Ethical Intervention and Treatment: A Guide to Ethical Practice

Contributions by Heather R. Hayes, M.Ed., LPC, CAI, CIP, Founder & CEO of Heather R. Hayes & Associates; Jack Kline, MS, LPC, LPCS, LCAS, CCS, CEO at Red Oak Recovery; Jay S. Crosson, MBA, CEO at Cumberland Heights Alcohol and Drug Treatment Center; and Andrew Rothermel, President & CEO of Origins Behavioral Healthcare.

September 27, 2017

As addiction continues to wreak havoc on this country, the need for effective treatment options grows. However, with no governing body in place for the interventionist/treatment industry, unethical providers and facilities are widespread. These unethical practices leave those suffering from addiction vulnerable and make it difficult for them to get the help they so desperately need.

Ninety-one people die each day from opiate overdose.¹ The time to act is now. Without legal and licensing requirements in place, anyone can declare oneself an interventionist or even open a self-proclaimed treatment facility or sober house. It’s imperative that we combat the addiction epidemic in this country in order to save tens of thousands of lives every year.

Congressional help is needed. The following is a basic framework of ethical practices from the pre-treatment process (intervention) to residential treatment and continuing care to help inform legislation governing the various aspects of this industry.

A Guide to Intervention Best Practices

Intervention is the desire by family members, friends, employers and other members of the support network to actively assist someone in moving out of addiction and/or crisis and into recovery. It is a pre-treatment approach to assist the person struggling with addictive behavior to seek help.

To date, there are a few primary qualifications of an effective and ethical Interventionist. In best practice, an Interventionist should be 1) trained in the area of the specific disorder that will be treated (addiction, eating disorders, personality disorders, etc.); 2) have a level of expertise that allows them to provide clear insight to the patient and family members about where to start and how to navigate treatment options; and 3) be certified or licensed. These best practices also entail a governing body to monitor for compliance and field complaints. In addition, an Interventionist should not have a financial relationship with a treatment center or other referring professional.

Intervention work is not an entry-level position and requires a high-level skillset. An Interventionist needs to be prepared for complex issues within the family system, and safety must be considered (harm to self or others, withdrawal issues, trauma). In best practice, an Interventionist will help the person of concern – and the family – accept the reality of the destructive behaviors and provide each family member with a care plan. In order to provide the best care, an Interventionist should not practice outside of their scope of expertise.

While every case is different and each patient should be treated as a unique individual, these are guidelines for effective interventions:

1.     The first step is the initial call from a family member or loved one to the Interventionist, who will then assess the situation and help identify appropriate services (making sure it’s within the Interventionist’s scope of practice). This includes evaluating the level of crisis and assessing all safety issues. A timeline for intervention is established.

2.     A contractual agreement is made between the person calling about the intervention and the Interventionist. The contractual agreement may be between a family member, friend, employer, trust officer or other.

3.     In order to better understand the dynamics at work, the Interventionist gathers as much history as possible – including family history, history of trauma and abuse, medical issues, history of use and/or other destructive behaviors. Treatment center recommendations are made based on history, clinical need and finances.

4.     Depending upon the model of intervention used, there may or may not be a family preparation meeting. During this preparation session, the Interventionist walks the family through the intervention process, educates on the dynamics of the Issues being intervened on and helps solidify a plan of action.

·       In some models the loved ones will come with two letters they have been previously instructed to write. Both are strength-based, and the first letter focuses on what the family and support system love about the patient. These letters should remind the patient that they are supported, valuable, and resilient. The first letter also outlines why the family wants their loved one to seek help. The letter will explain what the family has observed about the disease and how it impacts the patient. The second letter is only read if the patient refuses the offer of treatment. This letter outlines realistic boundaries the family is prepared to enforce if the patient doesn’t get help.

·       If an invitational model of intervention is being utilized, the family will invite the patient to a family meeting the next day. The Interventionist will guide family and loved ones as to what to say in their invitation to the patient. If the intervention follows a surprise model, the preparation session gives the patient’s support system an opportunity to discuss what will happen at the intervention, review their letters and the family history, and determine the logistics of where and when to meet.

5.     During the intervention, the patient will accept or refuse help. Once a decision to accept help has been made, the interventionist will assist the patient in moving forward with treatment, including physically supporting the patient in transportation to treatment.  If the patient refuses help, the interventionist will continue to work with the family to best support them in following through on boundaries and initiating self-care plans.

6.     Throughout the intervention process, the Interventionist is responsible for the safety of all involved in the meeting. The communication should be kept positive and non-confrontational or combative.

7.     Intervention services should continue post intervention and should include long-term support and case management services for the patient’s family and support system and coordinated care with the patient’s treatment center.

8.     Because trauma and addiction are so entwined, it’s important that anyone facilitating interventions should understand how to deal with someone who has experienced trauma. A trauma-informed approach to interventions is “grounded in an understanding of and responsiveness to the impact of trauma.” It also focuses on not re-traumatizing someone.

With or without trauma present, Interventionists should:

·       Be skilled at identifying dissociation

·       Know grounding techniques

·       Examine whether the patient’s behaviors are addiction or high-risk behaviors

·       Make the correct placement

·       Look at the behavior within the context of the family system

·       Teach families communication and bonding skills

Elements of a Good Treatment Center

Once a person agrees to get help, ensuring the treatment center is right for them is crucial. Ethical addiction treatment centers adopt or exhibit the following assessment and treatment practices to maintain high-quality, consistent addiction treatment:

1.     Initial engagement: The goal of a treatment center is to inform and educate, which includes discussing Substance Use Disorders, the prevalence of co-occurring issues and the importance of seeking help, as well as using evidence-based practices, is Imperative. A treatment center should gather information to help the patient and their family make the most informed decision regarding their care. A treatment center should not hesitate to refer out to a more suitable program when they cannot meet the patient’s clinical needs.

2.     Marketing: All marketers and business development staff should be fully transparent that they represent a treatment center or corporation. They should never mislead the public into thinking that they are clinical professionals that will provide an unbiased opinion. Paid initiatives include traditional advertisements, such as television ads, radio spots, print and digital media. Marketing is relationship-based and includes alumni referrals, those through clinical intervention or other clinical professionals, or referrals made by facilities that maintain similar ethical standards. Paid brokers and call aggregators must never be employed. This includes “infomercials” or other TV-based advertisements, websites, or other types of patient brokering.

3.     Accreditation: A facility should hold a state license and be accredited by the Joint Commission or CARF. It is voluntarily participating in efforts to demonstrate its commitment to maintain the highest standard of patient care.

4.     Placement: Individualized assessment and placement are critical practices for ethical treatment centers. Detailed assessment according to admission criteria is paramount. Programs will have well-defined exclusionary criteria; should the patient and program not be a good fit, a referral should be made to another facility based on patient needs and input. Referrals for financial gain or on a quid pro quo basis are prohibited. According to SAMHSA (Substance Abuse and Mental Health Services Administration), a length of engagement in treatment for 90 days or more yields better outcomes.

5.     Aid: Any financial aid offered to a patient must be based on verifiable financial need. Waiving fees not based on need may constitute fraud or inducement. A treatment center should have a well-defined, written financial hardship policy.

6.     Evidence-based practices: There is no single approach that is always better than others, or suitable for everyone. Treatment should be individualized based on that patient’s particular needs and clinical make up. Ethical treatment centers maintain structured programs implemented by licensed therapists who follow their own licensing board’s ethical guidelines ( LPC, LCSW, MAC, LMFT, LADAC, LCAS, etc). A variety of evidence-based practices is employed, including but not limited to CBT, DBT, ACT, MI, 12-step facilitation, gender-specific groups, developmental issues, and trauma-informed therapy as appropriate. An ethical program will be able to clearly articulate its clinical approach and explain the research that it has used and currently uses to develop that clinical approach.

7.     Detoxification: Medical detoxification and medications are appropriate when indicated and ordered by a licensed professional. An abstinence-based approach is best, but when Medication Assisted Treatment (MAT) is indicated, there should be clearly defined written protocols around that. It should never be offered to someone as an initial option. Psychotropic medications as needed should be supported.

8.     Team approach: An interdisciplinary team develops a greater understanding of the complex, wide-ranging issues contributing to a patient’s recovery. Ethical treatment centers utilize a variety of clinical approaches and clinicians to create and implement comprehensive treatment plan and implement that. All clinicians should be licensed in their field, or operate under proper clinical supervision in the licensing process. All professionals involved in patient care should have knowledge and training in addictive disorders.

9.     Peer support: Many reputable facilities integrate a 12-step program philosophy, such as AA or NA, with other clinical modalities. Spiritual care directors may be employed to help a patient process emotional blocks and loss in one-on-one and group settings. These facilitators may also be brought in to help patients learn 12-step-based spiritual tools. Members from AA or NA may also be invited in to educate clients about the 12-step programs.

10.   Alternative therapies: Experiential and expressive therapies are evidence-based when delivered by trained facilitators. Examples include adventure-based counseling, equine-assisted therapy, art therapy, music-assisted therapy, sand tray therapy, and therapeutic writing. Practices such as yoga or mindfulness groups, are also EBPs and quite effective at helping patients. Exercise and physical activity are some of the best remedies for emotional distress. As such, an ethical treatment center will incorporate exercise and activity appropriate for the population they serve, factoring in acuity and medical complications. “A vigorous five-mile walk will do more good for an unhappy but otherwise healthy adult than all the medicine and psychology in the world.” -Dr. Paul Dudley White, co-founder of the American Heart Association.

11.  Family services: Addiction is a disease that affects entire families (which often means multi-generational), who need guidance and education. Family services focus on the healing of each member in the family and identify how to rebuild trust, create healthy boundaries, and use safe, clear communication. Ethical programs include some level of family support, therapy or education in their clinical offerings. Research has shown that when families are involved in the treatment and recovery process, the prognosis is much better.

12.  Continuing Care: Comprehensive plans are created with patients prior to discharge and include follow-up care with local clinicians and primary care physicians as well as a recovery plan for peer-support groups. Best practices include stepping down to a lower level of care, individualized for each patient based upon their emotional, financial, medical, family and clinical needs. Addiction is classified as a chronic, brain-based disease with cycles of remission and relapse, according to ASAM (American Society of Addiction Medicine), and needs to be treated as such. Treating addiction in an acute, episodic way, such as we treat the flu, runs counter to research and science.

Family Guide to Identifying Quality Treatment

Effective addiction treatment systems which operate with quality, transparency and legal care may be difficult to recognize. Learning what to ask potential providers is an important step in securing superior care for those struggling with substance use disorders. The following questions can help loved ones and their families make informed decisions about the care they receive.

1.     Is the facility licensed to provide true residential care that offers 24-hour support to its patients?

Residential programming is one of the most effective tools in the treatment of addiction. These facilities remove patients from their unhealthy environments by allowing them the physical and mental space to focus on their health and recovery. Conversely, sober living and outpatient services leave patients unmonitored for extended periods of time. While these services can be helpful after extensive residential treatment, they are not a substitute for it.

Residential treatment is vital for acute cases of addiction. Facilities which admit residents to lower levels of care when inpatient treatment is needed are not working in the best interest of the individual.

2.     Are the program offerings accredited by an internationally-recognized addiction treatment organization?

Beware of treatment centers that do not tell you who they are accredited by. Accreditation by independent organizations is one distinction that supports the validity and effectiveness of programming. At a minimum, quality programs will hold accreditation from recognized organizations that have determined that the providers have demonstrated adherence to basic standards.

3.     Is the program transparent, or do they simply tell you what you want to hear?

Be sure to look for treatment centers with a clear website and a firm social media presence. Read reviews and learn what others are saying about their treatment experiences. Generic websites or advertisements that don’t clearly identify what treatment program the site or advertiser represents may signal that that the “organization” is merely collecting phone numbers and email addresses for patient “brokers,” who will then try to connect you with whatever treatment center is paying them.

4.     Does the program offer to provide airfare/travel expenses or waive insurance deductibles?

Waiving deductibles and paying for travel expenses is illegal. In fact, it is insurance fraud. If a facility is engaging in these practices, this is only the tip of the proverbial iceberg. Ask yourself: If the program is willing to do this, what other corners will they cut in treating your loved one?

5.     Does the program incorporate the medical history, trauma background, culture or gender identity of the patient?

Beware of programs that offer a “one size fits all” approach to programming. Humans are complex beings and addiction is a complex disorder. Look for programs that gather in-depth information about their patients prior to admission in order to set up the appropriate care and treatment planning. During this process, ask what populations the program does not best serve. Quality programs will always be transparent about their skill set. When not appropriately suited for a patient, professional organizations will provide alternative options that suit the patient’s needs.

6.     Can the treatment center handle medical needs other than addiction, such as mental health issues or communicable diseases that often occur alongside substance use?

According to addiction studies and clinical experience, 70-80% of all those who experience addiction also suffer from mental disorders such as anxiety or depression. Likewise, many have placed their bodies at risk for illnesses through their drug misuse experience. These conditions must be treated simultaneously with the disease of addiction in order to achieve sustained recovery. Quality programs will take the time to identify co-occurring disorders, and treat them in conjunction with an individual’s primary addiction.

7.     Does the program offer extended lengths of stay beyond the 28-day model?

Research has shown unequivocally that good outcomes are contingent on adequate treatment length. A model of addiction treatment that routinely recycles patients through a brief stabilization period (often 28 to 30 days), and does not adequately provide for ongoing support after that period, is an ineffective model for treating addiction. Quality programs walk alongside their patients through multiple levels of care, including medically managed detox, as well as varying intensities of residential treatment and outpatient care.

8.     Does the program take the time to ensure that the patient is provided with an in-depth continuing care plan?

Quality programs provide patients with a continuing care plan, often at decreasing levels of intensity to facilitate both healing and integration back into normal life. This is a critical element of both stabilization and long-term care which promotes sustained recovery as well as the development of a rich life in sobriety.

9.     What kind of support are offered after treatment? Is there an alumni program that offers follow-up and aftercare services?

Accountability is a vital component of recovery from addiction, and it can mean the difference between relapse and sustained recovery. Look for programs with dedicated alumni support staff who focus on providing the informed, compassionate aftercare services necessary to foster a sustainable, sober life.

10.  Does the facility incorporate families into the treatment process? Do they help patients and their families put together an aftercare plan? 

It is widely acknowledged that a patient’s prospects for sustained recovery are improved significantly when the family is involved in treatment. When searching for a program, find treatment centers that offer family programming as well as family-oriented aftercare services.

 

1 Centers for Disease Control and Prevention, 2015 Opioid Overdose Report.

 

Heather R. Hayes, M.Ed., LPC, CIP, CAI
Heather Hayes is the Founder and CEO of  Heather R. Hayes & Associates, Inc. Heather specializes in the treatment of adolescents/young adults, trauma, brain disorders, complex mental health issues and the full spectrum of addictive disorders.

Jay Crosson, MBA
Jay Crosson is the CEO at Cumberland Heights, a nonprofit alcohol and drug-addiction treatment center in Nashville, Tennessee. Cumberland Heights was established more than 50 years ago and Crosson’s experience there has spanned half that time.

Jack Kline, MS, LPC, LPCS, LCAS, CCS
Jack Kline is the CEO & Founder of Red Oak Recovery, an addiction treatment provider that specializes in treating young adults, ages 18 to 30 years, along with their families.

Andrew Rothermel, MBA, J.D.
Andrew Rothermel is the President & CEO of Origins Behavioral Healthcare, a comprehensive continuum of individual alcohol and drug addiction treatment programs and recovery support services for adults, including those with co-occurring disorders.