Summary

In an RCT study of 353 women assigned to either 12 sessions of trauma-focused or health education group treatment the researchers found that PTSD severity reductions were more likely associated with substance use improvement whereas minimal reduction in PTSD was found with substance use reduction (Hein et al., 2010). These findings have important implications because of the high rate of comorbidity between PTSD and substance abuse (Back, 2010). These findings also support earlier research. This research calls into question the commonly held assumption that abstinence from substances should be gained before undertaking exposure therapy. The previously held assumption that beginning trauma therapy before reduction or elimination of substance use will lead to an increase in substance use has not been borne out.

Clinical Implications

The evidence suggests that when treating comorbid PTSD and substance use the clinicians should actively initiate integrated treatment to address the PTSD actively while working on the substance abuse.

References

Hein, D. A., Jiang, H., Campbell, A. N., Hu, M-C et al. (2010). Do treatment improvements in PTSD severity affect substance use outcomes?  A secondary analysis from a randomized clinical trial in NIDA’s clinical trials network. American Journal of Psychiatry, 167(1), 95-101.

Back, S. E. (2010).  Toward an improved model of treating co-occurring PTSD and substance use disorders. American Journal of Psychiatry, 167(1), 11-13.

I have been treating a man with complex PTSD who started to see me after his transference feelings toward his previous psychotherapist became unmanageable. He sees me infrequently and has consulted with about 5 subsequent therapists who he reports trigger his trauma. He frequently emails me and occasionally sees me for a session but also sees other therapists. I have decided to allow him to do so even though I worry about his overall stability and therapist shopping. I sometimes feel as if I would like to tell him to discontinue treatment with me but feel that allowing him to utilize me this way provides some benefit. Is it OK to continue to allow him to see me infrequently and use email to maintain the attachment?

Response from Dr. Barnett

Jeffrey, Thanks for submitting the first question to Division 29’s new website feature “Ask the Ethicist.” You present a very interesting situation. I think it is very important that we not be constrained by the rigidity of weekly 50 minute long in-person psychotherapy sessions. Some clients benefit from being seen more frequently and some benefit from being seen less frequently. I think it really comes down to conducting a thoughtful assessment of each client’s clinical needs and responding accordingly. Also, what seems appropriate at one point in time my not be at another, so we must be flexible and willing to change our approach over time.

A lot has to do with your theoretical orientation and your assessment of the client’s treatment needs. While you should act consistently with both, you still have some flexibility with regard to how you proceed. The use of various technologies such as the telephone, e-mail, Skype, and others can be very appropriate for certain clients. These may be useful adjuncts to in-person treatment sessions. But, caution should be used if ever considering them as the sole means of providing treatment. Certainly e-mails miss the non-verbal cues so important to many communications. It is also important to ensure you know with whom you are communicating when using e-mail. Also, it may be important to use encryption software if privacy concerns exist.

I would also want to keep in mind our overarching goal of promoting each client’s autonomy and independence of us over time. While it should be a collaborative decision with your client, it is important to ensure that ongoing professional contacts are not promoting the client’s dependency on you. Relevant to this point is Standard 10.10(a), Terminating Therapy, of the APA Ethics Code, which states: “Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.” (p. 1073). When unsure about the appropriateness of continued treatment, consultation with experienced colleagues (with the client’s appropriate consent) is recommended.

Relevant standards from the APA Ethics Code include those relevant to informed consent and confidentiality. Informed consent is important in that the client should understand all factors relevant to your work together that the average client might reasonably want to know prior to deciding on if they should participate. Further, all substantive changes to the treatment relationship and process over time necessitate an updating of the informed consent agreement. Clients should be informed of reasonably accessible options and alternatives to the treatment being provided along with all reasonably anticipated risks and benefits of each (to include not participating in treatment). We need to actively ensure that clients understand all this prior to proceeding with treatment. A discussion of confidentiality and any limits to it are especially important to include in the informed consent discussion when the use of technology is involved. While various technologies help clients to receive needed services in ways never before possible, they also bring risks and threats to privacy. Clients should understand these threats and psychotherapists should take necessary steps to minimize the risks of inappropriate breaches of confidentiality.

Providing psychotherapy or other services to a client who is also receiving services from other professionals is also an important issue to consider. At times, it is a client’s best interest for professionals to consult with each other, especially when trying to ensure they are not working at cross purposes. Standard 3.09, Cooperation With Other Professionals, of the APA Ethics Code is relevant here as well, stating: “When indicated and professionally appropriate, psychologists cooperate with other professionals in order to serve their clients/patients effectively and appropriately (See also Standard 4.05, Disclosures)” (p. 1065). Of course, obtaining the client’s verbal and written consent to contact other professionals is important to do first.

When billing for services be sure the client understands the implications of using technologies and bill appropriately. For example, if a client’s insurance is paying for treatment but it only pays for in-person treatment sessions, the e-mail contacts may not be covered services. The client should know this up front. E-mail (and other technologies) sessions should never be billed as in-person sessions. But, brief e-mail contacts between sessions may prove very therapeutic for some clients. If fact, brief communications such as Twitter (under 140 characters per communication) may be quite helpful.

In summary, the answer to most ethical dilemmas is “It depends.” In this case, it depends on the client’s history and clinical needs; conducting a thorough assessment of the client’s treatment needs is essential. I would also want to know what the other professionals are offering as well. It is important to ensure that you are not working at cross purposes with these other professionals. Regularly reassessing the client’s treatment needs and the appropriateness of your treatment plan is important. As long as the client is fully informed and is benefiting from the continued treatment is may be quite appropriate to continue it.

When faced with ethical dilemmas one finds that there typically is no one correct answer. Rather, there are a number of important questions to ask, and depending on the answers to them, there may be a number of possible solutions, each bringing with them various pros and cons for us to consider. Thus, there likely are other reasonable perspectives on this situation and I very much welcome comments, reactions, and further discussion from all who read this post. Thanks and best wishes for your success with this client. Jeff

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