Ethics in Social Work

Course Objectives

1. Describe the responsibilities social workers have to their clients.

2. Describe the parameters of informed consent.

3. Identify and describe mandatory reporting laws.

4. Identify the ethical and legal principals of confidentiality.

5. Describe confidentiality laws and the impact of those laws on the therapeutic relationship.

6. Describe how HIPAA provides standards for protecting the records and privacy of individuals. 

 

Scope of Practice

Social workers practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Social workers gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population.

No person may engage in the practice of social work, unless he or she holds a valid license as a social worker, or unless he or she is specifically exempted from that requirement, nor may any person advertise himself or herself as performing the services of a social worker, or other name, word initial, or symbol in connection with or following his or her name to imply that he or she performs these services without a license.

Any licensed social worker who conducts a private practice under a fictitious business name shall not use any name that is false, misleading, or deceptive, and shall inform the patient, prior to the commencement of treatment, of the name and license designation of the owner or owners of the practice.

An associate shall inform each client or patient, prior to performing any professional services, that he or she is unlicensed and under the supervision of a licensed social worker, a licensed marriage, family social worker, a licensed psychologist, or a licensed physician certified in psychiatry by the American Board of Psychiatry and Neurology.

In order to continuously improve the competence of licensed social workers and as a model for all psychotherapeutic professions, the Legislature encourages all licensees to regularly engage in continuing education related to the profession or scope of practice.  

As a model for all therapeutic professions, and to acknowledge respect and regard for the consuming public, all social workers are encouraged to provide to each client, at an appropriate time and within the context of the psychotherapeutic relationship, an accurate and informative statement of the social worker's experience, education, specialties, professional orientation, and any other information deemed appropriate by the licensee.

Every person who holds a license to practice social work shall be governed by the rules of professional conduct.

Specialty Areas of Practice

Social workers practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, social workers take steps to ensure the competence of their work and to protect others from possible harm.

Recordkeeping

Record Keeping Requirements for Licensed Clinical Social Workers: the failure to keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services being rendered is considered unprofessional conduct.

It is your responsibility to maintain the confidentiality of the records. Patient records should be kept in locked containers except when in use. They should be shredded when they are discarded to avoid the potential of having the notes fall into the hands of others. Office staff and others who handle the files should be made aware of the importance of confidentiality. Handle these records as if they were notes made by your own therapist about you. Your patient feels the same need to have the notes be private. Office staff, filing clerks, billing agencies, and others do not have the same burden of confidentiality as does the clinician. However, it is the responsibility of the social worker to inform the staff about the importance of confidentiality and to take reasonable action to be certain that staff does not violate the patient's confidentiality. While this is a solid part of HIPAA, it seems to be regularly violated by clerks and other office staff. Often my patients who work for or with social workers in the community or in government report cases which are confidential which they have read with avid interest. Try to keep this sort of clerk off your staff.

Standards for Client Records

The documentation standards are described below under key topics related to client care. All standards should be addressed in the client record; however, there is no requirement that the record have a specific document or section addressing these topics.

A. Assessments

1. The following areas should be included as appropriate as a part of a comprehensive client record.

• Relevant physical health conditions reported by the client should be prominently identified and updated as appropriate.

• Presenting problems and relevant conditions affecting the client’s physical health and mental health status should be documented, for example: living situation, daily activities, and social support.

• Documentation should describe client strengths in achieving client plan goals.

• Special status situations that present a risk to client or others should be prominently documented and updated as appropriate.

• Documentation should include medications that have been prescribed by mental health plan physicians, dosages of each medication, dates of initial prescriptions and refills, and documentation of informed consent for medications.

• Client self report of allergies and adverse reactions to medications, or lack of known allergies/sensitivities should be clearly documented.

• A mental health history should be documented, including: previous treatment dates, providers, therapeutic interventions and responses, sources of clinical data, relevant family information and relevant results of relevant lab tests and consultation reports.

• For children and adolescents, pre-natal and perinatal events and complete developmental history should be documented.

• Documentation should include past and present use of tobacco, alcohol, and caffeine, as well as illicit, prescribed and over-the counter drugs.

• A relevant mental status examination should be documented.

• A five axis diagnosis from the most current DSM should be documented, consistent with the presenting problems, history, mental status evaluation and /or other assessment data.

B. Client Plans

1. Client Plans should:

• have specific observable and/or specific quantifiable goals

• identify the proposed type(s) of intervention

• have a proposed duration of intervention(s)

• be signed (or electronic equivalent) by :

• the person providing the service(s), or

• a person representing a team or program providing services

• when the client plan is used to establish that services are provided under the direction of an approved category of staff

• a physician

• a licensed/”waivered” psychologist

• a licensed/registered/waivered social worker

• a licensed/registered/waivered Marriage, Family and Child Counselor or

• In addition:

• client plans should be consistent with the diagnoses, and the focus of intervention should be consistent with the client plan goals, and there should be documentation of the client’s participation in and agreement with the plan. Examples of documentation include, but are not limited to, reference to the client’s participation and agreement in the body of the plan, client signature on the plan, or a description of the client’s participation and agreement in progress notes.

• client signature on the plan can be used as the means by which it documents the participation of the client

• when the client is a long term client, and

• the client is receiving more than one type of service

• when the client’s signature is required on the client plan and the client refuses or is unavailable for signature, the client plan should include a written explanation of the refusal or unavailability.

• the clinician should give a copy of the client plan to the client on request.

2. Timeliness/Frequency of Client Plan:

• Should be updated at least annually.

• The clinician should establish standards for timeliness and frequency for the individual elements of the client plan described in item 1.

C. Progress Notes

1. Items that must be contained in the client record related to the client’s progress in treatment include:

• The client record should provide timely documentation of relevant aspects of client care

• Clinicians should use client records to document client encounters, including relevant clinical decisions and interventions

• All entries in the client record should include the signature of the person providing the service (or electronic equivalent); the person’s professional degree and licensure

• All entries should include the date services were provided

• The record should be legible

• The client record should document referrals to community resources and other agencies, when appropriate

• The client record should document follow-up care, or as appropriate, a discharge summary

Patient Access to Records

The holder of the privilege also has the right to read all information in his or her file with the exception of your personal notes which belong solely to you. Some social workers find this requires them to keep separate files so their personal notes do not become part of the patient's legal record. Your patient can read all notes which have their identifying information, diagnosis, treatment plan, prognosis, and other information including billing and information from other sources which you have included in the file such as notes from other physicians and hospitals. Any spare notes in the patient's file also have information which must be passed to the patient. All information in HIPAA notes are the patient's property and must be released. The file is the property of the clinician so copies must be made if the patient requests a copy of their file.

Dual Relationships

For both social workers and supervisors, any dual relationship is problematic if it increases the potential for exploitation or impairs professional objectivity (Kitchener, 1988). There has been greater divergence of opinion about what constitutes an inappropriate dual relationship between supervisor and counselor than between counselor and client. Ryder and Hepworth (1991), for example, stated that dual relationships between supervisors and supervisees are endemic to many educational and work contexts. Most supervisors will, in fact, have more than one relationship with their supervisees (e.g., graduate assistant, co-author, co-facilitator). The key concepts remain "exploitation" and "objectivity." Supervisors must be diligent about avoiding any situation which puts a supervisee at risk for exploitation or increases the possibility that the supervisor will be less objective. It is crucial, however, that supervisors not be intimidated into hiding dual relationships because of rigid interpretations of ethical standards. The most dangerous of scenarios is the hidden relationship. Usually, a situation can be adjusted to protect all concerned parties if consultation is sought and there is an openness to making adjustments in supervisory relationships to benefit supervisee, supervisor and, most importantly, clients.

Social Workers are committed to promoting the welfare and well-being of the patient over and above any personal consideration. Indeed, this fiduciary obligation is one of the defining characteristics of a “profession” as such. This concept of a profession gives rise to the notion of boundaries in client-professional relationships, that is, to the notion that there are limits of ethically appropriate professional behavior. A boundary violation occurs when a health care professional’s behavior goes beyond appropriate professional limits. Boundary violations generally arise when a personal interest displaces the professional’s primary commitment to the patient’s welfare in ways that harm the patient or the patient-clinician relationship. Interactions between health care professionals and patients are ethically problematic when they can reasonably be expected to affect the care the individual or other patients receive or the health care professional’s relationships with colleagues—or when they give the appearance of doing so.

Social Workers should:

  • Critically examine their own actions by asking themselves the following questions:  

Is this activity a normal, expected part of practice for members of my profession?  Might engaging in this activity compromise my relationship with this patient? With other patients? With my colleagues? With my institution? With the public?  Could this activity cause others to question my professional objectivity?  Would I want my other patients, other professionals, or the public to know that I engage in such activities?

  • Take appropriate action if the answers to these questions indicate that an activity may violate professional ethical boundaries:  Determine if there are applicable standards.  Consult a trusted and objective peer for a second opinion about the activity.  Seek assistance from a supervisor or ethics committee. Communicate his or her concern to the individual involved.  Transfer the patient to another clinician’s care if the professional relationship has been compromised, or if avoiding the violation will damage the relationship.
  • Be familiar with:  Relevant professional codes of ethics, standards of practice, guidelines, and position statements;  Applicable policies in their facilities; and  Laws pertaining to relationships between patients and health care professionals.

Boundaries define the limits of appropriate behavior by a professional toward his or her clients. By establishing boundaries, a social worker creates a safe space for the therapeutic relationship to occur. Concerns about professional boundaries in the relationship between patients and social workers and the damage that results when boundaries are transgressed captured public and professional attention following reports of inappropriate sexual relationships between health care professionals and patients. Relatively little attention has been paid to the “boundary question” outside this context, but many other interactions raise concerns about boundaries as well. Social worker’s need guidance if they are to avoid engaging in interactions with their patients that may prove ethically problematic.

 The notion of boundaries in the health care setting is rooted in the concept of a “profession.” While this concept is understood in several different ways in the medical and sociological literature, there is consensus regarding one of the defining characteristics of professions and professionals: commitment to serve the profession’s clients. That is, professionals are expected to make a fiduciary commitment to place their clients’ interests ahead of their own. In exchange for faithfully applying their unique knowledge and skills on behalf of their clients, members of a profession are granted the freedom to practice and to regulate themselves.

Professionals, as such, are held to different standards of conduct from other persons. Relationships and interactions that may be ethically unproblematic among nonprofessionals may be unacceptable when one of the parties is a professional. An individual may have a personal interest that is perfectly acceptable in itself, but it conflicts with an obligation the same individual has as a social worker. The nature of professions is such that “the human needs the professions address and the human relationships peculiar to them ... are sufficiently distinct to warrant, indeed to demand, expectations of a higher morality and a greater commitment to the good of others than in most other human activities.” The clinical relationship is one of both great intimacy and great disparity in power and knowledge, giving rise to special obligations for health care professionals.

A boundary violation occurs when a social worker’s behavior goes beyond appropriate professional limits. Boundary violations generally arise when the interaction between parties blurs their roles vis-à-vis one another, or creates a “double bind” situation in which a personal interest displaces the professional’s primary commitment to the patient’s welfare in ways that harm—or appear to harm—the patient or the patient-clinician relationship, or might reasonably be expected to do so.

A variety of standards establish the limits of appropriate professional behavior, whether those limits are explicitly enumerated in standards of conduct, codes of ethics, or law, or tacitly conveyed through professional training and widespread acceptance. Individuals who seek help must rely on the professional they consult to be trustworthy when clinicians behave in ways that call their professional judgment and objectivity into question, the trust on which the relationship depends is compromised. And when trust is compromised, the efficacy of the therapeutic relationship is adversely affected.

It is important to note that personal and professional interests are not inherently in conflict with one another; in fact, they often coincide. A social workers personal desire to be compassionate is compatible with his or her professional obligations. It is natural to want to earn money through one’s professional activity. That desire becomes problematic only when the personal interest in earning a livelihood interferes with one’s commitments and obligations as a health care professional. Standards regarding professional boundaries can be found in a variety of sources. Directly or indirectly, professional codes of ethics, consensus statements, position papers, policies, and laws define the boundaries of appropriate behavior for professionals.

Thus, for example, the National Association of Social Work’ Code of Ethics requires that social workers “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” and broadly defines “dual or multiple relationships,” but does not suggest criteria by which professionals should assess the nature or level of risk a particular dual relationship would pose for a client. The message implicitly shared by all such documents, however, is that being a professional entails forgoing some interactions or relationships in which one might otherwise wish to engage in order to protect the interests and well-being of clients/patients.

Many kinds of interaction potentially interfere with the primary clinical relationship between practitioner and patient and pose concerns about acceptable conduct for clinicians. Becoming socially involved or entering into a business relationship with a patient, for example, can impair, or appear to impair, the professional’s objectivity. Accepting a gift is sometimes an appropriate way to allow a patient to express his or her gratitude, and at other times is problematic. Showing favoritism by giving a particular patient extra attention, time, or priority in scheduling appointments, for example can cross the boundary between action that is appropriate advocacy on behalf of a particular patient and action that is unfair to others. Such interactions or activities are ethically problematic when they can reasonably be expected to affect the care received by the individual or by other patients or the practitioner’s relationships with his or her colleagues, or when they give the appearance of doing so. Yet not all behavior that might be considered inappropriate necessarily violates professional obligations. Health care professionals should be alert to situations in which they may be likely to be motivated to behave in ways that violate accepted ethical standards. Ambiguous interactions and relationships, for example, have the potential both to impair the professional’s objectivity and compromise his or her judgment, and to give rise to conflicting expectations on the patient’s part, which can contaminate the therapeutic relationship and potentially undermine the patient’s trust.

Finally, seeming to “play favorites” by accommodating individual patients in special ways can also raise concerns about ethical professional boundaries. Social Workers commit themselves to treating all patients fairly. Patients often need more than just clinical care, and it is not necessarily inappropriate for professionals to provide help in other ways. But their actions on behalf of a particular patient must not adversely affect the clinical relationship with that patient or compromise the care available to other patients, or appear to others to do so. Just what activities might constitute a violation of professional boundaries depends very much on the specific context in which such actions take place and their foreseeable likely consequences for others.

Insurance Reimbursement

Reports to Third Parties

Patients are generally unaware of the information provided to their insurance carrier. As a provider, you may want to inform your patients about the information you plan to release to their insurance company as well as changes in what you release if required to so for authorization of sessions from the insurance company. It is not necessary to give your patients this information, but they may appreciate your candor.

If you bill insurance, you automatically must be HIPAA-compliant. If you choose not to bill insurance and instead collect directly from each patient, there are still some circumstances that require you to become compliant. Generally, it is simply a matter of following good office procedures that are designed to protect your patient's Private Medical Information (PMI). When a patient signs the standard HCVA 1500 form for billing, it gives permission to the provider to give Private Medical Information to an insurance carrier including their name, date of birth, insurance identification number or Social Security Number, and their DSM IV-R diagnosis. The information on this form should be treated with the highest security since release of it is illegal under HIPAA to anyone but the insurance company and the staff of the clinician's office. Staff should be educated about the importance of keeping this information secure since it is ultimately the clinician's responsibility if it is accidentally released. This information must not sent via the Internet since the Internet is not considered secure. Also, downloading information on a Notebook or other computer that may leave the office is considered unsafe since Notebooks are often stolen and the information on them, regardless of the level of security, has a possibility of being used by unauthorized people.

Billing that uses PMI must be sent by FAX or the US Postal Service. Some insurance companies have Internet billing that provides a secure link but it is incumbent on the clinician to determine that the material provided cannot be shared with persons or companies who are not authorized by the patient to receive the information.

Insurance companies may ask for further information about the patient including treatment plans, case notes, and other information. They can do this legally without further consent from the patient. Although many clinicians consider it less problematic to send the information to the insurance company without informing the patient about the release of additional information, other clinicians find it more ethical to inform the patient about the information that is requested. Some patients consider their privacy to be more important than the payment the insurance company may provide and would prefer that clinicians keep more of their information private. The population with whom the clinician works may help determine whether the patient would prefer to be informed about the information that may be sent for authorization of benefits.

Insurance companies must be billed only for sessions in which the patient was seen and only for the amount of time the patient was seen. While some insurance companies pay for telephone or Internet sessions, the clinician should check with the insurance company prior to billing for these services and should not bill for them under an "office" visit without prior approval. Billing for sessions in which the patient is not seen is considered fraud and is prosecuted as a felony. If you find an error in your billing or in the EOB from the insurance company for additional sessions, notify the insurance company immediately and return the payment to them, otherwise you are breaking the law. If your patient does not come to their session, you cannot bill the insurance company. It is best to include this information in the initial contract with your patients so they are aware that they will be responsible for the entire fee when they miss sessions, regardless of cause, unless the clinician decides they will not charge for that session. It is NEVER acceptable to charge the insurance company for missed sessions.

Patients who use insurance, must always pay their co-payment, rather than accepting insurance as "payment in full." Part of the contract the clinician has with the patient and the insurance company is to collect the co-payment, thereby making the patient at least partially responsible for payment of fees. It is incumbent on the clinician, unless otherwise agreed prior to service, to determine the fee the patient is to pay each session. Because of the complexity of using the insurance as a third-party-payer, it is sometimes necessary to bill the insurance and receive payment prior to determining how much the patient's co-pay is. Social workers ethically are not to allow their patients to acquire bills they are unable to pay. If there are surprises in billing the insurance, make certain that they occur early in the treatment process to avoid the awkwardness of dunning patients for bills they did not expect or discovering you have made a large contribution to charity in unpaid psychotherapy hours. (No, you cannot deduct them).

In addition to general practices that apply to clinicians who bill insurance, there are also State Laws which are unique to each State. Inquire directly with your State to determine which laws apply to you and your practice.

Some States have laws that require insurance companies to reimburse clinicians who are treating psychological conditions that are considered to have a medical basis in the same manner as other medical illnesses. Generally, these diagnoses include Major Depression, Manic-Depression, Generalized Anxiety, Eating Disorders, Schizophrenia, and other psychological illnesses that have been shown to either have a hereditary basis or be treated by medication. Insurance companies will supply a list of such illnesses. Psychological problems caused by environmental, social, or relational in nature are generally not covered under the "biologically based" clause. If an illness  is found to be "biologically-based" the limits on number of sessions for psychotherapy are suspended and the patient can be seen as often and for as long as is considered "medically necessary" by the social worker and the insurance company. Unfortunately, even if you are treating a severe schizophrenic who happened to purchase insurance in a State that does not recognize "biologically based" you may find yourself trying to treat your patient in the five sessions approved for psychotherapy by their insurance company.

Additionally, the insurance company can ask for treatment plans, progress notes, and other paperwork to ascertain that the treatment benefits the patient and falls within their guidelines for treatment of this type of disorder. The laws pertaining to this are Byzantine at best. Insurance companies are to have written rules about the type and amount of treatment allowed as well as provisions for determining whether the treatment is useful for the patient's improvement or recovery. Needless to say, these rules are vague and, in practice, rarely exist, but many States require that the insurance companies maintain these documents. In practice, be kind to yourself and your patient: call their insurance company to check on coverage and bill for the first session immediately so both you and your patient have a clearer idea about what their insurance will cover. As an added complication, some companies are retaining their insurance carrier but using another carrier, generally with less coverage, for psychotherapy so do not assume that an insurance carrier which is known to you automatically carries the same benefits for psychotherapy for one patient as it does with another. It is always worthwhile to check with the insurance carrier, bill in a timely manner, and keep good records about payment.

Ethical Standard: Social workers are accurate, honest, and objective in reporting their professional activities and judgments to appropriate third parties, including courts, health insurance companies, those who are the recipients of evaluation reports, and others. Social workers observe all applicable HIPAA regulations.

Termination of Therapy

Abandonment Prohibited

Social workers do not abandon clients. Social workers make appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, illness, and following termination.

Inability to Assist Clients

If social workers determine an inability to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Social workers are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives. If clients decline the suggested referrals, social workers should discontinue the relationship.

Appropriate Termination

Social workers terminate a professional relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling. Social workers may terminate counseling when in jeopardy of harm by the client, or another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Social workers provide pre-termination counseling and recommend other service providers when necessary.

Appropriate Transfer of Services

When social workers transfer or refer clients to other practitioners, they ensure that appropriate clinical and administrative processes are completed and open communication is maintained with both clients and practitioners.

Standard of Care

Standard of Care refers to what most professionals would consider to be a reasonable amount and type of care.  Perhaps the reason there is no legally defined Standard of Care is because there are so many different diagnoses and combinations of diagnoses as well as so many treatment approaches that are considered valid within the psychotherapy community. When a social worker decides to treat a patient, s/he decides on a course that uses skills the clinician has already acquired and that are accepted within the psychotherapy community as a reasonable  means for treating the patient. At this point, the clinician writes a Treatment Plan as a template for ongoing psychotherapy. The treatment plan should include the diagnosis, reasons why that diagnosis is correct, the area(s) the treatment will address, the specific treatment for each diagnosis listed, the frequency of treatment with the reason(s) why that amount of treatment is required, and the length of treatment. The length of treatment, while always an estimation should be an exact amount of time. Revisions to the Treatment Plan can be made as other issues arise and should be included as Revisions to the Treatment Plan.

Despite having the Standard of Care not be specific, there are certain ethical and professional guidelines that should be followed.  These guidelines reflect a broad-based view that all clinicians should be compliant with what are considered to be normal standards within psychotherapy. Primary among these is a social worker should not do therapy outside of their area of expertise. While all clinicians have patients who present unique symptoms, this provision refers to offering treatment to a patient who presents with generally serious problems that the social worker has had no training, supervision, or experience in treating. An example of this is an eating disorder.

Generally, clinicians who treat eating disorders have training, supervision, and experience prior to embarking on the treatment of a person who could easily move into a life-threatening condition. An inexperienced social worker may not even know the patient was suffering from symptoms that indicated a medical emergency. Social workers, who act in a manner that goes beyond their level of expertise or even experience, may find themselves in legal trouble for providing treatment they are not qualified to provide. Instead of doing this, social workers should refer the patient to another social worker who is an expert in treating patients with that diagnosis or they may seek supervision and training so they can become skilled at treating that population. If they decide to learn about treatment, the patient should be informed, in writing, and should give consent to the social worker to share information with a supervisor as well as to provide treatment. This allows the patient to choose a different social worker who has more training as well as giving the social worker documentation that the patient was made aware of the situation prior to treatment and offered alternatives should the treatment fail and the patient or the patient's family decided to sue the clinician for attempting to treat a patient without adequate training or experience in the problem the patient suffered. If you have any doubts, refer the patient to another clinician rather than take a risk with the patient's life and your license.

The Standard of Care also refers to providing your patients with appropriate referrals within the medical community as part of your Treatment Plan.  Most importantly, patients who have diagnoses of different types of depression, anxiety disorders, eating disorders, psychosis, and other  illnesses considered to have a biological basis, must be referred to medical professionals who are licensed to evaluated the patient for possible medication. To share information with this physician requires that the patient sign a Release of Information so you may share their confidential information as well as a Release of Information so the physician may share confidential information with you. Choosing not to do so is a breach of ethical responsibility and endangers both the patient and the license of the social worker.  The physician is primarily responsible for the medication received by the patient. It is considered optimal, if the patient is prescribed medication, to have the clinician and physician work together as a team to give input to each about the usefulness of the medication and the psychotherapy. Patients who receive both psychotherapy and medication have consistently been shown, as a group, to have the best outcome. While this does not imply that an individual patient will do best in treatment without medication that decision is not left to the social worker. The wisest course is to refer all patients who present with a diagnosis that may include a biological basis to refer them to a physician for evaluation. A good course of action is to develop a network of physicians who are experienced at treating either a range of diagnoses or specific ones as well, to keep track of the insurance plans they accept, and to maintain a good working alliance with them over the years. Patients can be very difficult so having a physician who you trust to provide medication can be invaluable in the treatment process.

Another physician to involve in the treatment process to provide an optimal Standard of Care is the patient's Primary Care Physician.  Patients who present for psychotherapy often are taking other medications for other illnesses as well. The Primary Care Physician can be invaluable in flagging interactions between medications as well as providing a history of the patient that may include information omitted from the intake for various reasons. While some social workers prefer not to have information about the patient that was not provided within sessions, there are times when this preference can lead to life-threatening or even fatal consequences. Again, it is necessary to have the patient sign a Release of Information prior to talking with their primary care physician. Generally patients will see these communications as evidence of concern about their well-being. If they are reluctant or refuse to sign a release, discuss the matter with them and make a judgment about whether their reason is a valid one.

Some people are assigned a Primary Care Physician with whom they have little contact and may feel uncomfortable about having information given of a sensitive nature  to someone they consider to be a stranger. Sometimes understanding the risks and benefits of having a physician who holds all records about treatment and medication will provide them with the information to make an informed decision about their health care.

Social workers are expected to maintain a record of their treatment sessions with patients whether or not they are required to be HIPAA compliant. Under the Standard of Care, these notes generally include the patient's name, date of session, length of session, problems discussed, progress made, and plan for subsequent sessions (if any). If you are not required to be HIPAA compliant, these may be progress notes and may include your own impression of the session and thoughts about it and are not shared with the patient or other professionals. These should be kept in a locked container to maintain the patient's privacy.

Some clinicians are trained in techniques considered to be experimental or untested. Some are openly in violation of the Standard of Care for psychological services. Others feel competent without training or experience to treat people with symptoms that are dangerous to their own health and those around them. Do not be one of these social workers or you will face not only prosecution for malpractice but also criminal charges.

Malpractice and the Licensing Board

Avoid doing anything which will cause you to have problems with the Licensing Board. Get your Continuing Education Units done on time and make sure they count. Keep up on your paperwork. The State Board can require you to produce case notes in a very short time. If the Licensing Board sends you any sort of inquiry, do not take it lightly. Consult with the best attorney you possibly can even if it means traveling. Preferably find someone who teaches ethics and is both a clinician and an attorney. Make sure they have experience. Do not just dash off a letter which answers the questions asked by the board. If they have written you and asked for a response, it is a serious inquiry about your treatment practices. The Licensing Board takes your responses seriously and what may appear to be a simple misunderstanding between yourself and your patient could result in having to defend yourself and your license before a member of the Licensing Board. Make sure you have Malpractice insurance to cover the fee for an attorney to defend you. Being sanctioned by the Licensing Board is a public process and even if you do not lose your license temporarily and have to take additional classes or other tasks to bring your standard of practice up to that of other social workers, you may lose your referral base. You will also be likely to find yourself the subject of gossip. The Licensing Board also may determine that you should lose your license to practice permanently. This does not preclude having criminal or civil charges brought against you by your patient(s). All of this is quite public also.

Malpractice and Ethics Committees

Avoid actions by ethics committees by following the rules and guidelines for practice. Make it a habit to check in on the  Licensing Board Web site on a regular basis so you know when laws are changing. Unfortunately, some social workers were convicted of violating ethics of their profession when they were following what had been a typical pattern but was in the process of changing. When you are uncertain about the rules, ask. Get answers in writing if possible. Know the name of the person with whom you spoke regarding how to most appropriately do tasks or render treatment. Consult with other professionals and inform them of the difficulties you face. Seek formal supervision. Seek legal consultation. The fee you spend may save your livelihood. Be wary of dual relationships. Be wary of any sort of variation in billing and collecting fees. Be aware of what you put in writing and that the information can be passed on to others even without your knowledge or consent, leaving you in a legal limbo which will certainly require an attorney.

Malpractice due to Criminal Allegations

The Attorney General is involved in these proceedings. They are the most serious offenses, usually involving fraud, collusion in criminal activities, and a variety of criminal offences. Social workers, while held to a higher legal standard, are people and become involved in illegal schemes just as other people do. In your practice, you do many things totally on your own and you are aware that within your office what occurs is privileged information. This requires that you set the standard higher for yourself because a small bit of cheating quickly spirals into greater corruption. Do not lie, cheat, steal or engage in any behavior which could appear to have involved illicit activities. Do not enter into relationships with your patients or partners which involve felonious behavior. Patients may see a social worker as someone who is above the law and would not be suspected of criminal behavior. Do not see yourself in this manner and make it clear to patients who wish to have you collude with them in illegal activities that you will not do that and you must report behavior which would cause harm to others. Although social workers are rarely involved in these activities, conviction results not only in the loss of your license, it also results in criminal prosecution and incarceration. Some of the most frequent offenses involve defrauding Medicare by claiming to have performed services which were either not performed or were not reasonable treatment for the patients involved. These have usually involved large numbers of patients.

Informed Consent

Social workers  shall inform clients/consumers of services the extent and nature of services available to them, as well as the limits, rights, opportunities and obligations associated with the services to be provided which might affect the clients/consumers of services decisions to enter into or continue the relationship.

Licensees and registrants shall provide services to clients only in the context of a professional relationship based on valid informed consent. Licensees and registrants shall use clear and understandable language to inform clients of the purposes of services, limit to the services due to legal requirements, relevant costs, reasonable alternatives, the clients' rights to refuse or withdraw consent, and the time frame covered by the consent.

In instances when clients are unable to read or understand the consent document or have trouble understanding the primary language contained in the informed consent document, licensees must take steps to ensure the clients comprehension including providing a detailed verbal explanation or arranging for a qualified interpreter or translator as needed. If a client because of age of mental condition is not competent to provide informed consent the licensee will obtain consent from the parent, guardian, or court appointed representative. Best professional practice dictates that a social worker should adhere to the court documents. If a social worker does not understand the court document, they must contact the court for clarification before proceeding with treatment.

In situation when clients are receiving services involuntarily, social workers shall provide information about the nature and extent of the services and about the client's right to refuse services.  Social workers who provide services via electronic means shall inform the clients and recipients of the limitations and risks associated with such services.

When a social worker provides services to two or more clients who have a relationship with each other and who are aware of each other's participation in treatment (for example couples, family members), a social worker shall clarify with all parties the nature of the licensee's professional obligations to the various clients who are receiving services, including limits of confidentiality. A social worker who anticipates a conflict of interest among the clients receiving services or anticipate having to perform in potentially conflicting roles (for example a licensee who is asked or ordered to testify in a child custody dispute or divorce proceeding involving clients) should clarify their role with the parties involved and take appropriate action to minimize any conflict of interest.

When a social worker sees clients for individual or group treatment, there may be reason for a third party to join the session for a limited purpose. The client of legal guardian must provide a release document so the third party can join the session. The social worker must make clear that the third party is not a client and there is no confidentiality between the licensee and the third party. The social worker must make it clear to the third party that he/she will not have rights to access the client's file but would have rights to the individual session notes in which he/she participated. A social worker shall not make recommendations to courts, attorneys or other professionals concerning non-clients.

Sexual Relationships

Social workers shall not engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced. Social workers shall not have sexual intimacies with clients and shall not counsel persons with whom they have had a sexual relationship.

Social workers shall not engage in sexual intimacies with former clients after terminating the therapeutic relationship. Social workers shall not engage in sexual activities or sexual contact with client's 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 the client maintains a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker 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.

If the social worker engages in conduct contrary to this prohibition or claims that an exception to this prohibition is warranted because of extraordinary circumstances, it is the social worker's not his/her clients, who assumes the full burden of demonstrating that the client or former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.

Testing services

Social workers who provide test scoring and test interpretation services to support the assessment process confirm the validity of such interpretations. They accurately describe the purpose, norms, validity, reliability, and applications of the procedures and any special qualifications applicable to their use. The public offering of an automated test interpretations service is considered a professional-to-professional consultation. The formal responsibility of the consultant is to the consulted, but the ultimate and overriding responsibility is to the client.

Test security: Social workers maintain the integrity and security of tests and other assessment techniques consistent with legal and contractual obligations. Social workers do not appropriate, reproduce, or modify published tests or parts thereof without acknowledgment and permission from the publisher.

Obsolete tests and outdated test results: social workers do not use data or test results that are obsolete or outdated for the current purposes, social workers make every effort to prevent the misuse of obsolete measures and test data by others.

Test construction: social workers use established scientific procedures, relevant standards, and current professional Knowledge for test design in the development, publication, and utilization of educational and psychological assessment techniques.

Research responsibilities:

 Use of human subjects

 Social workers plan, design, conduct, and report research in a manner consistent with pertinent ethical principles, federal and state laws, host institutional regulations, and scientific standards governing research with human subjects. Social workers design and conduct research that reflects cultural sensitivity appropriateness.

Precautions to avoid injury

Social workers who conduct research with human subjects are responsible for the subjects' welfare throughout the experiment and take reasonable precautions to avoid causing injurious psychological, physical, or social effects to their subjects. Social workers warn clients of any possible harm that might come from being involved in a research project.

Confidential Communication

Confidential communication between patient and social worker means information, including information obtained by an examination of the patient, transmitted between a patient and his social worker in the course of that relationship and in confidence by a means which, so far as the patient is aware, discloses the information to no third persons other than those who are present to further the interest of the patient in the consultation, or those to whom disclosure is reasonably necessary for the transmission of the information or the accomplishment of the purpose for which the social worker is consulted, and includes a diagnosis made and the advice given by the social worker in the course of that relationship.

Confidentiality is designed to reduce the stigma associated with seeking mental health care, foster trust in the treatment relationship and ensure individuals privacy in their health care decisions. Informed consent and confidentiality are important anchors to the principle of autonomy. If a patient believes that the information they share will be disseminated they will be less likely to seek treatment and be less likely to be completely honest.

When a patient enters our office and psychotherapy begins, everything which is said or done by that patient, with few exceptions, are confidential. The patient holds the privilege to release the confidential information in legal proceedings. While you may object to the patient using these records, you must have solid grounds for your objection. While these are quite variable, generally patients can request and use their records in any way they please. In some instances, a legal guardian or conservator may hold the privilege if the patient is unable to do so. If the patient dies, their privilege passes to the patient's personal representative who handles legal affairs.

The holder of the privilege also has the right to read all information in his or her file with the exception of your personal notes which belong solely to you. Some social workers find this requires them to keep separate files so their personal notes do not become part of the patient's legal record. Your patient can read all notes which have their identifying information, diagnosis, treatment plan, prognosis, and other information including billing and information from other sources which you have included in the file such as notes from other physicians and hospitals. Any spare notes in the patient's file also have information which must be passed to the patient. All information in HIPAA notes are the patient's property and must be released. The file is the property of the clinician so copies must be made if the patient requests a copy of their file. 

It is your responsibility to maintain the confidentiality of the records. Patient records should be kept in locked containers except when in use. They should be shredded when they are discarded to avoid the potential of having the notes fall into the hands of others. Office staff and others who handle the files should be made aware of the importance of confidentiality. Handle these records as if they were notes made by your own therapist about you. Your patient feels the same need to have the notes be private. Office staff, filing clerks, billing agencies, and others do not have the same burden of confidentiality as does the clinician. However, it is the responsibility of the social worker to inform the staff about the importance of confidentiality and to take reasonable action to be certain that staff does not violate the patient's confidentiality. While this is a solid part of HIPAA, it seems to be regularly violated by clerks and other office staff. Often my patients who work for or with social workers in the community or in government report cases which are confidential which they have read with avid interest. Try to keep this sort of clerk off your staff.

Holder of Privilege

Holder of the privilege means: (a) patient when he has no guardian or conservator. (b) A guardian or conservator of the patient when the patient has a guardian or conservator. (c) The personal representative of the patient if the patient is dead. Except as otherwise provided  the patient, has a privilege to refuse to disclose, and to prevent another from disclosing, a confidential communication between patient and social worker if the privilege is claimed (a) by the holder of the privilege. (b) A person who is authorized to claim the privilege by the holder of the privilege. (c) The person who was the social worker at the time of the confidential communication, but the person may not claim the privilege if there is no holder of the privilege in existence or if he or she is otherwise instructed by a person authorized to permit disclosure.

Laws Regarding Confidentiality

Exception to Confidentiality

Detention of Mentally Disordered Persons For Evaluation and Treatment (5150)

If a client is a danger to him or herself or others or gravely disabled as a result of a mental disorder, a social worker may have him or her involuntary hospitalized for 72 hours. In cases in which hospitalization is required, voluntary hospitalization is always preferable to involuntary hospitalization. Under certain conditions, a person can be detained for longer than 72 hours.

How to Initiate a Hold: Persons legally authorized by Welfare and Institutions Code 5150 to involuntarily confine an individual include police officers, members of the attending staff (e.g., a Psychiatric Emergency Team, or PET) of a facility certified by the county to hold a patient or other professional persons designated by a county. A social worker who believes that his or her client should be hospitalized involuntarily should contact the police or a PET.

5150: When any person, as a result of a mental disorder, is a danger to others, or to himself or herself, or gravely disabled, a peace officer, a member of the attending staff,  of an evaluation facility designated by the county, designated members of a mobile crisis team or other professional person designated by a county, may, upon probable cause, take, or cause to be taken, the person into custody and place him or her in a facility designated by the county and approved by the State Department of Mental Health as a facility for 72-hour treatment and evaluation.

Such facility shall require an application in writing stating the circumstances under which the person's condition was called to the attention of the officer, member of the attending staff, or professional person, and stating that the officer, member of the attending staff, or professional person has probable cause to believe that the person is, as a result of a mental disorder, a danger to others, or to himself or herself, or gravely disabled. If the probable cause is based on a statement of a person other than the officer, member of the attending staff, or professional person, such person shall be liable in a civil action for intentionally giving a statement which he or she knows to be false.

The law provides for confinement for a greater period than 72 hours if certain conditions are met. For instance, a person detained for 72 hours may be held for not more than 14 days of involuntary intensive treatment if the professional staff finds that the person is a danger to him or herself, others or gravely disabled as the result of a mental disorder or chronic alcoholism. Someone who has threatened to take his or her own life may be held an additional 14 days beyond the original 14. Finally, someone whose mental disorder causes continued imminent dangerousness (i.e., someone who has threatened, attempted or inflicted physical harm upon another after custody) may be held for an additional 90 days.

The decision as to how long to hold a dangerous patient is made by designated staff after the person is taken into custody. Unless he or she is a designated staff member, a social worker would NOT participate in this decision.

Exceptions to Confidentiality - continued

Tarasoff

law and ethics ceusProsenjit Poddar was born into the Harijan (untouchable) caste in Bengal, India. He arrived at the University of California at Berkeley and resided in the International House. In the fall of 1968, he met Tanya Tarasoff while she was attending folk dancing classes at the International House. They saw each other weekly throughout the fall, and on New Year's Eve, Tanya kissed Poddar. Poddar interpreted the kiss to be the recognition of the existence of a serious relationship. This view was not shared by Tanya who, when learning of his feelings, told him she was involved with other men and otherwise indicated that she was not interested in entering into an intimate relationship with him.

As a result of this rebuff, Poddar underwent a severe emotional crisis. He became depressed and neglected his appearance, his studies, and his health. He remained by himself, frequently abed, speaking disjointedly, and often weeping. He spoke to a friend of being in love with Tanya and about killing her, in particular, by blowing up her room. He told this friend he could not control himself. His condition persisted with steady deterioration throughout the spring and into the summer of 1969. Poddar did have occasional meetings with Tanya during this period and tape-recorded many of their conversations in an attempt to ascertain why she did not love him.

ethics ceusDuring the summer of 1969, Tanya went to Brazil. After her departure, Poddar began to improve and at the suggestion of a friend, sought psychological assistance. The exact date Poddar entered therapy is not available, but on August 18, 1969, he was a voluntary outpatient at Cowell Memorial Hospital (also called University Hospital in some reports). Although he initially had been seen by a psychiatrist, Dr. Stuart Gold, on August 18, 1969, he was under the care of a staff psychologist, Dr. Lawrence Moore. During the August 18 psychotherapy session, his ninth such session, Poddar confided in Dr. Moore that he was going to kill an unnamed girl, readily identifiable as Tanya, when she returned from Brazil.

On August 20, Dr. Moore personally notified campus police officers Everett D. Atkinson and Johnny C. Teel that Poddar was capable of doing harm to himself or others. On that same day, Dr. Moore wrote a letter to the Chief of Campus Police, William Beal, stating that Poddar suffered from a "paranoid schizophrenic reaction, acute and severe" and was a danger to himself and to others. Dr. Moore further stated that, if the campus police would pick Poddar up and transfer him to Herrick Hospital, Dr. Moore would sign a 72-hour emergency detention order on Poddar. Finally, Dr. Moore informed the campus police that Poddar's behavior could be quite rational at times. Dr. Gold and Dr. James Yandell, Dr. Moore's psychiatric supervisor and Assistant Director of the Department of Psychiatry, concurred in Dr. Moore's diagnosis and the need for Poddar's hospitalization.

The campus police took Poddar into custody. Officers Gary L. Browning, Joseph P. Halleran, and Atkinson talked to Poddar and were satisfied that he was rational and had "changed his attitude altogether." After the officers elicited a promise from Poddar that he would try to stay away from Tanya, the campus police released him.

It would appear that the campus police released Poddar on their own initiative; however, either simultaneously with the release or shortly thereafter, Dr. Harvey Powelson, Director of Psychiatry at Cowell Memorial Hospital, learned of the attempt to institute a 72-hour emergency detention order. Dr. Powelson requested that Chief Beall return Dr. Moore's letter, and ordered Moore to destroy all copies of the letter and his  notes on Poddar. In addition, Dr. Powelson ordered his staff to take no further action to place Poddar in a 72-hour treatment and evaluation facility.

Tanya returned from Brazil in October. Poddar continued to follow her and reportedly heard her tell friends of an affair with a "playboy." The criminal cases indicate that in October, after Tanya had returned, Poddar stopped seeing Dr. Moore. However, the Supreme Court, looking to the same source, stated that Poddar stopped his therapy immediately after his detention by the campus police. In any case, on October 27, 1969, Poddar went to Tanya's home to speak to her. Tanya was not at home and her mother told Poddar to leave. Poddar returned later armed with a pellet gun and a kitchen knife. He found Tanya alone. She refused to speak to him and, when he persisted, she screamed. At this point, Poddar shot her with the pellet gun and Tanya ran wildly from the house. Poddar caught her in the yard and stabbed her repeatedly and fatally. Poddar then returned to the house and called the police. Poddar told the police he had stabbed Tanya and asked that he be handcuffed.

Poddar was examined within 24 hours of the stabbing by Dr. Kermit Gruberg, a Berkeley Police Department psychiatrist. Gruberg confirmed the diagnosis of paranoid schizophrenia. Poddar was charged with the murder of Tanya. He pled not guilty and not guilty by reason of insanity. Some time prior to trial, Poddar was examined by Dr. Wilmer Anderson, a neurologist hired by the defense, who testified that, on the basis of neurologic tests, including an electroencephalogram, there were organic abnormalities in Poddar's brain. At trial, Dr. Philip Grossi, a psychiatrist hired by the defense, Dr. Gruberg, Dr. Anderson, Dr. Moore, and Dr. Gold testified that Poddar was insane and a paranoid schizophrenic.

Dr. John Peschau, a court-appointed psychiatrist, testified that Poddar was not a paranoid schizophrenic and that he could understand the duty the law placed upon him. During Dr. Moore's testimony, the details of Poddar's threats against Tanya and the attempt to secure an emergency commitment were revealed in open court. If Tanya's family members were unaware of these facts previously, then they certainly became aware of them at this time. It is not possible from the case reports to establish a temporal relationship between the testimony of Drs. Moore and Gold and the filing of the civil suit. However, their presentation for the defense at trial could not have established a cordial relationship with the family.

The jury convicted Poddar of murder in the second degree. Poddar appealed the decision on multiple grounds. The court of appeals heard the case in 1972 and focused on trial court instruction errors, including a failure to reinstruct the jury as follows: "Also, if you find that his mental capacity was diminished to the extent that you have a reasonable doubt whether he did harbor malice aforethought, you can not find him guilty of murder in either the first or second degree." The court reduced his conviction from murder in the second degree to manslaughter and remanded the case to the trial court to pronounce judgment. Two years later the Supreme Court vacated the judgment of the appeals court, holding that the instructions given by the trial court, "failed to serve the needs of the jurors to understand and properly apply the evidence of diminished capacity to the underlying issues." The court concluded that the error was prejudicial and remanded the case for retrial.

Poddar was not retried. Rather than go through another lengthy trial (the first was over three weeks), more than five years after the fact, the state released Poddar on condition he immediately leave for India and not reenter the United States. He returned to India and, according to one commentator, is happily married to an attorney.

Vitaly and Lydia Tarasoff, Tanya's parents, filed wrongful death suits against the university and the health care worker. They alleged four causes of action. The first cause of action was directed against the health care workers’ failure to detain Poddar. The second was directed against the health care workers’ failure to warn the Tarasoffs that Poddar was a grave danger to Tanya. The third was directed against Dr. Powelson and sought punitive damages for his actions following the attempt at 72-hour emergency detention. Dr. Powelson's actions were characterized as "malicious and oppressive abandonment of a dangerous patient." The fourth cause of action was titled "Breach of Primary Duty to Patient and the Public," and involved essentially the same allegations as the first cause of action.

The Alameda County Superior Court issued "a judgment of dismissal upon an order sustaining a demurrer without leave to amend." The Tarasoffs appealed. The court of appeals affirmed the superior court judgment, ruling the first and fourth causes of action were statutorily barred. The court could find no special relationship between the defendants and Tanya or her parents and therefore found no duty to warn. The court ruled that Dr. Powelson had no duty to commit Poddar and, even if he did, such action was discretionary and protected under statute. The Tarasoffs appealed once more.

Duty of [Physicians] to Take Precautions against Patient Violence.

1.Scope of cause of action. Except as provided in paragraph 5, no cause of action shall lie against a [physician], nor shall legal liability be imposed, for breaching a duty to prevent harm to person or property caused by a patient unless a) the patient has communicated to the [physician] an explicit threat to kill or seriously injure a clearly identified or reasonably identifiable victim or victims, or to destroy property under circumstances likely to lead to serious personal injury or death, and the patient has the apparent intent and ability to carry out the threat; and b) the [physician] fails to take such reasonable precautions to prevent the threatened harm as would be taken by a reasonably prudent [physician] under the same circumstances. Reasonable precautions include, but are not limited to, those specified in paragraph 2.

2. Legally sufficient precautions. Any duty owed by a [physician] to take reasonable precautions to prevent harm threatened by a patient is discharged, as a matter of law, if the [physician] either a) communicates the threat to any identified victim or victims; or b) notifies a law enforcement agency in the vicinity where the patient or any potential victim resides; or c) arranges for the patient to be hospitalized voluntarily; or d) takes legally appropriate steps to initiate proceedings for involuntary hospitalization.

3.Immunity for disclosure. Whenever a patient has explicitly threatened to cause serious harm to person or property, or a [physician] otherwise concludes that a patient is likely to do so, and the [physician], for the purpose of reducing the risk of harm, discloses any confidential communications made by or relating to the patient, no cause of action shall lie against the [physician] for making such disclosure.

Patient means any person with whom a physician has established a [physician]-patient relationship. Many states, enacted laws limiting a social worker's liability so long as certain specific actions are taken by the social worker when a patient threatens violence. Such statutes have sought to reconcile the competing policy concerns for public safety, while limiting intrusion into the therapeutic relationship. Alan Stone commented on this development that "the duty to warn is not as unmitigated a disaster for the enterprise of psychotherapy as it once seemed to critics like myself." 

Reporting Child Abuse and Neglect

Mandated Reporting Law: When a social worker in his or her professional capacity, acquires knowledge or a reasonable suspicion that a child is being abused (or has been abused), he or she must make a telephone report immediately and a written follow-up within 36 hours to the appropriate authorities.

Categories of Child Abuse: physical abuse, sexual abuse, severe and general neglect, willful cruelty and unjustifiable punishment, corporal punishment and injury and abuse in out-of-home care.

Categories of Sexual Abuse: The two categories of sexual abuse are sexual assault and sexual exploitation. Sexual assault includes rape and rape in concert, oral copulation and sodomy, lewd and lascivious acts upon a child under the age of 14, penetration of a genital or anal opening by a foreign object and child molestation. Unlawful sexual intercourse with a child under the age of 16 when the perpetrator is over the age of 21 is reportable as child abuse. Another crime also reportable is lewd and lascivious acts with a child of 14 or 15 years of age when the perpetrator is more that 10 years older than the victim. Sexual exploitation includes conduct involving matter depicting minors engaged in obscene acts; promoting, aiding or assisting a minor to engage in prostitution, a live performance involving obscene sexual conduct or posing for a pictorial depiction involving obscene conduct for commercial purposes; and depicting a child in or knowingly developing a pictorial depiction in which a child engages in obscene sexual conduct.

A report of child abuse is not required when a social worker learns of the abuse in a setting outside his or her professional capacity. A report is also not mandated when a social worker learns of a case involving an adult who was abused as a minor. In this case, however, clinical and ethical considerations will bear on a social worker's course of action. For example, when a social worker learns of an adult who was abused as a child, that social worker should make an effort to learn whether the perpetrator continues to have access to children. If so, and the circumstances arouse a reasonable suspicion of child abuse, the clinician must file a report. Consensual, non-abusive sex between two 13-year-olds is not reportable, but would become reportable when just one of the partners turns 14.

When, in the course of his or her professional role, a social worker either knows or reasonably suspects that a minor is being abused, they have a legal obligation to report what he or she knows of the situation to the proper authorities (Child Protective Services, police, county probation offices or county welfare office) by telephone as soon as possible, with a written follow-up required within 36 hours. The social worker has no discretion in this matter and may be liable for prosecution if he or she does not report.

The requirement to report child abuse and neglect became public policy in all States by 1965 with the passage of the first child abuse reporting law, which only required physicians to report physical abuse. Since that time, neglect, emotional abuse, and sexual abuse have been recognized as injurious to a child's physical and mental health, and reporting laws were amended to include these forms of child maltreatment. Those professionals required by law to make child abuse reports also expanded over the years to include teachers, nurses, mental health professionals, social workers, school custodians, day care providers, and others who are in regular contact with children.

Mental health professionals are now required by law in all States to report child abuse and neglect. The specific language of the States' reporting laws varies, but they typically cover circumstances when one acquires knowledge of or observes a child under conditions that give rise to a reasonable suspicion of child abuse and/or neglect; or, when one has knowledge of or observes a child whom he or she knows has been the victim of child abuse and neglect. "Reasonable suspicion" definitions may vary, but it is generally considered to occur when it is objectively reasonable for a person to entertain such a suspicion, based on his or her training and experience.

Child abuse must be reported when one who is a legally mandated reporter, has knowledge of or observes a child in his or her professional capacity, or within the scope of his or her employment whom he or she knows or reasonably suspects has been the victim of child abuse.

The Reporting Mandate to Whom You Must Report

The report must be made to a "child protective agency." A child protective agency is a county welfare or probation department or a police or sheriff's department. Exceptions are reports by commercial print and photographic print processors, which are made to the law enforcement agency having jurisdiction. The mandated reporter must report the known or suspected incidence of child abuse to a child protective agency immediately or as soon as practically possible by telephone. You will speak to the clinician or law enforcement officer on duty.

Mandated reporters, however, are not legally required to tell involved individuals that a report is about to be made. The law does not require mandated reporters to tell the parents that a report is being made; however, in the majority of cases, advising the client is therapeutically advisable. First, the social worker is employing clinical leverage by using authority to set a firm and necessary limit. Reporting child abuse responds to the parents' nonverbal plea for help. The social worker can reassure the clients that steps will be taken to help the parents regain control so that the abuse does not lead to serious injury or emotional trauma to the child. Second, if the social worker does not mention the report, there is secrecy and tension, which may result in the clients' feelings of suspicion, isolation, or betrayal. In some cases, reporting may elicit an extreme response from the clients. It is contra-indicated to inform parents about the report if the individual seems psychotic, has poor impulse control coupled with a history of violent behavior, has a problem with alcohol or drugs, or is likely to flee. It can be very beneficial to give clients the opportunity to make the reports themselves in the social worker's presence. A self-report, however, does not negate the social worker's mandate to report.

Health practitioners, including MFTs, psychologists, and social workers, are legally mandated reporters. Other legally mandated reporters include child care custodians, teachers, teacher's assistants, employees of child protective agencies and commercial film and photographic print processors. Legally mandated reporters are required to give their names.

Child abuse is defined as “a physical injury which is inflicted by other than accidental means on a child by another person.” Child abuse also means the sexual abuse of a child or any act or omission, willful cruelty or unjustifiable punishment of a child, or unlawful corporal punishment or injury. Child abuse also means the neglect of a child or abuse in out-of-home care. Child abuse does not include any injury caused by reasonable and necessary force used by a peace officer . Abuse must be reported “even if a suspected child abuse victim has expired, regardless of whether or not the possible abuse was a factor contributing to the death, and even if suspected child abuse was discovered during an autopsy.”

Please keep in mind that your responsibility is only to report suspected abuse, not investigate it. Your attempts to investigate may have unforeseen negative impacts on the child and family. Leave it for the child welfare professionals.

The following types of abuse must be reported by legally mandated reporters:

Physical Abuse: Physical injury inflicted by other than accidental means.

Sexual Abuse: Sexual abuse includes sexual assault and sexual exploitation.

Sexual assault is defined as:

Rape and rape in concert: This includes any forced sexual activity with anyone under age 18, or helping someone else rape a minor.

Incest: Incest is any sexual activity between parents and children, ancestors and descendants, siblings and between uncles or nieces and aunts or nephews.

Oral copulation and sodomy

Lewd and lascivious acts upon a child under the age of 14: This refers to any sexual touching or intercourse with a male or female child under the age of 14, even if it is consensual. If “lewd and lascivious” behavior occurring between minors, when each is under the age of 14 years, is not reportable, as long as the minors are of roughly the same age and there is no coercion involved. However, lewd and lascivious acts with a child of 14 or 15 years of age when the perpetrator is more than 10 years old than the victim is reportable.

Child Molestation

Sexual Explotation - Conduct depicting a minor engaged in obscene acts, including preparing, selling or distributing the obscene matter and/or employing a minor to perform obscene acts; any person knowingly promoting, aiding or assisting, employing, using, persuading, inducing or coercing a child, or any parent or guardian of a child under his or her control knowingly permitting or encouraging a child to engage in or assisting either to engage in prostitution or a live performance involving obscene sexual conduct or to either pose or model alone or with others for purposes of preparing a film, photograph, negative, slide, drawing, picture or other pictorial depiction involving obscene sexual conduct for commercial purposes; any person depicting a child in or who knowingly developing, duplicating, printing or exchanging any film, photograph, videotape, negative or slide in which a child is engaged in an act of obscene sexual conduct.

Severe and General Neglect: Acts or omissions committed by a person responsible for a child that harm or threaten to harm the child's health or welfare.

Severe neglect: “the negligent failure of a person having the care or custody of a child to protect the child from severe malnutrition or medically diagnosed nonorganic failure to thrive.” Severe neglect also means those situations of neglect where “any person having the care or custody of a child willfully causes or permits the person or health of the child such that his or her person or health is endangered including the intentional failure to provide adequate food, clothing, shelter or medical care.”

General neglect: This is defined as “the negligent failure of a person having the care or custody of a child to provide adequate, food, clothing, shelter, medical care or supervision where no physical injury has occurred.”

Willful Cruelty and Unjustifiable Punishment: This refers to situations in which “any person willfully causes or permits any child to suffer, or inflicts thereon, unjustifiable physical pain or mental suffering.

Corporal Punishment and Injury: This refers to “a situation where any person willfully inflicts upon any child any cruel or inhuman corporal punishment or injury resulting in a traumatic condition.”

If a social worker hears about child abuse from a third party, and this raised a reasonable suspicion of abuse, the social worker must make a report if the information was revealed to the social worker within their professional capacity.

Confidentiality: The identity of all reporters is considered confidential and is disclosed only between child protective agencies.

Immunity: Mandated reporters have immunity from criminal and civil liability for reporting as required.

Any other person who reports a known or suspected case of child abuse is also protected from civil and criminal liability, unless it can be proven that the person deliberately made a false report.

Privilege: The Child Abuse Reporting Law takes precedence over laws governing the social worker-patient privilege.

Failure to Report: A failure to report known or suspected child abuse when mandated to do so is considered a misdemeanor and is punishable by a term in jail not to exceed six months or by a fine not to exceed $1,000 or by both.

Indicators of Possible Child Abuse

The following physical and behavioral indicators are listed as signs of possible child abuse for you to consider in making your report. These indicators need to be evaluated in the context of the child’s environment. The presence of one or more of these symptoms does not necessarily prove abuse. These lists are examples and are not all-inclusive.

Physical Indicators 

  • Bruises and welts on the face, lips, mouth, torso, back, buttocks, or thighs in various stages of healing
  • Bruises and welts in unusual patterns reflecting the shape of the article used (e.g., electric cord, belt buckle) or in clusters indicating repeated contact
  • Bruises on infant, especially facial bruises
  • Subdural hematomas, retinal hemorrhages, internal injuries
  • Cigarette burns, especially on the soles, palms, backs or buttocks
  • Immersion burns (sock-like, glove-like, doughnut-shaped) on buttocks or genitalia
  • Burns patterned like an electric element, iron or utensil
  • Rope burns on arms, legs, neck or torso
  • Fractures of the skull, nose, ribs or facial structure in various stages of healing
  • Multiple or spiral fractures
  • Unexplained (or multiple history for) bruises, burns or fractures
  • Lacerations or abrasions to the mouth, frenulum, lips, gums, eyes or external genitalia
  • Bite marks or loss of hair
  • Speech disorders, lags in physical development, ulcers
  • Asthma, severe allergies or failure to thrive
  • Consistent hunger, poor hygiene, inappropriate dress
  • Consistent lack of supervision; abandonment, unattended physical or emotional problems or medical needs
  • Difficulty in walking or sitting
  • Pain or itching in the genital area
  • Bruises, bleeding or infection in the external genitalia, vaginal or anal areas
  • Torn, stained or bloody underclothing
  • Frequent urinary or yeast infections
  • Venereal disease, especially in pre-teens
  • Pregnancy
  • Substance abuse – alcohol or drugs
  • Positive test for presence of illegal drugs in the child’s body

Behavior Indicators

  • Afraid to go home; frightened of parents
  • Alcohol or drug abuse
  • Apprehensive when children cry, overly concerned for siblings
  • Begging, stealing or hoarding food
  • Behavioral extremes, such as aggressiveness or withdrawal
  • Complaints of soreness, uncomfortable movement
  • Constant fatigue, listlessness or falling asleep in class
  • Delay in securing or failure to secure medical care
  • Delinquent, runaway or truant behaviors
  • Destructive, antisocial or neurotic traits, habit disorders
  • Developmental or language delays
  • Excessive seductiveness or promiscuity
  • Extended stays at school (early arrival and late departure)
  • Extreme aggression, rage, or hyperactivity
  • Fear of a person or an intense dislike of being left with someone
  • Frequently absent or tardy from school or drops out of school or sudden school difficulties
  • History of abuse or neglect provided by the child
  • Inappropriate clothing for the weather
  • Massive weight change
  • Indirect allusions to problems at home such as, “I want to live with you”
  • Lack of emotional control, withdrawal, chronic depression, hysteria, fantasy or infantile behavior
  • Lags in growth or development
  • Multiple or inconsistent histories for a given injury
  • Overly compliant, passive, undemanding behavior; apathy
  • Poor peer relationships; shunned by peers
  • Poor self-esteem, self-devaluation, lack of confidence or self-destructive behavior
  • Role-reversal behavior or overly dependent behavior; states there is no caretaker
  • Suicide attempts
  • Unusual interest in or knowledge of sexual matters, expressing affection in inappropriate ways
  • Wary of adult contacts, lack of trust, uncomfortable with or threatened by physical contact or closeness

Physical Abuse 

“Physical abuse” is defined as any non-accidental physical injury, or injury which is at variance with the history given of it, suffered by a child as the result of the acts or omissions of a person responsible for the care of the child. Common indicators could include unusual or unexplained burns, bruises, or fractures. Health services personnel should be especially alert to cases of child abuse where inconsistent histories are presented. Inconsistent histories can take the form of an explanation that does not fit the degree or type of injury to the child, or where the story or explanation of the injury changes over time. Some indicators of child abuse are not visible on the child’s body. Many times there are no physical indicators of abuse. A child’s behavior can change as a result of abuse. Health services personnel need to be alert to possible behavioral indicators of abuse and if they believe those to be present, they are required to make a report. Behavioral indicators include behaviors such as:

  • Extreme aggression.
  • Withdrawal.
  • Seductive behaviors.
  • Being uncomfortable with physical contact or closeness.

Mental Injury

“Mental injury” is defined as any mental injury to a child’s intellectual or psychological capacity as evidenced by an observable and substantial impairment in the child’s ability to function within the child’s normal range of performance and behavior as the result of the acts or omissions of a person responsible for the care of the child.

Examples of mental injury may include:

  • Ignoring the child and failing to provide necessary stimulation, responsiveness, and validation of the child’s worth in normal family routine.
  • Rejecting the child’s value, needs, and request for adult validation and nurturing.
  • Isolating the child from the family and community; denying the child normal human contact.
  • Terrorizing the child with continual verbal assaults, creating a climate of fear, hostility, and anxiety, thus preventing the child from gaining feelings of safety and security.
  • Corrupting the child by encouraging and reinforcing destructive, antisocial behavior until the child is so impaired in socio-emotional development that interaction in normal social environments is not possible.
  • Verbally assaulting the child with constant, excessive name-calling, harsh threats, and sarcastic put downs that continually “beat down” the child’s self-esteem with humiliation.
  • Over pressuring the child with subtle but consistent pressure to grow up fast and to achieve too early in the areas of academics, physical or motor skills, or social interaction, which leaves the child feeling that he or she is never quite good enough.

Sexual Abuse

  • “Sexual abuse” is defined as the commission of a sexual offense with or to a child as a result of the acts or omissions of the person responsible for the care of the child.

There are several sub-categories of sexual abuse:

  • First degree sexual abuse
  • Second degree sexual abuse
  • Third degree sexual abuse
  • Detention in a brothel
  • Lascivious acts with a child
  • Indecent exposure
  • Assault with intent to commit sexual abuse
  • Indecent contact with a child
  • Lascivious conduct with a minor
  • Incest
  • Sexual exploitation by a counselor or therapist
  • Sexual exploitation of a minor
  • Sexual misconduct with offenders and juveniles

Behavioral indicators of sexual abuse could include things such as excessive knowledge of sexual matters beyond their normal developmental age or seductiveness. Physical indicators of sexual abuse could include things such as bruised or bleeding genitalia, venereal disease, or even pregnancy.

Denial of Critical Care

“Denial of critical care” is defined as the failure on the part of a person responsible for the care of a child to provide for the adequate food, shelter, clothing or other care necessary for the child’s health and welfare when financially able to do so or when offered financial or other reasonable means to do so.

Note: What most people think of as an issue of “neglect” is covered under the child abuse category of “denial of critical care.”

A parent or guardian legitimately practicing religious beliefs who does not provide specified medical treatment for a child for that reason alone shall not be considered abusing the child. However, this does not preclude a court from ordering that medical service be provided to the child where the child’s health requires it.

  • Denial of critical care includes the following eight sub-categories:
  • Failure to provide adequate food and nutrition to such an extent that there is danger of the child suffering injury or death.
  • Failure to provide adequate shelter to such an extent that there is danger of the child suffering injury or death.
  • Failure to provide adequate clothing to such an extent that there is danger of the child suffering injury or death.
  • Failure to provide adequate health care to such an extent that there is danger of the child suffering serious injury or death.
  • Failure to provide the mental health care necessary to adequately treat an observable and substantial impairment in the child’s ability to function.
  • Gross failure to meet the emotional needs of the child necessary for normal development evidenced by the presence of an observable and substantial impairment in the child’s ability to function within the normal range of performance and behavior.
  • Failure to provide proper supervision of a child which a reasonable and prudent person would exercise under similar facts and circumstances, to such an extent that there is danger of the child suffering injury or death. This definition includes cruel and undue confinement of a child and the dangerous operation of a motor vehicle when the person responsible for the care of the child is driving recklessly or driving while intoxicated with the child in the vehicle.

Other situations that fall under this subcategory include:

• Illegal drug usage by the caretaker of a child

When you make an allegation of denial of critical care because a child lacks proper supervision due to illegal drug usage by a caretaker you may be asked questions to help DHS determine the type of drug and the degree of risk to the child. Some illegal drugs may have a greater impact on the supervision abilities of the caretaker than others. For example, methamphetamine usage by a child’s caretaker has inherent risks to the child given the known effects of methamphetamines. DHS will consider the known effect of the drug named and other information to assess risk to the child’s safety.

• Children home alone

DHS receives many inquiries each year regarding when a child can be left home alone safely. Each situation is unique. Examples of questions to help determine whether there are safety concerns for the child include:

  • Does the child have any physical disabilities?
  • Could the child get out of the house in an emergency?
  • Does the child have a phone and know how to use it?
  • Does the child know how to reach the caretaker?
  • How long will the child be left home alone?
  • Is the child afraid to be left home alone?

Does the child know how to respond to an emergency such as fire or injury?

• Lice and truancy

Head lice and truancy are often reported as child abuse allegations. However, the endangerment does not generally rise to the level that must be present to constitute a child abuse allegation. If other conditions are present or the situation poses a risk to the child’s health and welfare, it should be reported as child abuse. Even if the report is rejected for assessment, other services may be offered to the child and family.

♦ Failure to respond to the infant’s life-threatening conditions by failing to provide treatment which in the treating physician’s judgment will be most likely to be effective in ameliorating or correcting all conditions. This subcategory or the denial of critical care abuse type is also known as “withholding of medically indicated treatment.” The type of treatments included are appropriate nutrition, hydration, and medication. The term does not include the failure to provide treatment other than appropriate nutrition, hydration and medication to an infant when, in the treating physician’s medical judgment, any of the following circumstances apply:

• The infant is chronically and irreversibly comatose.

• The provision of treatment would merely prolong dying, not be effective in ameliorating or correcting all of the infant’s life-threatening conditions, or otherwise be futile in terms of the survival of the infant.

• The provision of the treatment would be virtually futile in terms of the survival of the infant and the treatment itself under the circumstances would be inhumane.

Elder and Dependent Adult Abuse Reporting

Mandated Reports: A mandated reporter must report a known or suspected instance of elder or dependent adult abuse when, in his or her professional capacity, or within the scope of his or her employment, he or she (1) has observed or has knowledge of an incident that reasonably appears to be physical abuse, neglect, financial abuse, abandonment, abduction, or isolation; (2) is told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, neglect, financial abuse, abandonment, abduction, or isolation; or (3) reasonably suspects abuse.

Optional Reports: Mandated reporters may report a known or suspected instance of elder or dependent adult abuse when they have knowledge of or reasonably suspect that a form of elder or dependent adult abuse for which a report is not mandated has been inflicted upon an elder or dependent adult or that the elder or dependent adult's emotional well-being is threatened in any other way.

Definition of Elder: An “elder” is a person who is age 65 years or older.

Definition of Dependent Adult: a dependent adult is a person, between the ages of 18 years and 64 years, who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights.

What Must Be Reported: Under the current law, mandated reporters, including social workers, are now required to report the following:

Instances of known and reasonably suspected physical abuse of an elder or dependent adult. Instances of known and reasonably suspected neglect, financial abuse, abandonment, abduction, and/or isolation of an elder or dependent adult, and any other treatment that results in physical harm, pain, or mental suffering.

As a mandated reporter, a social worker is required to make a report of known or suspected elder or dependent adult abuse when, in his or her professional capacity, or within the scope of his or her employment, he or she has observed or has knowledge of an incident that reasonably appears to be abuse, is told by an elder or dependent adult that he or she has experienced behavior constituting abuse; and/or reasonably suspects abuse.

Abuse of an elder or dependent adult includes the following categories: Physical abuse, neglect, financial abuse, abandonment, abduction, isolation, and any other form of treatment that results in physical harm, pain, or mental suffering. Mental suffering may consist of fear, confusion, severe depression, agitation, or other serious emotional distress caused by threats, harassment, or other forms of intimidating behavior.

Physical Abuse includes assault, assault with a deadly weapon or with force likely to cause great bodily injury; battery; sexual assault, unreasonable physical restraint; prolonged or continual deprivation of water or food; and the use of physical or chemical restraint for punishment, for a period of time beyond that for which the medication was ordered through instructions from a licensed physician or surgeon caring for the elder or dependent adult, and/or for any purpose not authorized by the elder or dependent adult's physician or surgeon.

Neglect refers to the negligent failure of any person having the care or custody of an elder or dependent adult to exercise that degree of care that a reasonable person in a similar position would provide. Neglect also includes self-neglect, the negligent failure of an elder or dependent adult to provide a reasonable degree of care to himself or herself.

Specific examples of neglect include the failure to assist in personal hygiene or in the provision of food, clothing, or shelte,; the failure to provide medical care for physical or mental health needs and the failure to prevent malnutrition or dehydration.

Financial Abuse means concealing, taking, or appropriating an elder or dependent adult's property or money to any wrongful use or with the intent to defraud.

Abandonment, desertion or willful abandonment by a person having the care or custody of the elder or dependent adult person under circumstances in which a reasonable person would continue to provide care and custody.

Isolation, deliberately preventing an elder or dependent adult from receiving his or her mail or phone calls. False imprisonment; and/or the physical restraint of an elder or dependent adult for the purpose of preventing him or her from meeting with his or her visitors.

Reporting Elder Abuse

Reports of known or reasonably suspected elder or dependent adult abuse must be filed by telephone immediately or as soon as practically possible. A written report must then be sent within two working days.

Reporters should generally make reports to their county's adult protective agency or a local law enforcement agency. There are two exceptions to this, however: First, if the abuse occurred in a state mental health hospital or state developmental center, the report should be made to designated investigators of the State Department of Mental Health or the State Department of Developmental Services or to the local law enforcement agency. Second, if the abuse occurred in a long-term care facility (other than a state mental hospital or a state developmental center), reports should be made to the local ombudsman or to the local law enforcement agency.

Any person legally required to report elder or dependent adult abuse who knowingly fails to report can be found guilty of a misdemeanor that is punishable by not more than six months in the county jail or a fine not to exceed $1,000 or both imprisonment and a fine. A social worker who fails to make a timely mandated elder or dependent adult abuse report may also face disciplinary action by their governing board and civil action for damages. The law provides that no person required to make a report of elder or dependent adult abuse shall be criminally or civilly liable for such a report, as long as it cannot be proven that the report was made falsely.

HIPAA

Covered Entities:

 All health professionals who send information via electronic transmission are considered “Covered Entities” and all HIPAA rules apply to them. What one must do as a Covered Entity to become compliant with HIPAA will be covered here. However, this should not be seen as covering all aspects of compliance.

Individual practitioners may have practices which differ in important ways from the majority of other practitioners and may require additional changes in their operating procedures to become compliant. Also, as the task force continues its work on integrating laws governing the health professions with HIPAA regulations, new laws may become an additional part of what one must do to become or remain compliant. Continue to check with your professional organizations and licensing boards for updates.

Exempt Mental Health Professionals

If you are a health care provider who never transmits electronic data regarding patients you are not required, at this time, to comply with the HIPAA regulations and are not considered a “Covered Entity.” However, HIPAA is very quickly becoming the standard of care by which health care providers’ office practices are regulated. In other words, you may be found to be negligent with your patient’s records and confidentiality if you do not move your office practices into compliance.

PHI is Protected Health Information Information which you have about your patient which identifies them as an individual when it is transmitted is PHI. All such material must be treated with utmost caution and respect for the rights of your patient. When the patient is identified by name, Social Security Number, or other means which make the patient identifiable by others requires that the material be classified as PHI. If the information contains PHI, all past, present, and future physical or mental health diagnoses, treatment of any sort, and billing or payment become confidential material.

It is crucial that all material containing PHI or information which identifies a patient be protected within the office. It is advisable to personally chart the flow of this information through your office. For example:

  • Is incoming mail secure and protected from unauthorized disclosure?
  • Is the information created within the office stored and protected?
  • Is the information recorded in other areas, such as on or off-site billing personnel have storage which is protected from unauthorized disclosure?
  • Is all incoming and outgoing electronic transmission secure?

HIPAA also requires that PHI material be available to be legitimately shared, sent out, or given to those who are authorized. If you personally see where the information comes in, is stored, used, created, and released, you will feel more confident that there is protection for these documents all along the line of transfer. It is helpful to some therapists to pretend these are their own personal records when deciding whether or not the records of their patients are securely protected throughout the process.

HIPAA requires that PHI be available within five days to an authorized agency under law.

The consequences of failing to be in compliance with HIPAA can be severe. Fines of up to $250,000 and imprisonment for up to ten years or both can be levied against an individual who knowingly perpetrates “wrongful disclosure of individual, identifiable, health information. Additionally the Office of Civil Rights at the US Department of Health and Human Services can initiate administrative action against non-compliant therapists. Patients can also file lawsuits if a therapist is non-compliant because their private health information is endangered. There may also be civil penalties but these cannot exceed $25,000 in one year.

For a complete list of Ethical obligations please read from the link below.

Link to: NASW Code of Ethics

Author:

Code of Ethics of the National Association of Social Workers

Social Worker Ethics Continuing Education, Ethics CEUs for Social Workers

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

Social Worker Ethics Ceus

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