“The alcoholism and drug abuse counseling profession is at a turning point, facing threats that fundamentally could alter the character of this field. While some see health care reform and financial concerns as topping the list of challenges; many others depict a spiritual crisis – a crisis in values. This crisis has emerged out of two decades of unprecedented success in our field. Ironically, this very same success set the stage for our current crisis, which has emerged out of the excesses of our explosive growth and industrialization.” – William White (1994)
This article was excerpted from Bill White’s book, Critical Incidents: Ethical Issues in Substance Abuse Prevention and Treatment that was published by Lighthouse Training Institute a year earlier in 1993. As the quote above notes, the field was at a turning point. I worked in the trenches of our public funded treatment system in that era, and I could feel and see the things he referenced in this article.
In the five-page paper, he starts by listing six bullet points to highlight what he and many of us were seeing unfold in our field in that era, which I will summarize below:
- An abundancy of private pay units with open beds and a lack of access to publicly funded programs.
- As private sector programming rapidly expanded, there were many mergers and reorganizations impacting the field.
- Staff morale in the field had eroded, which contributed to excessively high turnover rates for direct service workers.
- Seasoned workers left the field because the spirit of the work had been lost.
- Harm in the name of help / exploitation for financial gain led to a crisis in public confidence in the field.
- A growing sense that the identify and character of the field was no longer in the control of those in the trenches who best understood the challenges and opportunities.
Special Concerns of Ethical Issues in the Field
In the next section of the paper, as the historian that he is, Bill reflected on our roots and how the field can be traced back to the American association for the study and cure of inebriety in 1870, but had only been organized in any meaningful way in the prior two decades or around 1970. As written the field in that era had risen out of the modern recovery advocacy movement and there were no parallels within healthcare or human service fields in which recipients evolved into service roles. When he wrote it, the unique makeup of the field and its rapid expansion necessitated a focus on service and business ethics within the profession. His concerns in his own words:
“Our most recent history has included the legitimization of addictive disorders via their inclusion in public and private health care reimbursement systems, the rapid proliferation of substance abuse treatment programs, the emergence of substance abuse services as popular and profitable business ventures, the intensification of competition within the field, and the explosion of legal and regulatory controls governing the delivery of substance abuse prevention and treatment services. For the first 100 years of our profession, ethical issues were addressed within the umbrella of our medical and clinical practices. Events of the past twenty years have forced us to extend the topic of ethics to cover our business practices.”
The section ends with some of the emerging trends in that time of increased criminalization of addiction, public safety concerns associated with impaired persons and public health facets in the era when HIV / AIDS was emerging.
The Goal of Ethical Sensitivity
The paper makes the case for our field to develop ethical frameworks citing Foundations of Ethical Counseling (1978) in order to consider ethical issues within the context of personal and professional dimensions. He advocates for a framework focused on ethical sensitivities that expand our “capacity to step outside ourselves and perceive the complexities of situations through the needs and experiences of the client, the agency allied institutions and the general public.” He highlights how staff members in addiction treatment programs could develop increased capacity to recognize ethical terrain, associated duties and how to formulate ethically appropriate and effective resolutions to complex situations.
Ethics and the Profession
He discusses the impact of the lack of ethical standards, preparation for those in our field to address ethical concerns and the broad devastation and reactive measures that unfold when festering challenges explode into the limelight of the media and the worst flaws become public spectacle. To me, the most important sentence in the section is this one:
“Our organizations have tended to define ethics as an individual rather than institutional issue.”
It is here he calls for the development of a broad ethical framework of how care is delivered and adhered to by the majority of our service institutions, which he notes was in that era vital for forward progress.
Systematic Approaches to Professional Practice Issues
At the end of the paper, he included a sample ethical decision-making tool across multiple domains, including: knowledge and skills to consider, ethical standards, organizational culture, ethical decision making, and ethical violations. Each section has questions to assist practitioners to consider the nuances of an ethical dilemma and support for effective resolution. It is a valuable tool that stands the test of time.
Questions for consideration in our own era
- In respect to the six challenges facing the field that Bill White raised in the mid-1990s, do we see any parallels in are own era? Are we at a turning point in our current times? Who or what is driving that change and how is the field and those they serve engaged in that change process, if at all?
- While we have seen a proliferation of ethical standards on the level of the addictions professional through certification boards and other oversight entities, what progress have we made on developing standards widely adhered to by the service and funding institutions to standardize their ethical responsibilities to the field?
- What is at stake? What do we want our own era to reflect in respect to moving our field forward ethically?
Additional thoughts for consideration
In reviewing Bill’s important paper from 1994, one of the things that struck me is that attempts to address challenges in the era he wrote the paper were limited in scope and focused primarily at the individual level. Challenges in providing effective and ethically grounded services that were more systemic in nature did not get addressed. This exacerbated challenges for professionals attempting to function ethically on the front lines that we can see even now. This led me to consider again the sentence from the paper “Our organizations have tended to define ethics as an individual rather than institutional issue.” The very definition of institution relates to our broad systems of care, how these services are developed, accessed and funded comprehensively. Failure to consider ethical frameworks that span and support our entire care system but only in terms of what is occurring on the ground will continue to fail to deliver in any meaningful way what we need for the future. We must do better to be better.
Recently, I wrote Macro Level Moral Injury Within the SUD Care System – Our Unaddressed Imperative. In it, I note a tendency to see ethical challenges in the light of poorly managed treatment programs run by managers who do not care about the outcomes of the services. Sadly, this does occur, but to solely focus here would miss the more important issue. Our systems are designed in a way that exacerbates ethical challenges on the programmatic and service level across the entire care system, even in well run, ethically grounded programming. We require overarching ethical frameworks that guide conduct at the institutional level consistent with processes that facilitate ethical conduct at the organizational and individual addiction professional level.
One example of such congruence is support for routine supervision. Supervision is vital for ethically driven care, and even though all our institutions know this, programming is rarely funded in ways to actually support routine supervision, which leads to a host of ethical challenges on the ground and in the trenches. Routine supervision must be funded and supported normatively across our field in all associated intuitions so that our systems actions are consistent with our articulated support for it. Our systems need to walk their talk on supporting supervision, so we are in congruency with it as a stated value in action and not just our words. Unless we address these fundamental challenges at the macro level, we will continue to see the six areas of challenges that Bill wrote about in 1994.
Three additional questions to consider:
- What models exist for reforming our intuitions in which they are reflective of ethical care across all related aspects of our substance use treatment and recovery support care system?
- How effective can our systems of care be if we fail to address these needs systemically and in essence reflect a “do as I say, not as I do” process?
- How can we engage our field to more effectively foster a systemic and consistent commitment to Ethical Action moving forward?
Are we keeping our “on the prize” of long-term recovery or are we moving off that path? While the answer of what we do now will be clearer in 20 or 30 years, the time to act in respect to that course is most likely right now.
Sources
Biggs, D. and Blocker, D. (1987). Foundations of Ethical Counseling. New York: Springer Publishing Company.
Dewey, J. (2015). American association for the study and cure of inebriety. In The SAGE encyclopedia of alcohol: Social, cultural, and historical perspectives (Vol. 3, pp. 122-124). SAGE Publications, Inc., https://doi.org/10.4135/9781483331096
Stauffer, W. (2025, January 15). Macro Level Moral Injury Within the SUD Care System – Our Unaddressed Imperative. Recovery Review. https://recoveryreview.blog/2025/01/15/macro-level-moral-injury-within-the-sud-care-system-our-unaddressed-imperative/
White, W. (1994). A commitment to ethical action. Counselor, May-June, 10-13. Chestnut Health the Papers of William White. https://www.chestnut.org/resources/a46dcc4b-27d3-4a9a-bd49-6040b1227c1d/1994-A-Commitment-to-Ethical-Action.pdf
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