Ethical Dilemmas Facing Substance Use Counselors During the COVID-19 Pandemic

Abstract

Introduction:

During the COVID-19 pandemic, substance use disorder (SUD) treatment settings experienced several abrupt changes, including decreased admissions, reduction in services, and modified requirements for medication for substance use disorder. While these changes were implemented to facilitate the maintenance of important treatment options, the ethical consequences of such changes remained unknown. The current study aimed to explore ethical issues related to COVID-19-related changes reported by counselors in SUD treatment facilities.

Method:

From May to August 2020, we conducted 60 to 90 minutes in-depth interviews with 18 front-line staff in 1 residential and 1 outpatient treatment program, exploring issues drawn from the ethical principles of the national organization representing SUD counselors. Counselors volunteered to participate via phone or email, and participation was confidential. Interviews were conducted via videoconferencing. Topics included day-to-day experiences of ethical dilemmas in the workplace, particularly during the COVID-19 era. Interviews were recorded, transcribed, and checked for accuracy and a trained team of analysts then coded transcripts using thematic analysis.

Results:

As a result of the COVID-19 pandemic, SUD treatment programs quickly modified procedures to adhere to public health mandates while also continuing to offer care to clients. SUD counselors reported several ways their programs adapted new and creative procedures to reduce the risk of COVID-19 transmission. SUD counselors also identified several novel ethical dilemmas that occurred during the COVID-19 pandemic, often resulting from the counselor balancing the needs for responding to public health mandates with providing services to clients. There were several ways that COVID-19 related changes resulted in therapeutic challenges for some clients, and the SUD counselors highlighted ways that changes resulted in more flexible services for other clients.

Conclusions:

This study highlights the quick response to COVID-19 that occurred within SUD treatment. While these changes resulted in novel ethical dilemmas, they also offered more flexible and client-centered approaches to treatment.

Introduction

The COVID-19 pandemic revolutionized the provision of health services in the United States,¹ with substance use disorder (SUD) treatment being no exception. At the onset of the pandemic, SUD treatment settings experienced several abrupt changes that deterred treatment, such as decreased admissions and reduction in number of services. More seemingly client-centered changes were also made, including increased use of novel approaches such as telehealth and less stringent requirements for previously offered services like medication for opiate use disorder (OUD).^2-4 In addition to the rapid changes in protocols, SUD treatment programs quickly pivoted to respond to public health mandates such as social distancing, masking, and COVID-19 testing while still offering treatment.^5-7 Despite these changes, the important need for SUD treatment remained, with 41.1 million people in the U.S. needing SUD treatment in 2020 alone.⁸

One important aspect of offering SUD treatment is the management of ethical dilemmas and the maintenance of ethical standards. An ethical dilemma is defined as a situation when the ethics code for SUD counseling fails to provide clear guidance on an issue, requiring the SUD counselor to make a reasonable decision informed by the code.⁹ Unique ethical dilemmas exist in SUD treatment that can impact treatment success. For example, voluntarism (or autonomy to make one’s own choices), confidentiality and truth-telling, and beneficence are ethical issues that uniquely occur within SUD treatment settings.¹⁰ Clients may be mandated to attend treatment (challenging their autonomy), they may feel concerned about how confidentiality is maintained if they truthfully report substance use, and they may experience limited beneficence if providers are unwilling to consider all treatment options (eg, taking harm reduction approaches). Notably, decisions around each of these ethical dilemmas could impact the overall success of treatment.¹⁰ Experience of ethical dilemmas is also detrimental at the staff level and is associated with high levels of stress and counselor burnout.¹¹ Burnout, in turn, is related to high staff turnover in SUD treatment.¹² SUD counselors also face unique ethical dilemmas, given that many counselors in the field are also in recovery themselves.^9,13

Standards for ethical behavior in the field of substance use counseling are set by the National Association for Addiction Professionals (NAADAC) and the National Certification Commission for Addicted Professionals (NCC AP). Together, these organizations produce a series of 9 principles that outline ethical guidelines for substance use counselors in areas such as confidentiality, professional responsibilities, workplace standards, and cultural sensitivity.¹⁴ However, despite the comprehensiveness of these codes, ethical dilemmas remain in SUD treatment.¹⁵

At the beginning of the COVID-19 pandemic, SUD treatment programs changed their service protocols while responding to ever-changing public health guidance. This abrupt change resulted in many SUD counselors having to modify work practices while trying to maintain ethical standards. Through commentary on 1 SUD treatment program’s experience, Johnson et al highlight the many trade-offs that staff had to make in order to continue providing services while minimizing spread of COVID-19, many times experiencing moral conflict between what is best for the client versus the legal, financial, and public health ramifications of decisions. They also note that during a public health emergency, ethical standards considered in decision making (eg, beneficence, non-maleficence) must be extended beyond the individual to the community as a whole.¹⁶

The ethical impact of COVID-19 on substance use treatment has been explored internationally. Ekqvist et al reported on COVID-19 related challenges experienced by 22 counselors, administrative staff, or support staff in inpatient substance use treatment in Finland. The qualitative results of this study revealed difficulty in following public health mandates of consistent use of personal protective equipment (PPE) while treating clients with psychosis or other severe mental illness. COVID-19 also limited treatment availability, as programs had to reduce the number of groups offered.¹⁷ A letter to the editor submitted by a team in India revealed how public health mandates resulted in a pivot to using telehealth, which limited ability to complete thorough medical exams and prescribe specific medication for substance use disorder. They also highlighted how shelter-in-place requirements limited access to substances (eg, alcohol), which could result in dangerous withdrawal symptoms. Finally, they highlighted the limited treatment availability as an ethical dilemma associated with COVID-19.¹⁸

While this literature sheds light into the unique ethical dilemmas that SUD treatment programs faced during the COVID-19 pandemic, the availability of empirical data is limited. Firsthand accounts reported by SUD counselors during qualitative research methods could address this gap. Given the novelty of such ethical dilemmas experienced during the COVID-19 pandemic, gaining information on how SUD counselors engaged in ethical decision making during this time could inform future training needs.

While literature exists outlining the many changes made in SUD treatment programs as they quickly changed to respond to public health mandates, less is known about how such changes may influence the ability of SUD counselors to uphold professional standards while encountering ongoing and novel ethical issues during a public health crisis. This is of particular importance, because evidence suggests SUD treatment providers are advocating for COVID-19 related changes in SUD treatment to be maintained after the pandemic.^5,19,20 In order to address this gap, we modified the procedures of an ongoing study examining ethical dilemmas facing SUD counselors in California to directly explore treatment changes during COVID-19 and the ways that public health strategies to contain COVID-19 produced new ethical dilemmas for SUD counselors.

Method

Participants

We conducted in-depth qualitative interviews with 18 front-line counselors working in residential (n = 10) and outpatient (n = 8) substance use treatment settings in San Francisco, CA from May to August 2020. No participants dropped out or refused to participate after the consent process.

Participants for the current study were included in a larger study focused broadly on ethical dilemmas faced by SUD counselors and desired ethical training. Data in the current study were from COVID-19-related questions that were added following the pandemic. Participants were recruited for the larger study from 2 substance use treatment clinics, following presentations on study objectives and eligibility that were presented at staff meetings by the study’s investigators (JS, CM, and KF). Flyers and emails with study information were also disseminated to staff at recruitment sites. Eligible participants were any staff members who had a SUD counseling position not requiring a graduate degree and had 12 or more months experience providing counseling to SUD patients. From February 2020 through early March 2020, study recruitment occurred in-person. The research team paused participant enrollment from March 2020 (the onset of state-wide COVID-19-related shelter in place policies) through April 2020 to shift the protocol to remote recruitment, informed consent, and data collection procedures. From May 2020 through August 2020, study recruitment occurred virtually through study invitations via email and referrals from other frontline staff. Interested individuals contacted the study team via a dedicated phone line, at which point a research team assistant conducted screening via phone to determine eligibility and to set up a time for the interview. All enrolling individuals provided verbal consent. Participants included in the current study were recruited using these remote procedures. Of note, 3 of the research team members [JS, KF, and CM] were known to the participating research sites due to their participation in other research and clinical duties within these settings. The University of California San Francisco Institutional Review Board reviewed and approved the study protocol (#19-28276).

Data collection

After receiving training from a medical anthropologist and senior qualitative researcher (co-author EA), the qualitative interviewers (JS [male], CM, KF, EA [female]) collected the data through semi-structured individual interviews through a secure video-conferencing platform, Zoom. The semi-structured interview guide consisted of open-ended questions related to participant training in resolving ethical dilemmas, as well as the participants’ experiences of ethical dilemmas encountered whilst delivering counseling services to their clients before and during the COVID-19 pandemic, allowing for exploration of any ethical dilemmas encountered due to the shift in protocols following pandemic-related shelter-in-place orders. The interview guide was piloted prior to data collection, but the COVID-related questions were added after the piloting process in response to the COVID-19 pandemic. Data from this analysis were collected broadly through the following questions: “How has the clinic and its procedures changed since COVID-19? How has your role/responsibilities changed as a part of dealing with COVID-19?” We also included ethical dilemmas that were related to COVID as elicited by the following queries: “Have you noticed any recent ethical issues related to the new COVID-19 guidelines? What was the issue? How did you or your workplace deal with it? Would you do anything differently?” Interviews lasted between 60 and 90 minutes and were recorded via Zoom’s audio recording feature. Research team members completed field notes after each interview. No repeat interviews were conducted. Demographic characteristics, such as race/ethnicity, age, and job type, were collected via a self-report questionnaire. At the end of the interview, participants received $75 for their time. Theoretical saturation,^21,22 where no new findings emerged in the data, was discussed during weekly meetings and was determined after 18 participants. Therefore, no additional participants were recruited for the study.

Data analysis

A professional transcription company transcribed the interviews verbatim, and data were analyzed using thematic analysis.²³ Thematic analysis allows for the organization and categorization of qualitative data related to a well-defined topic or theme using pre-determined concepts but also allows for researchers to identify and document inductive themes as they emerge. The analytic domains and interview questions were guided by the content of the NAADAC Code of Ethics.¹⁴ Five researchers (EA, JS, KF, CM, JDS) read a subset of 3 transcripts, including participants from both residential and outpatient settings, and developed and defined a set of parent codes to capture key issues and themes. At weekly meetings, codes were applied to an additional set of 2 transcripts, and the codebook was iteratively refined through rounds of team-based coding and discussion. The final set of thematic codes and full dataset were entered into Dedoose,²⁴ an analytic cloud-based platform, for team-based management and analysis of qualitative data. Transcripts were then coded by the research team members, after all 5 team members had achieved a coder agreement threshold of 90%. Any coding disagreements or discrepancies were resolved via discussion at regular analytic team meetings. For the current study, member checking took place in 2 forms: report backs to each of our research sites to present preliminary findings, and presentations to an Ethics Advisory Board which consisted of experts in the field of substance use treatment and ethicists. This analysis is based on data captured under “impact of COVID-19” and “ethical dilemmas encountered” codes, which were reviewed and written up in analytic memos by CM and EA to further refine our understandings of the unique forms of ethical dilemmas encountered as SUD treatment facilities pivoted their clinical protocols in the face of the COVID-19 pandemic.

Results

Participant characteristics

Following the tenets of thematic analysis, we ceased data collection once our team had achieved theoretical saturation with a sample size of 18. Our 18 participants varied in gender (72% women), age (31-72 years, M = 49.5), counseling experience (1-8 years), and race/ethnicity (44% White, 33% Black, 22% Biracial). Eleven participants self-identified as in recovery from substance use. All participants had jobs that involved direct client contact. Ten were from a residential treatment program and 8 were from an outpatient treatment program.

Findings

Our results are organized into 4, related themes: (1) changes to SUD treatment programs to respond to public health mandates; (2) unique ethical dilemmas faced during the COVID-19 pandemic; (3) treatment challenges resulting from responding to public health mandates; and (4) unexpected ways that COVID-19-related changes to clinical protocols allowed for more client-centered treatment options.

Changes to SUD treatment programs to respond to public health mandates

In March 2020, San Francisco and the State of California quickly implemented several public health mandates to reduce the spread of COVID-19.²⁵ SUD treatment programs made drastic changes in response to the public health mandates while also continuing to provide care. These mandates developed quickly and iteratively over the course of the pandemic, often resulting in SUD treatment programs having to quickly pivot and modify procedures. SUD treatment counselors expressed understanding the need for such quick and iterative changes, but also highlighted their disruptive nature.

“Like I think that they were trying to kind of make policy as things were going, you know, as they were trying to react to the Department of Public Health changing policy. Which was reacting to the state. . .in real time. So, that’s not an easy way to decide how to do stuff.” (Residential SUD counselor, 1010)

Programs worked quickly to implement creative changes in response to these dynamic public health mandates. For example, SUD counselors at the outpatient clinic described how dosing medication for substance use disorder was moved outside to a van in order to provide more space for social distancing. The program also developed flexible ways to support clients while socially distancing.

“We’re doing predominantly phone counseling at the moment. The clinic has just started setting up some iPads to do Zoom with clients who are able. A lot of our clients are homeless and/or below . . .poverty income level. And so having things like an iPad or a smart phone. . .is not something they often have. And so we’ve been doing predominantly true phone counseling.” (Outpatient SUD Counselor, 1004)

Procedures on approving clients to get take home doses of medication for OUD were also modified to reduce the number of clients attending the program daily. For example, use of stimulants was removed as a barrier to receiving take-home doses.

“And at [this clinic]. . . that’s a big percentage of people using stimulants. . .while being on medication for opioids. So, we’ve started giving a couple take homes to people with stimulants. Um, kind of thinking of what’s the bigger risk, like is the bigger risk. . .contracting coronavirus, or is the bigger risk overdose with methadone or any complications around that?” (Outpatient SUD counselor, 1003).

Several public health mandates were difficult to carry out in SUD treatment settings while maintaining treatment access for clients. For example, the residential program lacked adequate space for social distancing and quarantining, as noted here by a residential SUD counselor (1015), “There’s absolutely no way [clients are] housed six feet apart. . .[in] most of the rooms . . .they could hold hands.” Testing was also not widely available or consistently enforced for staff and clients.

“They also didn’t require staff to get tested at first. . .when we were testing the clients. . . [the clients] are like, well we are in the house all the time, you guys [the staff] are the ones that are going in and out.” (Residential SUD counselor, 1010)

Despite these efforts to adhere to public health mandates and program policies, SUD counselors also reported several examples of being concerned about COVID-19 exposure while providing treatment. For example, not quickly identifying COVID-19 positive clients resulted in concern regarding exposure for clients and staff in residential settings.

“They were bringing in [admitting] people from the streets every single day. And then they were somehow getting mixed up with us and [clients already in the program]. . ..Someone let this [new client] in. . .and they got into general population, touched some items, sat on the bench, got back in the van with people. . .and [then] the van got full of COVID-19.” (Residential SUD counselor, 1014)

Inconsistent mask-wearing, lack of symptom screening, and the inability to adequately socially distance were also of concern for outpatient counselors.

“None of the clients are screened at the van site. They are provided a mask. . .most of them argue about not wearing them. Counselors are exposed directly to the clients. . .. I’ve had clients that. . .. I’ve had a conversation with [a client] one day, the next day I find out they’re in isolation. They’ve been exposed. And I’m like, well maybe I have. . .I can’t really remember if I had a damn mask on or if I was six feet away.” (Outpatient SUD counselor, 1006)

SUD counselors reported that their programs implemented several changes to creatively adhere to public health mandates while maintaining treatment access. At times, these changes resulted in staff members experiencing uncertainty about COVID-19 exposure and/or transmission.

Unique ethical dilemmas faced during the COVID-19 pandemic

The clinic-level changes that occurred within the SUD programs resulted in a series of novel ethical dilemmas. Many were related to attempts to continue providing individualized care to clients who were impacted by the COVID-19 pandemic. For example, a residential SUD counselor described engaging in unorthodox approaches to build rapport and help a client cope with COVID-19 mandates, which resulted in an ethical dilemma regarding boundaries within the counseling relationship.

“A client of mine was waiting to get out of [two week quarantine] and he hardly had any contact with the free world in three years [due to being in jail]. . . so what we agreed [was] that I would walk him to the park. . . And then, several days passed and he wanted to go [to the store] to get some beef jerky and a soda. So, I walked him there based on the fact that he’s been holed up in a jail for three years and then released to our care and kept on a 14-day observation lockdown where you can’t leave. . .I basically had some sympathy for that. Then two days later. . .. he approached me again about doing the same thing. . ..And I said you’re about to leave observation, so this is the last time that I’m going to do this because the rest of my caseload is going to wonder why I’m taking you on these walks one-on-one. . . I can’t – that’s a double standard and I’m not going to do that any longer. And he seemed upset. . . but this double standard thing is not going to work.” (Residential Counselor, 1016)

An outpatient counselor also reported balancing the need to support a client’s welfare by ensuring they have access to medication, and a clear way of communicating with their providers, while still respecting the client’s boundaries of privacy and confidentiality. This outpatient counselor described a situation when they were struggling to contact a client during a time when in-person meetings within the outpatient clinic were limited.

“On the bus. . .as a rule of thumb. . . I don’t normally initiate in conversation [with clients]. But I had a client. . . we were discussing giving him some take homes. Uh, and so I had a conversation really brief on the bus with him. And I was telling him that we were going to issue him out a telephone [so he could be in touch with providers]. And we needed him to charge it and keep it charged, and to answer it. And so that bugged me all day because I felt like maybe I shouldn’t have had that conversation with him on the bus. . .I thought about it. . .hey, I wasn’t in a closed room, you know what I mean? It wasn’t in the traditional counseling areas.” (Outpatient Counselor, 1006)

Outpatient providers also experienced new ethical dilemmas related to a quick pivot to telehealth services. At the beginning of the COVID-19 pandemic, the program went from having virtually no telehealth services to encouraging counselors to offer phone and then subsequently Zoom-based services, often while working from home. One outpatient counselor expressed concern how Zoom-based services could impact boundaries within the counseling relationship.

“We’ve been only doing telephone calls. I’ve talked to other counselors in other programs who are doing video calls and [they] feel like an over sense of familiarity in seeing someone’s home and seeing them in their pajamas and seeing, you know, it kind of may be too personal. . ..I’ve actually been glad in my program that we’re just using telephone, but they’re trying to shift to Zoom and I don’t think I would be comfortable with that actually. . ..there is just definitely a finer line of personal boundaries. Even, you know, I’m on the phone and they’re hearing my kid cry because he fell down, and then they ask about my children. . .we’re kind of bleeding into each other’s personal space in a different way.” (Outpatient Counselor, 1007)

Another outpatient counselor echoed concern regarding boundaries within the counseling relationship when communicating with clients via text messaging. They reported concern regarding a lack of procedure for telehealth services, which became challenging specifically when dealing with clinically complex cases.

“I won’t give out my personal phone number but, um, but they can text. And so they’re texting now. And so that’s, yeah, so that’s a COVID-19 related thing. Like how do we deal with texts? We don’t have a policy around texting. And I have one client who sent me many. . . angry messages. . .what am I supposed to say to that?” (Outpatient Counselor, 1003)

SUD counselors reported several novel ethical dilemmas that were the direct result of changes during the COVID-19 pandemic. They described efforts to balance client welfare while responding to public health mandates or carrying out modified treatment approaches.

Treatment challenges resulting from responding to public health mandates

While the counselors recognized the importance of implementing public health mandates to reduce COVID-19 transmission, they also highlighted how these changes created treatment challenges when working with clients. Counselors noted the reduced contact with their clients and described how COVID-19 seemed to disrupt normal routines and negatively impact clients.

“But the real problem is having to move from a structured psychoeducational treatment model to not giving them the same experience. . .just doing groups with people who aren’t experienced to do groups, doing groups that are just fly by night. . . they’re disorganized. . .there’s no rhyme or reason as to what’s available. . .some days we don’t do groups at all. They don’t get the quality of treatment they got before.” (Residential Counselor, 1013)

Evidence-based approaches (eg, group and individual therapy) that were commonly integrated into treatment prior to COVID-19 were often disturbed. Within the outpatient clinic, the minimum requirement for 50 minutes of counseling per month was waived, resulting in clients not being required to check in with their counselors as frequently. Within the residential program, important relapse prevention approaches such as offering intensive outpatient treatment and job training were halted due to COVID-19.

“Ninety-day step-down, which involves giving outpatient classes, intensive outpatient. . .nine hours [of counseling] a week. . . The problem with COVID-19 is we had to shut down our outpatient program. . ..So basically we’re sending them to a sober living environment for the next ninety days. . ..Um, where hopefully they can get the job they want. The problem with that is, no jobs [due to COVID-19].” (Residential SUD Counselor, 1013).

SUD counselors also reported an interruption in their ability to collaborate with interdisciplinary treatment providers or other entities involved in the client’s treatment (eg, parole officers) which seemed to undermine the client’s progress in treatment.

“The reason that [clients] are here in the first place is to get substance abuse treatment. And because COVID-19 has hit does not mean that they’re no longer here for the substance abuse treatment. And so [clients]. . . they’re not held accountable to the rules. . .to the guidelines. They’re not enforced to attend treatment. . . and if you call or – which would be the normal course, would be to call the parole agent to get them involved, the parole agents don’t even come out. . .That undermines a lot. . ..” (Residential SUD counselor, 1017)

One of the most reported COVID-19-related treatment challenges was the impact that public health mandates had on the therapeutic alliance. Specifically, counselors reported how mandates such as social distancing and masking requirements influenced the counselor-client relationship by limiting rapport and creating challenges related to privacy and confidentiality. One residential counselor described the experience of clients feeling anxious during COVID-19 and shared how social distancing was perceived as a potential barrier to rapport-building. This, in turn, impacted their ability to provide support.

“There’s just a lot more. . .anxiety I guess, on both sides. I can’t, uh, be as close to clients as I’d like to be, six feet is kind of an impersonal. . .distance to me. And. . .wearing a mask and stuff like that. . . the anxiety on their end. . . I can only imagine it is pretty intense. . .. . .they’re generally. . ..disoriented or like sort of aloof.” (Residential SUD Counselor 1016).

With the shift to providing services at a nearby van site, outpatient counselors reported concern regarding privacy and confidentiality. One outpatient counselor described how they implemented an alternative strategy of meeting with their clients in an outdoor garden space in order to achieve some level of privacy, though this was not seen as an adequate alternative to meeting in a private office within the clinic.

“. . .just not [being able to] give our patients the opportunity to talk to us anytime when they feel that they need to talk in person with somebody privately. I have even had clients who are not allowed to come into the clinic and I have to meet them in the garden or. . .in the alcove. . . in the hallway. . ..to have some privacy with them. . .that’s something that bothers me, yeah. . . they are not allowed to come into the clinic because they are in some kind of risk [group].” (Outpatient SUD Counselor, 1009).

Another outpatient counselor reiterated the challenge with having a lack of private space to discuss potentially stigmatizing information such as substance use patterns, and how that lack of comfort with providing counseling in a semi-public setting undermined their ability to build and maintain rapport necessary to have a high-quality counseling interaction.

“I’m still just trying to get used to and trying to navigate. . . having to meet with clients in a public outside space. . .or over the phone when you don’t know who’s around them. Like, the privacy part of it. . .we’re taking the precautions but it’s still, like – from my training experience, it’s like – this isn’t just like, oh, I could go sit with my client outside, like more of like a mental health setting, you could go sit in the garden. . .And now it’s like, okay, you’re sharing with me really personal stuff about your [substance use] and how you’re using, and you’re standing outside in a parking lot around other people and you say you’re okay with it, but I don’t know if I am.” (Outpatient Counselor, 1019)

The counselor went on to describe how the outpatient program was working to address this issue by providing more private spaces to allow for therapy to occur outside while socially distancing.

“Like I said, [our program] has been great with the medical team and the supervision around trying to make this as easy and safe for the clients and for us as possible. One of the suggestions we had was building, like, an office space down at the van site and having, like, little spaces, like indoor spaces for the clients to meet via Zoom. Being that it’s as, as uncomfortable and like, maybe claustrophobic as some clients may be, it’s like. . .this is protecting your confidentiality.” (Outpatient Counselor, 1019)

COVID-19 resulted in novel treatment challenges that SUD counselors had to face while maintaining treatment for their clients. Counselors reported the most concern regarding the impact of COVID-19 on the counselor-client relationship.

Unexpected ways that COVID-19-related changes to clinical protocols allowed for more client-centered treatment options

While COVID-19 created unique challenges for counselors and clients, several participants reported unexpected changes during the pandemic that seemed to make treatment more individualized for some clients. This was seen primarily in the outpatient program, where the relaxation of strict rules related to receiving take-home medications allowed for some clients to have more flexibility within treatment that they would have previously been denied (eg, due to ongoing stimulant use). This change was supported through increased interdisciplinary collaboration with the counselors and medical team.

“I think the take homes of medication is something that could’ve potentially been an ethical issue, but I was actually felt really good about how the clinic handled it. I felt there was good coordination from the medical staff identifying people who would be eligible. And then they coordinated with clinical staff to make decisions that felt appropriate and safe.” (Outpatient Counselor, 1004)

Outpatient providers also reported that several clients on their caseloads enjoyed the flexibility of telehealth sessions, which was previously not available within the program. For some clients, this change seemed to have a positive impact on counselor/client rapport.

“It seems to have offered people some control. Which I think for some people was very freeing. To be on their own turf in their own pajamas in their own house on their own couch. . . for a quarter of my case load, I would say it’s been a positive change. . . I feel like people have opened up in a deeper way.” (Outpatient Counselor, 1007)

With the implementation of telehealth, the outpatient counselors also reported positive changes in the reduction of personal work-related barriers such as commute-related stress and interruptions at work. The reduction of these time-consuming burdens allowed for more time to dedicate to clients.

“You know what? I miss my clients, but you know, I really like working from home. What I like about it, I ain’t bothering nobody and ain’t nobody bothering me. You know what I’m saying? How people come to your office, “Hey girl, how you doing” and blah, blah, “What’s you doing” and, uh, “Hey, could you help me do this,” and you saying this – it goes both ways. . .I just get into it and get my work done. I just come right in the kitchen and set up. . .fix my coffee and start calling my clients.” (Outpatient Counselor, 1005)

Similar benefits related to a reduction in time-consuming tasks were reported by residential counselors as a result of more lax documentation requirements.

“Believe it or not, it’s made my life as a counselor a lot less stressful in terms of having to work with these clients. . ..Our primary funding source is Medi-Cal and from the outset of this pandemic, they’ve relaxed their note taking requirements. . .across many standards and that’s made my life a lot easier. I have a lot more time to engage and connect with the clients.” (Residential Counselor, 1016)

While the COVID-19 pandemic resulted in unexpected treatment challenges for some clients, SUD counselors also reported that some changes seemed to result in more client-centered treatment options. Counselors also reported how reductions in other competing tasks (eg, workplace distractions or administrative requirements) allowed for more opportunities for connecting with clients.

Discussion

Public health mandates implemented to reduce the transmission of COVID-19 greatly impacted many health organizations, including SUD treatment programs. The mandate shifts were part of efforts to prevent the spread of the new coronavirus infections. Physical distancing, cutting down on crowds, and curbing public transportation use were all necessary to prevent the virus’ spread.²⁶ However, those shifts were difficult in clinic settings, where long lines and close contact are common as people wait for treatment. Patients also may have underlying medical conditions stemming from a history of SUD, which may elevate their risk of contracting and spreading the virus. Thus, the pandemic created urgency for SUD treatment programs to ensure continued access to care for existing patients, promotes patient safety, and expand to new patients. While some programs decreased services or were shut down completely, the 2 SUD treatment programs involved in this study utilized creative methods to remain open and provided client-centered services during the initial months of the COVID-19 pandemic.

Counselors in these SUD treatment programs reported innovative and novel ways that workflows were quickly modified to adhere to mandates while continuing to provide treatment to clients. For example, programs implemented testing and quarantine policies, reduced the number of clients entering treatment programs, enforced universal masking policies, and even developed a new outdoor site to allow for increased social distancing. Many of the highlighted changes were developed through interdisciplinary collaboration between counselors and program leadership; this collaboration was identified as a way of ensuring the COVID-19-related changes resulted in the least amount of disruption for clients as possible.

Despite reported challenges, many SUD counselors highlighted that COVID-19-related changes resulted in unique client-centered treatment options within the program, which were beneficial for some clients and staff. At the outpatient program, the requirements for take-home methadone and buprenorphine were relaxed, allowing for clients who were previously not eligible for take homes (eg, clients with current stimulant use) more flexible ways to receive treatment. This was generally seen as a positive change among participants in the current study, which aligned with recent literature revealing that opiate treatment program directors across the U.S. and clients viewed the relaxed take-home requirements as a positive change for both staff and clients.^27,28 Recent data from Ontario also supports less-stringent take-home procedures, suggesting that extended take-homes may support treatment retention.²⁹

The outpatient program also quickly integrated telehealth during COVID-19, which led to some positive changes in the ways that staff connected with clients. This rapid integration of technology enabled ongoing treatment access throughout the pandemic.^30,31 Like the outpatient program in our study, a recent survey of 457 substance use disorder treatment programs across the U.S. found that over 70% had integrated some form of telehealth services via phone or video during the pandemic. Participants were receptive to telehealth integration and reported intent to use these services in a post-COVID-19 era.³²

Due to the observed benefits, specific COVID-19-related changes (eg, relaxed take-home requirements and telehealth integration) may likely be sustained after the COVID-19 pandemic. Therefore, the ethical dilemmas related to these changes should be considered and addressed. For example, several counselors in the current study highlighted the new ethical dilemmas that arose due to the shift to telehealth services. These challenges could be reflective of the complex clinical needs of some clients, as a recent survey of behavioral health providers revealed that clinicians perceive telehealth to be more complicated with clients with higher symptom severity.³³ Previous findings from directors of residential SUD treatment programs also highlight that older or economically disadvantaged clients (such as those served by the counselors in the current study) may struggle to navigate the technology needed to engage in telehealth,⁵ which could in turn lead to more complicated (and perhaps more ethically complex) telehealth sessions.

Counselors also reported several other incidents that created a need to balance several ethical principles (eg, maintaining the counseling relationship vs protecting the welfare of the client) with responding to public health mandates. Our qualitative data mirrors a commentary made by Johnson et al,¹⁶ highlighting how counselors balanced their ethical requirements toward their client with the ethical requirements to society for reducing COVID-19 risk. As COVID-19-related changes in services persist, specific training, supervision, or consultation opportunities should be developed and utilized to address the unique ethical dilemmas that can arise. For example, training on how to maintain the boundaries within the counselor-client relationship while conducting telehealth at home would address several of the novel dilemmas that emerged from this study.

In addition to the emergence of ethical dilemmas, the quick pivot to respond to public health mandates also resulted in unique clinical challenges, specifically related to the therapeutic alliance. As outlined by Hougaard, therapeutic alliance is based, in part, on the personal relationship between client and therapist. This relationship is comprised of therapist contributions (eg, therapist is warm, friendly, genuine, empathetic) and client contributions (eg, patient is trusting of therapist).³⁴ Within the current study, SUD counselors reported several challenges related to COVID-19 that reflect a potential strain on therapeutic alliance. For example, counselors reported an inability to feel close to clients given the “impersonal” social distancing requirement of 6 or more feet. They also reported strains on their ability to engage with clients in private locations, which could influence the client’s trust in divulging potentially stigmatizing information to the counselor. Despite these challenges, SUD counselors reported responding in a client-centered manner and modifying their clinical approach in unique and flexible ways to maintain and/or build rapport.

Limitations

While the current study highlights important changes occurring in SUD treatment programs during the COVID-19 pandemic, it is not without limitation. Data were collected from Mayto August 2020, which represents the first 6 months of the COVID-19 pandemic. Programs have likely continued to modify and refine protocols based on ever-changing public health messaging. Future research is warranted on how protocols enacted at the beginning of the COVID-19 pandemic have been modified over the course of the pandemic. It would also be important to explore the effectiveness of such changes over time. It is also likely that SUD counselors have different perspectives of the COVID-19-related changes and accompanying ethical dilemmas over time. Another limitation is the narrow focus on SUD counselors, which omits the perspectives of clients in treatment for SUD. More information is needed regarding client-level perceptions of COVID-19-related changes and corresponding ethical dilemmas. The data for this study was collected from Californian SUD treatment programs. COVID-19 related public health mandates differed substantially across the United States and even more so globally. Ethical dilemmas facing SUD counselors in other settings should also be examined. Finally, questions remain regarding potential differences in perspectives based on setting (eg, outpatient vs residential) or counselor background (eg, in recovery vs not) that are outside the scope of the current paper. The findings of this research should be interpreted within the particular lens of the research team, many of whom have worked in clinical or research roles in SUD treatment settings, potentially influencing participant rapport, data collection, analysis, and interpretation of results.

Conclusions and Recommendations

Despite these limitations, results from the current study highlight ways that SUD treatment programs quickly implemented changes in response to the COVID-19 pandemic. SUD counselors identified several ethical dilemmas and treatment challenges that accompanied these changes. Conversely, SUD counselors also identified several ways that COVID-19-related changes were seemingly beneficial to clients and staff. While the COVID-19 pandemic is ever-changing, evidence indicates that SUD treatment programs are advocating for COVID-19 related changes to be maintained after the end of the pandemic.^5,19,20 This underscores the importance of understanding the ethical dilemmas related to these seemingly more permanent changes. This study can also inform public health recommendations. Results can inform SUD treatment programs on how to prepare for future emergency or disaster responses that may have a similar impact on treatment accessibility and operation and provide additional considerations for the development of future ethical training programs (eg, trainings on how to manage alternative forms of medication distribution such as increased take-home medication allowance and provide evidence-based services via telehealth).