yourmftethics

ETHICS FOR TEXAS LICENSED SOCIAL WORKERS: GENERAL REQUIREMENTS    

 (3 hours)

Introduction

Overview

This course is intended to familiarize the student with the legal and ethical issues in social work, and is specifically intended for licensed clinical social workers in Texas. Thus, this course will include many specifics from applicable state and federal laws, as well as from the ethical codes of the National Association of Social Workers.


Laws, regulations, and ethical guidelines figure very importantly in the conduct of social workers and other professionals. Laws and regulations serve a variety of purposes. These purposes are as concrete as the equity transfer of taxes and licensing fees that support communities and help to maintain the regulatory infrastructure, and as esoteric as serving the mandates of constitutional law. Of course, they are mostly for the more obvious purposes, those of protecting the public and improving mental health.

History

Known ethical standards for healers date back to the Hippocratic Oath, developed roughly 2,500 years ago (Hippocratic) and even farther back to the Nigerian healer’s code. (O’Donohue, W. T. & Ferguson, K. E., 2003) Attempts to regulate professions have a long history, and many have been triggered by problems with the conduct of the professionals themselves, as is discussed in the section on boundaries. Enforcement ranges from sanctions such as letters of warning, to punishments that can include loss of license, fines and imprisonment.

Nature of Laws

Laws pertaining to social work can be found in various statutes and codes that serve a variety of purposes such as maintaining confidentiality and requiring adequate levels of training. There are also laws collected together under the rubric of professional conduct. Violations constitute unprofessional conduct, for which there are various enforcement measures. (Tex Occ. Code §105, 2007)


In the United States, state boards have the primary responsibility to regulate professional behavior. In Texas, the Texas State Board of Social Worker Examiners  regulates licensed clinical social workers.


There are numerous laws and regulations that give this board the authority, responsibility, and the procedures to regulate the professionals under its authority. The board itself must obey numerous laws and regulations pertaining to its conduct. The board’s regulatory responsibilities include reviewing complaints from the public, issuing sanctions and even working with law enforcement when necessary.


The state law primarily enacted to regulate social workers is chapter 505 of the Texas Occupations Code, known as the Social Work Practice Act. (Tx. Occ. Code § 505, 2003). Social work is also regulated in chapter 781 of the Texas Administrative Code, entitled Social Worker Licensure, which is intended to implement the Social Work Practice Act. (Tex. Admin. Code, Title 22, §781, 2007)

Principles & Perspectives

The student is encouraged to participate in this course with an eye to the principles that underlie the specific laws, regulations and guidelines covered. Understanding these principles will help the student learn and apply the material in this course. This introductory section has already taken a stab at describing such principles by touching on the sources and motivations for the regulation of professional conduct.


Licensed social workers should include in their perspective on legal and ethical issues the fact that their profession must be aware not only of individual psychology, but also on the dynamics of social systems, including the family. Awareness of these systems can extend the focus of intervention beyond the individual client and create challenges in identifying desired outcomes. As Maddock put it, “The willingness to bring social systems into the domain of mental health care has created added layers of legal and ethical complexity never envisioned by the original architects of the psychotherapeutic process…” (Maddock, J. W., 1993) 

What are Ethics in Social Work Practice?

The American Heritage Dictionary defines ethics as, “The study of the general nature of morals and of the specific moral choices to be made by a person; moral philosophy.” (American Heritage Dictionary, 2007) It defines morality as, “The quality of being in accord with standards of right or good conduct. (Ibid)


The National Association of Social Workers (NASW) offers the following overview of its ethical principles in the preamble to its Code of Ethics:


The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. A historic and defining feature of social work is the profession's focus on individual well-being in a social context and the well-being of society. Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living.


Social workers promote social justice and social change with and on behalf of clients. "Clients" is used inclusively to refer to individuals, families, groups, organizations, and communities. Social workers are sensitive to cultural and ethnic diversity and strive to end discrimination, oppression, poverty, and other forms of social injustice. These activities may be in the form of direct practice, community organizing, supervision, consultation, administration, advocacy, social and political action, policy development and implementation, education, and research and evaluation. Social workers seek to enhance the capacity of people to address their own needs.

Social workers also seek to promote the responsiveness of organizations, communities, and other social institutions to individuals' needs and social problems. (National Association of Social Workers, 1999)


The NASW Code of Ethics covers responsibility to patients, colleagues, in practice settings, as professionals, to the social work profession, and to society. (Ibid) It expresses six purposes:


The Code identifies core values on which social work's mission is based.
The Code summarizes broad ethical principles that reflect the profession's (sic) core values and establishes a set of specific ethical standards that should be used to guide social work practice.
The Code is designed to help social workers identify relevant considerations when professional obligations conflict or ethical uncertainties arise.
The Code provides ethical standards to which the general public can hold the social work profession accountable.
The Code socializes practitioners new to the field to social work's mission, values, ethical principles, and ethical standards.
The Code articulates standards that the social work profession itself can use to assess whether social workers have engaged in unethical conduct. NASW has formal procedures to adjudicate ethics complaints filed against its members. In subscribing to this Code, social workers are required to cooperate in its implementation, participate in NASW adjudication proceedings, and abide by any NASW disciplinary rulings or sanctions based on it. (Ibid)
These six purposes are expressed in a set of values, which are annotated. Below are the unannotated values: (Ibid)
Value: Service
Ethical Principle: Social workers' primary goal is to help people in need and to address social problems.
Value: Social Justice
Ethical Principle: Social workers challenge social injustice.
Value: Dignity and Worth of the Person
Ethical Principle: Social workers respect the inherent dignity and worth of the person.
Value: Importance of Human Relationships
Ethical Principle: Social workers recognize the central importance of human relationships.
Value: Integrity
Ethical Principle: Social workers behave in a trustworthy manner.
Value: Competence
Ethical Principle: Social workers practice within their areas of competence and develop and enhance their professional expertise.
The codes express these values in its Ethical Standards. An outline of the topics covered follows. (Ibid)
1. Social Workers' Ethical Responsibilities to Clients
1.01 Commitment to Clients
1.02 Self-Determination
1.03 Informed Consent
1.04 Competence
1.05 Cultural Competence and Social Diversity
1.06 Conflicts of Interest
1.07 Privacy and Confidentiality
1.08 Access to Records
1.09 Sexual Relationships
1.10 Physical Contact
1.11 Sexual Harassment
1.12 Derogatory Language
1.13 Payment for Services
1.14 Clients Who Lack Decision-Making Capacity
1.15 Interruption of Services
1.16 Termination of Services
2. Social Workers' Ethical Responsibilities to Colleagues
2.01 Respect
2.02 Confidentiality
2.03 Interdisciplinary Collaboration
2.04 Disputes Involving Colleagues
2.05 Consultation
2.06 Referral for Services
2.07 Sexual Relationships
2.08 Sexual Harassment
2.09 Impairment of Colleagues
2.10 Incompetence of Colleagues
2.11 Unethical Conduct of Colleagues
3. Social Workers' Ethical Responsibilities in Practice Settings
3.01 Supervision and Consultation
3.02 Education and Training
3.03 Performance Evaluation
3.04 Client Records
contracts.
3.05 Billing
3.06 Client Transfer
3.07 Administration
3.08 Continuing Education and Staff Development
3.09 Commitments to Employers
3.10 Labor-Management Disputes
4. Social Workers' Ethical Responsibilities as Professionals
4.01 Competence.
4.02 Discrimination.
4.03 Private Conduct
4.04 Dishonesty, Fraud, and Deception.
4.05 Impairment
4.06 Misrepresentation
4.07 Solicitations
5. Social Workers' Ethical Responsibilities to the Social Work Profession
5.01 Integrity of the Profession
5.02 Evaluation and Research
6. Social Workers' Ethical Responsibilities to the Broader Society
6.01 Social Welfare
6.02 Public Participation.
6.03 Public Emergencies
6.04 Social and Political Action

Stress-Reducing Beliefs about Ethical Practice

The following guidelines are adapted from Pope and Vasquez’s textbook on ethics (Pope, K. S. & Vasquez, J. T., 2007).

A Continuous, Active Process

Many factors can challenge and even interfere with ethical decision making. Laws and ethical codes cannot foresee every circumstance. Thus, a commitment to conscious analysis of ethical issues and gaining support for ethical conduct are essential.

Enlightened Use of Literature, Training and Research Data

Literature, training and research can result in conflicting and erroneous claims and ideas, or be misapplied through overgeneralization or misinterpretation. It is important to think critically and compare multiple sources and biases in developing and applying therapeutic procedures and ethical behavior.

Most Ethical Gaffes are a Matter of Fallibility, not Corruption

Most social workers are dedicated, caring individuals who are committed to competent, ethical practice. However, we can make mistakes or inadvertently succumb to pressures that result in breaches of ethics or effectiveness. By being open-minded about one’s own fallibility, and by thinking critically, the social worker is in a better position to prevent or recover from errors while minimizing harm. Continuous questioning as to better ways to perform or think critically is needed. Preoccupation with the faults of others is a red flag that we are distracted from our own faults. Even where large numbers of clinicians have been highly confident, history has shown that we can be wrong.

Ethical Dilemmas do not Always Have Clear Answers

If you have a pulse, expect to struggle with ethical dilemmas. They arise inevitably from clinical work. It is subtle and complex, and as fraught with societal and legal issues. This is another motive for continuing education in the issues, and for peer support in teasing out the answers. Where legal implications exist, consulting with the state board, agencies that are involved in the case, and an appropriate attorney are advisable to consider. Rather than being preoccupied with eliminating all risk of complaint or liability, the social worker should be actively involved in reducing risk in an ethical and lawful manner. Social workers who pursue perfect absence of risk tend to harm their performance through anxiety and perseveration. These symptoms deserve attention and help.

Concerns About Risk of Law Suits and Complaints

Social workers sometimes complain about situations in which there is no guarantee that a successful lawsuit can be prevented. Even an unsuccessful lawsuit can pose great demands and stress. Much of the ambiguity of the legal environment comes from changes in society. It takes time for laws and court cases to catch up with changes in society. Even then, there may be conflicts between laws and between court judgments and laws. Further, technology has completely changed the face of confidentiality, leading to extensive federal law.


Sometimes laws seem to go against common sense, or at least the instincts of social workers and the people they serve. When we trace a law or judgment back to its roots, we can usually understand and comply in good conscience. However, it is not always possible to convince an angry parent or spouse of its wisdom.


Nonetheless, social workers must determine how much defensive practice is too much. Wishing to avoid liability and even the risk of an unfounded complaint or lawsuit, social workers may be tempted to go too far.

Excessively defensive practice can deprive clients of appropriate and needed services. In other words, the social worker must ask whether a defensive strategy is an ethical one. The social worker must accept a certain level of risk along with the privilege of licensure in a healing profession.


An example of an excessively risk-aversive approach would be refusing to work with children going through divorce simply because there is a higher likelihood of complaints or suits. Another is that of the psychiatrist who complacently prescribes medication to relatively easy cases, but will not accept cases that are complex, and neglects or actively alienates clients who become complex, simply because they are not as profitable. Refusing to accept cases that may be demanding is known as cherry picking.


On the other hand, one can proceed with too much abandon. Social workers driven to play the hero may mishandle delicate ethical or legal issues. For example, one psychotherapist took his client’s problems so personally, that he would make bold moves without initially gaining adequate rapport. When a client expressed hopeless self-pity, he tried to prove that people would be helpful. He offered to loan her money to get out of a jam. The client was so confused, surprised and alienated that she left his care. This same psychotherapist later ended up with two separate disciplinary actions by the board for other infractions, and got the highest rate of complaints to a managed care company.


Social workers should not react with excessive risk aversion, nor with rash heroism. Instead, counselors should take care to draw the line between these extremes with an ethical perspective that considers client welfare. By considering their existing competencies, social workers can ethically reduce risk of complaints and lawsuits. Appropriate strategies include the following:


Provide informed consent (as covered later in this course).
Set expectations of clients at the beginning of treatment.
Educate clients about what you can and cannot do, and about the legal and ethical requirements that are relevant to the situation at hand. Do this in a preventative manner, rather than reactively.
Stay up-to-date with the changing legal landscape and evolving ethical guidelines.
Get adequate support when an ethical or legal concern arises. Use contact with experienced peers, the state board, the attorney available through your professional organizational membership, educational materials, and reviewing the actual laws and guidelines.

Key Issues in Ethics

Personal Ethical Conflicts

Individual

Emotion, the drive to exceed one’s boundaries

Philosophy and Values in Ethics

Whether you know it or not, your actions are based upon a philosophy that embodies values to produce your ethics. These ethics have a profound effect on your work as a social worker. Your ethics have either a harmonious or stressful relationship with the more general ethical frameworks of the law and your profession. The American Heritage Dictionary defines philosophy as:


A study that attempts to discover the fundamental principles of the sciences, the arts, and the world that the sciences and arts deal with; the word philosophy is from the Greek for “love of wisdom.” Philosophy has many branches that explore principles of specific areas, such as knowledge (epistemology), reasoning (logic), being in general (metaphysics), beauty (aesthetics), and human conduct (ethics).


Different approaches to philosophy are also called philosophies. (See also epicureanism, existentialism, idealism, materialism, nihilism, pragmatism, stoicism, and utilitarianism.) (The American heritage, new dictionary of cultural literacy, 2005)


Whatever answers one finds in philosophy, it is not a fixed base of knowledge or opinion. It is highly influenced by the biases of its culture, and it is ultimately personal. For example, the very influential philosopher, Schopenhauer was quite misogynistic and anti-Semitic, and felt that sex was disgusting. (Janaway, C., 1999)

Philosophers and their philosophies need to be seen not only as being influential, but also as having been profoundly influenced.


From the clinician’s perspective, “philosophy is a set of generalizations and guidance regarding the identification and expression of human values…” Psychotherapy is “value laden” not value free. (Tjeltveit, A. C., 1999)


Everything you do can be seen as an expression of values. Consider the act of opening a can of tuna. You can view it in terms of contributing to your health and family, taking a political position on the hunting of dolphins, or the ecological aspects of waste management. These views depend on what kind of tuna you purchased, who you gave the tuna to, and what you did with the can. Esthetics looms large in some schools of philosophy. It would affect how you prepare tuna.


Values are so deeply embedded in our culture from thousands or millions of years of patterned behavior, that identifying values can be like trying to get a fish to identify water. Values can be seen in the highest aspirations and the most raw physiology, as in the drives that support procreation and survival. It is an essential responsibility of social workers to “unpack,” inspect, and refine their values in ways that are of practical value to their clients and to their own careers. A great additional benefit to this process is that it makes the social worker more effective at helping clients identify and act on their own highest and practical values.


One of the challenges to identifying values and adhering to functional values is that of rationalization. A social worker who states that he or she is having sex with a client because it is giving him or her a positive relational experience and practice at being uninhibited is actually performing a very commonplace mental trick. Here are the steps: 1) Disguise physiologically primitive drives (the drives to procreate and to pursue pleasure, or hedonism). Do this by unconsciously generating a higher-level value statement (value to the client). 2) Adopt this higher-level value as the surrogate reason for the behavior (soliciting sex). This mental prestidigitation serves the parallel purposes of shielding the social worker’s awareness from information that would damage his or her self-esteem, while permitting the social worker to act on primitive impulses.


Mental tricks such as this have survival value. From the perspective of evolutionary psychology, the conscious mind and rational thought are of less value than procreation and survival. Rationality and ethical principles are younger and more delicate than our more primitive impulses. It’s no wonder that ethics in psychotherapy has such a checkered past, and poses great challenges to social workers and to the legal system.


A substantial percentage of clinicians who sexually transgress are repeat offenders and are difficult or impossible to rehabilitate. Therefore, it is important to distinguish between social workers who need to refine their values as opposed to social workers who perceive people as objects whose needs exist only to manipulate so as to fulfill the social worker’s needs. This kind of narcissistic, antisocial character pathology is not a matter of limited insight, psychological defenses, and surrendering to impulses. It is not a matter of limited professional experience. It is a highly ingrained way of being and perceiving that is very difficult to treat, and generally leads the offender to evade treatment except in so far as it can be used to manipulate the system. This is a very good argument for taking assertive action that will create oversight and accountability when violations of ethics are discovered, particularly where personal boundaries are concerned.

Self Management

Our culture values will power and conscious decision-making, but managing our impulses can be more about preventing the need to use much will power. This is about preventing overly risky situations and cultivating ethical habits. Comparing will power to managing influences is a little like comparing steering a car to navigating a boat while playing the piano. However, for a social worker with antisocial personality disorder, it’s more like sailing a piano.


In thinking about self-management where impulses may attempt to overwhelm ethics, the neuropsychological concept of kindling is of value. It means what it sounds like it means, that impulses, given enough promotion, become increasingly powerful. A common expression for this, where sexuality is concerned, is “playing with fire.” A strategy to avoid kindling where sexual attraction is concerned would be in refraining from sexual fantasies about clients. It is important to respect the power of our own physiology, and to manage it effectively.


Another approach is to self-monitor for signs of losing objectivity. Such signs include rationalization, changes in physiology such as heart rate, beginning to think of ways to cross boundaries, and finding oneself unconsciously crossing boundaries. Isolation is bad for ethics. It is very valuable to discuss ethical challenges with supervisors and mature, experienced peers.

Religious Belief

The social worker must have effective ways of responding to clients whose religious beliefs differ from those of the social worker. This situation can create special challenges for rapport-building and the pursuit of therapeutic outcomes.


Religious beliefs and attitudes span the range from values that are aligned with client welfare to values that are unhinged from client welfare. The disconnection from client welfare occurs when the intervention is based exclusively on principles that must be applied regardless of their outcome, as we shall show below.

Insularity

Insularity is an adjective that can refer to applying principles without regard to outcomes, or with blind faith that the outcomes will be good. Related words are fanaticism, zealotry, doctrine, and dogma. Counseling modalities applied in an insular manner can produce disastrous results. Rigid adherence to prescribed techniques or acting on a theory independently of its outcome are two ways a doctrinaire approach to treatment can fail clients.

Three red flags for insular or overzealous treatment include the psychotherapist being unable to adequately explain the theory behind the treatment, limiting client assessment to areas that the psychotherapist’s biases allow, or not changing the approach to treatment despite bad results.

An Example of Insularity in Rebirthing

The smothering of a young girl undergoing rebirthing therapy (a part of her attachment therapy) as a treatment for attachment disorder, as diagnosed by an unlicensed and unregistered Colorado psychotherapist, resulted from applying the technique despite abundant evidence that it was harming the child. (Nicholson, K., 2001) The psychotherapist, her three assistants, and the adoptive mother had every intention of helping the girl, but her pleas for help and insistence that she was dying were misperceived through the therapeutic orientation or “filter” of the rebirthers. Among other evidence, videotape of the session convinced jurors to convict the psychotherapists in the child’s death. (Lowe, P. & Ames, M., 2001)


Two of the psychotherapists were sentenced to sixteen years in prison for reckless child abuse resulting in death. They received the minimum punishment because the judge believed that they did not intend to harm the victim. (Janofsky, M., 2001) The deaths of several other children have been linked to rebirthing, also known as holding therapy. (Chaffin M, et. al., 2006)


This case had additional elements of zealotry, in that promotional materials and statements about rebirthing stated that it was the only therapy that was evidence based, when there was no research supporting it, and in that the primary psychotherapist indicated in her materials that she was a licensed clinical social worker, which was false. The strength of the rebirthers’ beliefs eclipsed fundamental principles of clinical thought and ethics, despite the fact that the primary psychotherapist was a nurse.


Additionally, they were using somatic interventions in the sense that there was physical restraint, application of physical pressure, and deprivation of oxygen. When using methods that can have a direct physiological impact (or an acute or dramatic psychological impact, for that matter) it is especially important to become well-informed about any potential risks and any advisable safety measures. This assumes that the methods are appropriate in the first place.

The Example of Recovered Memory

The recovery of repressed memories of child abuse was popularized in the early 1980’s. A wave of prosecutions and law suits against alleged perpetrators followed. At the same time, many children provided accounts of current or recent abuse as well. In the 1990’s a wave of malpractice claims against psychotherapists and organizations accused of eliciting false memories followed. The recovered memories were often elicited through methods such as hypnosis and manipulative interrogation techniques directed at children. The incidents were often unsupportable by evidence or even extremely improbable.


The debate over recovered memories has often occurred as a polarity between whether or not abuse occurs and whether or not a person is a true feminist. Many feel that this period constituted a modern witch-hunt. In Manhattan Beach, California, as the McMartin Preschool case was unfolding, many cars displayed bumper stickers saying, “We Believe the Children.”


A sober discussion of the issue centers on science and the establishment of facts. Despite the emotion and smear campaigns directed at people who questioned the recovered memory movement, guidelines for interviewing children and for assessing symptoms that may occur as the result of a history of child abuse have been established. There is a great deal of research that has helped clarify the nature of memory, therapy, and testimony relevant to this issue. (Loftus, E. F. & Davis, D., 2006)


Successful cases against clinicians using inappropriate means of producing memories of childhood abuse have resulted in large penalties. (Star Tribune, 1995)


The wave of repressed memory and questionable abuse cases peaked in the mid 1990’s, and have greatly diminished as a result of research and increased sophistication in the courts, social services, the public, and counseling.

Competence to Practice and Self Monitoring

“The ability of a therapist to help a client is strongly influenced by the nature of that therapist’s psychological functioning.” (Epstein, R. S., 1994, p. 35)

Integrity of the Social worker’s Personal Boundaries

For this section, the word integrity is not used in a moralistic sense, but in a structural sense. Intactness of the social worker’s ego boundaries will vary with stress on the social worker. Depending on the social worker’s existing vulnerabilities, which will in some cases include a mental disorder, stressors such as illness, relationship problems, lack of sexual satisfaction, loss of self esteem, legal problems, loss, and trauma may result in an increase in impulsiveness or neediness on the part of the social worker that may intrude upon the therapeutic relationship. The social worker’s self assessment, preparedness for such eventualities, and external support from family, friends, peers, supervision, and counseling are all factors that may help to prevent a bad outcome and even improve the quality of good therapy. (Ibid)


The following subsections provide examples of opportunities for social workers to improve their self-knowledge, as well as their assessment of clients and supervisees, coworkers and employees.

Cognitive Profile of the Social worker

Cognitive strengths and vulnerabilities have implications for ethics. If the social worker has significant cognitive difficulties, he or she may have trouble with a large caseload, case management, or case conceptualization and treatment planning. Problems such as attention deficit disorder may leave treatment planning intact, but interfere with managing details when case management demands exceed a certain threshold. Social workers must know their cognitive abilities to avoid taking on responsibilities outside their scope of competence. This may require outside assistance, because persons with some neurological problems may experience what is known as a positive illusory bias, in which they overestimate their abilities.

Personality Style of the Social worker

The social worker’s personal reaction (countertransference) to clients can significantly alter the course of treatment for better or worse. One area where this issue has received attention is the treatment of individuals with personality disorders. For example, psychotherapists have been shown to be more likely to have negative reactions to clients with cluster A and B personality disorders. This tended to be associated with high drop out rates, and affected clients’ feelings about therapy. (Rossberg, J. I., Karterud, S., Pedersen, G, Friis, S., 2007)
Much research has shown a correlation between the quality of the clinician-client relationship and good therapeutic outcomes. In a good clinician-client relationship, the clinician’s personal issues do not interfere.


A divergent theory is that the licensee’s ability to form a good relationship is actually symptomatic of the licensee not having a personality disorder or other problems that interfere with mature relationships. Accordingly, the social worker’s ability to mature and to adapt are the key to this effectiveness, rather than the relationship itself. This would explain why treatment that does not involve developing much of a relationship with the client can still be effective.


Red flags that tell a social worker that he or she may have critical needs for personal development include their reaction to people with personality disorder symptoms, to highly victimized people, and to highly assertive people.

Impulse Control and the Social worker

Social workers with impulse control difficulties may have a history of “blurting” that is, saying something that is not altogether socially acceptable (or of therapeutic value) before they think about the consequences, or they may experience little concern for the consequences. There may be a history of poorly thought out efforts to be the hero or to react to perceived slights. These incidents may be more likely when there is a sense of heightened emotion or urgency, or when there is more sensory stimulation or recent blows to the ego.


Social workers with this kind of history must work conscientiously with supervision to develop accommodative measures and stress reduction or self-soothing methods.

Evidence-Based Practice

Clinicians are facing increasing challenges to justify their approaches in terms of evidence such as outcome studies and other research published in peer-reviewed journals. Experts have raised concerns regarding inadequate training in evidence-based practice on the part of academic institutions. (The Institute of Medicine of the National Academies, 2006, pp. 264-299) (The President’s New Freedom Commission on Mental Health, 2003) (Hoge, M. A., Morris, J. A., Daniels, A. S., Stuart, G. W., Huey, L.Y., & Adams, N. 2007) The prosecution for the case of Candace Newmaker, the girl who died in rebirthing therapy, repeatedly returned to this issue in cross-examination the psychotherapists.


However, there are significant challenges in fulfilling this aspiration. There can be difficulty, “converting clinical guidelines into active performance measures,” or in, “integration of findings into daily operations.” (Stout, C. E., Hayes, R. A., 2005) Research may appear to have implications for therapy in real-life situations that are misleading. Research studies may not be as relevant to practice conditions as they appear. Clinicians in research studies may not actually carry out therapy with as much fidelity to the prescribed method as is believed, because they may put clients’ needs ahead of the research objectives, or because the client cohort is not as homogenous as intended.


Often, there is not enough consistent data available to form a secure evidence-based opinion, despite the existence of practice guidelines and texts that synthesize what information is available. Psychotherapists often use methods that are not yet well researched, but that they have faith in because of an abundance of clinical experience. In this circumstance, avoiding blind faith by staying outcome-focused and carefully assessing risks and one’s own scope of practice and competence are essential.


Staying up-to-date is the first priority in evidence-based practice. However, it is important to understand the limitations of research such as biases. This topic is covered in research courses. Much medical research has been called into question because of the influence of “big pharma” (the pharmaceutical industry) on research and its publication. This has included the suppression of negative information about medications.

Informed Consent

At the outset of therapy, clinicians provide their clients with verbal and written information, much of which is legally required. Some information is not legally required to be offered, but affords some legal protection to the social worker. Other information provided is helpful in setting client expectations in order to improve client understanding and adherence to terms and conditions of the services provided by the social worker. HIPAA and state regulations require psychotherapists to provide specific information in the service of informed consent at the outset of treatment.


Informed consent refers to a client having adequate information to make a decision regarding medical care. This prevents a medical procedure from being considered battery. (Alban, A., 2007) Information that assists the client in understanding the risks and rewards of their mental health services affords the client the ability to give “informed consent.”


At the outset of therapy, clinicians provide their clients with verbal and written information, much of which is legally required. Some information is not legally required to be offered, but affords some legal protection to the counselor. Other information provided is helpful in setting client expectations in order to improve client understanding and adherence to terms and conditions of the services provided by the counselor. HIPAA and state regulations require counselors to provide specific information in the service of informed consent at the outset of treatment.


Informed consent refers to a client having adequate information to make a decision regarding medical care. This prevents a medical procedure from being considered battery. (Alban, A., 2007) Information that assists the client in understanding the risks and rewards of their mental health services affords the client the ability to give “informed consent.”


In Texas, § 681.41(e) requires licensed social workers to inform new clients, in writing, of a variety of specific aspects of the counseling process. This information must be provided before or during the initial consultation. Under the statute, such information includes:


(1) fees and arrangements for payment;
(2) counseling purposes, goals, and techniques;
(3) any restrictions placed on the license by the board;
(4) the limits on confidentiality;
(5) any intent of the licensee to use another individual to provide counseling treatment intervention to the client; and
(6) supervision of the licensee by another licensed health care professional including the name and qualifications of the supervisor.
In Texas, § 781.403 (7) “General Standards of Practice” requires LBSWs, LMSWs, and LCSW’s to inform new clients, in writing, of a variety of specific aspects of the counseling process. This information must be provided before or during the initial consultation. Under the statute, such information includes:
(A) qualifications of the provider and any intent to delegate service provision;
(B) any restrictions placed on the license by the board;
(C) the limits on confidentiality and privacy; and
(D) fees and arrangements for payment. (Tx. Admin. Code § 781.403, 7)


Subsection (8) of § 781.403 requires that an licensee advise the client, in writing and in advance, of any changes to any of the information required under subsection (7). This requirement applies regardless of when any such change is made. For example, if the state legislature passes a new law that will alter confidentiality and reporting requirements, a licensee must notify each of his or her clients of the changes in writing before the new law actually takes effect. Moreover, he must notify every client, from the person who has been a client since day he or she began his practice to the new client who received her initial consultation only one day previously.

The Counseling Process

It is also advisable to establish with clients a mutually acceptable treatment plan. This should be done, at least in an initial form, as early as possible in treatment. This should include the goals and methods expected to be used.


The degree of detail that should be shared with clients will vary greatly according to individual circumstances. A client's psychological state, including mental and intellectual capacities and levels of emotional vulnerability, will often dictate the amount and type of information that a licensee feels should legitimately be shared. During the course of treatment, if a client's condition improves or deteriorates, it may become necessary to reevaluate the amount and type of information that has been disclosed thus far, and adjust such disclosures accordingly.
How to reconcile client welfare with obligations of informed consent may present challenges for social workers. Pope, et al., summarize the problem succinctly:


Should the clients have full access to assessment and treatment data that concern them? On the one hand, access to data about the client's condition may be important to the client's reaching a truly informed decision about initiating or continuing treatment. For example, if clients are not honestly told the diagnosis, it may be hard for them to know whether they want to be treated without knowing what they are to be treated for. On the other hand, psychologists may feel that certain technical terms or raw data may actually exacerbate the client's condition. (Pope, K. S. & Vasques, J. T., 1998)


They cite the results of one study showing that psychotherapists' opinions vary regarding how much to disclose about therapy. "About one in five believe that it is unethical to refuse to disclose the diagnosis (21.5%) or to refuse access to a test report (21.7%)." (Ibid) However, far fewer psychotherapists see ethical problems with denying patients access to "chart notes (14.5%)" or "raw test data (12.1%)." (Ibid) Refusing to share particular types of information with clients is not uncommon: "Around half of the respondents have denied their clients access to the diagnosis (48.0%), to the testing report (49.6%), to their chart notes (55.5%), or to raw test data (57.4%)." (Ibid)


Other duties associated directly with the counseling process arise under separate subsections. A licensee may not "persistently or flagrantly over treat a client." (Tx. Admin. Code § 781.403, 4)


The social worker must terminate , “…services when in the licensee's professional opinion the client either has met the service goals or is not benefiting from those services. When services to the client are still indicated, the licensee shall take reasonable steps to facilitate the transfer to an appropriate referral or sources…” (Tx. Admin. Code § 781.404, h) State law addresses this three times in the occupational code.


State law also prohibits receiving or offering “commission or rebate or any other form of remuneration” for referrals. (Tx. Admin. Code §781.404 b)

Additional Guidelines

Client Recruitment and Referral

Those social workers who do advertise their services presumably do so to recruit clients. Client recruitment also occurs through non-standard methods, such as referrals. Professionals in some fields are permitted to use the referral process with few limits. However, licensees must be aware of the significant restrictions that § 681.41(h) imposes on referral processes for counselors.


This subsection provides:
A licensee shall not intentionally or knowingly offer to pay or agree to accept any remuneration directly or indirectly, overtly or covertly, in cash or in kind, to or from any person, firm, association of persons, partnership, corporation, or entity for securing or soliciting clients or patronage for or from any health care professional.
Licensees are forbidden to provide or accept any form of compensation for referrals to or from another individual or entity, or on behalf of another individual or entity. Under § 781.410 (a), “A licensee shall not intentionally or knowingly offer to pay or agree to accept any remuneration directly or indirectly, overtly or covertly, in cash or in kind, to or from any person, firm, association of persons, partnership, corporation, or entity for securing or soliciting clients or patronage for or from any health care professional.” Under subsection (b), “In accordance with the provisions of the Act, §505.451, a licensee is subject to disciplinary action if the licensee directly or indirectly offers to pay or agrees to accept remuneration to or from any person for securing or soliciting a client or patronage."


First, even if an licensee does not intend to exchange some form of compensation ("remuneration") for a referral, but knows that giving or receiving compensation will occur, she will likely be found to have violated this subsection. Second, this subsection applies regardless of whether the social worker is making or receiving the referral: Se may not accept compensation for referring a client to another provider, nor may she compensate another provider for referring a client to her.


Third, this subsection prohibits any form of compensation made via any method; it need not be an explicit financial reward for making a referral. These restrictions apply regardless of whether the compensation takes the form of direct cash payment or is compensation "in kind" (i.e., providing a non-cash payment or reward). "In-kind" compensation may include virtually anything: free products or services; payment of tuition or professional fees; meals or tickets to entertainment or recreational events; or any number of other benefits, both tangible and intangible. The restrictions also apply regardless of how the payment is made: Examples may include (but are not limited to) sending a check, "bundling" payment into a payment for other services, providing cash "off the books," or providing special services for equivalent value (e.g., providing free advertising in an amount equal to the cost of the referral).


Fourth, the subsection prohibits compensation for referrals "to or from any person, firm, association of persons, partnership, corporation, or entity." This language makes these restrictions applicable to virtually any individual or entity, including other licensees, hospitals, clinics, educational, religious, or charitable institutions, and most other sources. One exception applies under subpart (c)


 A licensee employed or under contract with a chemical dependency facility or a mental health facility, shall comply with the requirements in the Texas Health and Safety Code, §164.006, relating to soliciting and contracting with certain referral sources. Compliance with the Treatment Facilities Marketing Practices Act, Texas Health and Safety Code, Chapter 164, shall not be considered as a violation of state law relating to illegal remuneration.

Fees and Payment

A thorough understanding of the licensee's fees and payment structure is necessary to the client's informed consent. Clients seeking counseling are likely to be under significant pressures; in some instances, financial pressures may play a role. As noted above, some clients may be uninsured or underinsured and unable to afford private therapy fees. Some licensees, or their affiliating organizations, may not accept particular insurance plans. Clients thus need to be fully apprised of the costs of the therapeutic process in order to make an informed decision as to whether such counseling is affordable (or, for some, even possible). Under § 781.403 (9), a social worker engaging in bartering, “…has the responsibility to assure that the market value of the barter does not exceed the customary charge for the service.”


As noted in the previous subsection, § 781.403 (8) requires that licensees notify clients in writing of any changes, including changes in fees or payment arrangements. However, the licensee must notify clients of such a change in writing, and must do so before the change takes effect. Under § 781.404 (g), a licensee is permitted to, “…bill clients or third parties for only those services actually rendered or as agreed to by mutual written understanding.” Thus, social workers must notify clients in writing of any changes in fees, billing, or payment before those changes take effect.


Moreover, advising the client in writing at the outset of the therapeutic relationship helps a licensee to avoid misunderstandings and conflicts later. Written explanations of fees, costs, and payment expectations helps clients understand their own responsibilities in the patient/therapist relationship. In the event of a client's subsequent failure or refusal to pay, it also provides evidence that the client received notice of fees and costs.

360 Degree Quality

360 degree quality management is a business term that refers to having a well-rounded approach to quality. It involves taking stock and intervening anywhere in the spectrum of services and products that may adversely affect the customer experience of quality. Importing this concept to the provision of treatment means reviewing infrastructure and policies necessary to ensure safety, consistent care, confidentiality, outcomes and all other aspects of quality care.


Examples of specific elements include having coverage while away in case of a patient emergency, secure and confidential records management, orientation and contracts with staff and contractors and services, and consistent provision of informed consent at the outset of treatment. A professional will, that is, having a will that specifies how your clinical and administrative records will be handled in the event of your death or infirmity, is an important example. It is specifically considered to be an important ethical requirement.


Thinking of treatment as a complete cycle, with a beginning, middle and end, can help the social worker enhance quality. Initiation and termination of treatment are each very important subjects that command considerable attention from ethical, legal, and clinical perspectives. Termination, for example, brings up issues such as avoiding patient abandonment (such as through transfer of care), terminating when treatment is no longer cost effective for the client (as opposed to the social worker), appropriate follow up, making sure the patient feels comfortable about resuming treatment if needed, and collaboration with the client to ensure a clinically appropriate termination process.

Assessment

One of the most important criticisms leveled at the mental health field is the inadequacy of assessment, and the resulting errors in diagnosis. Research has shown a tendency for clincians to have pet diagnoses and to do overly brief assessments that rely too much on initial comments by the client. In many cases, problems such as drug and alcohol abuse, domestic violence, cognitive impairment, and personality disorders go unacknowledged and untreated, ultimately sabotaging the treatment.

Treatment Plans and Collaborating with Clients

Identifying Blocks to Treatment

Highly naïve, defensive, and cognitively impaired clients, especially those with problems that impair thinking and judgment, such as substance abuse, antisocial personality disorder, and psychosis, may be very difficult to collaborate with. There are many reasons such clients may be unable to see the wisdom of the treatment plan the social worker is inclined to propose. One of the highest arts of psychotherapy is that of rapport-building with these defensive, resistant clients. Some trainers say that there is no such thing as a resistant client, only a failure to gain rapport. This is an extreme position taken in order to make a point.


Clients should not be written off as resistant, at least not after creative work to gain collaboration. After all, clients come to psychotherapy because they are experiencing mental or emotional distress. The greatest source of such distress is that of mental disorders. A knee-jerk response to a resistant client is akin to saying that such persons should seek mental health treatment from a skilled social worker. The obvious conclusion is that the social worker seeing the resistant client needs more training, specifically on managing defenses and difficult-to-treat problems.


There are two primary blocks to gaining agreement on the treatment plan. One is that the client has an agenda that is antithetical to their well being. Substance abuse is an obvious example. This “agenda” may be conscious or unconscious, but can be very powerful. Many substance abusers do not hit bottom, but die instead. The other block is high sensitivity to any specific demands that tend to occur in psychotherapy. These demands can include work to increase inner awareness, work to take on new demands such as being more assertive, and even tasks as seemingly innocuous as relaxing or imagining a positive outcome in a job interview. Generally, these high sensitivities occur in people with high levels of dissociation and significant trauma histories. Often this is coupled with difficulty maintaining emotional stability or engaging in normal self-soothing behaviors. Borderline Personality Disorder involves a challenging mix of these problems.


One of the most important areas in which a social worker can grow, is in developing skill in working with challenging clients in a way that does not alienate or destabilize them. Taking this on as a professional challenge is very commendable. Some social workers unwittingly write off such clients or take their behavior personally, responding in a moralistic, but futile manner.

Whither Morality?

As scientific study of mental health yields new information, it challenges moral positions that are so much a part of our culture that people defend and act them out unconsciously, but often with very firmly held rationales that do not fully address the sources of their biases. Polls have shown that much of the American public believe that persons who exhibit mental illnesses could behave normally if they wanted to. The high number of persons with mental illnesses in jails is testimony to the bias toward personal responsibility that overrides current medical knowledge about the nature of those mental illnesses, and worse, the ability of the medical and psychotherapy fields to treat and manage those illnesses in less restrictive and non-punitive environments. If jail is hellish for a person without a mental illness, that hell must be multiplied many times over for a person with a mental illness. Such people are not merely sensitive to their environment and more inclined to regress or decompensate, but are also much more vulnerable to abuse by other inmates.


Attributions of blame come from pervasive beliefs of the culture in which they occur. For example, thousands of persons believed to be possessed or practicing witchcraft were put to death. Bizarre tests for these conditions had no basis in reality.


As demonic metaphysics yielded to a more scientific perspective, the bulk of society has managed to hold onto a more subtle metaphysics of personal responsibility. Often this perspective is revealed by a simple act of complacence; the statement that a person is, “just that way.” This implies that there is no explanation other than free will. This, in turn, implies that there can be no alternative but making life miserable enough that the person will stop the behavior. In other words, when suffering, the person is getting what he or she deserves.


This simplistic view fails to account for the dramatic improvements in behavior and stability that occur when appropriate treatment is provided. It cannot square itself with the increased attention, responsibility and academic performance of a child with attention deficit disorder who receives appropriate medication, nor the veteran with post traumatic stress disorder who becomes interested in seeking employment after successful psychotherapy. There was no punishment involved in such dramatic turnarounds.


Where there is an impulse on the part of the social worker to punish, write off, or blame the client, the social worker should carefully inspect the source of such impulses, and make sure that he or she truly is up-to-date on the evidence-based approaches to the problem at hand. Morality in a clinical setting should be an expression of values that contribute to the welfare of clients, not the poorly inspected acting out of cultural patterns that are based on harmful beliefs such as demonic possession, the absence of a medical basis for mental disorders, and the social worker as an authority empowered with the responsibility to dispense punishment for what he or she had judged to be bad behavior.


The most essential red flag for the social worker is a sense of impulse that is not well inspected for groundedness in clinical knowledge that can be defended in terms of the treatment plan and evidence-based practice. Perhaps the key to today’s morality is in being highly accountable for getting outcomes that express our highest values.

Continuing Education, Up-To-Date Knowledge

There is a strong trend in our culture to be content with beliefs that support our biases and satisfy our desire to have socially desirable opinions, or at least opinions that are desirable within our professional community. The satirist Stephen Colbert refers to this as “truthiness.” This is identical to the concept from George Orwell’s dystopian and socially critical novel, 1984, of “bellyfeel.”


What matters, though, is what matters. That is to say, that outcomes are our business. The more research is available, and the more sophisticated the research becomes, the more we are challenged to adapt our opinions and practices to new, useful knowledge. It is very important that social workers not only engage in continuing education, but that they select educational material and journal articles that are recent and help the social worker understand current research.


An excellent example of an important trend in research is the influence of genetics on our understanding of psychology. Genetics is upending some of our beliefs about the causes of developmental, behavioral and family problems. Research is showing us that there is a widespread influence of genetic factors on risk to psychopathology. (Eaves, L. J., et. al., 1997)


For example, consider the widely held belief that corporal punishment causes children to become violent. Genetic research suggests that children are not made more violent by corporal punishment. Instead, it appears that the more violent or conduct disordered children are more likely to receive corporal punishment, and are more likely to have parents who are prone to administering corporal punishment. (Moffitt, T. E., 2005) (Scourfield, J., Van den Bree, M., Martin, N., & McGuffin, P., 2004)


One study was this straightforward: “There is a cross-situational conduct problems' phenotype, underlying the behavior measured by all informants, that is wholly genetic in origin. No significant influence of shared environmental effects was found.” (Ibid)


For many cases, this knowledge will shift the focus to interventions that assist multiple family members in reducing incidences of violence, crime, and harmful involvement with authorities, from the prior focus on preventing corporal punishment as an isolated problem and cause of violence in minors and adults. Genetic research is likely to expand the emphasis on systems interventions, which are emphasized in the training of social workers and family social workers. This kind of systems thinking is likely to expand attention beyond the victim-perpetrator dyad to include a broader assessment of needs and potential interventions.


The cornerstone of continuing education is asking what makes a difference in people’s lives.

Managed Care

Adapting to managed care has posed ethical challenges to social workers and other professionals. Clinicians have been tempted to use an inaccurate diagnosis in order to get the client’s insurance to cover treatment or managed care companies have refused to cover legitimate and necessary treatment. Clinicians may be pushed to provide treatment that is too short; shorter treatment is rewarded with more referrals regardless of the client diagnosis.


Managed care companies conduct utilization review in which statistics pertaining to each clinician result in designation of certain providers as preferred providers for their referrals. A clinician was told by a managed care executive that she should consider reducing the ratio of highly traumatized clients she saw, even though this was her specialty, in order to change her utilization numbers and receive more referrals. (Yourell, R. A., 2007) Obviously, this recommendation would result in more referrals of these challenging cases to less specialized and qualified providers, and presumably result in poorer outcomes and higher drop out rates.


The economic concept of “perverse incentives” refers to people and systems reacting to incentives in a manner that is not good for their customers or for society, especially where there is a duty to society, such as to prevent pollution or improve clinical services. It is a ponderous issue in managed care. Peer support can be especially valuable in navigating managed care issues.

Telemedicine and Online Treatment

Mental health clinicians have found a number of ways to use electronic communication in conducting and augmenting therapy. This may include email, instant messaging, and videoconferencing. This is referred to as telemedicine. Subchapter 781.404 (m) refers to this as telepractice. It states, “Telepractice may be used as part of the social work process. Social workers engaging in Telepractice must adhere to each provision of this chapter as well as those in the jurisdictions where the services take place.” Note that telepractice carries the same standards of care as other clinical work. This includes fully carrying out informed consent responsibilities.
Telemedicine is becoming increasingly commonplace, and is used to increase the services available to rural areas, and to provide specialists to areas where such specialists are not readily available. It is also used to reduce costs by reducing travel, and to increase appropriate utilization by individuals who have difficulty travelling to the physician’s office. All of these benefits can apply to treatment so long as certain standards are applied. There is a growing body of research supporting the use of telemedicine and telephone contact in psychotherapy. (Lovell, K., Cox, D., Haddock, G., Jones, C., Raines, D., Garvey, R., Roberts, C., & Hadley, S., 2006) (Sulzbacher, S., Vallin, T., Waetzig, E. Z., 2006) (Carlbring, P., Gunnarsdóttir, M., Hedensjö, L., Andersson, G., Ekselius, L., Furmark, T., 2007) (Shepherd, L., Goldstein, D., Whitford, H., Thewes, B., Brummell, V., & Hicks, M., 2006)


Social workers are cautioned to carefully consider the risks inherent in telemedicine. It is important to have policies and procedures in place for responding to interruptions in service, for evaluating whether a patient is appropriate for telemedicine, and for coping with the limitations inherent in the medium being used. The mood and intent of a communication can be misperceived more easily when it is not in face-to-face communication. The provider must be competent in the use of the technology required for the services he or she intends to provide.


The confidentiality of patient information is at increased risk through telemedicine. The social worker should be fully competent in protecting privacy when using the desired technology.


Telemedicine makes it feasible to work with patients who do not reside in the same state as the social worker. The state in which the patient resides may have laws regulating such practice, and it may be considered an unlicensed practice of psychotherapy and, as such, illegal.

Predicting Violence and Suicide

Mental health professionals are notoriously poor at predicting violence, especially in the absence of a history of violence, and they consistently overpredict violence. (Underwager, R. & Wakefield, H., 2007) (Litwack, T. R., Schlesinger, L. B., 1987, pp.205-257) (Monahan, J., 1983, pp.147-176) (Melton, G. B., Petrila, J., Poythress, N. G., & Slobogin, C., 1987) (Wyda, J., Black, B., 1989)


Our difficulty in predicting violence is a key reason for the stringent laws set up to protect people from being held in mental hospitals based on overzealous assessments. The other side of the coin, of course, is that untreated individuals may be violent as a result of these same stringent laws. Their social worker must be well-versed in managing potential violence and suicide, as well as understand the benefits to society of the protections against confinement as well as the legal basis for confinement.

Conclusion

Over the history of psychotherapy knowledge, sophistication and tools have converged for effective, humane, clinical practice and for providing services to a diverse population. Know the principles upon which the specific ethical guidelines and laws are based, and you will work with more relevance and confidence. Remember the resources available for resolving ethical and legal concerns for a less stressful and better supported practice. You are part of a profession filled with great minds discovering new answers.


MAKE SURE YOU READ THE FOLLOWING APPENDICES:


Appendix A: Texas Administrative Code, RULE §781.401, Code of Conduct


(a) A social worker must observe and comply with the code of conduct and standards of practice set forth in this Subchapter. Any violation of the code of conduct or standards of practice will constitute unethical conduct or conduct that discredits or tends to discredit the profession of social work and is grounds for disciplinary action.


  (1) A social worker shall not refuse to do or refuse to perform any act or service for which the person is licensed solely on the basis of a client's age, gender, race, color, religion, national origin, disability, sexual orientation, or political affiliation.
  (2) A social worker shall truthfully report or present her or his services, professional credentials and qualifications to clients or potential clients.
  (3) A social worker shall only offer those services that are within his or her professional competency, and the services provided shall be within accepted professional standards of practice and appropriate to the needs of the client.
  (4) A social worker shall strive to maintain and improve her or his professional knowledge, skills and abilities.
  (5) A social worker shall base all services on an assessment, evaluation or diagnosis of the client.
  (6) A social worker shall provide the client with a clear description of services, schedules, fees and billing at the initiation of services.
  (7) A social worker shall safeguard the client's rights to confidentiality within the limits of the law.
  (8) A social worker shall be responsible for setting and maintaining professional boundaries.
  (9) A social worker shall not have sexual contact with a client or a person who has been a client.
  (10) A social worker shall refrain from providing service while impaired due to the social worker's physical or mental health or the use of medication, drugs or alcohol.
  (11) A social worker shall not exploit his or her position of trust with a client or former client.
  (12) A social worker shall evaluate a client's progress on a continuing basis to guide service delivery and will make use of supervision and consultation as indicated by the client's needs.
  (13) A social worker shall refer a client for those services that the social worker is unable to meet and terminate service to a client when continued service is no longer in the client's best interest.
(b) The grounds for disciplinary action of a social worker shall be based on the code of conduct or standards of practice in effect at the time of the violation.

Texas Administrative Code: RULE §781.

403- General Standards of Practice
The scope of this section establishes standards of professional conduct required of a social worker. The licensee, following applicable statutes.


  (1) Shall not knowingly offer or provide professional services to an individual concurrently receiving professional services from another mental health services provider except with that provider's knowledge. If a licensee learns of such concurrent professional services, the licensee shall take immediate and reasonable action to inform the other mental health services provider.
  (2) Shall terminate a professional relationship when it is reasonably clear that the client is not benefiting from the relationship. When professional services are still indicated, the licensee shall take reasonable steps to facilitate the transfer to an appropriate referral or source.
  (3) Shall not evaluate any individual's mental, emotional, or behavioral condition unless the licensee has personally interviewed the individual or the licensee discloses with the evaluation that the licensee has not personally interviewed the individual.
  (4) May not persistently or flagrantly over treat a client.
  (5) Shall not aid and abet the unlicensed practice of social work by a person required to be licensed under the Act.
  (6) Shall not participate in any way in the falsification of applications for licensure. Nor shall an applicant for licensure participate in any way in the falsification of applications for licensure.
  (7) Shall ensure that the individual has been informed of the following before or at the time of the individual's initial appointment with the licensee:
    (A) qualifications of the provider and any intent to delegate service provision;
    (B) any restrictions placed on the license by the board;
    (C) the limits on confidentiality and privacy; and
    (D) fees and arrangements for payment.
  (8) Shall ensure that the individual has been informed of any changes to the items in paragraph (7) of this subsection prior to initiating the change.
  (9) If bartering for services, has the responsibility to assure that the market value of the barter does not exceed the customary charge for the service.

Appendix B: Code of Ethics of the NASW

Approved by the 1996 NASW Delegate Assembly and revised by the 1999 NASW Delegate Assembly
Preamble


The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. A historic and defining feature of social work is the profession's focus on individual well-being in a social context and the well-being of society. Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living.


Social workers promote social justice and social change with and on behalf of clients. "Clients" is used inclusively to refer to individuals, families, groups, organizations, and communities. Social workers are sensitive to cultural and ethnic diversity and strive to end discrimination, oppression, poverty, and other forms of social injustice. These activities may be in the form of direct practice, community organizing, supervision, consultation, administration, advocacy, social and political action, policy development and implementation, education, and research and evaluation. Social workers seek to enhance the capacity of people to address their own needs. Social workers also seek to promote the responsiveness of organizations, communities, and other social institutions to individuals' needs and social problems.


The mission of the social work profession is rooted in a set of core values. These core values, embraced by social workers throughout the profession's history, are the foundation of social work's unique purpose and perspective:

  • service
  • social justice
  • dignity and worth of the person
  • importance of human relationships
  • integrity
  • competence.

This constellation of core values reflects what is unique to the social work profession. Core values, and the principles that flow from them, must be balanced within the context and complexity of the human experience.

Purpose of the NASW Code of Ethics

Professional ethics are at the core of social work. The profession has an obligation to articulate its basic values, ethical principles, and ethical standards. The NASW Code of Ethics sets forth these values, principles, and standards to guide social workers' conduct. The Code is relevant to all social workers and social work students, regardless of their professional functions, the settings in which they work, or the populations they serve.


The NASW Code of Ethics serves six purposes:
The Code identifies core values on which social work's mission is based.
The Code summarizes broad ethical principles that reflect the profession's core values and establishes a set of specific ethical standards that should be used to guide social work practice.
The Code is designed to help social workers identify relevant considerations when professional obligations conflict or ethical uncertainties arise.
The Code provides ethical standards to which the general public can hold the social work profession accountable.
The Code socializes practitioners new to the field to social work's mission, values, ethical principles, and ethical standards.
The Code articulates standards that the social work profession itself can use to assess whether social workers have engaged in unethical conduct. NASW has formal procedures to adjudicate ethics complaints filed against its members.* In subscribing to this Code, social workers are required to cooperate in its implementation, participate in NASW adjudication proceedings, and abide by any NASW disciplinary rulings or sanctions based on it.


*For information on NASW adjudication procedures, see NASW Procedures for the Adjudication of Grievances.


The Code offers a set of values, principles, and standards to guide decision making and conduct when ethical issues arise. It does not provide a set of rules that prescribe how social workers should act in all situations. Specific applications of the Code must take into account the context in which it is being considered and the possibility of conflicts among the Code's values, principles, and standards. Ethical responsibilities flow from all human relationships, from the personal and familial to the social and professional.


Further, the NASW Code of Ethics does not specify which values, principles, and standards are most important and ought to outweigh others in instances when they conflict. Reasonable differences of opinion can and do exist among social workers with respect to the ways in which values, ethical principles, and ethical standards should be rank ordered when they conflict. Ethical decision making in a given situation must apply the informed judgment of the individual social worker and should also consider how the issues would be judged in a peer review process where the ethical standards of the profession would be applied.


Ethical decision making is a process. There are many instances in social work where simple answers are not available to resolve complex ethical issues. Social workers should take into consideration all the values, principles, and standards in this Code that are relevant to any situation in which ethical judgment is warranted. Social workers' decisions and actions should be consistent with the spirit as well as the letter of this Code.


In addition to this Code, there are many other sources of information about ethical thinking that may be useful. Social workers should consider ethical theory and principles generally, social work theory and research, laws, regulations, agency policies, and other relevant codes of ethics, recognizing that among codes of ethics social workers should consider the NASW Code of Ethics as their primary source. Social workers also should be aware of the impact on ethical decision making of their clients' and their own personal values and cultural and religious beliefs and practices. They should be aware of any conflicts between personal and professional values and deal with them responsibly. For additional guidance social workers should consult the relevant literature on professional ethics and ethical decision making and seek appropriate consultation when faced with ethical dilemmas. This may involve consultation with an agency-based or social work organization's ethics committee, a regulatory body, knowledgeable colleagues, supervisors, or legal counsel.


Instances may arise when social workers' ethical obligations conflict with agency policies or relevant laws or regulations. When such conflicts occur, social workers must make a responsible effort to resolve the conflict in a manner that is consistent with the values, principles, and standards expressed in this Code. If a reasonable resolution of the conflict does not appear possible, social workers should seek proper consultation before making a decision.


The NASW Code of Ethics is to be used by NASW and by individuals, agencies, organizations, and bodies (such as licensing and regulatory boards, professional liability insurance providers, courts of law, agency boards of directors, government agencies, and other professional groups) that choose to adopt it or use it as a frame of reference. Violation of standards in this Code does not automatically imply legal liability or violation of the law. Such determination can only be made in the context of legal and judicial proceedings. Alleged violations of the Code would be subject to a peer review process. Such processes are generally separate from legal or administrative procedures and insulated from legal review or proceedings to allow the profession to counsel and discipline its own members.


A code of ethics cannot guarantee ethical behavior. Moreover, a code of ethics cannot resolve all ethical issues or disputes or capture the richness and complexity involved in striving to make responsible choices within a moral community. Rather, a code of ethics sets forth values, ethical principles, and ethical standards to which professionals aspire and by which their actions can be judged. Social workers' ethical behavior should result from their personal commitment to engage in ethical practice. The NASW Code of Ethics reflects the commitment of all social workers to uphold the profession's values and to act ethically. Principles and standards must be applied by individuals of good character who discern moral questions and, in good faith, seek to make reliable ethical judgments.

Ethical Principles

The following broad ethical principles are based on social work's core values of service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. These principles set forth ideals to which all social workers should aspire.


Value: Service
Ethical Principle: Social workers' primary goal is to help people in need and to address social problems.


Social workers elevate service to others above self-interest. Social workers draw on their knowledge, values, and skills to help people in need and to address social problems. Social workers are encouraged to volunteer some portion of their professional skills with no expectation of significant financial return (pro bono service).


Value: Social Justice
Ethical Principle: Social workers challenge social injustice.


Social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people. Social workers' social change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice. These activities seek to promote sensitivity to and knowledge about oppression and cultural and ethnic diversity. Social workers strive to ensure access to needed information, services, and resources; equality of opportunity; and meaningful participation in decision making for all people.


Value: Dignity and Worth of the Person
Ethical Principle: Social workers respect the inherent dignity and worth of the person.


Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients' socially responsible self-determination. Social workers seek to enhance clients' capacity and opportunity to change and to address their own needs. Social workers are cognizant of their dual responsibility to clients and to the broader society. They seek to resolve conflicts between clients' interests and the broader society's interests in a socially responsible manner consistent with the values, ethical principles, and ethical standards of the profession.


Value: Importance of Human Relationships
Ethical Principle: Social workers recognize the central importance of human relationships.


Social workers understand that relationships between and among people are an important vehicle for change. Social workers engage people as partners in the helping process. Social workers seek to strengthen relationships among people in a purposeful effort to promote, restore, maintain, and enhance the well-being of individuals, families, social groups, organizations, and communities.


Value: Integrity
Ethical Principle: Social workers behave in a trustworthy manner.


Social workers are continually aware of the profession's mission, values, ethical principles, and ethical standards and practice in a manner consistent with them. Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated.


Value: Competence
Ethical Principle: Social workers practice within their areas of competence and develop and enhance their professional expertise.


Social workers continually strive to increase their professional knowledge and skills and to apply them in practice. Social workers should aspire to contribute to the knowledge base of the profession.

Ethical Standards

The following ethical standards are relevant to the professional activities of all social workers. These standards concern (1) social workers' ethical responsibilities to clients, (2) social workers' ethical responsibilities to colleagues, (3) social workers' ethical responsibilities in practice settings, (4) social workers' ethical responsibilities as professionals, (5) social workers' ethical responsibilities to the social work profession, and (6) social workers' ethical responsibilities to the broader society.


Some of the standards that follow are enforceable guidelines for professional conduct, and some are aspirational. The extent to which each standard is enforceable is a matter of professional judgment to be exercised by those responsible for reviewing alleged violations of ethical standards.


1. Social Workers' Ethical Responsibilities to Clients


1.01 Commitment to Clients
Social workers' primary responsibility is to promote the well-being of clients. In general, clients' interests are primary. However, social workers' responsibility to the larger society or specific legal obligations may on limited occasions supersede the loyalty owed clients, and clients should be so advised. (Examples include when a social worker is required by law to report that a client has abused a child or has threatened to harm self or others.)


1.02 Self-Determination
Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients' right to self-determination when, in the social workers' professional judgment, clients' actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.


1.03 Informed Consent
(a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients' right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions.
(b) In instances when clients are not literate or have difficulty understanding the primary language used in the practice setting, social workers should take steps to ensure clients' comprehension. This may include providing clients with a detailed verbal explanation or arranging for a qualified interpreter or translator whenever possible.
(c) In instances when clients lack the capacity to provide informed consent, social workers should protect clients' interests by seeking permission from an appropriate third party, informing clients consistent with the clients' level of understanding. In such instances social workers should seek to ensure that the third party acts in a manner consistent with clients' wishes and interests. Social workers should take reasonable steps to enhance such clients' ability to give informed consent.
(d) In instances when clients are receiving services involuntarily, social workers should provide information about the nature and extent of services and about the extent of clients' right to refuse service.
(e) Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services.
(f) Social workers should obtain clients' informed consent before audiotaping or videotaping clients or permitting observation of services to clients by a third party.


1.04 Competence
(a) Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.
(b) Social workers should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques.
(c) When generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps (including appropriate education, research, training, consultation, and supervision) to ensure the competence of their work and to protect clients from harm.


1.05 Cultural Competence and Social Diversity
(a) Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.
(b) Social workers should have a knowledge base of their clients' cultures and be able to demonstrate competence in the provision of services that are sensitive to clients' cultures and to differences among people and cultural groups.
(c) Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, and mental or physical disability.


1.06 Conflicts of Interest
(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client.
(b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.

c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)
(d) When social workers provide services to two or more people who have a relationship with each other (for example, couples, family members), social workers should clarify with all parties which individuals will be considered clients and the nature of social workers' professional obligations to the various individuals who are receiving services. Social workers who anticipate a conflict of interest among the individuals receiving services or who anticipate having to perform in potentially conflicting roles (for example, when a social worker is asked to testify in a child custody dispute or divorce proceedings involving clients) should clarify their role with the parties involved and take appropriate action to minimize any conflict of interest.


1.07 Privacy and Confidentiality
(a) Social workers should respect clients' right to privacy. Social workers should not solicit private information from clients unless it is essential to providing services or conducting social work evaluation or research. Once private information is shared, standards of confidentiality apply.
(b) Social workers may disclose confidential information when appropriate with valid consent from a client or a person legally authorized to consent on behalf of a client.
(c) Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation that social workers will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a client or other identifiable person. In all instances, social workers should disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made should be revealed.
(d) Social workers should inform clients, to the extent possible, about the disclosure of confidential information and the potential consequences, when feasible before the disclosure is made. This applies whether social workers disclose confidential information on the basis of a legal requirement or client consent.
(e) Social workers should discuss with clients and other interested parties the nature of confidentiality and limitations of clients' right to confidentiality. Social workers should review with clients circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. This discussion should occur as soon as possible in the social worker-client relationship and as needed throughout the course of the relationship.
(f) When social workers provide counseling services to families, couples, or groups, social workers should seek agreement among the parties involved concerning each individual's right to confidentiality and obligation to preserve the confidentiality of information shared by others. Social workers should inform participants in family, couples, or group counseling that social workers cannot guarantee that all participants will honor such agreements.
(g) Social workers should inform clients involved in family, couples, marital, or group counseling of the social worker's, employer's, and agency's policy concerning the social worker's disclosure of confidential information among the parties involved in the counseling.
(h) Social workers should not disclose confidential information to third-party payers unless clients have authorized such disclosure.
(i) Social workers should not discuss confidential information in any setting unless privacy can be ensured. Social workers should not discuss confidential information in public or semipublic areas such as hallways, waiting rooms, elevators, and restaurants.
(j) Social workers should protect the confidentiality of clients during legal proceedings to the extent permitted by law. When a court of law or other legally authorized body orders social workers to disclose confidential or privileged information without a client's consent and such disclosure could cause harm to the client, social workers should request that the court withdraw the order or limit the order as narrowly as possible or maintain the records under seal, unavailable for public inspection.
(k) Social workers should protect the confidentiality of clients when responding to requests from members of the media.
(l) Social workers should protect the confidentiality of clients' written and electronic records and other sensitive information. Social workers should take reasonable steps to ensure that clients' records are stored in a secure location and that clients' records are not available to others who are not authorized to have access.
(m) Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible.
(n) Social workers should transfer or dispose of clients' records in a manner that protects clients' confidentiality and is consistent with state statutes governing records and social work licensure.
(o) Social workers should take reasonable precautions to protect client confidentiality in the event of the social worker's termination of practice, incapacitation, or death.
(p) Social workers should not disclose identifying information when discussing clients for teaching or training purposes unless the client has consented to disclosure of confidential information.
(q) Social workers should not disclose identifying information when discussing clients with consultants unless the client has consented to disclosure of confidential information or there is a compelling need for such disclosure.
(r) Social workers should protect the confidentiality of deceased clients consistent with the preceding standards.


1.08 Access to Records
(a) Social workers should provide clients with reasonable access to records concerning the clients. Social workers who are concerned that clients' access to their records could cause serious misunderstanding or harm to the client should provide assistance in interpreting the records and consultation with the client regarding the records. Social workers should limit clients' access to their records, or portions of their records, only in exceptional circumstances when there is compelling evidence that such access would cause serious harm to the client. Both clients' requests and the rationale for withholding some or all of the record should be documented in clients' files.
(b) When providing clients with access to their records, social workers should take steps to protect the confidentiality of other individuals identified or discussed in such records.


1.09 Sexual Relationships
(a) Social workers should under no circumstances engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced.
(b) Social workers should not engage in sexual activities or sexual contact with clients' relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Sexual activity or sexual contact with clients' relatives or other individuals with whom clients maintain a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker and client to maintain appropriate professional boundaries. Social workers--not their clients, their clients' relatives, or other individuals with whom the client maintains a personal relationship--assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.
(c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers--not their clients--who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.
(d) Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries.


1.10 Physical Contact
Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact.


1.11 Sexual Harassment
Social workers should not sexually harass clients. Sexual harassment includes sexual advances, sexual solicitation, requests for sexual favors, and other verbal or physical conduct of a sexual nature.


1.12 Derogatory Language
Social workers should not use derogatory language in their written or verbal communications to or about clients. Social workers should use accurate and respectful language in all communications to and about clients.


1.13 Payment for Services
(a) When setting fees, social workers should ensure that the fees are fair, reasonable, and commensurate with the services performed. Consideration should be given to clients' ability to pay.
(b) Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers' relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client's initiative and with the client's informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship.
(c) Social workers should not solicit a private fee or other remuneration for providing services to clients who are entitled to such available services through the social workers' employer or agency.


1.14 Clients Who Lack Decision-Making Capacity
When social workers act on behalf of clients who lack the capacity to make informed decisions, social workers should take reasonable steps to safeguard the interests and rights of those clients.


1.15 Interruption of Services
Social workers should make reasonable efforts to ensure continuity of services in the event that services are interrupted by factors such as unavailability, relocation, illness, disability, or death.


1.16 Termination of Services
(a) Social workers should terminate services to clients and professional relationships with them when such services and relationships are no longer required or no longer serve the clients' needs or interests.
(b) Social workers should take reasonable steps to avoid abandoning clients who are still in need of services. Social workers should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Social workers should assist in making appropriate arrangements for continuation of services when necessary.
(c) Social workers in fee-for-service settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to the client, if the client does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed and discussed with the client.
(d) Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.
(e) Social workers who anticipate the termination or interruption of services to clients should notify clients promptly and seek the transfer, referral, or continuation of services in relation to the clients' needs and preferences.
(f) Social workers who are leaving an employment setting should inform clients of appropriate options for the continuation of services and of the benefits and risks of the options.


2. Social Workers' Ethical Responsibilities to Colleagues


2.01 Respect
(a) Social workers should treat colleagues with respect and should represent accurately and fairly the qualifications, views, and obligations of colleagues.
(b) Social workers should avoid unwarranted negative criticism of colleagues in communications with clients or with other professionals. Unwarranted negative criticism may include demeaning comments that refer to colleagues' level of competence or to individuals' attributes such as race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, and mental or physical disability.
(c) Social workers should cooperate with social work colleagues and with colleagues of other professions when such cooperation serves the well-being of clients.


2.02 Confidentiality
Social workers should respect confidential information shared by colleagues in the course of their professional relationships and transactions. Social workers should ensure that such colleagues understand social workers' obligation to respect confidentiality and any exceptions related to it.


2.03 Interdisciplinary Collaboration
(a) Social workers who are members of an interdisciplinary team should participate in and contribute to decisions that affect the well-being of clients by drawing on the perspectives, values, and experiences of the social work profession. Professional and ethical obligations of the interdisciplinary team as a whole and of its individual members should be clearly established.
(b) Social workers for whom a team decision raises ethical concerns should attempt to resolve the disagreement through appropriate channels. If the disagreement cannot be resolved, social workers should pursue other avenues to address their concerns consistent with client well-being.


2.04 Disputes Involving Colleagues
(a) Social workers should not take advantage of a dispute between a colleague and an employer to obtain a position or otherwise advance the social workers' own interests.
(b) Social workers should not exploit clients in disputes with colleagues or engage clients in any inappropriate discussion of conflicts between social workers and their colleagues.


2.05 Consultation
(a) Social workers should seek the advice and counsel of colleagues whenever such consultation is in the best interests of clients.
(b) Social workers should keep themselves informed about colleagues' areas of expertise and competencies. Social workers should seek consultation only from colleagues who have demonstrated knowledge, expertise, and competence related to the subject of the consultation.
(c) When consulting with colleagues about clients, social workers should disclose the least amount of information necessary to achieve the purposes of the consultation.


2.06 Referral for Services
(a) Social workers should refer clients to other professionals when the other professionals' specialized knowledge or expertise is needed to serve clients fully or when social workers believe that they are not being effective or making reasonable progress with clients and that additional service is required.
(b) Social workers who refer clients to other professionals should take appropriate steps to facilitate an orderly transfer of responsibility. Social workers who refer clients to other professionals should disclose, with clients' consent, all pertinent information to the new service providers.
(c) Social workers are prohibited from giving or receiving payment for a referral when no professional service is provided by the referring social worker.


2.07 Sexual Relationships
(a) Social workers who function as supervisors or educators should not engage in sexual activities or contact with supervisees, students, trainees, or other colleagues over whom they exercise professional authority.
(b) Social workers should avoid engaging in sexual relationships with colleagues when there is potential for a conflict of interest. Social workers who become involved in, or anticipate becoming involved in, a sexual relationship with a colleague have a duty to transfer professional responsibilities, when necessary, to avoid a conflict of interest.


2.08 Sexual Harassment
Social workers should not sexually harass supervisees, students, trainees, or colleagues. Sexual harassment includes sexual advances, sexual solicitation, requests for sexual favors, and other verbal or physical conduct of a sexual nature.


2.09 Impairment of Colleagues
(a) Social workers who have direct knowledge of a social work colleague's impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.
(b) Social workers who believe that a social work colleague's impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.


2.10 Incompetence of Colleagues
(a) Social workers who have direct knowledge of a social work colleague's incompetence should consult with that colleague when feasible and assist the colleague in taking remedial action.
(b) Social workers who believe that a social work colleague is incompetent and has not taken adequate steps to address the incompetence should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.


2.11 Unethical Conduct of Colleagues
(a) Social workers should take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues.
(b) Social workers should be knowledgeable about established policies and procedures for handling concerns about colleagues' unethical behavior. Social workers should be familiar with national, state, and local procedures for handling ethics complaints. These include policies and procedures created by NASW, licensing and regulatory bodies, employers, agencies, and other professional organizations.
(c) Social workers who believe that a colleague has acted unethically should seek resolution by discussing their concerns with the colleague when feasible and when such discussion is likely to be productive.
(d) When necessary, social workers who believe that a colleague has acted unethically should take action through appropriate formal channels (such as contacting a state licensing board or regulatory body, an NASW committee on inquiry, or other professional ethics committees).
(e) Social workers should defend and assist colleagues who are unjustly charged with unethical conduct.


3. Social Workers' Ethical Responsibilities in Practice Settings


3.01 Supervision and Consultation
(a) Social workers who provide supervision or consultation should have the necessary knowledge and skill to supervise or consult appropriately and should do so only within their areas of knowledge and competence.
(b) Social workers who provide supervision or consultation are responsible for setting clear, appropriate, and culturally sensitive boundaries.
(c) Social workers should not engage in any dual or multiple relationships with supervisees in which there is a risk of exploitation of or potential harm to the supervisee.
(d) Social workers who provide supervision should evaluate supervisees' performance in a manner that is fair and respectful.


3.02 Education and Training
(a) Social workers who function as educators, field instructors for students, or trainers should provide instruction only within their areas of knowledge and competence and should provide instruction based on the most current information and knowledge available in the profession.
(b) Social workers who function as educators or field instructors for students should evaluate students' performance in a manner that is fair and respectful.
(c) Social workers who function as educators or field instructors for students should take reasonable steps to ensure that clients are routinely informed when services are being provided by students.
(d) Social workers who function as educators or field instructors for students should not engage in any dual or multiple relationships with students in which there is a risk of exploitation or potential harm to the student. Social work educators and field instructors are responsible for setting clear, appropriate, and culturally sensitive boundaries.


3.03 Performance Evaluation
Social workers who have responsibility for evaluating the performance of others should fulfill such responsibility in a fair and considerate manner and on the basis of clearly stated criteria.


3.04 Client Records
(a) Social workers should take reasonable steps to ensure that documentation in records is accurate and reflects the services provided.
(b) Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future.
(c) Social workers' documentation should protect clients' privacy to the extent that is possible and appropriate and should include only information that is directly relevant to the delivery of services.
(d) Social workers should store records following the termination of services to ensure reasonable future access. Records should be maintained for the number of years required by state statutes or relevant contracts.


3.05 Billing
Social workers should establish and maintain billing practices that accurately reflect the nature and extent of services provided and that identify who provided the service in the practice setting.


3.06 Client Transfer
(a) When an individual who is receiving services from another agency or colleague contacts a social worker for services, the social worker should carefully consider the client's needs before agreeing to provide services. To minimize possible confusion and conflict, social workers should discuss with potential clients the nature of the clients' current relationship with other service providers and the implications, including possible benefits or risks, of entering into a relationship with a new service provider.
(b) If a new client has been served by another agency or colleague, social workers should discuss with the client whether consultation with the previous service provider is in the client's best interest.


3.07 Administration
(a) Social work administrators should advocate within and outside their agencies for adequate resources to meet clients' needs.
(b) Social workers should advocate for resource allocation procedures that are open and fair. When not all clients' needs can be met, an allocation procedure should be developed that is nondiscriminatory and based on appropriate and consistently applied principles.
(c) Social workers who are administrators should take reasonable steps to ensure that adequate agency or organizational resources are available to provide appropriate staff supervision.
(d) Social work administrators should take reasonable steps to ensure that the working environment for which they are responsible is consistent with and encourages compliance with the NASW Code of Ethics. Social work administrators should take reasonable steps to eliminate any conditions in their organizations that violate, interfere with, or discourage compliance with the Code.


3.08 Continuing Education and Staff Development
Social work administrators and supervisors should take reasonable steps to provide or arrange for continuing education and staff development for all staff for whom they are responsible. Continuing education and staff development should address current knowledge and emerging developments related to social work practice and ethics.


3.09 Commitments to Employers
(a) Social workers generally should adhere to commitments made to employers and employing organizations.
(b) Social workers should work to improve employing agencies' policies and procedures and the efficiency and effectiveness of their services.
(c) Social workers should take reasonable steps to ensure that employers are aware of social workers' ethical obligations as set forth in the NASW Code of Ethics and of the implications of those obligations for social work practice.
(d) Social workers should not allow an employing organization's policies, procedures, regulations, or administrative orders to interfere with their ethical practice of social work. Social workers should take reasonable steps to ensure that their employing organizations' practices are consistent with the NASW Code of Ethics.
(e) Social workers should act to prevent and eliminate discrimination in the employing organization's work assignments and in its employment policies and practices.
(f) Social workers should accept employment or arrange student field placements only in organizations that exercise fair personnel practices.
(g) Social workers should be diligent stewards of the resources of their employing organizations, wisely conserving funds where appropriate and never misappropriating funds or using them for unintended purposes.


3.10 Labor-Management Disputes
(a) Social workers may engage in organized action, including the formation of and participation in labor unions, to improve services to clients and working conditions.
(b) The actions of social workers who are involved in labor-management disputes, job actions, or labor strikes should be guided by the profession's values, ethical principles, and ethical standards. Reasonable differences of opinion exist among social workers concerning their primary obligation as professionals during an actual or threatened labor strike or job action. Social workers should carefully examine relevant issues and their possible impact on clients before deciding on a course of action.


4. Social Workers' Ethical Responsibilities as Professionals


4.01 Competence
(a) Social workers should accept responsibility or employment only on the basis of existing competence or the intention to acquire the necessary competence.
(b) Social workers should strive to become and remain proficient in professional practice and the performance of professional functions. Social workers should critically examine and keep current with emerging knowledge relevant to social work. Social workers should routinely review the professional literature and participate in continuing education relevant to social work practice and social work ethics.
(c) Social workers should base practice on recognized knowledge, including empirically based knowledge, relevant to social work and social work ethics.


4.02 Discrimination
Social workers should not practice, condone, facilitate, or collaborate with any form of discrimination on the basis of race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability.


4.03 Private Conduct
Social workers should not permit their private conduct to interfere with their ability to fulfill their professional responsibilities.


4.04 Dishonesty, Fraud, and Deception
Social workers should not participate in, condone, or be associated with dishonesty, fraud, or deception.


4.05 Impairment
(a) Social workers should not allow their own personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties to interfere with their professional judgment and performance or to jeopardize the best interests of people for whom they have a professional responsibility.
(b) Social workers whose personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties interfere with their professional judgment and performance should immediately seek consultation and take appropriate remedial action by seeking professional help, making adjustments in workload, terminating practice, or taking any other steps necessary to protect clients and others.


4.06 Misrepresentation
(a) Social workers should make clear distinctions between statements made and actions engaged in as a private individual and as a representative of the social work profession, a professional social work organization, or the social worker's employing agency.
(b) Social workers who speak on behalf of professional social work organizations should accurately represent the official and authorized positions of the organizations.
(c) Social workers should ensure that their representations to clients, agencies, and the public of professional qualifications, credentials, education, competence, affiliations, services provided, or results to be achieved are accurate. Social workers should claim only those relevant professional credentials they actually possess and take steps to correct any inaccuracies or misrepresentations of their credentials by others.


4.07 Solicitations
(a) Social workers should not engage in uninvited solicitation of potential clients who, because of their circumstances, are vulnerable to undue influence, manipulation, or coercion.
(b) Social workers should not engage in solicitation of testimonial endorsements (including solicitation of consent to use a client's prior statement as a testimonial endorsement) from current clients or from other people who, because of their particular circumstances, are vulnerable to undue influence.


4.08 Acknowledging Credit
(a) Social workers should take responsibility and credit, including authorship credit, only for work they have actually performed and to which they have contributed.
(b) Social workers should honestly acknowledge the work of and the contributions made by others.


5. Social Workers' Ethical Responsibilities to the Social Work Profession


5.01 Integrity of the Profession
(a) Social workers should work toward the maintenance and promotion of high standards of practice.
(b) Social workers should uphold and advance the values, ethics, knowledge, and mission of the profession. Social workers should protect, enhance, and improve the integrity of the profession through appropriate study and research, active discussion, and responsible criticism of the profession.
(c) Social workers should contribute time and professional expertise to activities that promote respect for the value, integrity, and competence of the social work profession. These activities may include teaching, research, consultation, service, legislative testimony, presentations in the community, and participation in their professional organizations.
(d) Social workers should contribute to the knowledge base of social work and share with colleagues their knowledge related to practice, research, and ethics. Social workers should seek to con-tribute to the profession's literature and to share their knowledge at professional meetings and conferences.
(e) Social workers should act to prevent the unauthorized and unqualified practice of social work.


5.02 Evaluation and Research
(a) Social workers should monitor and evaluate policies, the implementation of programs, and practice interventions.
(b) Social workers should promote and facilitate evaluation and research to contribute to the development of knowledge.
(c) Social workers should critically examine and keep current with emerging knowledge relevant to social work and fully use evaluation and research evidence in their professional practice.

(d) Social workers engaged in evaluation or research should carefully consider possible consequences and should follow guidelines developed for the protection

of evaluation and research participants. Appropriate institutional review boards should be consulted.
(e) Social workers engaged in evaluation or research should obtain voluntary and written informed consent from participants, when appropriate, without any implied or actual deprivation or penalty for refusal to participate; without undue inducement to participate; and with due regard for participants' well-being, privacy, and dignity. Informed consent should include information about the nature, extent, and duration of the participation requested and disclosure of the risks and benefits of participation in the research.
(f) When evaluation or research participants are incapable of giving informed consent, social workers should provide an appropriate explanation to the participants, obtain the participants' assent to the extent they are able, and obtain written consent from an appropriate proxy.
(g) Social workers should never design or conduct evaluation or research that does not use consent procedures, such as certain forms of naturalistic observation and archival research, unless rigorous and responsible review of the research has found it to be justified because of its prospective scientific, educational, or applied value and unless equally effective alternative procedures that do not involve waiver of consent are not feasible.
(h) Social workers should inform participants of their right to withdraw from evaluation and research at any time without penalty.
(i) Social workers should take appropriate steps to ensure that participants in evaluation and research have access to appropriate supportive services.
(j) Social workers engaged in evaluation or research should protect participants from unwarranted physical or mental distress, harm, danger, or deprivation.
(k) Social workers engaged in the evaluation of services should discuss collected information only for professional purposes and only with people professionally concerned with this information.
(l) Social workers engaged in evaluation or research should ensure the anonymity or confidentiality of participants and of the data obtained from them. Social workers should inform participants of any limits of confidentiality, the measures that will be taken to ensure confidentiality, and when any records containing research data will be destroyed.
(m) Social workers who report evaluation and research results should protect participants' confidentiality by omitting identifying information unless proper consent has been obtained authorizing disclosure.
(n) Social workers should report evaluation and research findings accurately. They should not fabricate or falsify results and should take steps to correct any errors later found in published data using standard publication methods.
(o) Social workers engaged in evaluation or research should be alert to and avoid conflicts of interest and dual relationships with participants, should inform participants when a real or potential conflict of interest arises, and should take steps to resolve the issue in a manner that makes participants' interests primary.
(p) Social workers should educate themselves, their students, and their colleagues about responsible research practices.


6. Social Workers' Ethical Responsibilities to the Broader Society


6.01 Social Welfare
Social workers should promote the general welfare of society, from local to global levels, and the development of people, their communities, and their environments. Social workers should advocate for living conditions conducive to the fulfillment of basic human needs and should promote social, economic, political, and cultural values and institutions that are compatible with the realization of social justice.


6.02 Public Participation
Social workers should facilitate informed participation by the public in shaping social policies and institutions.


6.03 Public Emergencies
Social workers should provide appropriate professional services in public emergencies to the greatest extent possible.


6.04 Social and Political Action
(a) Social workers should engage in social and political action that seeks to ensure that all people have equal access to the resources, employment, services, and opportunities they require to meet their basic human needs and to develop fully. Social workers should be aware of the impact of the political arena on practice and should advocate for changes in policy and legislation to improve social conditions in order to meet basic human needs and promote social justice.
(b) Social workers should act to expand choice and opportunity for all people, with special regard for vulnerable, disadvantaged, oppressed, and exploited people and groups.
(c) Social workers should promote conditions that encourage respect for cultural and social diversity within the United States and globally. Social workers should promote policies and practices that demonstrate respect for difference, support the expansion of cultural knowledge and resources, advocate for programs and institutions that demonstrate cultural competence, and promote policies that safeguard the rights of and confirm equity and social justice for all people.
(d) Social workers should act to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class on the basis of race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability.

References

Legislation

45 CFR § 164.526
Tx. Admin. Code, Title 22, § 781 (2005).
Tx. Health & Safety Code § 611.0045 (a)
Tex. Hum. Res. Code Ann. tit. 2 (A) § 48.
Tx. Occ. Code §105 (1999)
Tx. Occ. Code §503 (1999)
Tx. Occ. Code § 505 (2003).

Case Law

Brady v. Hopper, District Court of Colorado, John P. Moore, 1983, http://www.law.umkc.edu/faculty/projects/ftrials/hinckley/civil.htm.
Ewing v. Goldstein, 15 Cal Rptr. 3d 864 (Cal. Ct. App. 2004) and Ewing v. Northridge Hospital Medical Center, 16 Cal Rptr. 3d 591 (Cal. Ct. App. 2004)
Hamman v. County of Maricopa, 1989.
Jablonski v United States of America, 1983.
Lindsey v. United States of America, (693 F. Supp. 1012 [U.S. Dist. 1988]).
Mark L. (2001) 94 Cal. App. 4th 573, and Evid. Code, ' 1013, subds. (a), Evid. Code, ' 1013, subds. (b).
White v. United States, 1986.

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