Ethics Alive! Ethics and the Clinical/Nonclinical Distinction
by Allan Barsky, J.D., MSW, Ph.D.
According to the National Association of Social Workers, social work is a single profession with a distinct set of values, ethical principles, and standards. Under the Council on Social Work Education’s (n.d.) 2015 Educational Policy and Accreditation Standards, we have a common set of core competencies and receive common degrees at the baccalaureate or master’s levels. BSW and MSW programs introduce students to the single profession concept early on, and it is not long before many students are faced with the question of whether they want to become clinical social workers. Unfortunately, people who are new to the profession may not be familiar with the notion of clinical social work, what it means, and what the other options are. This article seeks to answer these questions, as well as the question of what the clinical/nonclinical distinction means in terms of our ethical obligations.
Clinical social work (CSW) refers to a “specialty practice area of social work which focuses on the assessment, diagnosis, treatment, and prevention of mental illness, emotional, and other behavioral disturbances. Individual, group and family therapy are common treatment modalities” (NASW, n.d.). To practice CSW, the laws in all 50 states require social workers to be licensed. To obtain licensure, they require an MSW with a CSW concentration (including classes and field), at least two years of post-MSW supervised clinical practice, and successful completion of a CSW exam (Association of Social Work Boards, n.d.). State laws provide licensed clinical social workers with a number of legal benefits, typically including the legal authority to diagnose mental health disorders, to conduct psychotherapy, to bill clients for third-party insurance reimbursement, to open an independent private practice, to provide clinical supervision, and to have the protection of “privilege” (i.e., courts cannot compel clinical social workers to testify unless clients provide permission).
So, what is nonclinical social work (NCSW)? This term is reminiscent of the theme song for Gilligan’s Island when the lyrics enumerate key characters, “There’s Gilligan, the Skipper, too....” Rather than naming everyone, however, one version of the jingle states, “And the rest,” as if they have no name, no special identity. What social worker wants to be defined by who they are not? For the purposes of this article, I am using the term NCSW for convenience, to indicate social workers who engage in case management, counseling, administration, advocacy, community development, social action, and any other social work role that is not specifically clinical. I apologize if the term sounds dismissive, and I certainly believe that social workers should identify themselves by who they are rather than who they are not.
Across the United States and Canada, approximately 29% of licensed social workers have clinical licensure (Association of Social Work Boards, 2015). In most states, NCSWs can operate with either a BSW or MSW degree. About 30 states have nonclinical licensure for social workers with BSW or MSW degrees. In practice, however, people can engage in many of the nonclinical social work functions without having a social work license—and without even having a social work degree.
Although the NASW Code of Ethics (2017) applies to all social workers, certain parts of the Code have more relevance for some social workers than for others. Part 1 of the Code refers to ethical responsibilities to clients, which certainly fits well for clinical social workers. Depending on the type of NCSW, some standards in this part may not be so relevant.
Consider a policy advocate who is not working for a particular client. How does this advocate obtain informed consent (Standard 1.03) from a client if there is no client? Consider the prohibition against having sex with clients under Standard 1.09. If a community organizer is working for the whole country, does this mean that the organizer cannot have sexual relations with anyone in the country?
Note also how boundary issues may be different for CSWs and NCSWs. Standard 1.06 states, “Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client.” Thus, it would be inappropriate for CSWs to provide psychotherapy to their children or other close family members. In contrast, it might be ethically appropriate for NCSWs to provide a gun violence awareness program in a school that includes their children. Note that Standard 1.06 does not prohibit all dual relationships, but rather, advises social workers to avoid dual relationships when there is risk of exploitation or harm. CSWs are often working with vulnerable clients in situations where dual relationships are particularly risky. For NCSWs, the riskiness of dual relationships varies widely, depending on the specific type of work they are doing. Contrast, for instance, an NCSW who is managing a homeless shelter who avoids hiring relatives because of concerns of nepotism, versus an NCSW who teams up with a relative to advocate for improvements to the health care system.
Despite the challenges in applying some standards from Part 1 to some forms of NCSW, other standards are certainly relevant to all forms of social work. Being competent to provide services under Standard 1.04, for instance, applies whether one is conducting diagnoses, empowering communities, or managing a social agency. Further, some NCSW functions are similar to clinical social work in terms of working with identifiable clients. The obligations under Part 1 are easily applicable to case managers, counselors, and advocates for specific clients.
Part 6 of the NASW Code refers to social work’s obligations to the broader society. Arguably, some standards in this part align more closely with NCSW than CSW. Standard 6.04 says social workers should participate in social and political action. If a social worker has a private practice specializing in psychotherapy, how is this participating in social and political action? In contrast, policy advocates and community organizers are participating in social and political action by their very nature. Despite the clinical/nonclinical divide, however, social work is a single profession. The NASW Code does not say that only certain social workers should promote social justice. All of us have this obligation. Thus, social workers who specialize in clinical practice should devote some of their time to promoting social justice.
Parts 2, 3, 4, and 5 of the NASW Code of Ethics include social workers’ obligations to colleagues, obligations to practice settings (employers), obligations as professionals, and obligations to the social work profession. Most standards under these parts fit equally for clinical social workers and non-clinical social workers. For instance, demonstrating respect for colleagues (Standard 2.01) and avoiding discrimination (Standard 4.02) apply whether a social worker specializes in psychotherapy, community organization, or case management.
Virtually all social workers are familiar with the NASW Code of Ethics. Many social workers, unfortunately, are not familiar with NASW’s practice standards. Whereas the NASW Code applies to all areas of practice, practice standards are guidelines for particular areas of social work practice—for instance, clinical social work, peace and social justice, aging, child welfare, health, and violence. Social workers who specialize in these areas should become familiar with the relevant standards. Social workers who specialize in certain areas should also consider joining groups that focus on these areas—for instance, the Clinical Social Work Association, the Association for Community Organization and Social Administration, the International Association for Social Work with Groups, and the American Case Management Association. Even though we are one profession, there is nothing inherently wrong with having areas of specialization and different groups that promote and support different areas of practice. Medicine has specializations in oncology, cardiology, radiology, psychiatry, and so on, yet few would question whether medicine is a single profession. Similarly, social work may have divisions for the purposes of specialization, yet it still retains its core values and ethical principles.
The tensions between clinical and nonclinical social work have existed since the times of Jane Addams and Mary Richmond. Although different social workers may prefer one form of social work over another, we are one profession with a dual interest—promoting the well-being of particular clients, while also promoting the well-being of the broader society. As the social work mantra goes, “Policy affects practice, and practice affects policy.” From this perspective, CSWs and NCSWs are not polar opposites, but the complementary yin and yang of the social work profession. While it is crucial that students and new social workers understand the difference between clinical and nonclinical social work, it is also vital that they understand what brings us together as a profession.
References
Association of Social Work Boards. (n.d.). About licensing and registration. Retrieved from https://www.aswb.org/licensees/about-licensing-and-regulation
Association of Social Work Boards. (2015). Social work licensure requirements in the United States and Canada. Retrieved from https://www.aswb.org/wp-content/uploads/2015/09/Social-work-licensing-requirements-9.17.pdf
Council on Social Work Education. (n.d.). About CSWE accreditation. Retrieved from https://www.cswe.org/Accreditation
National Association of Social Workers (NASW). (n.d.). Clinical social work. Retrieved from https://www.socialworkers.org/practice/clinical/default.asp
National Association of Social Workers (NASW). (2017). Code of Ethics. Retrieved from https://www.socialworkers.org/pubs/code/default.asp
Allan Barsky, Ph.D., J.D., MSW, is Professor of Social Work at Florida Atlantic University and author of Social Work Values and Ethics (Oxford University Press).
The views expressed in this article do not necessarily represent the views of any of the organizations to which the author is affiliated, or the views of The New Social Worker magazine or White Hat Communications.