The First Amendment and Clinical Harm: Protecting Client Self-Determination in Social Work Practice

by Jenny Tanis, PhD, LMSW-C

     I remember the day I received my clinical social work license. I remember the relief of passing the ASWB exam and the thousands of hours logged with my limited license, processing difficult cases and navigating heavy ethical questions in supervision. It was a proud milestone, but more than that, I remember the immense responsibility and the promise that document represents—a promise to prioritize my clients’ well-being, safety, and self-determination. Today, as a social work educator, I spend a great deal of time trying to impart the gravity of that promise to the next generation of practitioners. 

     On March 31, 2026, my social media feed filled with news of the latest U.S. Supreme Court (SCOTUS) ruling. In an 8-1 decision, SCOTUS ruled against the Colorado ban on conversion therapy in Chiles v. Salazar, the legal defense asserting that state regulation of talk therapy infringes on freedom of speech. In her lone dissenting opinion, Justice Ketanji Brown Jackson warned that the decision opens a “dangerous can of worms” (p.35) that threatens to impair a state’s ability to regulate medical care. 

     Now, to be clear, I am not a lawyer or constitutional law expert. I approach this issue from the perspective of a social worker educator and former clinical practitioner. If you are reading this, you might be feeling the anxiety of the can of worms Justice Jackson warned about being opened. You might be wondering: What does this mean for our profession? How do we protect our clients when the highest court in the nation protects a harmful practice as “speech”? While the legal landscape feels chaotic, our professional duty remains unchanged. In this article, we will explore how to navigate this moment together. 

The Therapy Room Is Not the Public Square 

     Above all else, this ruling is a direct threat to the safety, mental health, and lives of LGBTQ+ individuals, particularly vulnerable youth. We cannot ignore the human cost of this ruling, and for competent social workers, this moment should not feel ethically ambiguous. Professionally, we have been standing ten toes down against conversion therapy for more than a decade. Instead, this moment is a call to leadership. The court’s framing fundamentally misunderstands the function of therapy, conflating conversational free speech with regulated clinical speech.  

     In the public square, the First Amendment importantly protects the expression of personal beliefs. You can stand on a street corner and profess virtually any ideology you choose without government interference. But the therapy session is not the public square. When an individual seeks mental health treatment, the words we use are the delivery mechanism for a regulated medical intervention. As the American Psychological Association explained in an amicus brief, “The scientific, professional nature of therapy justifies the state’s regulation of professional conduct.” 

     According to several federal statutes—including Medicare and Medicaid Services (42 C.F.R. § 410.73; 42 U.S.C. § 1395x) and the Family and Medical Leave Act (29 C.F.R. § 825.125)—social workers are categorized as licensed health professionals, authorizing us to diagnose and treat mental illness alongside physicians and psychologists. In Michigan, for example, my license is categorized as a “Health Professional.” This designation anchors our practice in an evidence-based, medical standard of care and subjects us to regulatory oversight, ensuring we do no harm. 

     This regulation is vital because sexual orientation and gender identity (SOGI) are not mental illnesses. They are not pathologies to be cured or conditions to be treated. Therefore, attempting to treat or alter a client’s core identity falls entirely outside our regulated scope of practice. Allowing clinical social workers to practice conversion therapy in the name of free speech is a serious breach of our licensing mandate.

     Furthermore, the empirical research regarding conversion therapy is exceptionally clear: it is proven to cause significant harm. This practice is linked to severe adverse mental health outcomes, including increased depression, anxiety, PTSD, self-harm, and suicidal attempts. It preys on youth who are already experiencing heightened isolation and rejection, significant risk factors for traumatic stress. Because of these empirical findings, major medical and mental health associations have unequivocally denounced this practice, including the American Psychological Association, the American Medical Association, the American Academy of Pediatrics, and the National Association of Social Workers. 

The Danger of a Predetermined Outcome

     As a new clinician, it can be difficult to feel confident in your clinical skills and release your own agenda for your clients. We learn that wanting what is best for our clients does not allow us to make decisions on their behalf. The principle of self-determination elicits clear boundaries that empower clients and protect their agency. The legal defense in Chiles ignores this clinical boundary. It assumes a clinician is entitled to have a predetermined outcome for the person sitting across from them. 

     Imagine you are a newly hired clinician at a community mental health office. A 15-year-old client is assigned to your caseload after recently coming out to their family as transgender. Their parents demand that you use your sessions to “steer them back” to their sex assigned at birth to alleviate family tension. It can be intimidating to push back against parental demands, especially when you are new. But if you accept that clinical goal, you are no longer practicing therapy—you are engaged in ideological manipulation. 

     True clinical work in this scenario begins with affirming the client’s truth and recognizing their inherent self-knowledge. As social workers, we are a clinical tool meant to facilitate internal discovery. We are not an authority tasked with imposing a specific identity or outcome. Think about how often you have heard: Meet clients where they are. Clients are the experts of their own lives. When a practitioner leverages the tremendous power of the therapeutic relationship to force a fixed outcome, they inflict deep psychological harm and fundamentally invalidate the client’s core sense of self. This approach violates the very heart of the NASW Code of Ethics and our commitment to client self-determination. 

How We Show Up Tomorrow: Advocacy in Action

     Although the provider at the center of the Chiles case is not a social worker, every clinical provider has a responsibility to respond. Here are some ways we can show up right now.

  • Follow the lead of LGBTQ+ advocates. Social work advocacy is most effective when we take direction from those directly impacted by injustice. As we mobilize, we must first actively partner with and support LGBTQ-led organizations and community advocates (see resources below) who have been at the forefront of this work for decades. Only then can we leverage our clinical credentials to amplify existing advocacy strategies and stand in unwavering solidarity. 
  • Hold the line in your agency. We often practice in multidisciplinary teams, and because of this, you may face pressure from an agency that interprets Chiles as legal permission to introduce “reparative” therapies to appease certain stakeholders. We must firmly reject the integration of discredited modalities into our practice environments, in accordance with our professional obligation to the NASW Code of Ethics.
  • Audit your agency’s policies. Take a leadership role by reviewing your internal policies and intake documents. Through this process, advocate for the explicit language that outlines your agency’s commitment to evidence-based, affirming care. By making this standard practice, you overtly protect your clients the moment they walk through the door. 
  • Engage with state licensing boards. SCOTUS applied strict scrutiny to a legislative ban, but state licensing boards retain the authority to regulate clinical competence and define professional malpractice. Partner with NASW state chapters to petition licensing boards to codify conversion/reparative therapies as professional malpractice. 
  • Educate the next generation. Educators, field instructors, clinical supervisors, or mentors have an obligation to provide explicit instruction on ethical professional practice. Begin with the resources below to ensure your students and mentees understand that the therapeutic environment is a sacred, regulated space and to equip them with the tools to defend it. 

     The shifting legal landscape will always present new dilemmas for social work practitioners, but our ethical responsibilities remain steadfast. The First Amendment is a critical foundation of our democracy, and the social work profession is deeply aligned with its necessity. This right, however, does not justify professional malpractice. If a practitioner’s clinical survival depends on utilizing a discredited, harmful modality, we must question their professional competence and remain committed to prioritizing evidence-based practice, protecting our most vulnerable clients from harm, and fiercely defending their right to self-determination. 

Resources for Further Reading and Advocacy

Dr. Jenny Tanis is a licensed clinical social worker and social work educator based in Michigan. Jenny teaches courses related to social policy, child welfare, and family practice. Her research explores how macro-level policies can be effectively utilized to prevent child maltreatment and support overall family well-being.