Ethics and Dual Diagnosis:
Does Categorization Matter?
VSIAS: July 19, 2017
Michael A. Gillette, Ph.D.
(434)384-5322 [email protected]
http://www.bsvinc.com
Some Review
from 2009
Dealing With Dual Diagnosis
Ethical Issues
• Expertise
• The Hockey Puck
• Prioritization of Need
Co-Occurring Disorders
Relevant Questions
Where Should This Person Receive
Services?
What Type of Services Should This Person
Receive?
Does This Person Have The Right To
Refuse Specific Types of Service?
What If This Person’s Needs Are Outside
My Area Of Expertise?
Dealing With Dual Diagnosis
Which Values Apply?
The Arete of the Provider
Ethics in Long-Term Care
“Psychiatric Instability”
Mr. C is a resident in assisted living who has requested to return to
independent living. Staff indicate that Mr. C was admitted to assisted
living based on concern surrounding his documented suicidal ideation
and a desire to closely monitor his medication management, even though
he did not meet UAI criteria for assisted living. It is unclear how Mr. C
scores on the UAI currently but his physical function has not deteriorated
since admission. However, Mr. C does have a history of depression and
there is some concern that we will be less able to monitor his mental
health status in independent living. The primary ethical issue is based,
therefore, on whether or not depression, without associated losses of
physical function, creates a legitimate basis for ruling out an individual
for living independently.
The Ethics of Disclosure
“But We’re On The Team”
The CSB has been contracted to provide therapeutic supports
for non-violent juvenile offenders, and as part of that work, two
sets of charts are kept; An Alcohol and Drug Services chart that
is kept under the strictest of confidence, and a second chart to
which probation officers have access. During a recent meeting,
a consumer’s probation officer wanted to know if the therapist
had information to suggest that any rules are being infringed by
adolescents in their program. The parole officer had a clear
expectation that information revealed in the therapeutic
relationship would be shared with the parole officer. Should the
parole officer have access to information relevant to the
operation of the program?
Aristotelian Ethics
Always Act Consistently With
The Standards of the Role
You Play In Life
Moral Management
“Being Nice Vs. Being Ethical”
Supererogation
Moral Management
“Identify the Default Assumptions”
Background Obligations
Moral Management
“The Source of Obligation”
What Is Your Role?
Moral Management
“The Source of Obligation II”
What Are Your Relationships?
Moral Management
“How Relationships Work”
Tacit Expectations
Explicit Promises
Aristotelian Virtue Theory
Remember Your Arête
Case Studies
The Ethics of Harm Management
“I Don’t Want To Quit, I Just Want To Slow Down”
Mr. H is a 24-year-old individual who is seeking outpatient services. He
complains of hearing voices, feeling anxious, and wanting help to reduce
his daily alcohol intake. He recently moved to the area and wants to
transfer all of his treatment services including medication to our agency.
He was living alone in another state and now moved in with his mother.
Mr. H is diagnosed with Schizoaffective Disorder- Paranoid Type, Anxiety
Disorder, and ETOH Dependence. He was involuntarily civilly committed
twice in the past three years for suicide attempts via overdose but currently
denies any suicidal ideation. Mr. H drinks alcohol daily, usually .75liters
of liquor and 4 40oz beers. He does not want to stop drinking alcohol, but
he does want to decrease the quantity he uses. His treatment goals are to
decrease the voices he hears, decrease his anxiety, and decrease his alcohol
intake. Is it ethical to develop a treatment plan for Mr. H that seeks to
achieve his stated goals when a reduction of alcohol use but not the
elimination of alcohol use continues to present serious risks of harm for
Mr. H?
Substance Abuse Cases
“Does Categorization Matter?”
Mr. A is a 51-year-old client who has been diagnosed with Bipolar Affective
Disorder and Poly-Substance Abuse. Mr. A has been receiving services from
the CSB for several years and is currently receiving Welbutrin, Depakote and
Seroquel. This ethics consult was requested because Mr. A also reports a
history of marijuana, valium and benzodiazepine abuse and describes current
heavy alcohol use. Furthermore, Mr. A indicates that he has been doubling
his Seroquel dose but he is unwilling to accept SA treatment or to undergo
regular drug and alcohol screenings. The ID team, including the attending
physician, has become concerned that continued provision of Seroquel is
dangerous. The team offered to continue to provide Seroquel only if Mr. A
agreed to a 30 day Inpatient SA treatment program, an aftercare program, and
drug/alcohol screenings. Mr. A has not agreed to this plan and continues to
demand that his Seroquel prescription be renewed. This ethics consult was
requested to determine whether or not CSB staff may ethically refuse to
provide Seroquel in these circumstances.
Substance Abuse Cases
“How Categorization Matters”
Mr. J is a 28-year-old individual who was TDO’ed after
demonstrating psychotic symptoms. The assigned therapist
believes that Mr. J suffers from mental illness, but he also
believes that many of the symptoms are triggered by substance
abuse. The therapist does not believe that meaningful progress
can be made unless Mr. J’s SA issues are handled first. SA staff
believe that Mr. J’s current psychosis obscures insight and
eliminates any likelihood for progress with SA issues. The MH
professional believes that SA is the primary diagnosis and only
wants to deal with MH issues after substance abuse has been
eliminated. The SA professional believes that MI is the primary
diagnosis and only wants to deal with SA issues once Mr. J’s
mental health has been stabilized. How should staff proceed?
Substance Abuse Cases
“Whose Categorization Matters?”
Mr. K has requested mental health counseling and
indicates a history of bipolar affective disorder. He
also admits to chronic marijuana use. When the
psychologist assigned to Mr. K suggests that drug use
could exacerbate his mood disorder, Mr. K states that
he has no drug problem, that that is not why he has
accessed services, and that he does not want to access
any services that target drug use. Mr. K hints at the
fact that he considers the marijuana to be efficacious in
dealing with his symptoms.
Supervision Ethics
“Cross Pollenization”
Staff person A works in Adult and Family services
supervising MH caseloads. Staff person B works in
Adult Protective Services as a supervisor. Both staff
persons A and B report to the same manager. During a
staff meeting it became clear that both supervisors have
a common client who has a history of neglect in the
care of his mother and ETOH abuse. Staff person B
asks A if the client has been drinking again. How
should staff person B respond?
Substance Abuse Cases
“For The Good Of The Client”
Staff from the Women’s Shelter requested consultation regarding the ethical
implications of loosening current standards for removing consumers from the
shelter. Currently, the Women’s Shelter is advertised as a drug free
environment. However, there are times when women who are housed at the
shelter test positive for use of illicit substances. In some cases, they either
use or sell drugs on site. In the most dangerous situations, consumers are
removed from the shelter when they are found to be using drugs. Staff
members are concerned, however, that this policy may be too strict and that
many of these women should continue to receive services at the shelter. On
the other hand, children often live in the Shelter, and staff members want to
protect them from harm and exposure to illegal behavior. The tension
between the desire to maintain a drug free environment and the desire to help
all those in need generates an ethical concern.
Case Studies
“Illegal Activity”
Mr. O is a 46-year-old client who receives DAP funding to
support him in a supported living program. Mr. O has a job,
and therefore he also has funds that he spends on his own.
Mr. O engages in a variety of disrupting behaviors including
disregard for the program's curfew and frequent illegal
substance abuse behavior. On one occasion, Mr. O
completed a drug deal while being transported by staff to the
store. Mr. O was removed from another living environment
when he sold illicit substances to another member. Staff
believes that other clients who engage in this type of
behavior would not be allowed to remain in the program and
would forfeit their placement. They are concerned that they
should not discontinue current services to Mr. O, however,
because, being well known for previous behaviors at other
programs, finding another placement for him would be
difficult. Furthermore, given the DAP funding, staff
members feel that they may not refuse to provide service.
The Ethics of Scarcity
“Best Use?”
Ms. F is a 28-year-old SA client who has missed
three of her last four scheduled visits. She indicates
that she wants to continue with services, but CSB
policy indicates that failure to keep appointments is
grounds for discontinuing services. Should Ms. F be
placed back on the waiting list for services?
The Ethics of Scarcity
“Best Use?”
Should our response change if Ms. F failed to show
secondary to her delusional disorder? Should our
response change if Ms. F has also been diagnosed as
operating at the level of mild intellectual disabilities?
Withholding Treatment
To Treat or Not To Treat…
Mr. J is a 40-year-old patient with schizoaffective
disorder, dementia NOS and has a history of polysubstance abuse. Mr. J became progressively more
disoriented and is now being treated with Aricept. The
Aricept is achieving marked results and has improved
Mr. J’s alertness and orientation, to the point where his
is able to act on his delusions. Is it ethically better to
treat Mr. J with Aricept, which increases his autonomy,
or to withhold Aricept so that, although clearly less
oriented, Mr. J will not engage in confrontational
behavior and will experience reduced agitation?
Withholding Treatment
To Treat or Not To Treat…
Mr. J is a 40-year-old patient with schizoaffective
disorder, dementia NOS and has a history of polysubstance abuse. Mr. J became progressively more
disoriented and is now being treated with Aricept. The
Aricept is achieving marked results and has improved
Mr. J’s alertness and orientation, to the point where his
is able to secure illicit drugs to feed his addiction. Is it
ethically better to treat Mr. J with Aricept, which
increases his autonomy, or to withhold Aricept so that,
although clearly less oriented, Mr. J will not engage in
substance abuse behavior?
Safety and Confidentiality
“Can I Take His Keys?”
Client L showed up for his counseling session in an
inebriated condition. Although this condition was not
obvious at first, it became clear during the session. At
first, the counselor was unsure if the session should
continue (ethical question #1), but the client decided
that he wasn’t able to continue and chose to leave the
session early. Mr. L then took out his car keys and
headed for the door. The counselor believes that Mr. L
is under the influence of alcohol and is unsure how to
proceed (ethical question #2)
Dual Diagnosis
“He Can’t Stay Here”
Mr. J currently resides in an ID group home and carries a
diagnosis of Down Syndrome. Recently, Mr. J began to develop
dementia. At times he becomes extremely agitated, and staff
members are convinced that Mr. J experiences a delusional
component of his illness. They are unsure how to deal with Mr.
J’s aggressive behavior toward others and believe that he should
be transferred to a mental health group home. Staff members in
mental health services indicate that they cannot support a client
who requires such close ADL support.