Ethical Practices

June 13, 2014

The problem of Addiction to Alcohol and Drugs is a growing social concern. This is especially so with an increasing number of our adolescents and young adults, experimenting not only with alcohol and nicotine, but also marijuana (ganja), narcotics, prescription medication and various forms of inhalants. In response to this, we are witnessing a growth in the number of facilities for the treatment of Alcoholism and Drug Addiction. For instance, the De-Addiction Network coordinated by NIMHANS, Bangalore, currently has a membership of over 15 such facilities, most of which are spread in and around Bangalore.

We acknowledge the fact that some differences may exist among the various treatment centres with regards to philosophy and approaches to treatment modalities and intervention. However, there are also concerns about some treatment interventions that include various forms of emotional and physical abuse and violence currently in practice. While such interventions have little or no therapeutic value in themselves, they also fail to comply with contemporary standards of mental health care.

The basic goals of treatment and rehabilitation of persons suffering from alcoholism and drug addiction is shared by all treatment facilities. However, as health professionals committed to this common cause, we need to call to question practices such as violence that compromise the respect and dignity of individuals under our care.

Thus for the sake of greater professionalism and therapeutic effectiveness among the growing number of service providers, there is a need to work towards some common guidelines that elicit ‘Standards of Minimum Care and Ethical Practices’, in the treatment of Alcoholism and Drug Addiction.

Administrative Procedures
Minimum documentation and case records on both medical care and therapy should be maintained on all patients. This enhances the effectiveness of the ongoing treatment plan and serves to keep a therapeutic continuity in case of a relapse. These may include but not limited to the following:

  • The admission contract made between the treatment centre and the patient and family
  • A Family Documentation Form filled by the family, supplying detailed information about the patient addiction history and past addictive behaviours
  • An in-depth Case History on each patient needs to be documented on file, from information gathered from both the patient and the family. This record should include information on the patient’s medical, addiction, and psychiatric history, with special reference to any suicidal thoughts and/or attempts in the past.

The organizational structure should facilitate an environment that promotes treatment and recovery in a holistic manner. Primacy should be given to both the therapeutic and the medical care of patients by ensuring full time medical personnel and a healthy counsellor-to-patient ratio of 1:8 on the staff. This results in greater individual attention and care during treatment.

Medical Care
An Emergency Protocol should be developed to effectively deal with any emergencies, such as medical complications during withdrawals, accidents, suicide and other medical emergencies. Observation and medical supervision by medical personnel should be ensured for the patients during the phase of withdrawal

Patients should have access to regular medical check-ups and treatment when indicated. Periodic psychological and mental status evaluation should be facilitated, and when dual diagnosis is indicated, access to psychiatric evaluation and treatment should be ensured. Supervised administration of medication should be ensured for patients in withdrawals and those with dual diagnosis.

Developing a well-balanced dietary schedule could monitor nutritional care. Patients should be provided with an aggressive education and awareness campaign on the subject of HIV/AIDS and other sexually transmitted diseases. This is a critical issue considering the fact that the relationship between alcoholism / drug addiction and HIV / AIDS is very high in our country. Consequently, alcoholics and drug addicts comprise a high-risk group for the above diseases.

During treatment the following should be ensured:

  • Awareness and education on HIV / AIDS and other sexually transmitted diseases.
  • Availability of diagnostic testing for the above diseases.
  • Pre-test and post-test counselling particularly in the case of HIV/AIDS

Treatment & Rehabilitation
Daily activities should be structured so as to facilitate treatment and rehabilitation.
Activities could include but not limited to the following:

  • Psycho-educational inputs that cover topics on the roots of addiction, its progression, its intervention and treatment, relapse and its prevention, emotional management, the 12-Step program of recovery, assertiveness and social skills development, communication and conflict resolution, and the like.
  • Individual counselling during which the patient’s personal work and reflections are processed. This may include their autobiography, the 12-Step work, and various assignments based on the input sessions. Individual counselling will also include any specialized focus such as regression therapy, grief counselling, child sexual abuse, and other forms of past traumatic experiences.
  • Group counselling is a powerful therapeutic intervention that should be used in order to break denial about one’s addiction, to help find identification and a recovery support system, and to enhance motivation and hope about one’s recovery. This happens in processing the patient’s personal recovery work and reflections in therapy groups.
  • Introduction and regular participation in self-help groups such as the Alcoholics Anonymous and the Narcotics Anonymous will ensure that the patients will have a healthy support system for ongoing recovery even after discharge from treatment.
  • Alternative approaches such as yoga, gym, meditation, etc., should be made available as part of treatment and rehabilitation. This will not only assure self-development but also help in addressing recovery from a holistic perspective.
  • Some form of physical exercise and recreational activities should also be included.

The treatment staff should ideally represent an inter-disciplinary team of mental health professionals in the treatment of alcoholism and drug addiction. This could comprise both regular and consultative roles, such as the following:

  • Medical staff including doctors, nurses and para-medical workers.
  • De-Addiction & Co-Dependency counsellors and therapy staff.
  • Individuals who are recovering from alcoholism and drug addiction.
  • Psychologists to provide psychological evaluation and insight.
  • Psychiatrists to evaluate dual diagnosis and to initiate psychotropic medication when warranted.

Personal care and grooming of every patient should be ensured especially of those with dual diagnosis and those in the initial withdrawal period. This includes monitoring their personal hygiene such as regular bath, clean clothes, lice infestation, haircuts, etc.

De-Addiction literature describes Alcoholism and Drug Addiction as a family disease. Hence, any treatment intervention of a chemically dependent individual would remain incomplete without the family’s active participation in their own treatment and recovery as co-dependents.

Education and counselling for the family members should be provided, considering the characteristic co-dependent family dynamics that often accompanies alcoholism and drug addiction. Some of these areas of growth include denial, detachment, obsession, repression, dependency, anger, guilt, lack of trust, poor communication, low self-worth, and weak ego boundaries.

Regular family education and family therapy sessions at the treatment facility will ensure greater awareness and effective participation of the family in the patient’s long term recovery. Regular participation of the family in local self-help groups such as the Al-Anon, Alateen, and the Nar-Anon, will ensure a healthy support system for the families in dealing with their co-dependency issues and in their own self-development.

The completion of treatment and the subsequent rehabilitation back to normal life is a very critical period in the life of a person recovering from alcoholism and drug addiction. Care and preparation at the time of discharge could help address many ongoing issues and assist in the prevention of a possible relapse.
This could include the following:

  • The patient and the family should be given an education on the dynamics of a relapse, its possibility, and discuss ways of minimizing a relapse from occurring.
  • Relapse Prevention Plan (RPP) should be developed by the patient and processed with the counsellor. This could also be discussed with the family and thus serve as a supportive aid in the ongoing recovery of the individual.
  • Communication Exercise should be facilitated between the patient and the family to address and possibly resolve interpersonal issues of the past, the present, and the fears, anxieties, and expectations for the future. This is aimed at promoting an environment of openness and healthy dialogue between the patient and the family.

In the eventuality of a relapse back to active addiction, the patient should be provided with a relapse treatment of a shorter duration. The focus will then be on the dynamics and process of the recent relapse and ways of preventing one in the future.

Staff Development and Training
Staff at all level should have opportunities for ongoing professional development and training as a means to enhance professional competence and motivation. This should also include input and discussion on specific areas of growth such as the following:

  • Stress and Burnout
  • Communication & Conflict Resolution
  • Transference & and Healthy Boundaries

Extension Services
The treatment facility could make themselves available whenever possible to impart education and awareness within the community and particularly among the student population on the facts about drug addiction and alcoholism. This will serve as a preventive measure in dealing with the problem of addiction.

Unhealthy Treatment Practices that need to be abolished
An area of growing concern in the treatment of alcoholism and drug addiction is the use of out-dated and harmful intervention techniques that include various forms of physical, verbal, or emotional abuse and violence towards the patients. Similar practices (such as keeping a patient in chains or in dark cells) existed in the care of the mentally ill at the turn of the last century. However, such practices have long become obsolete in the face of advancements made in the fields of mental health care, psychiatry, psychotherapy, and pharmacology.

In the light of the above concerns, urgent changes are now required in the treatment of alcoholism and drug addiction. Punitive intervention techniques should be done away with, such as shaving of head, food/nutritional sanctions, placement in isolation and dark rooms, any form of physical, verbal, or emotional violence and abuse, or the deprivation of minimum living conditions.

Such punitive interventions have the potential of doing a great deal of harm to an individual. Feelings of anger, aggression, and resentment often only get worse with punishment. This in turn will reinforce the already existing problem of denial, which is a primary characteristic in the disease of addiction, thereby further hindering any progress.

Many alcoholics and drug addicts often exhibit concurrent psychiatric symptoms and conditions including paranoia, obsessive compulsive disorder, schizophrenia, depression, manic-depressive psychosis, and anxiety disorder. Such individuals with a dual diagnosis require a specialized treatment plan that simultaneously addresses both their addiction and psychiatric problems. Punitive interventions in such cases will actually aggravate the psychiatric symptoms and be counter-productive therapeutically

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