcia, 2011). something that occurs via computer. In 1985, few people owned home The National Board of Certified Counselors (NBCC) has spent computers, and the ones that existed were nothing like we have today. many years examining the role of internet therapy in the practice There were no webcams, email accounts, or even an internet. of counseling. The NBCC prefers the term “distance professional Certainly, the last vignette with Jackie could occur with a provider services” rather than online therapy, as they recognize that other modes who provides face-to-face therapy only and snoops on social media of communication, such as phone calls, play in role in these types of trying to glean information regarding clients. Thus, even for therapists therapeutic relationships. who do not provide online services, the power of the medium cannot The organization has a detailed list of ethical considerations and some be ignored as a potential source of regulatory and ethical issues, and of the highlights summarized are: many therapists will at least use email with a client. ●● Maintaining strict control over computer security and the Distance can create a real concern for safety and ethical practice appropriate backup to ensure that records are not lost in the event in online therapy. One of the more complex issues surrounds the that a computer system fails. differences in state laws. Hertlein, Blumer, and Mihaloliakos (2013) ●● Educating patients fully and clearly regarding the licensing and cited the work of Derrig-Palumbo and Eversole (2011), who brought credentials of the counselor. up an interesting dilemma. For example, duty-to-warn laws may differ ●● Explicit, written information explaining the process of distance substantially from the state where the therapist practices and the state professional services and the appropriateness of the interventions in which the patient lives. Does the therapist follow the laws of his/her for the patient’s presenting issues. home state or that of the client? Hertlein, Blumer, and Mihaloliakos ●● Proper screening of clients for the appropriateness for distance noted that the management of crisis, concerns for privacy, laws and professional services. regulations, training and education, and the quality of the therapeutic ●● Taking extra caution to ensure that electronic information alliance remain the biggest ethical concerns for marriage and family regarding a client is not accidentally sent to someone else. therapists. ●● Counselors must adhere to regulations in their home state, as well as the state in which the client lives and note this compliance in the Crisis management was the greatest concern, with the therapist being record as appropriate. concerned about not knowing the location of a client who was suicidal ●● Counselors must provide clients with detailed instructions on how to obtain emergency services. Therapists were also concerned about to obtain emergency treatment in their community if it is needed. the security of the internet in general, how emails and chat transcripts ●● Counselors shall create codes or passwords to ensure the client is might be hacked, and noted that they were unsure as to how long to really the one involved in distance professional services and have a keep these items. These therapists also were worried that the person on written procedure as to how this will occur. the phone or the computer may not be the person the therapist believed ●● Counselors will provide information to clients on where to obtain they were dealing with. For example, what if someone’s significant internet service for free. other somehow got into the correspondence between the patient ●● Copies of emails and other materials shall be kept and maintained and therapist and wrote emails to the therapist in hopes of gleaning for at least 5 years, unless otherwise indicated by state laws that confidential information regarding the patient’s issues. Several the records should be kept longer. therapists developed special passwords and other security procedures ●● Counselors shall ensure their personal social media accounts to ensure this type of situation did not occur. Rummell and Joyce are carefully distinguished from their professional accounts and (2010) also expressed concerns that a counselor has no way to verify counselors should avoid interacting with patients in a personal if the patient is actually a consenting adult. There is a possibility, for manner on social media. example, that an adolescent could be the patient and the counselor ●● Counselors will respect the privacy of their patients on social would be violating several laws by treating a minor without parental media and will not view personal information on websites such as consent. Facebook or Twitter. Another potential risk that emerges in this form of therapy is, due The American Counseling Association (ACA) addresses similar to issues with email servers and programs and software, if a client issues in their code of ethics. In addition, they specify in section inadvertently does not receive the therapist’s communication and then H.4.f. Communication Differences in Electronic Media, “Counselors does not respond, the therapist may assume the client has dropped out consider the differences between face-to-face and electronic of services and discharge them inappropriately. In addition, clients communication (nonverbal and verbal cues) and how these may affect may have unrealistic expectations of response times and become upset the counseling process. Counselors educate clients on how to prevent when a therapist does not answer within a few quickly (Reamer, 2013). and address potential misunderstandings arising from the lack of

SocialWork.EliteCME.com Page 140 visual cues and voice intonations when communicating electronically,” 6.6 Training and use of current technology (American Counseling Association, 2014). The ACA also requires that Marriage and family therapists ensure they are well trained and counselors who maintain websites provide accessibility for those with competent in the use of all chosen technology assisted professional disabilities and language translation when possible. services. Careful choices of audio, video, and other options are made The American Association of Marriage and Family Therapists to optimize quality and security of services, and to adhere to standards (AAMFT) code of ethics covers several broad areas, but is not as of best practices for technology assisted services. Furthermore, such detailed as those of the ACA or NBCC. The general areas covered choices of technology are to be suitably advanced and current so as to under the Standard VI: Technology Assisted Professional Services best serve the professional needs of clients and supervises” (AAMFT, include: 2012). “Therapy, supervision, and other professional services engaged in The National Association of Social Workers (NASW) Code of Ethics by marriage and family therapists take place over an increasing was last revised in 2008 and does contain a section specific to online number of technological platforms. There are great benefits and therapy, or distance professional services. However, certain sections of responsibilities inherent in both the traditional therapeutic and the code cover some of the same areas addressed in other accrediting supervision contexts, as well as in the utilization of technologically body’s more specific codes. While the sections below do not mention assisted professional services. This standard addresses basic online service directly, the sections still cover important aspects of ethical requirements of offering therapy, supervision, and related online therapy: professional services using electronic means. b. Social workers should provide services in substantive areas or use 6.1 Technology assisted services intervention techniques or approaches that are new to them only Prior to commencing therapy or supervision services through after engaging in appropriate study, training, consultation, and electronic means (including but not limited to phone and internet), supervision from people who are competent in those interventions marriage and family therapists ensure they are compliant with all or techniques. relevant laws for the delivery of such services. Additionally, marriage c. When generally recognized standards do not exist with respect and family therapists must: (a) Determine that technology assisted to an emerging area of practice, social workers should exercise services or supervision are appropriate for clients or supervisees, careful judgment and take responsible steps (including appropriate considering professional, intellectual, emotional, and physical needs; education, research, training, consultation, and supervision) to (b) inform clients or supervisees of the potential risks and benefits ensure the competence of their work and to protect clients from associated with technology assisted services; (c) ensure the security harm (NASW, 2008). of their communication medium; and (d) only commence electronic Sections of the Code of Ethics that address confidentiality also cover therapy or supervision after appropriate education, training, or distance services: supervised experience using the relevant technology. l. Social workers should protect the confidentiality of clients’ written 6.2 Consent to treat or supervise and electronic records and other sensitive information. Social Clients and supervisees, whether contracting for services as workers should take reasonable steps to ensure that clients’ records individuals, dyads, families, or groups, must be made aware of are stored in a secure location and that clients’ records are not the risks and responsibilities associated with technology assisted available to others who are not authorized to have access. services. Therapists are to advise clients and supervisees in writing m. Social workers should take precautions to ensure and maintain of these risks, and of both the therapist’s and clients’/supervisees’ the confidentiality of information transmitted to other parties responsibilities for minimizing such risks. through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic 6.3 Confidentiality and professional responsibilities or computer technology. Disclosure of identifying information It is the therapist’s or supervisor’s responsibility to choose should be avoided whenever possible (NASW, 2008). technological platforms that adhere to standards of best practices related to confidentiality and quality of services, and that meet The American Psychological Association (APA) offers advice for those applicable laws. Clients and supervisees are to be made aware in seeking online therapy and their tips for consumers offer important writing of the limitations and protections offered by the therapist’s or details for providers to consider as well. In general, they note that supervisor’s technology. consumers should be aware of the following items: 1. Online therapy is not right for everyone in all situations. 6.4 Technology and documentation 2. Is the therapist or counselor actually licensed? Consumers are Therapists and supervisors are to ensure all documentation containing advised to investigate who the provider of the services actually is, identifying or otherwise sensitive information that is electronically and verify he/she is a qualified, licensed provider. stored and/or transferred is done using technology that adheres to 3. Check with your state licensing board to verify the provider is standards of best practices related to confidentiality and quality of licensed where you live. Licensing is not across all 50 states. services, and that meet applicable laws. Clients and supervisees are to 4. For reasons of privacy and security, please make sure the website be made aware in writing of the limitations and protections offered by is HIPPA-compliant, there is a process in place to ensure you can the therapist’s or supervisor’s technology. verify the identity of the therapist, and there is a way to ensure the 6.5 Location of services and practice therapist can also verify your identity. Therapists and supervisors follow all applicable laws regarding 5. Check to make sure your insurance company will cover online location of practice and services and do not use technology assisted therapy and, if not, you will need to pay for services yourself. means for practicing outside of their allowed jurisdictions.

Page 141 SocialWork.EliteCME.com Ethics and laws by state States vary in regulation and oversight of online therapy. The most This lack of specific guidance at the state level is an issue that needs comprehensive review to date (Haberstroh, Barney, Foster and to be addressed as the practice of online therapy continues to grow. Duffey, 2014) noted that no state boards prohibited online therapy Some states, such as Oklahoma, have developed specific laws, noting for counselors or psychologists, but only half specifically allowed that social work services provided to anyone living in Oklahoma, for the practice in regulations and laws. However, 32% of states regardless of where the social worker is located or how the service is offered no guidance on the practice of online therapy. Many states delivered, are to be regulated by the state of Oklahoma. referred to the national organization’s code of ethics for guidance.

Suggestions for practice Sucala et al. (2013) suggested that having more than one mode of I think, here on Web counseling. I think it’s really neat because I communication such as email, video chat, phone, etc. enabled a think it adds a different component to it. You can’t really express stronger therapeutic alliance to form. Fewer forms of communication empathy or understanding nonverbally, and so I think it really available seemed to impact the therapeutic alliance negatively. In helps me make sure I’m reflecting or summarizing rather than addition, more means of communication led to an easier ability to going straight to a question. So I kind of like that, and it kind of assess patients for suicidality. strengthens those skills. It seems like there’s some real specific In overcoming some of the deficits of not being face-to-face, Barak, techniques that can be effective for Web counseling, and it’s like we Klein, and Proudfoot (2009) suggested, “therapists should take special don’t know what those are yet. We’re defining those. I think some action, especially employing words and expressions that might not be of those would be more homework stuff because it feels a little bit used in face-to-face contact, to communicate empathy, care, concern, like you can’t cover as much ground in the same amount of time. and warmth toward their clients. Similarly, clients have to be aware So if you could have the client do something that they typed out, that their feelings are not as obvious and vivid as they would be in whether it’s a journal entry. . . something to process that week, or a face-to-face relationship. Therefore, clients have to communicate whatever. And then if the counselor reads it right at the beginning their emotions in more explicit ways, sometimes even describing what of the session, then I think that might be helpful. I guess that I was could easily have been visible (e.g., crying, sweating, laughing)” (p. thinking about some theories that already have a lot of that in 10). place. Like cognitive [theory] seems to have a lot of worksheets and charts and different stuff like that. So it seems like that would Clinicians who have provided online therapy successfully have be real conducive to Web counseling, but I think that you could important insight into what types of techniques work in these settings. also adapt whatever theory it is that you go by and just whether it’s One therapist noted: an assignment to explore this particular issue this week and write “It would be important that they [online counselors] could do a a little entry about it” (p.466, Haberstroh, et al., 2008). lot of reflecting and summarizing and that they can pull together the session that way, because I think it could get real fragmented if There are a few ideas regarding a set of best practices that are being you don’t. And, so I think it’s real important to use that technique. developed, but it is not yet fully formulated. Some suggestions from I also think that, because it seems like you are a little limited NASW are: 1) Requiring pre-session information gathering from in terms of what you can cover, it should be a little more action clients, 2) license practitioners in all states to allow for service delivery oriented, and even if it is insight oriented, taking action to increase across state lines, 3) require that clients give therapists proof of their insight. It’s funny because so many of the techniques you learn in physical location and a list of emergency contacts, 4) provide clients school kind of need to be done in a face-to-face session. I think you with several means of electronic support, 5) make policies regarding can adapt a lot of them. It becomes almost a different technique, payment, privacy, treatment outcomes, and such in plain language on the social worker’s website (NASW, 2007).

Future directions There is a definite need to have education and training in the field of viable and growing option that cannot be ignored. The need is vast for online therapy. One recent survey showed that around 80% of marriage more research concerning efficacy, particularly in comparing models and family therapists reported that online or cyber issues had not been of therapy for different needs. Regardless, any therapist or counselor presented in their graduate training (Goldberg et al. 2008). Only 1.2% seeking to provide these services should seek appropriate training of all presentations at marriage and family therapy conferences were under supervision of a knowledgeable practitioner. Furthermore, it is on cyber-related issues (Blumer et al. 2014a). critical to seek ethical and legal guidance from governing bodies and Family therapists who responded to a survey regarding their interest in professional associations. learning more about online therapy identified five key areas where they Client safety and confidentiality remain two major issues that need felt they were least knowledgeable and most in need of education. The to be addressed by any provider of online therapy. If a therapist is areas were: planning to develop a website, this should only be undertaken with 1. Ethical issues and legal advice. IT professionals who are experienced in cyber security and HPAA 2. Privacy and confidentiality. compliance for websites. A therapist should stay abreast of the 3. General training in how to provide online clinical services. constantly changing regulatory and ethical issues with online therapy. 4. Information on safety and security. Certainly, the advantages are there: flexible schedules, low overhead, 5. Evidence-based practices information for online services (Blumer, and the ability to reach more clients in a larger geographical area. Hertlein, and VandenBosch, 2015). However, not all practitioners will ever feel comfortable with this The field of online therapy is likely to continue to grow as the internet approach and the lack of face-to-face interaction with a patient, just and other forms of electronic communication become part of our daily as not all potential clients are satisfied with not seeing a therapist and lives. The younger generation of people who have grown up with instead working through electronic means. Nonetheless, the potential Facebook, email, and texting as a way of life are particularly likely of online therapy cannot be ignored and providers should be aware of to have an interest in online therapy. It is not likely to ever replace the growing trend in this area. face-to-face therapy as the leading format of service delivery, but it is a

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Page 143 SocialWork.EliteCME.com the use of the internet in therapy: GUIDELINES AND BEST PRACTICES Final Examination Questions Select the best answer for each question and proceed to SocialWork.EliteCME.com to complet your final examination. 1. ______could be said to be the father of distance therapy. 7. A frequently cited area of dissatisfaction for therapists in online a. Freud. therapy is: b. Einstein. a. The lack of therapeutic alliance. c. Jung. b. Increased work load. d. Erikson. c. Increased burnout. d. Increased paperwork. 2. Hamburger’s study noted that confidentiality was: a. A major problem in online therapy. 8. Crisis management and internet security are: b. Not at all a concern in online therapy for most people. a. Two of the biggest concerns for patients in online therapy. c. Also a concern in in-person therapy and not exclusive to b. Two of the biggest concerns for therapists in online therapy. online therapy. c. Not a factor in online therapy. d. The outcomes for online therapy were better than in person d. Two of the biggest variables in treatment adherence. therapy for PTSD. 9. Describing verbally what is visible (crying, laughing) is 3. Convenience, ease of accessibility, and easier disclosure are all: recommended to clients in online therapy: a. Perceived patient benefits from online counseling. a. Only in crisis. b. Factors in treatment outcomes. b. Never. c. Areas for key research questions. c. To assist the therapist in understanding what he/she cannot see. d. Terms used in CBT. d. If the client wants to.

4. Responsibilities with childcare and elder care are part of: 10. 1.2% of training at marriage and family therapy conferences was a. Patient outcomes. on: b. A reason to seek online therapy. a. Cyber-related issues. c. Therapist burnout. b. Domestic violence. d. Anxiety. c. Ethics. d. Confidentiality. 5. Frustration with technology: a. Was not a problem for most clients. b. Was a pervasive issue in online therapy. c. Resulted in negative feelings about the online process. d. Only happened with older adults.

6. Fantus and Mishna noted that for this type of patient, online therapy could be especially helpful. a. Nonverbal. b. Bipolar. c. Anxiety disorders. d. Females.

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