Law and Professional Ethics CE Course 12 CE Units/Hours

Law and Professional Ethics CE Course 12 CE Units/Hours
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Law and Professional Ethics CE Course
12 CE Units/Hours
© 2015 by Aspira Continuing Education. All rights reserved. No part of this material may be transmitted
or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira
Continuing Education.
Course Disclaimer: The contents of this course in its entirety are for informational purposes only and are in no way intended as a
replacement for legal advice. In no event shall Aspira Continuing Education or its content providers be liable for any claims or
damages resulting from the use of or inability to use this course or the content, whether based on warranty, contract, tort, or any
other legal theory, and whether or not we are advised of the possibility of such damages and is not liable for any personal injury
caused by the use or misuse of any information contained throughout the following course.
Course Objectives: In addition to the course objectives listed below, this course
addresses the following content areas related to law and professional ethics:
 Assessment
 Professional practice issues
1. Identify Legal and Ethical issues in counseling including but not limited
to professional ethical standards and significant legal considerations.
2. Increase familiarity with the licensing law and process.
3. Define and increase fluency in regulatory laws that delineate the
profession’s scope of practice, counselor-client privilege, confidentiality, the
client dangerous to self or others, treatment of minors with or without
parental consent, relationship between practitioner’s sense of self and human
values, functions and relationships with other human service providers,
strategies for collaboration, and advocacy processes needed to address
institutional and social barriers that impeded access, equity, and success for
clients.
4. Increase familiarity with HIPAA requirements and standards.
5. Identify unprofessional conduct and negligence.
6. Define best standards of practice.
7. Identify necessary continuing education requirements.
8. Increase knowledge of professional ethics.
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9. Increase Familiarity with clinical supervision law and ethics.
10. Increase knowledge regarding emergencies and confidentiality.
Table of Contents
1. Scope of Practice…………………………………………..
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1A. MFT Scope of Practice…………………………………
4
1B. LCSW Scope of Practice……………………………….
5
1C. LPCC Scope of Practice………………………………..
6
2. Unprofessional Conduct, Negligence, Law, Ethics, and Standard of
Care ……………………………………………………………
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2A. Unprofessional Conduct and Negligence ………………
8
2B. Law………………………………………………………
20
2C. Ethics……………………………………………………
21
2D. Standard of Care………………………………………...
23
3. Legal Issues ............................................................................
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3A. Privilege ………………………………………………….
24
3B. Confidentiality ……………………………………………
33
3C. Exceptions to Confidentiality: Child Abuse, Dependent Adult and
Elder Abuse, Tarasoff, Danger to Self and/or Others……….
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3D. Treatment of Minors …………………………………..
48
3E. Sex with Clients ………………………………………..
50
3F. Record Retention and Storage ………………………….
69
3G. Termination …………………………………………….
69
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3H. Informed Consent ………………………………………
72
3I. Malpractice………………………………………………
73
4. HIPAA and Third Party Reimbursement for Mental
Health Services…………………………………………………..
74
5. Continuing Education...............................................................
93
6. Professional Ethics ……………………………………………
6A. CAMFT Ethical Standards PT 2 Section ………………
97
97
6B. Revised CAMFT Ethical Standards ……………………
99
6C. NASW Ethical Standards ………………………………
129
6D. NBCC Code of Ethics………………………………….
151
6E. The American Mental Health Counselors Association
(AMHCA) Code of Ethics…………………………… 164
6F. The ACA Code of Ethics………………………………..
184
6G. NAADAC Code of Ethics………………………………
219
7. Ethics and Confidentiality with HIV/AIDS……………………
245
8. Clinical Supervision Law and Ethics Considerations…………
276
9. Self Disclosure…………………………………………………..
281
10. Legal and Ethical Issues in Emergencies……………………..
292
11. Domestic Violence and the Law……………………………….
297
12. Child Abuse Reporting………………………………………..
303
13. References………………………………………………………
348
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1. Scope of Practice
The Attorney General describes scope of practice as the following:
1. MFTs and LCSWs “may practice psychotherapy” as it relates to the
treatment of relational issues and social adjustments.
2. MFTs and LCSWs may diagnose and treat mental disorders as it relates to
the treatment of relational issues and social adjustments.
3. MFTs and LCSWs may administer psychological tests, as long as the
testing instrument used is within a therapist’s scope of competence as
established by education, training, or experience and as long as the test is
administered within the context of providing therapy. In other words, standalone testing of persons who are not psychotherapy clients would be outside
the scope of practice for MFTs and LCSWs.
Circumstances exist in which a “special relationship” is presumed by law to
exist when one person is particularly vulnerable and dependent on another
person who, correspondingly, has some control over the person’s welfare
(Kockelman v. Segal). The relationship between a therapist and his or her
patient constitutes this type of relationship. This special relationship
imposes an affirmative duty on the therapist to protect others from either the
therapist’s own negligence or from the client’s dangerousness towards self
or others.
1A. MFT Scope of Practice
MFT scope of practice is defined in Section 4980.02 of the California
Business and Professions Code, “For the purposes of this chapter, the
practice of marriage, family, and child counseling shall mean that service
performed with individuals, couples, or groups wherein interpersonal
relationships are examined for the purpose of achieving more adequate,
satisfying, and productive marriage and family adjustments. This practice
includes relationship and pre-marriage counseling. The applications of
marriage, family, and child counseling principles and methods includes, but
is not limited to, the use of applied psychotherapeutic techniques, to enable
individuals to mature and grow within marriage and the family, and the
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provision of explanations and interpretations of the psychosexual and
psychosocial aspects of relationships.”
Pursuant to Business and Professions Code Section 4980.08, the title
"licensed marriage, family and child counselor" or "marriage, family and
child counselor" is hereby renamed "licensed marriage and family therapist"
or "marriage and family therapist," respectively. Any reference in any statute
or regulation to a "licensed marriage, family and child counselor" or
"marriage, family and child counselor" shall be deemed a reference to a
"licensed marriage and family therapist" or "marriage and family therapist."
1B. LCSW Scope of Practice
LCSW scope of practice is defined in Section: 4996.9 of the California
Business and Professions Code, “The practice of clinical social work is
defined as a service in which a special knowledge of social resources, human
capabilities, and the part that unconscious motivation plays in determining
behavior, is directed at helping people to achieve more adequate, satisfying,
and productive social adjustments. The application of social work principles
and methods includes, but is not restricted to, counseling and using applied
psychotherapy of a non-medical nature with individuals, families, or groups;
providing information and referral services; providing or arranging for the
provision of social services; explaining or interpreting the psychosocial
aspects in the situations of individuals, families, or groups; helping
communities to organize, to provide, or to improve social or health services;
or doing research related to social work. “Psychotherapy, within the
meaning of this chapter, is the use of psychosocial methods within a
professional relationship, to assist the person or persons to achieve a better
psychosocial adaptation, to acquire greater human realization of
psychosocial potential and adaptation, to modify internal and external
conditions which affect individuals, groups, or communities in respect to
behavior, emotions, and thinking, in respect to their intrapersonal and
interpersonal processes.”
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1C. LPCC Scope of Practice
Section §4999.20 : of the California Business and Professions Code:
SCOPE OF PRACTICE; TREATMENT OF COUPLES OR
FAMILIES (a) (1) “Professional clinical counseling” means the application
of counseling interventions and psychotherapeutic techniques to identify and
remediate cognitive, mental, and emotional issues, including personal
growth, adjustment to disability, crisis intervention, and psychosocial and
environmental problems. “Professional clinical counseling” includes
conducting assessments for the purpose of establishing counseling goals and
objectives to empower individuals to deal adequately with life situations,
reduce stress, experience growth, change behavior, and make well-informed
rational decisions. (2) “Professional clinical counseling” is focused
exclusively on the application of counseling interventions and
psychotherapeutic techniques for the purposes of improving mental health,
and is not intended to capture other, nonclinical forms of counseling for the
purposes of licensure. For the purposes of this paragraph, “nonclinical”
means nonmental health. (3) “Professional clinical counseling” does not
include the assessment or treatment of couples or families unless the
professional clinical counselor has completed all of the following additional
training and education, beyond the minimum training and education required
for licensure: (A) One of the following: (i) Six semester units or nine quarter
units specifically focused on the theory and application of marriage and
family therapy. (ii) A named specialization or emphasis area on the
qualifying degree in marriage and family therapy; marital and family
therapy; marriage, family, and child counseling; or couple and family
therapy. (B) No less than 500 hours of documented supervised experience
working directly with couples, families, or children. (C) A minimum of six
hours of continuing education specific to marriage and family therapy,
completed in each license renewal cycle. (4) “Professional counseling” does
not include the provision of clinical social work services. (b) “Counseling
interventions and psychotherapeutic techniques” means the application of
cognitive, affective, verbal or nonverbal, systemic or holistic counseling
strategies that include principles of development, wellness, and
maladjustment that reflect a pluralistic society. These interventions and
techniques are specifically implemented in the context of a professional
clinical counseling relationship and use of a variety of counseling theories
and approaches. (c) “Assessment” means selecting, administering, scoring,
and interpreting tests, instruments, and other tools and methods designed to
measure an individual’s attitudes, abilities, aptitudes, achievements,
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interests, personal characteristics, disabilities, and mental, emotional, and
behavioral concerns and development and the use of methods and techniques
for understanding human behavior in relation to coping with, adapting to, or
ameliorating changing life situations, as part of the counseling process.
“Assessment” shall not include the use of projective techniques in the
assessment of personality, individually administered intelligence tests,
neuropsychological testing, or utilization of a battery of three or more tests
to determine the presence of psychosis, dementia, amnesia, cognitive
impairment, or criminal behavior. (d) Professional clinical counselors shall
refer clients to other licensed health care professionals when they identify
issues beyond their own scope of education, training, and experience.
(a) Incorporating the words “licensed professional clinical counselor” and
shall not state that they are licensed to practice professional clinical
counseling, unless they are otherwise licensed to provide professional
clinical counseling services. (b) Nothing in this chapter shall be construed to
constrict, limit, or withdraw provisions of the Medical Practice Act, the
Clinical Social Worker Practice Act, the Nursing Practice Act, the
Psychology Licensing Law, or the Marriage and Family Therapy. (c) This
chapter shall not apply to any priest, rabbi, or minister of the gospel of any
religious denomination who performs counseling services as part of his or
her pastoral or professional duties, or to any person who is admitted to
practice law in this state, or who is licensed to practice medicine, who
provides counseling services as part of his or her professional practice. (d)
This chapter shall not apply to an employee of a governmental entity or a
school, college, or university, or of an institution both nonprofit and
charitable, if his or her practice is performed solely under the supervision of
the entity, school, college, university, or institution by which he or she is
employed, and if he or she performs those functions as part of the position
for which he or she is employed. (e) All persons registered as interns or
licensed under this chapter shall not be exempt from this chapter or the
jurisdiction of the board.
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2. Unprofessional Conduct, Negligence, Law, Ethics, and Standard of
Care
2A. Unprofessional Conduct and Negligence
The Business and Professions Code, Section 4982 indicates examples of
unprofessional conduct including “negligence or incompetence in the
performance of marriage and family therapy; misrepresentation involving
type of license held, educational credentials, professional qualification or
professional affiliations; performing, or holding oneself out as being able to
perform services outside the scope of the license; failing to maintain
confidentiality, except as otherwise permitted or required by law; and
soliciting or paying remuneration for referrals. Unprofessional conduct is
punishable by revocation or suspension of a license or an intern's
registration; it is also a misdemeanor punishable by imprisonment in the
county jail not exceeding six months, by a fine not exceeding $2,500, or
both.”
In regards to recordkeeping, 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.
No person may, for remuneration, engage in the practice of marriage and
family therapy or social work as defined by Section 4980.02, unless he or
she holds a valid license as a Marriage and Family Therapist or social
worker, or unless he is specifically exempted from such requirement, nor
may he advertise himself or herself as performing the services of a marriage,
family, child, domestic, or marital consultant, or in any way use these or any
similar titles to imply that he or she performs these services without a license
as provided by this chapter.
1. When an intern employed in private practice is supervised by someone
other than the employer, the supervisor must be employed by and practice at
the same site as the intern's employer.
2. Interns are not to be supervised by anyone with whom they have a
personal relationship. Nor should interns receive supervision from their
psychotherapists.
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3. Individual supervision means one supervisor and one person being
supervised. The intent of law is that supervision will occur face to face.
4. Group supervision means a group of no more than eight persons being
supervised by a supervisor. Two supervisors for a group of sixteen
supervisees is not acceptable.
5. A supervisor may supervise an unlimited number of interns and trainees in
any appropriate work setting, but is limited to supervising two interns when
those interns are employed in private practice.
6. Hour requirements: During each week in which experience is claimed, the
intern must have at least one hour of individual supervision or two hours of
group supervision, for each work setting. Three hours is the maximum
amount of supervision that can be credited during any single week. Group
supervision is optional, but the intern must have at least one hour of
individual supervision per week (the weeks need not be consecutive) for a
minimum of 52 weeks.
The following laws outline the possible penalties for unprofessional conduct
and list examples of such conduct:
B&PC 4982 (Denial, Suspension, Revocation, Grounds)
The Board may refuse to issue an intern registration or a license or may
suspend or revoke the license or intern registration of any registrant or
licensee if the applicant, licensee, or registrant has been guilty of
unprofessional conduct. Unprofessional conduct shall include, but not be
limited to:
(a) The conviction of a crime substantially related to the qualifications,
functions, or duties of a licensee or registrant under this chapter. The record
of conviction shall be conclusive evidence only of the fact that the
conviction occurred. The board may inquire into the circumstances
surrounding the commission of the crime in order to fix the degree of
discipline or to determine if the conviction is substantially related to the
qualifications, functions, or duties of a licensee or under this chapter. A plea
or verdict of guilty or a following a plea of nolo contendere made to a charge
substantially related to the qualifications, functions, or duties of a licensee or
registrant under this chapter shall be deemed to be a conviction within the
meaning of this section. The board may order any license or registration
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suspended or revoked, or may decline to issue a license or registration when
the time for appeal has elapsed, or the judgment of conviction has been
affirmed on appeal, or, when an order granting probation is made suspending
the imposition of sentence, irrespective of a subsequent order under Section
1203.4 of the Penal Code allowing any such person to withdraw a plea of
guilty and enter a plea of not guilty, or setting aside the verdict of guilty, or
dismissing the accusation, information, or indictment.
(b) Securing a license or registration by fraud, deceit, or misrepresentation
on any application for licensure or registration submitted to the board,
whether engaged in by an applicant for a license or registration, or by a
licensee in support of any application for licensure or registration.
(c) Administering to himself or herself any controlled substance or using of
any of the dangerous drugs specified in Section 4211, or of any alcoholic
beverage to the extent, or in such manner, as to be dangerous or injurious to
the person applying for a registration or license or holding a registration or
license under this chapter, or to any other person, or to the public, or, to the
extent that such use impairs the ability of such person applying for or
holding a registration or license to conduct with safety to the public the
practice authorized by the registration or license, or the conviction of more
than one misdemeanor or any felony involving the use, consumption, or selfadministration of any of the substances referred to in this subdivision, or any
combination thereof. The board shall deny an application for a registration
or license or revoke the license or registration of any person other than one
who is licensed as a physician and surgeon, who uses or offers to use drugs
in the course of performing marriage and family therapy services.
(d) Gross negligence or incompetence in the performance of marriage and
family therapy.
(e) Violating, attempting to violate, or conspiring to violate any of the
provisions of this chapter or any regulation adopted by the board.
(f) Misrepresentation as to the type or status of a license or registration held
by the person, or otherwise misrepresenting or permitting misrepresentation
of his or her education, professional qualifications, or professional
affiliations to any person or entity.
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(g) Impersonation of another by any licensee, registrant, or applicant for a
license or registration, or, in the case of a licensee, allowing any other
person to use his or her license or registration.
(h) Aiding or abetting any unlicensed or unregistered person to engage in
conduct for which a license or registration is required under this chapter.
(i) Intentionally or recklessly causing physical or emotional harm to any
client.
(j) The commission of any dishonest, corrupt, or fraudulent act substantially
related to the qualifications, functions, or duties of a licensee or registrant.
(k) Engaging in sexual relations with a client, soliciting sexual relations with
a client, or committing an act of sexual abuse, or sexual misconduct with a
client, or committing an act punishable as a sexually related crime, if that act
or solicitation is substantially related to the qualifications, functions, or
duties of a marriage and family therapist.
(l) Performing, or holding one's self out as being able to perform, or offering
to perform or permitting, any trainee or intern under supervision to perform
any professional services beyond the scope of the license authorized by this
chapter.
(m) Failure to maintain confidentiality, except as otherwise required or
permitted by law, of all information that has been received from a client in
confidence during the course of treatment and all information about the
client which is obtained from tests or other means.
(n) Prior to the commencement of treatment, failing to disclose to the client
or prospective client the fee to be charged for the professional services, or
the basis upon which that fee will be computed.
(o) Paying, accepting, or soliciting any consideration, compensation, or
remuneration, whether monetary or otherwise, for the referral of professional
clients. All consideration, compensation, or remuneration shall be in relation
to professional counseling services actually provided by the licensee.
Nothing in this subdivision shall prevent collaboration among two or more
licensees in a case or cases. However, no fee shall be charged for that
collaboration, except when disclosure of the fee has been made in
compliance with subdivision (n).
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(p) Advertising in a manner which is false, misleading, or deceptive.
(q) Reproduction or description in public, or in any publication subject to
general public distribution, of any psychological test or other assessment
device, the value of which depends in whole or in part on the naiveté of the
subject, in ways that might invalidate the test or device.
(r) Any conduct in the supervision of any intern or trainee by any licensee
that violates this chapter or any rules or regulations adopted by the board.
B&PC 4983 (Penalties)
Any person who violates any of the provisions of this chapter is guilty of a
misdemeanor punishable by imprisonment in the county jail not exceeding
six months, or by a fine not exceeding two thousand five hundred dollars
($2500), or by both.
4983.1 (Proceedings, Court Action)
In addition to other proceedings provided for in this chapter, whenever any
person has engaged, or is about to engage, in any acts or practices which
constitute, or will constitute, an offense against this chapter, the superior
court in and for the county wherein the acts or practices take place, or are
about to take place, may issue an injunction, or other appropriate order,
restraining such conduct on application of the board, the Attorney General,
or the district attorney of the county.
Acts considered unprofessional conduct are enumerated in California
Business and Professions Code 4982 including: "The board may refuse to
issue any registration or license, or may suspend or revoke the license or
registration of any registrant or licensee if the applicant, licensee, or
registrant has been guilty of unprofessional conduct."Unprofessional
conduct shall include, but not be limited to:
(1) The conviction of a crime substantially related to the qualifications,
functions, or duties of a licensee or registrant under this chapter.
(2) Securing a license or registration by fraud, deceit, or misrepresentation
on any application for licensure or registration submitted to the board,
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whether engaged in by an applicant for a license or registration, or by a
licensee in support of any application for licensure or registration.
(3) Administering to himself or herself any controlled substance or using of
any of the dangerous drugs specified in Section 4022, or of any alcoholic
beverage to the extent, or in a manner, as to be dangerous or injurious to the
person applying for a registration or license or holding a registration or
license under this chapter, or to any other person, or to the public, or, to the
extent that the use impairs the ability of the person applying for or holding a
registration or license to conduct with safety to the public the practice
authorized by the registration or license, or the conviction of more than one
misdemeanor or any felony involving the use, consumption, or selfadministration of any of the substances referred to in this subdivision, or any
combination thereof. The board shall deny an application for a registration
or license or revoke the license or registration of any person, other than one
who is licensed as a physician and surgeon, who uses or offers to use drugs
in the course of performing marriage and family therapy services.
(4) Gross negligence or incompetence in the performance of marriage and
family therapy.
(5) Violating, attempting to violate, or conspiring to violate any of the
provisions of this chapter or any regulation adopted by the board.
(6) Misrepresentation as to the type or status of a license or registration held
by the person, or otherwise misrepresenting or permitting misrepresentation
of his or her education, professional qualifications, or professional
affiliations to any person or entity.
(7) Impersonation of another by any licensee, registrant, or applicant for a
license or registration, or, in the case of a licensee, allowing any other
person to use his or her license or registration.
(8) Aiding or abetting, or employing, directly or indirectly, any unlicensed
or unregistered person to engage in conduct for which a license or
registration is required under this chapter.
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(9) Intentionally or recklessly causing physical or emotional harm to any
client.
(10) The commission of any dishonest, corrupt, or fraudulent act
substantially related to the qualifications, functions, or duties of a licensee or
registrant.
(11) Engaging in sexual relations with a client, or a former client within two
years following termination of therapy, soliciting sexual relations with a
client, or committing an act of sexual abuse, or sexual misconduct with a
client, or committing an act punishable as a sexually related crime, if that act
or solicitation is substantially related to the qualifications, functions, or
duties of the license.
(12) Performing, or holding oneself out as being able to perform, or offering
to perform, or permitting any registered trainee or registered intern under
supervision to perform, any professional services beyond the scope of the
license authorized by this chapter.
(13) Failure to maintain confidentiality, except as otherwise required or
permitted by law, of all information that has been received from a client in
confidence during the course of treatment and all information about the
client which is obtained from tests or other means.
(14) Prior to the commencement of treatment, failing to disclose to the client
or prospective client the fee to be charged for the professional services, or
the basis upon which that fee will be computed.
(15) Paying, accepting, or soliciting any consideration, compensation, or
remuneration, whether monetary or otherwise, for the referral of professional
clients.
(16) Advertising in a manner that is false, misleading, or deceptive.
(17) Reproduction or description in public, or in any publication subject to
general public distribution, of any psychological test or other assessment
device, the value of which depends in whole or in part on the naiveté of the
subject, in ways that might invalidate the test or device.
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(18) Any conduct in the supervision of any registered intern or registered
trainee by any licensee that violates this chapter or any rules or regulations
adopted by the board.
(19) Performing or holding oneself out as being able to perform professional
services beyond the scope of one's competence, as established by one's
education, training, or experience.
(20) Permitting a registered trainee or registered intern under one's
supervision or control to perform, or permitting the registered trainee or
registered intern to hold himself or herself out as competent to perform,
professional services beyond the registered trainee's or registered intern's
level of education, training, or experience.
(21) The violation of any statute or regulation governing the gaining and
supervision of experience required by this chapter.
(22) Failure to keep records consistent with sound clinical judgment, the
standards of the profession, and the nature of the services being rendered."
The BBS enforces laws regarding unprofessional conduct of LCSWs.
Acts considered unprofessional conduct are enumerated in California
Business and Professions Code 4992 including: "The board may refuse to
issue any registration or license, or may suspend or revoke the license or
registration of any registrant or licensee if the applicant, licensee, or
registrant has been guilty of unprofessional conduct. Unprofessional conduct
shall include, but not be limited to:
(1) The conviction of a crime substantially related to the qualifications,
functions, or duties of a licensee or registrant under this chapter. The record
of conviction shall be conclusive evidence only of the fact that the
conviction occurred. The board may inquire into the circumstances
surrounding the commission of the crime in order to fix the degree of
discipline or to determine if the conviction is substantially related to the
qualifications, functions, or duties of a licensee or registrant under this
chapter. A plea or verdict of guilty or a conviction following a plea of “nolo
contendere” made to a charge substantially related to the qualifications,
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functions, or duties of a licensee or registrant under this chapter is a
conviction within the meaning of this section. The board may order any
license or registration suspended or revoked, or may decline to issue a
license or registration when the time for appeal has elapsed, or the judgment
of conviction has been affirmed on appeal, or, when an order granting
probation is made suspending the imposition of sentence, irrespective of a
subsequent order under Section 1203.4 of the Penal Code allowing the
person to withdraw a plea of guilty and enter a plea of not guilty, or setting
aside the verdict of guilty, or dismissing the accusation, information, or
indictment.
(2) Securing a license or registration by fraud, deceit, or misrepresentation
on any application for licensure or registration submitted to the board,
whether engaged in by an applicant for a license or registration, or by a
licensee in support of any application for licensure or registration.
(3) Administering to himself or herself any controlled substance or using any
of the dangerous drugs specified in Section 4022 or any alcoholic beverage
to the extent, or in a manner, as to be dangerous or injurious to the person
applying for a registration or license or holding a registration or license
under this chapter, or to any other person, or to the public, or, to the extent
that the use impairs the ability of the person applying for or holding a
registration or license to conduct with safety to the public the practice
authorized by the registration or license, or the conviction of more than one
misdemeanor or any felony involving the use, consumption, or selfadministration of any of the substances referred to in this subdivision, or any
combination thereof. The board shall deny an application for a registration
or license or revoke the license or registration of any person who uses or
offers to use drugs in the course of performing clinical social work. This
provision does not apply to any person also licensed as a physician and
surgeon under Chapter 5 (commencing with Section 2000) or the
Osteopathic Act who lawfully prescribes drugs to a patient under his or her
care.
(4) Gross negligence or incompetence in the performance of clinical social
work.
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(5) Violating, attempting to violate, or conspiring to violate this chapter or
any regulation adopted by the board.
(6) Misrepresentation as to the type or status of a license or registration held
by the person, or otherwise misrepresenting or permitting misrepresentation
of his or her education, professional qualifications, or professional
affiliations to any person or entity. For purposes of this subdivision, this
misrepresentation includes, but is not limited to, misrepresentation of the
person's qualifications as an adoption service provider pursuant to Section
8502 of the Family Code.
(7) Impersonation of another by any licensee, registrant, or applicant for a
license or registration, or, in the case of a licensee, allowing any other
person to use his or her license or registration.
(8) Aiding or abetting any unlicensed or unregistered person to engage in
conduct for which a license or registration is required under this chapter.
(9) Intentionally or recklessly causing physical or emotional harm to any
client.
(10) The commission of any dishonest, corrupt, or fraudulent act
substantially related to the qualifications, functions, or duties of a licensee or
registrant.
(11) Engaging in sexual relations with a client or with a former client within
two years from the termination date of therapy with the client, soliciting
sexual relations with a client, or committing an act of sexual abuse, or sexual
misconduct with a client, or committing an act punishable as a sexually
related crime, if that act or solicitation is substantially related to the
qualifications, functions, or duties of a clinical social worker.
(12) Performing, or holding one's self out as being able to perform, or
offering to perform or permitting, any registered associate clinical social
worker or intern under supervision to perform any professional services
beyond the scope of the license authorized by this chapter.
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(13) Failure to maintain confidentiality, except as otherwise required or
permitted by law, of all information that has been received from a client in
confidence during the course of treatment and all information about the
client which is obtained from tests or other means.
(14) Prior to the commencement of treatment, failing to disclose to the client
or prospective client the fee to be charged for the professional services, or
the basis upon which that fee will be computed.
(15) Paying, accepting, or soliciting any consideration, compensation, or
remuneration, whether monetary or otherwise, for the referral of professional
clients. All consideration, compensation, or remuneration shall be in relation
to professional counseling services actually provided by the licensee.
Nothing in this subdivision shall prevent collaboration among two or more
licensees in a case or cases. However, no fee shall be charged for that
collaboration, except when disclosure of the fee has been made in
compliance with subdivision n.
(16) Advertising in a manner which is false, misleading, or deceptive.
(17) Reproduction or description in public, or in any publication subject to
general public distribution, of any psychological test or other assessment
device, the value of which depends in whole or in part on the naiveté of the
subject, in ways that might invalidate the test or device.
(18) Any conduct in the supervision of any registered associate clinical
social worker or intern by any licensee that violates this chapter or any rules
or regulations adopted by the board.
(19) Failure to keep records consistent with sound clinical judgment, the
standards of the profession, and the nature of the services being rendered."
Unprofessional conduct is a misdemeanor. Therapist sex with a client which
is defined as a felony. Therapists convicted of unprofessional conduct may:
a. Be punished by up to six months in jail and/or a fine of up to $2,500.
b. Have an injunction or restraining order placed against them.
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c. Have their license placed on probationary status.
d. Have their license is suspended or revoked.
2. A therapist's duty upon learning of unprofessional conduct on the part of
another therapist
a. Therapists are encouraged, but not required, to report unprofessional,
incompetent, or unethical conduct on the part of other therapists.
b. As encouraged by ethical standards, therapists may assist colleagues who
are impaired due to substance abuse, emotional problems, or mental illness
and may report such conduct to their professional organization.
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2B. Law
Laws provide direction concerning both what to do and what not to do under
certain circumstances and define provisions and penalties for noncompliance that include fines and incarceration. The law comes from three
sources: statutes and regulations that are established by the legislature,
boards authorized by the legislature, and through court cases.
Important legal requirements associated with the clinical practice of
psychotherapy in the state of California include the following:
 Abiding by laws established to protect and maintain client
confidentiality.
 Complying with responsibilities to report abuse and danger to others
to the appropriate authorities, and to protect clients who are dangerous
to themselves.
 Abiding by laws pertaining to the need for consent to treat a minor.
 Following laws that forbid sexual contact with clients and distributing
to clients the pamphlet “Professional Therapy Never Includes Sex” if
clients disclose that another therapist engaged in sexual misconduct.
 Disclosing fees prior to the commencement of treatment.
 Abiding by laws prohibiting making or receiving payments for client
referrals.
 Securing patient authorization to release or obtain confidential
information.
 Keeping patient records consistent with sound clinical judgment, the
standards of the profession, and the nature of the services being
rendered.
 For therapists who are “covered entities” under HIPAA, certain
additional laws pertaining to the Federal Privacy Act must be adhered
to which set forth further restrictions to protect the privacy of a client's
records and specify the language to be used to inform clients of these
additional rights and restrictions.
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2C. Ethics
The term “ethics” is characterized by behavior, practices, and standards
considered "right and good" and established by professional organizations
(e.g. NASW & CAMFT). The provisions for enforcement include social or
professional sanctions including suspension, revocation, or loss of license.
Failure to comply with or act in the spirit of professional ethical standards
can expose a therapist to legal liability and charges of negligence or
unprofessional conduct.
Important tasks associated with professional ethical behavior include, but are
not limited to:
 Establishment and maintenance of professional boundaries to protect
the welfare of the patient. Examples: the regulation of physical
contact in the counseling setting, providing a therapeutic frame with
consistent session times, and commonly understood office policies,
roles and responsibilities.
 Avoidance of dual relationships by not entering into business or social
relationships with clients simultaneous with or shortly after the
termination of therapy.
 Obtaining a client's informed consent for treatment by providing
necessary information about the nature of the therapeutic process so
that the client can make meaningful decisions for or against treatment.
By law, informed consent must include:
1) Fee disclosure and the basis for how fees will be determined prior to the
commencement of treatment.
2) the name and license designation of the practice owner(s) must be
disclosed if a therapist has a fictitious business name.
3) that therapist is required to conspicuously display his or her professional
license in his or her primary place of business.
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4) that an intern or associate shall disclose to clients their pre-licensed status
prior to the commencement of treatment.
Failure to provide other relevant information could mean that a therapist is
providing an inadequate standard of care. The following includes additional
recommended, although not required by law, elements of informed consent:
1) The process of treatment (explanations of psychotherapy etc.)
2) The limitations of confidentiality
3) The potential risks, drawbacks, and benefits of therapy.
4) Client access to records
5) Length of time the therapist retains records
6) Alternatives to treatment, which may include no treatment at all
7) Applicable CAMFT & NASW Ethical Standards regarding the patient
therapist relationship
8) The therapist’s professional qualifications and theoretical orientation
9) The length of time the therapist has been in practice
10) The expected length of sessions and treatment
11) The mutual right to terminate therapy by both the patient and the
therapist
12) Procedures for collecting and raising fees
12) Cancellation policy
13) Telephone policy
14) Therapist availability between sessions, for vacations, and in
emergencies
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2D. Standard of Care
In tort law, the standard of care is the degree of prudence and caution
required of an individual who is under a duty of care. A breach of the
standard is necessary for a successful action in negligence.
The requirements of the standard are closely dependent on circumstances.
Whether the standard of care has been breached is determined by the Trier of
fact, and is usually phrased in terms of the reasonable person. It was
famously described in Vaughn v. Menlove (1837) as whether the individual
"proceed[ed] with such reasonable caution as a prudent man would have
exercised under such circumstances."
In certain industries and professions, the standard of care is determined by
the standard that would be exercised by the reasonably prudent manufacturer
of a product, or the reasonably prudent professional in that line of work.
Such a test (known as the 'Bolam Test') is used to determine whether a
doctor is liable for medical malpractice.
Medical standard of care
A standard of care is a medical or psychological treatment guideline, and can
be general or specific. It specifies appropriate treatment based on scientific
evidence and collaboration between medical and/or psychological
professionals involved in the treatment of a given condition.
Some common examples include:


Treatment standards applied within public hospitals to ensure that all
patients receive appropriate care regardless of financial means.
Treatment standards for gender identity disorders
In legal terms, the level at which the average, prudent provider in a given
community would practice. It is how similarly qualified practitioners would
have managed the patient's care under the same or similar circumstances.
The medical malpractice plaintiff must establish the appropriate standard of
care and demonstrate that the standard of care has been breached.
Standard of care is defined as “the average degree of skill, care, and
diligence exercised by members of the same profession, practicing in the
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same or similar locality.” For therapists, this would be "the level of skill,
knowledge, and care in diagnosis and treatment that other reasonably careful
therapists would possess and use in similar circumstances." (California
Approved Civil Instructions (CACI) 502) Standard of care is a legal concept
used to prosecute or defend therapists accused of negligence or
incompetence.
Examples of maintaining a standard of care include, but are not limited to:
 Giving referrals when needed
 Completing a five axis diagnostic evaluation
 Conducting adequate assessments which may include a personal
history, medical history, family history, and mental status
 Documenting a treatment plan
 consulting with corresponding treatment providers such as doctors and
psychiatrists.
 Making appropriate and necessary referrals
 Taking reasonable and appropriate measures to ensure the well being
and safety of a client
 Obtaining a signed informed consent prior to the onset of treatment
3. Legal Issues
3A. Privilege
Privilege is essentially the client's right not to have confidential information
revealed during a legal proceeding without their prior authorization.
Privilege protects clients from confidences being revealed publicly without
prior authorization. Psychotherapist-client privilege applies not only to
licensed providers but also to MFT interns, associate social workers, and
trainees. MFT’s and LCSW’s have a legal responsibility to assert privilege
on behalf of their client unless the client or the court direct otherwise.
The right to hold, assert, and waive privilege is clarified in California
Evidence Code, Section 1013, which defines the holder of privilege as:
 The patient (regardless of age) when there is no guardian or
conservator.
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 A guardian ad litem (guardian for purposes of litigation) or
conservator when the patient has a guardian ad litem or conservator.
 The personal representative of the patient if the patient is dead.
California Evidence Code identifies those who can assert privilege as:
 The person who holds privilege.
 A therapist on behalf of a client must asset privilege until directed to
do otherwise by the client or by court order.
 MFT’s, LCSW’s, Psychologists, and Psychiatrists can and are
required to assert privilege on behalf of their clients whenever a
client's confidential information is sought pursuant to a legal
proceeding.
California Evidence Code identifies those who can waive privilege as:
 A client waives his or her own privilege. However, under certain
circumstances, privilege can be waived by people other than the
client.
 Circumstances in which privilege may be exercised by someone other
than the client:
1) If the client has a legally designated conservator or guardian ad
litem, then that person may exercise the privilege.
2) If the court has appointed an attorney as guardian ad litem, then
that person may exercise the privilege (the attorney would also be
entitled to access to the client's treatment records).
3) If the client has no legally designated conservator or guardian ad
litem, then the judge can waive the privilege.
4) If the client is deceased, then the personal representative of the
decedent can exercise the privilege.
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California Evidence Code states in regards to minors that
 The minor client holds privilege, unless there is a legally designated
guardian ad litem or conservator.
 Parents may not exercise the privilege on behalf of their child simply
because they are that child's parents.
 A parent may exercise a minor child's privilege only if designated a
guardian ad litem by the court. Although we commonly think of a
child’s parent as the child's “guardian,” this is not the same as being
the “guardian ad litem.”
 A therapist who receives a subpoena for the records of a minor client
would not look to the parents or guardians for instructions on whether
to release the records, but would instruct the parents or guardians to
petition the court for guardian ad litem status. (See example of a
guardian ad litem petition below).
 An individual cannot act as a guardian ad litem unless s/he is
represented by an attorney or is an attorney.
 An attorney (or other person) appointed guardian ad litem has the
right to access a minor client's treatment record.
California Evidence Code identifies exceptions to privilege which explains
that:
 Under certain circumstances, the law says, "there is no privilege."
 If as a psychotherapist, you believe upon receiving a subpoena that the
situation represents an "exception to privilege" (for example, a patient
has introduced his or her emotional condition into a legal proceeding)
your first responsibility is to assert privilege.
 It is beyond the scope of practice of a psychotherapist to decide if an
exception applies in any given circumstance.
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 The court determines if one of the following exceptions applies.
a. the client has introduced his or her emotional condition in a legal
proceeding. (Evidence Code 1016)
b. the client has treated privileged information as though it were
not confidential. (Evidence Code 1012)
c. breach of duty (Evidence Code 1020)
1) The therapist sues the client for non-payment (content of
therapy remains confidential).
2) The client sues the therapist for malpractice.
d. If the therapist has been appointed by the court to examine the
client. (Evidence Code 1017)
e. If the client has sought psychotherapy to commit a crime and/or
escape punishment for a crime. (Evidence Code 1018)
f. If the client is under 16 years of age and has been the victim of a
crime (e.g. extortion, statutory rape) (Evidence Code 1027)
g. In a proceeding requested by a defendant to determine sanity.
(Evidence Code1023)
h. If the client is dangerous to self or others (Evidence Code 1024),
there is no privilege if the therapist needs to act to prevent a client's
threatened danger to self or the person or property of others."
i. In a proceeding brought by or on behalf of a client to establish
competence. (Evidence Code 1025)
j. If a coroner requests information in the course of an investigation of
deaths involving public health concerns, abuse, suicides, poisonings,
accidents, SIDS, suspicious deaths, unknown deaths, criminal deaths,
or when authorized by the decedent's representative.
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Additional evidence codes include:
1011 A is used in this article, "patient" means a person who consults a
psychotherapist or submits to an examination by a psychotherapist for
the purpose of securing a diagnosis or preventive, palliative, or
curative treatment of his mental or emotional condition or who
submits to an examination of his mental or emotional condition for the
purpose of scientific research on mental or emotional problems.
1012 As used in this article, "confidential communication between
patient and psychotherapist" means information, including
information obtained by an examination of the patient, transmitted
between a patient and his psychotherapist 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 psychotherapist is consulted, and includes a
diagnosis made and the advice given by the psychotherapist in the
course of that relationship.
1013 As used in this article, "holder of the privilege" means:
(a) The 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.
1014 Subject to Section 912 and except as otherwise provided in this
article, the patient, whether or not a party, has a privilege to refuse to
disclose, and to prevent another from disclosing, a confidential
communication between patient and psychotherapist if the privilege is
claimed by:
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(a) 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 psychotherapist at the time of the
confidential communication, but such 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.
(d) The relationship of a psychotherapist and patient shall exist
between a
• Psychological corporation
• A marriage, family, and child counseling corporation
• A licensed clinical social workers corporation
• And the patient to whom it renders professional services.
1015 The psychotherapist who received or made a communication
subject to the privilege under this article shall claim the privilege
whenever he is present when the communication is sought to be
disclosed and is authorized to claim the privilege under subdivision
(c) of Section 1014. 1016 There is no privilege under this article as to
a communication relevant to an issue concerning the mental or
emotional condition of the patient if such issue has been tendered by:
(a) The patient;
(b) Any party claiming through or under the patient;
(c) Any party claiming as a beneficiary of the patient through a
contract to which the patient is or was a party; or
(d) The plaintiff in an action brought under Section 376 or 377 of the
Code of Civil Procedure for damages for the injury or death of the
patient.
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1017 There is no privilege under this article if the psychotherapist is
appointed:
(a) by order of a court to examine the patient, but this exception does
not apply where the psychotherapist is appointed by order of the court
upon the request of the lawyer for the defendant in a criminal
proceeding in order to provide the lawyer with information needed so
that he or she may advise the defendant whether to enter or withdraw
a plea based on insanity or to present a defense based on his or her
mental or emotional condition.
(b) by the Board of Prison Terms to examine a patient pursuant to the
provisions of Article 4 (commencing with Section 2960) of Chapter 7
of Title 1018 There is no privilege under this article if the services of
the psychotherapist were sought or obtained to enable or aid anyone to
commit or plan to commit a crime or a tort or to escape detection or
apprehension after the commission of a crime or a tort.
1019 There is no privilege under this article as to a communication
relevant to an issue between parties all of whom claim through a
deceased patient, regardless of whether the claims are by testate or
intestate succession or by inter vivos transaction.
1020 There is no privilege under this article as to a communication
relevant to an issue of breach, by the psychotherapist or by the patient,
of a duty arising out of the psychotherapist-patient relationship.
1021 There is no privilege under this article as to a communication
relevant to an issue concerning the intention of a patient, now
deceased, with respect to a deed of conveyance, will, or other writing,
executed by the patient, purporting to affect an interest in property.
1022 There is no privilege under this article as to a communication
relevant to an issue concerning the validity of a deed of conveyance,
will, or other writing, executed by a patient, now deceased, purporting
to affect an interest in property.
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1023 There is no privilege under this article in a proceeding under
Chapter 6 (commencing with Section 1367) of Title 10 of Part 2 of the
Penal Code initiated at the request of the defendant in a criminal
action to determine his sanity.
1024 There is no privilege under this article if the psychotherapist has
reasonable cause to believe that the patient is in such mental or
emotional condition as to be dangerous to himself or to the person or
property of another and that disclosure of the communication is
necessary to prevent the threatened danger.
1025 There is no privilege under this article in a proceeding brought
by or on behalf of the patient to establish his competence.
1026 There is no privilege under this article as to information that the
psychotherapist or the patient is required to report to a public
employee or as to information required to be recorded in a public
office, if such report or record is open to public inspection.
1027 There is no privilege under this article if all of the following
circumstances exist:
(a) The patient is a child under the age of 16.
(b) The psychotherapist has reasonable cause to believe that the
patient has been the victim of a crime and that disclosure of the
communication is in the best interest of the child.
Search Warrants
California Evidence Code, Section 1015 identifies the following in
relationship to a search warrant:
 If a search warrant names the therapist as being suspected of criminal
activity, the records that the search warrant is seeking must be
surrendered.
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 If the therapist is not suspected of criminal activity and the subject of
the search warrant is a client of the therapist:
1) The warrant must be issued in conjunction with Section 1524
of the Penal Code requiring a special master appointed by the
court to conduct the search.
2) A special master is a lawyer appointed by the court and can
be identified by paperwork certifying his or her status.
3) If the search warrant is not accompanied by a special master,
the therapist must assert privilege in accordance with Section
1015 of the Evidence Code.
Subpoenas
California Evidence Code, Section 1015 outlines the following in
relationship to Subpoenas:
 A subpoena commands a witness to appear before the court in order to
produce testimony that may be either in oral or written form.
 A subpoena “duces tecum” is a command to produce records or
written evidence.
 Subpoenas can be issued by a judge or by an attorney.
 Due to psychotherapist-patient privilege, therapists have a legal duty
to assert the privilege.
 A therapist must assert privilege on behalf of a client when testimony
or records are sought.
 The source of the subpoena should be identified.
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 After receiving a subpoena, a therapist:
a. Should contact the client to determine if s/he wants to assert or
waive the psychotherapist-client privilege.
b. May want to obtain a release authorization to talk to the client’s
attorney.
c. If the client asks questions about the subpoena, the therapist
should not give legal advice because it is not in the realm of scope
of practice.
 If the client decides to assert privilege, the client's attorney files a
motion to quash the subpoena.
 The judge either grants the motion and the subpoena is considered
void, or denies the motion and the therapist must comply with the
subpoena.
3B. Confidentiality
California Evidence Code, Section 1012 states "confidential communication
between patient and psychotherapist means information, including
information obtained by an examination of the patient, transmitted between a
patient and his psychotherapist 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 psychotherapist is consulted,
and includes a diagnosis made and the advice given by the psychotherapist
in the course of that relationship.”
The patient holds the privilege to release confidential information in legal
proceedings. While objections may exist to the patient using these records,
solid grounds must exist in order to object. The holder of the privilege also
retains the right to read all information in his or her file with the exception of
your personal notes which belong solely to you as the provider. Many
34
therapists keep separate files in order to ensure that their personal notes do
not become integrated into the patient's legal record.
3C. Exceptions to Confidentiality: Child Abuse, Dependent Adult and
Elder Abuse, Tarasoff, Danger to Self and/or Others
Section 5150
Section 5150 is a section of the California Welfare and Institutions Code
allows a qualified officer or clinician to involuntarily confine a person
deemed (or feared) to have a mental disorder that makes them a danger to
him or herself, and/or others and/or gravely disabled. A qualified officer,
who includes any California peace officer, as well as any specifically
designated county clinician, can request the confinement after signing a
written declaration. When used as a term, 5150 can informally refer to the
person being confined or to the declaration itself.
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.
5150 Rights
Inst. Code § 5325; 9 C.C.R. § 865.2):
 The right to wear one's own clothing. (Although many 5150
designated facilities have large contraband lists, for example often
35




times patients are not allowed to have shoelaces, wire bras, belts, hairties, or short tops).
The right to keep and use one's own personal possessions, including
toilet articles, in a place accessible to the patient.
The right to keep and spend a reasonable sum of one’s money for
small purchases.
The right to have access to individual storage space for one's own use.
The right to see visitors each day.
The right to have reasonable access to phones both to make and receive The
5150 hold may be written out on Form MH 302, Application for 72 Hour
Detention for Evaluation and Treatment.
Welfare and Institutions Code (WIC) 5150 is interpreted by the LA County
LPS Designation Handbook [1], page 5, as an application for involuntary
admission. According to this interpretation, WIC 5150 is not (page 5) ... a
direct admission form and does not of itself authorize the involuntary
admission; it merely gets the individual to the door. Then, as described in
WIC 5151: Prior to admitting a person to the facility, the professional
person in charge of the facility or his or her designee shall assess the
individual in person to determine the appropriateness of the involuntary
detention. Further, according to the LA County LPS Designation Handbook
... The ability to place a person on an involuntary hold in the community is
the only situation outside of law enforcement where an individual may take
away another individual's right to freedom and detain him or her against his
or her will…
During the period of confinement, a confined individual is evaluated by a
mental health professional to determine if a psychiatric admission is
warranted. Confinement and evaluation usually occurs in a county mental
health hospital or in a designated Emergency Department. If the individual is
then admitted to a psychiatric unit, only a psychiatrist may rescind the 5150
and allow the person to either remain voluntarily or be discharged. On or
previous to the expiration of the 72 hours, the psychiatrist must assess the
person to see if they still meet criteria for hospitalization. If so, the person
may be offered a voluntary admission. If it is refused, then another hold for
up to 14 days, the 5250 (WIC-5250), must be written to continue the
involuntary confinement of the person. A Certification Review Hearing
(W&I 5256) must occur within four days before a judge or hearing officer to
determine whether probable cause exists to support the 5250. Alternatively,
36
the person can demand a writ of habeas corpus to be filed for their release
after they are certified for a 5250, and once filed, by law, the person must be
in front of a judge in two (2) days, which, is two days sooner than the
Certification Review Hearing. If the person demands to file a writ of habeas
corpus right at the time of being given notice of certification, the
Certification Review Hearing will not take place. Many patients wait to see
how things go at the Certification Review Hearing first, because if the
person loses at the Certification Review Hearing, he/she can then take
advantage of the right to file writ of habeas corpus and end up having two
hearings, instead of just one. If the 72-hour timeframe has elapsed before the
person is offered a voluntary admission or placed on the 5250 hold, the
person must be immediately released.
A 5150 hold written by a peace officer is valid in any county in California;
therefore, a person could theoretically be moved from one county to another
according to available resources. When the 5150 hold is written by a
designated clinician, the hold is only valid in that county. The designated
clinician is only able to write a 5150 hold while present at the facility where
they work, unless they work as part of a Psychiatric mobile response team.
The person under a 5150 hold has a limited ability to contest the legality of
the hold. While the person has the right of demanding a writ of habeas
corpus, it is up to the county public defender whether to file it or not. Since
such a writ may take a day or two to file, the public defender usually
chooses not to pursue it as the hold would expire before the anticipated court
date.
The criteria for writing requires probable cause. This includes danger to self,
danger to others together with some indication, prior to the administering of
the hold, of symptoms of a mental disorder, and/or grave disability—as
noted below. The conditions must exist under the context of a mental illness.
1. Danger to self: The person must be an immediate threat to themselves,
usually by being suicidal. Someone who is severely depressed and
wishes to die would fall under this category.
2. Danger to others: The person must be an immediate threat to someone
else's safety.
3. Gravely disabled (W&I 5008(h)):
37
 Adult (patients over 18 years of age): The person's mental
condition prevents him/her from being able to provide for food,
clothing, and/or shelter, and there is no indication that anyone is
willing or able to assist him/her in procuring these needs. This
does not necessarily mean homeless, as a homeless person who
is able to seek housing (even in a temporary shelter) when
weather demands it would not fall under this category. Also, the
mere lack of resources to provide food, clothing, or shelter is
not dispositive; the inability must be caused by the psychiatric
condition.
 Minor (patients under 18 years of age): The person is unable to
provide for his/her food, clothing, and/or shelter or to make
appropriate use of them even if these are supplied directly--for
example, a psychotic adolescent who refuses to eat because
he/she believes their parents are poisoning them.
4. Mental disorder: Though undefined by statute or regulation, this is
generally taken to refer to a diagnosis listed in the Diagnostic and
Statistical Manual of Mental Disorders. Page 14 of the LA County
LPS Designation Manual states that the initiator must be able to
articulate behavioral symptoms of a mental disorder either temporary
or prolonged (People v. Triplett,(1983) 144 Cal. App. 3d 283).
Required documentation
Under WIC 5150-5157 there are two mandatory legal documents, the 5150
application itself and the patient advisement form as required by WIC
5157(c); the latter may be issued in the form of Form MH 303, Involuntary
Patient Advisement. The LA County LPS Designation Manual stipulates
that, prior to the completion of the 5150 application, the initiator must
conduct and document a face-to-face interview with the patient. On the 5150
application, the initiator is required to ..give sufficiently detailed information
to support the belief that the person for whom evaluation and treatment is
sought is in fact a danger to others, a danger to himself/herself and/or
gravely disabled. The 5150 Application contains the words ...as a result of a
mental disorder.. but does not stipulate documentation of evidence of
..behavioral symptoms of a mental disorder....., defined in People v. Triplett
(1983) as a necessary part of probable cause. The 5150 Application requests
no explicit documentation of the required face-to-face interview. WIC 51505157 does not stipulate mandatory documentation of paragraph two of WIC
38
5151 that requires that .. the professional person in charge of the facility or
his or her designee shall assess the individual in person to determine the
appropriateness of the involuntary detention.... Section 1 of the Fourteenth
Amendment to the US constitution, however, states that ...nor shall any
State deprive any person of life, liberty, or property, without due process of
law; nor deny to any person within its jurisdiction the equal protection of
the laws. See due process and equal protection clause. Additionally, when
patients who are placed on a 5150 hold for danger to self or danger to others,
a notification is filed which results in the person losing the right to purchase
or possess firearms for five years. This firearms prohibition may be
appealed.
When a person is detained or locked-up against their will under a 5150, it
can feel like they have no rights at all as a human being. This is why this
section on “rights” is so important.
Patients admitted under section 5150 retain all rights under the LantermanPetris-Short Act (Begins with WIC-5000) and under the Constitution and
other laws. As citizens, patients do not lose their rights by being hospitalized
or receiving services. With the exception of being able to freely leave the
facility they are placed in, patients have all rights accorded to a voluntarily
admitted client. Waivers signed by the patient, responsible relative,
guardian, conservator cannot be used to deny a right. California Code of
Regulations, Title 9 Section 865.2 (c); California Welfare & Institutions
Code Section 5325.
Cal. Welf. & Inst. Code § 5325 and § 5325.1 codify the statutory patients'
rights in California:
Under California law, the following rights may never be denied (Cal. Welf.
& Inst. Code § 5325.1):



The right to treatment services which promote the potential of the
person to function independently. Treatment should be provided in
ways that are least restrictive of the personal liberty of the individual.
The right to dignity, privacy, and human care.
The right to be free from harm, including unnecessary or excessive
physical restraint, isolation, medication, abuse, or neglect. Medication
may not be used as punishment, for the convenience of staff, as a
39






substitute for, or in quantities that interfere with the treatment
program.
The right to prompt medical care and treatment.
The right to religious freedom and practice.
The right to participate in appropriate programs of publicly supported
education.
The right to social interaction.
The right to physical exercise and recreational opportunities.
The right to be free from hazardous procedures.
Deniable rights with good cause



Psychiatric facilities must also uphold the following specific rights,
which can be denied only when "good cause" exists (Cal. Welf.)
The right to have access to letter-writing materials, including stamps.
The right to mail and receive unopened letters and correspondence.
When a right is denied, the reason given for denying the right must have
some clear relationship to the right denied (9 C.C.R. § 865.2). Example: A
patient is denied the right to keep his cigarettes (the right to keep and use
personal possessions) because he is burning himself and lighting fires and
lesser restrictive alternatives (1:1 supervision during smoking) have failed.
Additionally, every mental health client has the right to see and receive the
services of a Patients' Rights Advocate. All patients also have the following
treatment rights:




The right to give or withhold informed consent to medical and
psychiatric treatment, including the right to refuse medications (WIC5325.2) except in emergency (W&I 5008 (m)) situations where danger
to life is present; or by court order where the patient is found to lack
the capacity to give or refuse informed consent via either a Capacity
Hearing (see W&I 5332) and also known as a Riese hearing or via
conservatorship.
The right to refuse psychosurgery (Cal. Welf. & Inst. Code § 5326.6).
The right to confidentiality (Cal. Welf. & Inst. Code § 5328).
The right to inspect and copy the medical record, unless specific
criteria are met (Cal. Health & Safety Code § 1795).
40


The right to have family/friends notified of certain treatment
information with patient's permission (Cal. Welf. & Inst. Code §
5328.1).
The right to an aftercare plan (Cal. Welf. & Inst. Code § 5622).
Denying a patient's rights requires good cause. Good cause being defined as
the belief of the professional in charge of care for the client that the specific
right would cause
1. a danger to self or others;
2. a serious infringement on the rights of others; or
3. serious damage to the facility;
and that there is no less restrictive measure that would protect against those
occurrences.
Patient rights cannot be denied as a condition of admission nor as part of a
treatment plan such as being labeled a privilege or as punishment. Any time
a right is denied under good cause it must be documented in the patient's
medical record and explained to the patient. The denial must be reviewed
regularly and must be removed once good cause no longer exists. If a right
was denied without good cause, a patient can instruct their appointed public
defender to file an Ex Parte application with the court to restore a right that
was denied without good cause. A hearing will be set and an opportunity to
be heard by the judge concerning the merits of the case will be reviewed and
he will determine if the right will continued to be denied or be restored. An
Ex Parte can bring relief in a matter when a person is deprived of any
interest in liberty or property without due process of law.
Tarasoff and the Duty to Warn
Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P.2d
334, 131 Cal. Rptr. 14 (Cal. 1976), was a case in which the Supreme Court
of California held that mental health professionals have a duty to protect
individuals who are being threatened with bodily harm by a patient. The
original 1974 decision mandated warning the threatened individual, but a
1976 rehearing of the case by the California Supreme Court called for a
"duty to protect" the intended victim. The professional may discharge the
duty in several ways, including notifying police, warning the intended
victim, and/or taking other reasonable steps to protect the threatened
individual.
41
Prosenjit Poddar was born into the Dalit ("untouchable") caste in Bengal,
India. He came to UC Berkeley as a graduate student in September 1967 and
resided at the International House. In the fall of 1968 he attended folk
dancing classes at the International House, and it was there he met Tatiana
Tarasoff. They saw each other weekly throughout the fall, and on New
Year's Eve she kissed Poddar. He interpreted the act to be a recognition of
the existence of a serious relationship. This view was not shared by Tatiana
who, upon learning of his feelings, told him that she was involved with other
men and otherwise indicated that she was not interested in entering into an
intimate relationship with him. This gave rise to feelings of resentment in
Poddar. He began to stalk her and soon had feelings of killing her.
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, speaking disjointedly and often weeping. This
condition persisted, with steady deterioration, throughout the spring and into
the summer of 1969. The defendant had occasional meetings with Tatiana
during this period and tape recorded various of their conversations in an
attempt to ascertain why she did not love him.
During the summer of 1969 Tatiana went to South America. After her
departure Poddar began to improve and at the suggestion of a friend sought
psychological assistance. Prosenjit Poddar was a patient of Dr. Lawrence
Moore, a psychologist at UC Berkeley's Cowell Memorial Hospital in 1969.
Poddar confided his intent to kill Tatiana. Dr. Moore requested that the
campus police detain Poddar, writing that, in his opinion, Poddar was
suffering from paranoid schizophrenia, acute and severe. The psychologist
recommended that defendant be civilly committed as a dangerous person.
Poddar was detained, but shortly thereafter released, as he appeared rational.
Dr. Moore's supervisor, Dr. Harvey Powelson, then ordered that Poddar not
be subject to further detention.
In October, after Tatiana had returned, Poddar stopped seeing his
psychologist. Neither Tatiana nor her parents received any warning of the
threat. Poddar then befriended Tatiana's brother, even moving in with him.
Several months later, on October 27, 1969, Poddar carried out the plan he
had confided to his psychologist, killing Tarasoff. Tarasoff's parents then
sued Moore and various other employees of the University.
42
Poddar was convicted of second-degree murder, but the conviction was later
appealed and overturned on the grounds that the jury was inadequately
informed. A second trial was not held, and Poddar was released on the
condition that he return to India.
The California Supreme Court found that a mental health professional has a
duty not only to a patient, but also to individuals who are specifically being
threatened by a patient. This decision has since been adopted by most states
in the U.S. and is widely influential in jurisdictions outside the U.S. as well
("Protection and Advocacy, Inc., Contracted by the State of California to
advocate for involuntary persons, Hearing Options". http://www.paica.org/pubs/502401.pdf. Retrieved on 2009. 72-Hour Hold and Hearing
Options ).
In the majority opinion, Justice Mathew O. Tobriner famously stated: "... the
confidential character of patient-psychotherapist communications must yield
to the extent that disclosure is essential to avert danger to others. The
protective privilege ends where the public peril begins." Justice Clark
dissented, stating in his minority opinion that "the very practice of
psychiatry depends upon the reputation in the community that the
psychiatrist will not tell".
Child Abuse
When, in the course of his/her professional capacity, a psychotherapist 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. Reasonable suspicion exists 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 that he or she knows or
reasonably suspects has been the victim of child abuse. The report must be
made to a "child protective agency." Including a county welfare or probation
department or a police or sheriff's department. Exceptions are reports by
43
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.
Mandated reporters may not make an anonymous report. 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. It can be very beneficial to give
clients the opportunity to make the reports themselves in the therapist's
presence. A self-report, however, does not negate the therapist's mandate to
report. The role of a mandated reporter is to report and not investigate the
allegation. Any attempts to investigate may have a negative clinical impact
on the child and family.
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 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.
Sexual abuse is also defined as 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. Consensual,
non-abusive sex between two 13-year-olds is not reportable, but would
become reportable when one partner reaches the age of 14. 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 is
any sexual activity between parents and children, ancestors and descendants,
siblings and between uncles or nieces and aunts or nephews.
44
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 Exploitation - 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 neglect is defined as “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 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.”
If a therapist learns about suspected child abuse from a third party (hearsay),
45
and reasonable suspicion exists, the therapist must make a report if the
information was revealed to the therapist within their professional capacity.
The identity of all reporters is considered confidential and is disclosed only
between child protective agencies. 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. The Child Abuse Reporting Law takes precedence over
laws governing the psychotherapist-patient privilege. 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.
Elder and Dependent Adult Abuse Reporting
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.
46
Mandated reporters, including therapists, are now required to report the
following:
 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 psychotherapist 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.
47
Specific examples of neglect include the failure to assist in personal hygiene
or in the provision of food, clothing, or shelter,; 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.
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 therapist 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 making 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.
48
3D. Treatment of Minors
The law designates that minors hold privilege. However, except in special
circumstances, the parents of a non-emancipated minor in treatment have the
right to waive the privilege for the minor client. The confusion over this
issue stems from the fact that Evidence Code 1013 refers to clients with
guardians or conservators as not holding the privilege. Most courts have
interpreted this to mean that minors do NOT hold the privilege, or do not
have the right to waive the privilege. Parents are, therefore, recognized as
having the right to waive the privilege for the minor client, even though the
minor legally has the privilege. However, recent cases have upheld that the
privilege belongs to the child, as the patient. This means that, in a legal
proceeding, regardless of the minor's wishes and despite the fact that the
minor holds privilege, his or her parents could permit the release of
information about the minor's treatment.
The parents also have a legal right to access information about their minor's
treatment. This is true even of noncustodial parents. At the same time, in
situations in which parental access to a minor's records “would have a
detrimental effect on the provider's professional relationship with a minor
patient or the minor's physical safety or psychological well-being, a therapist
is legally permitted to deny parental access to those records.” Therapists
have to take steps to maintain a careful balance between a minor's legal and
ethical right to a confidential relationship and a parent's legal right to access
information.
Emancipated minors are treated legally as adults and, thus, may be treated
without parental permission. Therapists can treat minors age 12 or over
without parental permission when the minor is mature enough to participate
intelligently in mental health treatment or counseling and the minor would
present a serious danger of physical or mental harm to him or herself or
others without treatment or counseling or is the alleged victim of incest or
child abuse. The minor does hold privilege when being treated without
parental consent (unless he or she has a guardian or foster parent.) However,
when treating minors under these circumstances, the therapist can act as the
49
“claimer” of the privilege, but must obtain the minor's permission in order to
access the minor's medical records.
A therapist should protect the confidence of minors, even from the minors'
parents. Therefore, when working with a minor with parental knowledge and
consent, a therapist should, at the beginning of therapy, clearly outline for
both the parents and the minor, his or her policies with regard to
confidentiality and include this policy in the written Consent for Treatment.
The parent or guardian of a minor has the right to assert privilege on behalf
of the minor, except when the minor is a victim of a crime or when the
therapist is seeing the minor without parental consent.
Parents also have a legal right to inspect a therapist's records regarding the
child in treatment. However, therapists can deny the parents access to these
records of a minor in the following circumstance: Where the health care
provider determines that access to the patient records requested by the
representative would have a detrimental effect on the provider's professional
relationship with the minor patient or the minor's physical safety or
psychological well-being. The parents also have the right to waive the
privilege, which might require the therapist to testify in a legal proceeding
regarding the content of sessions with a minor client. This is true even if the
minor client does not want the therapist to testify. Further, when
communication of information involves a non-courtroom situation, it would
also be the parents, not the child, who determine whether or not the
information will be released.
Release of treatment information about minors becomes more complex when
noncustodial parent are involved. While only a custodial parent may give
consent to treatment, the law stipulates that “Notwithstanding any other
provisions of law, access to records and information pertaining to a minor
child, shall not be denied to a parent because such parent is not the child's
custodial parent" When dealing with requests from either custodial or
noncustodial parents, the therapist has an ethical obligation to act in the best
interests of the minor and would not reveal information about the client if
doing so would cause harm to the client.
A minor may become emancipated if they legally marry, enlists in the
military or files an emancipation petition with the courts stating that he or
she is at least 14 years of age, is willingly living separate and apart from
parents or guardians with their consent or acquiescence, is managing his or
50
her own financial affairs and is not deriving illegal income. The court will
grant the petition unless it judges that emancipation would be contrary to the
minor's best interests.
Legally, minors under age 12 are considered essentially unable to make their
own choices. Therefore, minors under the age of 12 may not receive any
type of treatment without parental consent. There is one exception, all
minors, regardless of their age, may consent to hospital, medical and
surgical care related to the prevention or treatment of pregnancy. However,
hospital, medical and surgical care does not include “mental health treatment
or counseling.”
Minors age 12 or over, on the other hand, can receive psychological services
without parental knowledge and consent under the circumstances defined by
law excluding electroshock therapy, psychosurgery, or psychotropic drugs.
When a therapist determines that it is legal and appropriate to treat a minor
age 12 or over without parental consent, there are certain procedures that
must be followed. The therapist must document in the minor’s record the
date and time that contact with the minor's parent or legal guardian was
attempted and whether the contact was successful or unsuccessful, or state
why it was not appropriate to contact the parent or legal guardian. In
addition, the law specifies that the parent(s) of the minor is not responsible
for the expenses of treatment if the parent(s) of the minor does not give
consent for treatment.
When a therapist treats a minor age 12 or over without parental consent or
knowledge, the therapist can act as the claimer of the privilege. This claim of
privilege does not extend beyond the therapeutic setting. The therapist would
not, for example, be able to obtain the minor client's medical records. To get
the records, he or she would have to get the minor client's consent; a client
age 12 or over, in treatment without parental knowledge or consent for
reasons defined in the law, may sign an authorization for release of his or her
medical records.
3E. Sex with Clients
A national survey of Psychologists found that “nearly one out of ten
participants reported engaging in sex with a client using the rationale of
patient welfare or deeper moral value highlights the risks, ambiguities, and
51
difficulties of evaluating the degree to which our own individual behavior is
ethical” (Pope and Bajt).
Psychotherapists can be prosecuted both civilly and criminally for engaging
in sexual relations with their clients. Prosecution may also occur if a
therapist engages in sex with a former client prior to two years following the
termination of therapy. In accordance with C.C. 43.93, therapists are civilly
liable when they engage in sexual relations with former clients prior to two
years after the termination of therapy. According to B.&P.C. 729, criminal
liability in such cases results only when therapists terminate therapy solely
for the purpose of engaging in sexual relations with a client. In effect as of
January 1, 1988, this law creates a separate cause of action for
psychotherapist sex with a patient. A client has a cause for civil action
against a psychotherapist when sexual contact occurs during the course of
therapy, within two years following termination of therapy and/or by means
of deception. This law also requires the therapist to give a brochure that
explains the client's right to any client that revealed prior sexual contact with
their therapist. Failure to distribute this brochure is considered
unprofessional conduct.
Criminal liability can result if a therapist engages in sex with a current client
or if he or she terminates a therapeutic relationship with a client for the
purposes of beginning a sexual relationship with that client. In addition,
under licensing laws, a clinician who has sex with a client can have his or
her license revoked.
It is very possible that a human service provider reading this will encounter
clients who have been sexually victimized by a previous therapist. A
national study of 1,320 psychologists found that 50% reported working with
at least one client who had been a victim of therapist-client sexual
intimacies (Pope & Vetter).
When a client reveals a previous or ongoing sexual relationship with his or
her former or other therapist, the client's subsequent or other therapist has a
legal obligation to give the client a brochure called “Professional Therapy
Never Includes Sex” which outlines client's rights and responsibilities.
Potential consequences of conviction include imprisonment in the county jail
for up to one year and fines (up to $1,000 for the first conviction and up to
$5,000 for the second conviction). Under law, the first violation is treated as
52
a misdemeanor and the second violation is treated as either a felony or a
misdemeanor, according to the discretion of the court and district attorney.
Further, the consent of the client may never be used as a defense.
Professional Therapy Never Includes Sex:
The following is included in the publication “Professional Therapy Never
Includes Sex” (CA Dept of Consumer Affairs, Revised 2009) and should be
given to any client who reports a sexual relationship of any kind with a
current or previous therapist:
“Professional psychotherapy never includes sex. It also never includes
verbal sexual advances or any other kind of sexual contact or behavior.
Sexual contact of any kind between a therapist and a patient is unethical and
illegal in the state of California. Additionally, with regard to former
patients, sexual contact within two years after termination of therapy is also
illegal and unethical. Sexual contact between a therapist and a patient can
also be harmful to the patient. Harm may arise from the therapist’s
exploitation of the patient to fulfill his or her own needs or desires,
and from the therapist’s loss of the objectivity necessary for effective
therapy.
All therapists are trained and educated to know that this kind of behavior is
inappropriate and can result in the revocation of their professional license.
Therapists are trusted and respected, and it is common for patients to admire
and feel attracted to them. However, a therapist who accepts or encourages
these normal feelings in a sexual way — or tells a patient that sexual
involvement is part of therapy —is using the trusting therapy relationship to
take advantage of the patient. And once sexual involvement begins, therapy
for the patient ends. The original issues that brought the patient to therapy
are postponed, neglected, and sometimes lost. Many people who endure this
kind of abusive behavior from therapists suffer harmful, long-lasting
emotional and psychological effects. Family life and friendships are often
disrupted, or sometimes ruined.
California’s lawmakers, licensing boards, professional associations and
ethical therapists want such inappropriate sexual behavior stopped. This
booklet was developed to help patients who have been sexually exploited by
their therapists. It outlines their rights and options for reporting what
53
happened. It also defines therapist sexual exploitation, gives warning signs
of unprofessional behavior, presents a “Patient Bill of Rights,” and
answers some frequently asked questions.
Definition of Terms
Throughout this booklet, the terms “therapist,” “therapy” and
“patient” will be used. “Therapist” refers to anyone who is licensed
to practice psychotherapy, or is training to become licensed, and
includes:









Psychiatrists (physicians practicing psychotherapy)
Psychologists
Registered psychologists
Psychological interns
Psychological assistants
Licensed clinical social workers
Registered associate clinical social workers
Licensed marriage and family therapists
Marriage and family therapist registered interns and trainees
“Therapy” includes any type of mental health counseling from any of the
licensed or registered therapists listed above. “Patient” refers to anyone
receiving therapy or counseling. The terms “therapy,” “therapist” and
“patient” in this booklet also refer to educational psychology, educational
psychologists and their clients. Though educational psychologists do not
practice psychotherapy, these licensed professionals work with clients,
performing educational evaluations, diagnosis and test interpretation.
According to California laws:
 Any act of sexual contact, sexual abuse, sexual exploitation,
sexual misconduct or sexual relations by a therapist with a
patient is unprofessional, illegal, as well as unethical as set
forth in Business and Professions Code sections 726, 729,
2960(o), 4982(k) and 4992.3(k).
 “Sexual contact” means the touching of an intimate part of
another person, including sexual intercourse.
 “Touching” means physical contact with another person either
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through the person’s clothes or directly with the person’s skin.
 “Intimate part” means the sexual organ, anus, groin or
buttocks of any person and the breast of a female.
Sexual exploitation can include sexual intercourse, sodomy, oral
copulation, or any other sexual contact between a therapist and
a patient or a former patient under certain circumstances. Sexual
misconduct includes a much broader range of activity, which may
include fondling, kissing, spanking, nudity, verbal suggestions,
innuendoes or advances. This kind of sexual behavior by a therapist
with a patient is unethical, unprofessional and illegal.
Warning Signs
In most sexual abuse or exploitation cases, other inappropriate
behavior comes first. While it may be subtle or confusing, it usually
feels uncomfortable to the patient. Some clues or warning signs are:




Telling sexual jokes or stories.
“Making eyes at” or giving seductive looks to the patient.
Discussing the therapist’s sex life or relationships excessively.
Sitting too close, initiating hugging, holding the patient or lying
next to the patient.
Another warning sign is “special” treatment by a therapist, such as:
 Inviting a patient to lunch, dinner or other social activities.
 Dating.
 Changing any of the office’s business practices (for example,
scheduling late appointments so no one is around, having
sessions away from the office, etc.).
 Confiding in a patient (for example, about the therapist’s love
life, work problems, etc.).
 Telling a patient that he or she is special, or that the therapist
loves him or her.
 Relying on a patient for personal and emotional support.
 Giving or receiving significant gifts.
 Providing or using alcohol (or drugs) during sessions.
Signs of inappropriate behavior and misuse of power include:
55
 Hiring a patient to do work for the therapist, or bartering goods
or services to pay for therapy.
 Suggesting or supporting the patient’s isolation from social
support systems, increasing dependency on the therapist.
 Any violation of the patient’s rights as a consumer (see Patient
Bill of Rights).
Therapy is meant to be a guided learning experience, during which therapists
help patients to find their own answers and feel better about themselves and
their lives. A patient should never feel intimidated or threatened by a
therapist’s behavior. If you are experiencing any of these warning signs,
trust your own feelings. Check on the therapist’s behavior with a different
therapist, or with any of the agencies in “Where To Start”. Depending on
what you find out, you may want to find another therapist.
What If It’s Me?
If you have been sexually abused or exploited by your therapist,
you may be feeling confused. You may feel:
 Guilty and responsible — even though it’s the therapist’s
responsibility to keep sexual behavior out of therapy.
 Mixed feelings about the therapist — protectiveness, anger,
love, betrayal.
 Isolated and empty.
 Distrustful of others or your own feelings.
 Fearful that no one will believe you or understand what happened, or
that someone will find out.
 Confused about dependency, control and power.
You may even have nightmares, obsessive thoughts, depression, or suicidal
or homicidal thoughts. You may feel overwhelmed as you try to decide what
56
to do or whom to tell. It’s essential that you face what happened. This may
be painful, but it is the first major step in healing and recovering from the
experience. You may have positive and negative feelings at the same time,
such as starting to feel personal control, being afraid of what may happen
in the future, remembering the experience, and feeling relieved that the
sexual relationship is over.
The second step in the healing process is to decide what YOU want to do
next. Try to be open-minded about your options. Remember: It doesn’t
matter if you, the patient, started or wanted the sexual involvement with the
therapist. Therapists are responsible for keeping sexual intimacy out of the
therapy relationship and are trained to know how to handle a patient’s
sexual attractions and desires.
Where To Start
You may need to (1) talk to someone who will understand what
you’re going through, (2) get information on whether the therapist’s
behavior was illegal and/or unethical, and (3) find out what you can
do about it. Three places to get help are:
Licensing Boards —
 In the Department of Consumer Affairs, three different boards license
therapists. They can give general information on appropriate behavior
for therapists and your rights for reporting what happened, as well as
how to file a complaint (see page 13 for licensing board contact
information).
 Sexual Assault/Crisis Centers — These centers have staff trained in
all types of sexual abuse and exploitation. They can provide general
information on appropriate behavior for therapists, crisis services,
your rights for reporting what happened, and names of therapists and
support groups that may be helpful. Centers are located throughout
California. Look in your telephone book under “sexual assault center”
or “crisis intervention service.”
 Professional Associations —Each licensed therapy profession has at
least one professional association. Associations can provide general
information on appropriate behavior for therapists, your rights for
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reporting what happened, and how to file a complaint. They can
provide names of therapists who may be helpful.
What You Can Do
You can deal with your situation in several different ways. Take
time to explore all of your rights and options. It may help to decide
what your goals are:
 Reporting the Therapist —Perhaps you want to prevent the therapist
from hurting other patients. You may want to make it known that
sexual exploitation is always wrong. If this is your decision, you have
several reporting options. It is important to note that reporting
misconduct is time-sensitive. What can be done in response to the
report of misconduct usually depends on:
o Who the misconduct is reported to, and the length of time
between the misconduct and when the report was filed. Such a
time limit is called a “statute of limitations.” As you consider
your options, be aware of these time limits.
o Your Recovery — You may also want to explore and process
what happened between you and the therapist. If you decide to
do this, you can look into therapy or support groups.
o Moving On — You may wish simply to move on past this
experience as quickly as possible and get on with your life.
Remember — you have the right to decide what is best for you.
Your Reporting Options
If you decide to report a therapist’s behavior that you believe is unethical
and illegal, there are four different ways to do so. All of these reporting
options are affected by time limits, so you should consider reporting
misconduct at the earliest appropropriate opportunity. You may choose one
or more of the options listed below. These options and their time limits are
discussed in more detail on following pages:
 Administrative Action — File a complaint with the therapist’s
licensing board.
 Professional Association Action— File a complaint with the ethics
committee of the therapist’s professional association.
 Civil Action — File a civil lawsuit.
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 Criminal Action— File a complaint with local law enforcement.
More About Administrative Action
Three California boards license and regulate therapists:
Board of Behavioral Sciences
1625 N. Market Blvd., Suite S-200
Sacramento, CA 95834
(916)574-7830
www.bbs.ca.gov
This board licenses and regulates educational psychologists;
licensed clinical social workers; registered associate clinical
social workers; licensed marriage and family therapists; and
registered marriage and family therapist interns.
Board of Psychology
2005 Evergreen Street, Suite 1400
Sacramento, CA 95815
(916)263-2699
www.psychboard.ca.gov
This board licenses and regulates psychologists, psychological assistants and
registered psychologists.
Medical Board of California
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815
(916)263-2389
www.medbd.ca.gov
This board licenses and regulates physicians, including psychiatrists. The
purpose of these licensing boards is to protect the health, safety and welfare
of consumers. Licensing boards have the power to discipline therapists by
using the administrative law process. Depending on the violation, the board
may revoke or suspend a license, and/or place a license on probation with
terms and conditions the licensed professional must follow. When a license
is revoked, the therapist cannot legally practice. In many cases, the
California Business and Professions Code requires revocation of a
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therapist’s license or registration whenever sexual misconduct is admitted or
proven. It is best to report any case of therapist-patient sexual exploitation
as soon as possible, since delays may restrict the disciplinary options
available to the board. Time limits require a licensing board to
initiate disciplinary action by filing an “accusation” against a licensed
professional accused of sexual misconduct:
 within three years from the date the board discovered the
alleged sexual misconduct, or
 within 10 years from the date the alleged sexual misconduct
occurred.
That means an accusation of sexual misconduct against a therapist
can’t be filed more than 10 years after the alleged incident. For
complaints involving allegations other than sexual misconduct, the
licensing board must file an accusation within seven years from the
date of the alleged offense.
How the Complaint Process Works
The licensing boards can give you information about the complaint filing
process and discuss your situation with you. To file a complaint, you can
request a complaint form, write a letter, or start the complaint process online
with the appropriate licensing board. With your complaint, be sure to include
your name, address, and telephone number; the therapist’s name, address,
and telephone number; a description of your complaint; copies of any
available documentation (for example, letters, bill receipts, canceled checks,
or pictures); and names, addresses and telephone numbers of any witnesses.
Each complaint is evaluated and investigated, and you and the therapist will
be notified if the board has sufficient evidence to initiate disciplinary action.
You and the therapist will be interviewed separately.
Most cases are settled by a stipulated agreement — the therapist typically
admits to the violation(s) and accepts the disciplinary action, no hearing is
held, and the patient does not have to testify. In the event that your case is
not settled by a stipulated agreement, a hearing will be held by an
administrative law judge, and you will be required to testify. When the judge
makes a decision about the case, the board will then decide whether to
accept this decision or to issue its own decision.
It is board policy to use only initials, rather than full names, to identify
patients in public disciplinary documents. However, hearings are open to the
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public, and there is a possibility that confidentiality may be jeopardized
during the investigation process or at the hearing itself. If you are concerned
about this, discuss it with the licensing board investigator.
The disciplinary process may take about two years from the time a
complaint is received to the time a final decision is made. Sometimes
the process takes longer. Keep in mind that you cannot receive monetary
compensation from the therapist by using this option, but you may affect the
therapist’s ability to practice and thereby protect other patients from similar
misconduct.
More About Professional Association Action
Many therapists join professional associations — organizations that provide
education and guidance to members of a profession. Each association has
ethics guidelines, and all such guidelines state that sexual involvement with
patients is unacceptable and unethical. If your therapist is a member of a
professional association, you may file a formal complaint with the
association. After investigating the complaint, the association may
recommend disciplinary actions that may include removal of the therapist
from its membership. Removing a therapist from the association will let
other members know about the person’s unethical behavior, but it will not
keep the therapist from practicing. Only a licensing board or court action
can do that. In addition, the action will not result in monetary recovery
for you (only a civil action can do that), and will not result in criminal
action against the therapist. Each association has different ways of filing
complaints. Call or write the appropriate association for this information. To
find out which association, if any, the therapist belongs to, call the
therapist’s office and request this information; have a friend call the office or
therapist for you; or check with the different associations.
Most professional association ethics committees will typically review only
those complaints that include allegations made within one year of the date of
the alleged misconduct. Contact the appropriate association for specifics
on reporting professional misconduct, or to get more general information.
Psychiatrist, Physician
American Psychiatric Association
1000 Wilson Blvd. Suite 1825
Arlinghton, VA 22209
(888)357-7924
www.psych.org
61
California Medical Association
1201 J Street, Suite 200
Sacramento, CA 95814
(916) 444-5532
www.cmanet.org
California Psychiatric Association
1029 K Street, Suite 28
Sacramento, CA 95814
(916)442-5196
www.calpsych.org
Licensed Psychologist
American Psychological Association
750 First Street, NE
Washington, DC 20002
(800)374-2721
www.apa.org
California Psychological Association
1231 I Street, Suite 204
Sacramento, CA 95814
(916)286-7979
www.cpapsych.org
Licensed Clinical Social Worker
National Association of Social Workers
1016 23rd Street
Sacramento CA 95816
(916) 442-4565
www.naswdc.org
California Society for Clinical Social Work
720 Howe Avenue Suite 112
Sacramento, CA 95825
(800) 952-5579 or
(916)923-0255
www.clinicalsocialworksociety.org
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Professional Associations
Licensed Marriage and Family Therapist
American Association for Marriage and Family Therapy
112 South Alfred Street
Alexandria, CA 22314-3061
(703)838-9808
http://www.aamft.org/
American Association for Marriage and Family Therapy, California Division
Post Office Box 6907
Santa Barbara, CA 93160
(800)662-2638
http://www.aamftca.org
California Association of Marriage and Family Therapists
7901 Raytheon Road
San Diego, CA 92111
(858) 292-2638
www.camft.org
Licensed Educational Psychologist
California Association of Licensed Educational Psychologists
26 Seascape Village
P.O. Box 387
Aptos, Ca 95001
(650)380-2011
www.calep.com
More About Civil Action
Suing the Therapist or Their Employer
Generally, civil lawsuits are filed to seek money for damages or injuries to a
patient. For a sexual misconduct case, a patient may want to sue the therapist
for injuries suffered and for the cost of future therapy sessions. Under
California law, you may file a lawsuit against the therapist or the therapist’s
employer if you believe the employer knew or should have known about the
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therapist’s behavior. If the employer is a local or state public mental health
agency for which the therapist works, you must first file a complaint with
the agency within six months of the sexual misconduct. Consult with an
attorney for specific advice.
If you think you want to file a lawsuit, it is important to consult an
attorney as soon as possible, since there are different time limits for
filing civil lawsuits. Most civil lawsuits must be filed within one year
after the sexual misconduct occurred.
Media Attention
Once a lawsuit is filed, there is the possibility of media coverage, especially
if the patient or therapist is well-known. While many cases are settled out of
court, some do go to trial, and it can take years before your case is tried.
Patients Don’t Always Win
You should be aware that some cases end up being decided in favor of the
therapist, rather than the patient.
Finding an Attorney
Take time to choose an attorney to represent you. You may need
to interview several. Here are some points to consider:
 Get a list of attorneys from your County Bar Association’s
referral service. You can also check with your local legal aid
society for legal assistance. Contact a lawyer referral service certified
by the State Bar of California. To find a certified lawyer referral
service, look in the telephone book yellow pages at the beginning of
the “Attorneys” listings, or visit the State Bar Web site at www.
calbar.ca.gov.
 Check with the State Bar of California (www.calbar.ca.gov)
to make sure the attorney has a clear license.
 While some attorneys are willing to wait to be paid based on the
outcome of the suit (contingency basis), some will not.
 Be sure that the attorney has civil litigation experience in
the area of medical and/or psychological malpractice.
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 Make sure that you feel comfortable with your attorney and
can trust and confide in him or her.
More About Criminal Action
Sexual exploitation of patients by therapists is wrong. The law makes it a
crime for a therapist to have sexual contact with a patient. For a first offense
with only one victim, an offender would probably be charged with a
misdemeanor. For this charge, the penalty may be a sentence of up to one
year in county jail, or up to $1,000 in fines, or both. Second and following
offenses, or offenses with more than one victim, may be misdemeanors or
felonies. The penalty in such felony cases can be up to three years in prison,
or up to $10,000 in fines, or both. This law applies to two situations:
1. The therapist has sexual contact with a patient during therapy, or
2. The therapist ends therapy primarily to start having sexual contact
with the patient (unless the therapist has referred the patient to an
independent and objective therapist who has been recommended by a
third-party therapist).
To file a criminal complaint against a therapist:
 Contact your local law enforcement agency. Many agencies in larger
cities have sexual assault units that handle these complaints.
 Contact your local victim/witness assistance program for help
through the legal process. Look in your local telephone book under
“District Attorney” or call 1-800-VICTIMS (842-8467). Once a
complaint is filed, it will be investigated by the law
enforcement agency, which will give the results of the investigation to
the district attorney’s office. The district attorney’s office will decide
whether there is enough evidence to file criminal charges. Time limits,
or statutes of limitations, affect this reporting option. If you are
considering this option, contact your local law enforcement agency.
The agency’s authority to take action may expire as soon as one year
from the date the alleged misconduct occurred.
Where to Get Help
Many patients who have been sexually exploited by therapists
find it difficult to see another therapist for help and support. However,
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for most people, the issues that brought them to therapy were never
worked on or resolved, and the sexual exploitation created even more
issues to handle. If this is your situation, therapy may be an important
tool in your healing process. Before selecting a therapist, interview several
until you find one you are comfortable with. Use the “Patient Bill of Rights”
as a guide. If you are unsure after one session, either consider a
different therapist or set up a follow-up session to clarify your concerns. Do
not feel pressured to stay with one therapist.
Finding a Therapist
Some ways of finding a therapist are:
 Asking someone you know who has been in therapy, who feels good
about the experience and who has changed in ways you consider
positive.
 Calling your local sexual assault center or crisis intervention service
(in the telephone book yellow pages). These centers can refer you to
therapists experienced in dealing with those who have suffered sexual
exploitation or abuse.
 Calling professional associations and asking for referrals to therapists
who specialize in helping those who have been sexually abused or
exploited by therapists.
After getting several names, call the appropriate licensing board
and professional association and ask if the therapists are licensed and if any
disciplinary actions have been filed against them. Also check your county
Superior Court to see if there is a record of any malpractice lawsuits filed
against the therapists.
Self-Help Support Groups
There is an informal network of self-help support groups throughout
California. While there might not be a group in your area specifically
focused on sexual exploitation by therapists, there may be groups dealing
with more general kinds of sexual abuse. To find out if there are any groups
in your area, call your local sexual assault center or crisis intervention
service
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Frequently Asked Questions
1. Is it normal to feel attracted to my therapist?
Yes. It is normal to feel attracted to someone who is attentive, kind
and caring. This is a common reaction toward someone who is
helping you. However, all therapists are trained to be aware of this
and to maintain a therapy relationship that is beneficial to the patient.
2. What if I was the one who brought up having sex?
That doesn’t matter. The therapist is the one who is responsible for
keeping sexual intimacy out of therapy.
3. Does this happen a lot?
A national study revealed that probably fewer than 10 percent of all
therapists have had sexual contact with their patients and that 80
percent of the sexually exploiting therapists have exploited more than
one patient. If a therapist is sexually exploiting a patient, they have
probably done so before and are likely to do so again. In recent years,
aggressive prosecution of offending therapists, and passage of laws
that facilitate the enforcement work of licensing boards, have helped
to significantly reduce the number of such cases being reported to the
licensing boards.
4. Why do some therapists sexually exploit their patients?
There are probably as many excuses as there are therapists who
engage in such unprofessional conduct. But no excuse is acceptable
for a therapist to abuse the therapeutic relationship and the trust of a
patient for the therapist’s own sexual gain. All therapists should know
that this conduct is unethical and illegal
5. Why do I feel scared or confused about reporting my therapist?
Feelings of confusion, protectiveness, shame or guilt are common. In
most cases, the therapist is an important person in the patient’s life.
Get as much information as possible about your options. Keep in mind
that you are in control and can choose what to do.
6. What if the therapist retaliates against me, harasses me or files a
lawsuit against me for reporting him or her?
Retaliation against a patient or harassment of a patient is illegal.
Contact your local district attorney. If the therapist files a lawsuit
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against you, you will be required to defend yourself in the lawsuit.
However, the law does provide immunity from monetary liability for
reporting misconduct to a licensing board.
7. How can I prevent this from happening again?
 Acknowledge your right to be free from sexual exploitation.
 When choosing a therapist, check with the licensing board
to see if the therapist is licensed and if the license is under
suspension or probation. Check on any complaints filed with
a professional association. Review county Superior Court
records to see if any malpractice lawsuit judgments are on file
against the therapist.
 Question any action that may seem sexual.
 Remember that while feelings of attraction are natural, therapy
is supposed to be a means to explore and resolve feelings,
without having to act them out.
 Feel free to end a relationship that no longer seems safe.
8. Can I file an anonymous complaint with a licensing board?
Anonymous complaints are accepted, but they are almost impossible
to investigate without the cooperation of the accuser.
Patient Bill of Rights
Patients have the right to:
Request and receive information about the therapist’s professional
capabilities, including licensure, education, training, experience,
professional association membership, specialization and limitations.
Have written information about fees, payment methods, insurance
reimbursement, number of sessions, substitutions (in cases of vacation
and emergencies), and cancellation policies before beginning therapy.
Receive respectful treatment that will be helpful to you.
A safe environment, free from sexual, physical and emotional
abuse.
Ask questions about your therapy.
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Refuse to answer any question or disclose any information you
choose not to reveal.
Request and receive information from the therapist about your
progress.
Know the limits of confidentiality and the circumstances in which
a therapist is legally required to disclose information to others.
Know if there are supervisors, consultants, students, or others
with whom your therapist will discuss your case.
Refuse a particular type of treatment, or end treatment without
obligation or harassment.
Refuse electronic recording (but you may request it if you wish).
Request and (in most cases) receive a summary of your file,
including the diagnosis, your progress, and the type of treatment.
Report unethical and illegal behavior by a therapist (see “Your
Reporting Options,”).
Receive a second opinion at any time about your therapy or
therapist’s methods.
Have a copy of your file transferred to any therapist or agency
you choose.
Nonsexual Dual Relationships
A dual relationship within the therapeutic relationship takes place when the
therapist is engaging in another, significantly different relationship with a
client. Dual relationships jeopardize professional judgment, the client’s
welfare, and the therapeutic process (Borys and Pope). Dual relationships
erode and distort the professional nature of the therapeutic relationship,
which is ideally built on reliable and predictable boundaries. Dual
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relationships also create conflicts of interest and thus compromise the
objectivity necessary for sound professional judgment.
3F. Record Retention and Storage
Currently, clinical records should be retained by the clinician for a minimum
of seven years following termination. The records of both active and
inactive clients should be stored in a secure, locked file cabinet or storage
area. It is also advantageous to have a “key policy” which outlines who is
in possession/has access to the file cabinet key and where the key is stored.
Following the seven year record retention period, The Psychologist’s Legal
Handbook (Stromberg) states that “records should not simply be placed in
the trash, since methods of trash collection and disposal can be haphazard
and can result in confidential papers being seen by passerby. Instead,
records should be shredded and destroyed”.
There are many important issues associated with the storage of records and
confidentiality. It is necessary to store information about clients out of sight
of people unauthorized to view the information. Thus, chart documents
should be placed inside of a chart or protective covering. The protection of a
client’s name may seem excessive but the person seeking mental health
needs to be treated with confidentiality.
The security of charts in an unattended area is another issue. There should be
a lock between the charts and anyone unauthorized to view those charts. An
important question to ask oneself may be “What steps would we want a
therapist to take if it was my charts containing my deepest secrets, personal
history, conflicts, and diagnosis?”
3G. Termination
Clients may terminate treatment at any time. Therapists may terminate
treatment for both clinical and/or ethical reasons. Termination of the
therapeutic relationship should be addressed during the early stages of
treatment. The termination process as well as termination possibilities
should be addressed in writing as a part of the informed consent. Many
therapists experience this as a helpful way to introduce the concept of
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termination at the onset of treatment. Termination is not advised when a
client is hospitalized, in crisis, or actively suicidal. Terminating a client
during a crisis could yield potentially unwanted liability including client
abandonment. The following includes the legal/ethical reasons for
termination:
 Non-payment
 Lack of treatment benefit/progress
 The therapist is physically or emotionally unable to continue
treatment
 Ethical conflicts and conflicts of interest
Documentation of the termination process is essential, including:
 Reason(s) for terminating
 Number of termination sessions
 The clients awareness that treatment has ended and that the therapist
is no longer responsible for the client's mental health care.
 Client's response to termination
 Referrals (at least three written referrals are recommended)
NASW Ethical Standards and client termination:
l. 1.16 (a) Social workers should terminate services to clients and
professional relationships with them when such services and relationships
are no longer required or no longer serve the clients' needs or interests.
2. 1.16 (b) Social workers should take reasonable steps to avoid abandoning
clients who are still in need of services. Social workers should withdraw
services precipitously only under unusual circumstances, giving careful
consideration to all factors in the situation and taking care to minimize
possible adverse effects. Social workers should assist in making appropriate
arrangements for continuation of services when necessary.
3. 1.16 (c) Social workers in fee-for-service settings may terminate services
to clients who are not paying an overdue balance if the financial contractual
arrangements have been made clear to the client, if the client does not pose
an imminent danger to self or others, and if the clinical and other
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consequences of the current nonpayment have been addressed and discussed
with the client.
4. 1.16 (d) Social workers should not terminate services to pursue a social,
financial, or sexual relationship with a client.
5. 1.16 (e) Social workers who anticipate the termination or interruption of
services to clients should notify clients promptly and seek the transfer,
referral, or continuation of services in relation to the clients' needs and
preferences.
6. 1.16 (f) Social workers who are leaving an employment setting should
inform clients of appropriate options for the continuation of services and of
the benefits and risks of the options.
CAMFT Ethical Standards and client termination:
1. 1.3.1 Marriage and family therapists terminate therapeutic relationships
for clinically sound reasons and in an appropriate manner. Reasons for
termination may include, but are not limited to, the patient is not benefiting
from treatment, continuing treatment is not clinically appropriate, the
therapist is unable to provide treatment due to physical or mental illness, or
the treatment becomes ethically questionable.
2. 1.3.2 Marriage and family therapists assist patients when terminating
relationships by making reasonable arrangements for continuation of
necessary treatment.
3. 1.3.3 It may be ethical to terminate a patient relationship for non-payment
of fees.
4. 1.6 Marriage and family therapists continue therapeutic relationships only
so long as it is reasonably clear that patients are benefiting from the
relationship.
5. 1.7 Marriage and family therapists assist persons in obtaining other
therapeutic services if a therapist is unable or unwilling to provide
professional help.
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6. 1.8 Marriage and family therapists do not abandon or neglect patients in
treatment. If a therapist is unable to continue to provide care, the therapist
will assist the patient in making reasonable arrangements for continuation of
treatment.
7. 1.9 When terminating employment or contractual relationships, marriage
and family therapists primarily consider the best interests of the patient when
resolving issues of continued responsibility for patient care.
3H. Informed Consent
Informed consent is a legal condition whereby a person can be said to have
given consent based upon a clear appreciation and understanding of the
facts, implications and future consequences of an action. In order to give
informed consent, the individual concerned must have adequate reasoning
faculties and be in possession of all relevant facts at the time consent is
given. Impairments to reasoning and judgment which would make it
impossible for someone to give informed consent include such factors as
severe mental retardation, severe mental illness, intoxication, severe sleep
deprivation, Alzheimer's disease, or being in a coma.
The ability to give informed consent will be governed by a general
requirement of competency. In common law jurisdictions, adults are
presumed competent to consent. This presumption can be rebutted, for
instance, in circumstances of mental illness or other incompetence. This may
be prescribed in legislation or based on a common-law standard of inability
to understand the nature of the procedure. In cases of incompetent adults,
informed consent--from the patients or from their families--is not required.
Rather, the medical practitioner must simply act in the patient's best interests
in order to avoid negligence liability.
By contrast, 'minors' (which may be defined differently in different
jurisdictions) are generally presumed incompetent to consent. In some
jurisdictions (e.g. much of the U.S.), this is a strict standard. In other
jurisdictions (e.g. England, Australia, Canada), this presumption may be
rebutted through proof that the minor is ‘mature’ (the ‘Gillick standard’). In
cases of incompetent minors, informed consent is usually required from the
parent (rather than the 'best interests standard') although a parens patriae
order may apply, allowing the court to dispense with parental consent in
cases of refusal.
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The process of informed consent provides the client and therapist an
opportunity to ensure adequate understanding of their shared venture. It is a
process of communication and clarification. Are expectations clearly stated?
Does the client understand the approach the therapist will be using?
Informed consent involves making decisions. The therapist must decide if
the patient is competent to exercise informed consent. The therapist must
evaluate if the competent client has relevant information in which to make a
decision and sufficiently understands the information.
3I. Malpractice
In law, malpractice is a type of negligence in which the misfeasance,
malfeasance or nonfeasance of a professional, under a duty to act, fails to
follow generally accepted professional standards, and that breach of duty is
the proximate cause of injury to a plaintiff who suffers damages. It is
committed by a professional or her/his subordinates or agents on behalf of a
client or patient that causes damages to the client or patient. Perhaps the
most publicized forms are medical malpractice and legal malpractice by
medical practitioners and lawyers respectively, though malpractice suits
against accountants (Arthur Andersen) and investment advisors (Merrill
Lynch) have featured in the news more recently.
Data from the Insurance Trust of the American Psychological Association
reveal the following primary reasons that clinicians are sued:
1. Sexual Impropriety accounts for 53.2% of the costs of malpractice cases
and for 20.4% of the total number of claims. Dual relationships, particularly
sexual dual relationships comprise the largest share of formal complaints
against psychologists.
2. Patient suicide comprises 11.2% of the total costs and about 5.8% of the
total number of cases.
3. Incorrect treatment meaning the incompetence in the selection or
implementation of the treatment plan comprises about 8.4% of the total costs
and about 13.2% of the total claims against psychologists.
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4. HIPAA and Third Party Reimbursement for Mental
Health Services
The Health Insurance Portability and Accountability Act (HIPAA) was
enacted by the U.S. Congress in 1996. According to the Centers for
Medicare and Medicaid Services (CMS) website, Title I of HIPAA protects
health insurance coverage for workers and their families when they change
or lose their jobs. Title II of HIPAA, known as the Administrative
Simplification (AS) provisions, requires the establishment of national
standards for electronic health care transactions and national identifiers for
providers, health insurance plans, and employers. It helps people keep their
information private (Wilson J, 2006). "Health Insurance Portability and
Accountability Act Privacy rule causes ongoing concerns among clinicians
and researchers"). The Administration Simplification provisions also address
the security and privacy of health data. The standards are meant to improve
the efficiency and effectiveness of the nation's health care system by
encouraging the widespread use of electronic data interchange in the U.S.
health care system.
Title II of HIPAA defines numerous offenses relating to health care and sets
civil and criminal penalties for them. It also creates several programs to
control fraud and abuse within the health care system. However, the most
significant provisions of Title II are its Administrative Simplification rules.
Title II requires the Department of Health and Human Services (HHS) to
draft rules aimed at increasing the efficiency of the health care system by
creating standards for the use and dissemination of health care information.
These rules apply to “covered entities” as defined by HIPAA and the HHS.
Covered entities include health plans, health care clearinghouses, such as
billing services and community health information systems, and health care
providers that transmit health care data in a way that is regulated by HIPAA.
Per the requirements of Title II, the HHS has promulgated five rules
regarding Administrative Simplification: the Privacy Rule, the Transactions
and Code Sets Rule, the Security Rule, the Unique Identifiers Rule, and the
Enforcement Rule.
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The Privacy Rule took effect on April 14, 2003, with a one-year extension
for certain "small plans." The HIPAA Privacy Rule regulates the use and
disclosure of certain information held by "covered entities" (generally,
health care clearinghouses, employer sponsored health plans, health insurers,
and medical service providers that engage in certain transactions.) It
establishes regulations for the use and disclosure of Protected Health
Information (PHI). PHI is any information held by a covered entity which
concerns health status, provision of health care, or payment for health care
that can be linked to an individual. This is interpreted rather broadly and
includes any part of an individual's medical record or payment history.
Covered entities must disclose PHI to the individual within 30 days upon
request. They also must disclose PHI when required to do so by law, such as
reporting suspected child abuse to state child welfare agencies (Wilson J
(2006). "Health Insurance Portability and Accountability Act Privacy rule
causes ongoing concerns among clinicians and researchers".).
A covered entity may disclose PHI to facilitate treatment, payment, or health
care operations or if the covered entity has obtained authorization from the
individual. However, when a covered entity discloses any PHI, it must make
a reasonable effort to disclose only the minimum necessary information
required to achieve its purpose.
The Privacy Rule requires covered entities to take reasonable steps to ensure
the confidentiality of communications with individuals. For example, an
individual can ask to be called at his or her work number, instead of home or
cell phone number. The Privacy Rule requires covered entities to notify
individuals of uses of their PHI. Covered entities must also keep track of
disclosures of PHI and document privacy policies and procedures. They
must appoint a Privacy Official and a contact person responsible for
receiving complaints and train all members of their workforce in procedures
regarding PHI.
An individual who believes that the Privacy Rule is not being upheld can file
a complaint with the Department of Health and Human Services Office for
Civil Rights (OCR). However, according to the Wall Street Journal, the
OCR has a long backlog and ignores most complaints. "Complaints of
privacy violations have been piling up at the Department of Health and
Human Services. Between April 2003 and Nov. 30, the agency fielded
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23,896 complaints related to medical-privacy rules, but it has not yet taken
any enforcement actions against hospitals, doctors, insurers or anyone else
for rule violations.
HIPAA covered entities such as providers completing electronic
transactions, healthcare clearinghouses, and large health plans, must use
only the National Provider Identifier (NPI) to identify covered healthcare
providers in standard transactions. The NPI replaces all other identifiers used
by health plans, Medicare (i.e., the UPIN), Medicaid, and other government
programs. However, the NPI does not replace a provider's DEA number,
state license number, or tax identification number. The NPI is 10 digits (may
be alphanumeric), with the last digit being a checksum. The NPI is unique
and national, never re-used, and except for institutions, a provider usually
can have only one.
The HIPAA process for a solo or small group of health professionals is a
fairly easy task, particularly if you have already been following the laws for
privacy within your field. Within a private practice, you can designate
yourself as the Privacy officer and take care of the necessary changes rather
smoothly.
Some therapists may need to complete and store two sets of notes, learn
HIPPA standards regarding patient’s access to records, and develop new
forms for Consent for Services and a HIPAA Acknowledgement. Also,
revised standards now exist regarding the security of computer records. The
recommendations discussed apply to solo practices or those of small groups
and do not apply to hospitals or large clinics.
The Standards for Privacy of Individually Identifiable Health Information
Privacy Rule establishes, for the first time, a set of national standards for the
protection of certain health information. The U.S. Department of Health and
Human Services Payment encompasses activities of a health plan to obtain
premiums, determine or fulfill responsibilities for coverage and provision of
benefits, and furnish or obtain reimbursement for health care delivered to an
individual and activities of a health care provider to obtain payment or be
reimbursed for the provision of health care to an individual. Health care
operations are any of the following activities: (a) quality assessment and
improvement activities, including case management and care coordination;
(b) competency assurance activities, including provider or health plan
performance evaluation, credentialing, and accreditation; (c) conducting or
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arranging for medical reviews, audits, or legal services, including fraud and
abuse detection and compliance programs; (d) specified insurance functions,
such as underwriting, risk rating, and reinsuring risk; (e) business planning,
development, management, and administration; and (f) business
management and general administrative activities of the entity, including but
not limited to: de-identifying protected health information, creating a limited
data set, and certain fundraising for the benefit of the covered entity. Most
uses and disclosures of psychotherapy notes for treatment, payment, and
health care operations purposes require an authorization as described below.
Obtaining consent (written permission from individuals to use and disclose
their protected health information for treatment, payment, and health care
operations) is optional under the Privacy Rule for all covered entities. The
content of a consent form, and the process for obtaining consent, are at the
discretion of the covered entity electing to seek consent.
Uses and Disclosures with Opportunity to Agree or Object
Informal permission may be obtained by asking the individual outright, or
by circumstances that clearly give the individual the opportunity to agree,
acquiesce, or object. Where the individual is incapacitated, in an emergency
situation, or not available, covered entities generally may make such uses
and disclosures, if in the exercise of their professional judgment, the use or
disclosure is determined to be in the best interests of the individual.
Although not required, by the Rule in recognition of the important uses
made of health information outside of the health care context. Specific
conditions or limitations apply to each public interest purpose, striking the
balance between the individual privacy interest and the public interest need
for this information.
Required by Law
Covered entities may use and disclose protected health information without
individual authorization as required by law (including by OCR Privacy Rule
Summary 7 Last Revised 05/03 statute, regulation, or court orders).
Public Health Activities
Covered entities may disclose protected health information to: (1) public
health authorities authorized by law to collect or receive such information
for preventing or controlling disease, injury, or disability and to public
health or other government authorities authorized to receive reports of child
abuse and neglect; (2) entities subject to FDA regulation regarding FDA
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regulated products or activities for purposes such as adverse event reporting,
tracking of products, product recalls, and post marketing surveillance; (3)
individuals who may have contracted or been exposed to a communicable
disease when notification is authorized by law; and (4) employers, regarding
employees, when requested by employers, for information concerning a
work-related illness or injury or workplace related medical surveillance,
because such information is needed by the employer to comply with the
Occupational Safety and Health Administration (OHSA), the Mine Safety
and Health Administration (MHSA), or similar state law. See OCR Public
Health Guidance; CDC Public Health and HIPAA Guidance.
Victims of Abuse, Neglect or Domestic Violence
In certain circumstances, covered entities may disclose protected health
information to appropriate government authorities regarding victims of
abuse, neglect, or domestic violence.
Health Oversight Activities
Covered entities may disclose protected health information to health
oversight agencies (as defined in the Rule) for purposes of legally authorized
health oversight activities, such as audits and investigations necessary for
oversight of the health care system and government benefit programs.
Judicial and Administrative Proceedings
Covered entities may disclose protected health information in a judicial or
administrative proceeding if the request for the information is through an
order from a court or administrative tribunal. Such information may also be
disclosed in response to a subpoena or other lawful process if certain
assurances regarding notice to the individual or a protective order are
provided.
Law Enforcement Purposes
Covered entities may disclose protected health information to law
enforcement officials for law enforcement purposes under the following six
circumstances, and subject to specified conditions: (1) as required by law
(including court orders, court-ordered warrants, subpoenas) and
administrative requests; (2) to identify or locate a suspect, fugitive, material
witness, or missing person; (3) in response to a law enforcement officials
request for information about a victim or suspected victim of a crime; (4) to
alert law enforcement of a person’s death, if the covered entity suspects that
criminal activity caused the death; (5) when a covered entity believes that
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protected health information is evidence of a crime that occurred on its
premises; and (6) by a covered health care provider in a medical emergency
not occurring on its premises, when necessary to inform law enforcement
about the commission and nature of a crime, the location of the crime or
crime victims, and the perpetrator of the crime.
OCR Privacy Rule Summary 8 Last Revised 05/03
Decedents
Covered entities may disclose protected health information to funeral
directors as needed, and to coroners or medical examiners to identify a
deceased person, determine the cause of death, and perform other functions
authorized by law.
Cadaveric Organ, Eye, or Tissue Donation
Covered entities may use or disclose protected health information to
facilitate the donation and transplantation of cadaveric organs, eyes, and
tissue.
Research
Research is any systematic investigation designed to develop or contribute to
generalizable knowledge. The Privacy Rule permits a covered entity to use
and disclose protected health information for research purposes, without an
individual’s authorization, provided the covered entity obtains either: (1)
documentation that an alteration or waiver of individuals authorization for
the use or disclosure of protected health information about them for research
purposes has been approved by an Institutional Review Board or Privacy
Board; (2) representations from the researcher that the use or disclosure of
the protected health information is solely to prepare a research protocol or
for similar purpose preparatory to research, that the researcher will not
remove any protected health information from the covered entity, and that
protected health information for which access is sought is necessary for the
research; or (3) representations from the researcher that the use or disclosure
sought is solely for research on the protected health information of
decedents, that the protected health information sought is necessary for the
research, and, at the request of the covered entity, documentation of the
death of the individuals about whom information is sought. A covered entity
also may use or disclose, without an individual’s authorization, a limited
data set of protected health information for research purposes (see discussion
below). See OCR Research Guidance; NIH Protecting PHI in Research.
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Serious Threat to Health or Safety
Covered entities may disclose protected health information that they believe
is necessary to prevent or lessen a serious and imminent threat to a person or
the public, when such disclosure is made to someone they believe can
prevent or lessen the threat (including the target of the threat). Covered
entities may also disclose to law enforcement if the information is needed to
identify or apprehend an escapee or violent criminal.
Essential Government Functions
An authorization is not required to use or disclose protected health
information for certain essential government functions. Such functions
include: assuring proper execution of a military mission, conducting
intelligence and national security activities that are authorized by law,
providing protective services to the President, making medical suitability
determinations for U.S. State Department employees, protecting the health
and safety of inmates or employees in a correctional institution, and
determining eligibility for or conducting enrollment in certain government
benefit programs. OCR Privacy Rule Summary 9 Last Revised 05/03
Workers Compensation
Covered entities may disclose protected health information as authorized by,
and to comply with, workers compensation laws and other similar programs
providing benefits for work-related injuries or illnesses. See OCR Workers
Compensation Guidance.
(6) Limited Data Set. A limited data set is protected health information from
which certain specified direct identifiers of individuals and their relatives,
household members, and employers have been removed. A limited data set
may be used and disclosed for research, health care operations, and public
health purposes, provided the recipient enters into a data use agreement
promising specified safeguards for the protected health information within
the limited data set.
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Authorized Uses and Disclosures
Authorization
A covered entity must obtain the individual’s written authorization for any
use or disclosure of protected health information that is not for treatment,
payment or health care operations or otherwise permitted or required by the
Privacy Rule. A covered entity may not condition treatment, payment,
enrollment, or benefits eligibility on an individual granting an authorization,
except in limited circumstances.
An authorization must be written in specific terms. It may allow use and
disclosure of protected health information by the covered entity seeking the
authorization, or by a third party. Examples of disclosures that would require
an individual’s authorization include disclosures to a life insurer for
coverage purposes, disclosures to an employer of the results of a preemployment physical or lab test, or disclosures to a pharmaceutical firm for
their own marketing purposes. All authorizations must be in plain language,
and contain specific information regarding the information to be disclosed or
used, the person(s) disclosing and receiving the information, expiration,
right to revoke in writing, and other data.
Psychotherapy Notes
A covered entity must obtain an individual’s authorization to use or disclose
psychotherapy notes with the following exceptions:
 The covered entity who originated the notes may use them for
treatment.
 A covered entity may use or disclose, without an individual’s
authorization, the psychotherapy notes, for its own training, and to
defend itself in legal proceedings brought by the individual, for HHS
to investigate or determine the covered entities compliance with the
Privacy Rules, to avert a serious and imminent threat to public health
or safety, to a health oversight agency for lawful oversight of the
originator of the psychotherapy notes, for the lawful activities of a
coroner or medical examiner or as required by law.
Marketing
Marketing is any communication about a product or service that encourages
recipients to purchase or use the product or service. The Privacy Rule carves
out the following health-related activities from this definition of marketing:
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Communications to describe health-related products or services, or payment
for them, provided by or included in a benefit plan of the covered entity
making the communication; Communications about participating providers
in a provider or health plan network, replacement of or enhancements to a
health plan, and health-related products or services available only to a health
plans enrollees that add value to, but are not part of, the benefits plan;
Communications for treatment of the individual; and Communications for
case management or care coordination for the individual, or to direct or
recommend alternative treatments, therapies, health care providers, or care
settings to the individual. Marketing also is an arrangement between a
covered entity and any other entity whereby the covered entity discloses
protected health information, in exchange for direct or indirect remuneration,
for the other entity to communicate about its own products or services
encouraging the use or purchase of those products or services.
A covered entity must obtain an authorization to use or disclose protected
health information for marketing, except for face-to-face marketing
communications between a covered entity and an individual, and for a
covered entities provision of promotional gifts of nominal value. No
authorization is needed, however, to make a communication that falls within
one of the exceptions to the marketing definition.
An authorization for marketing that involves the covered entities receipt of
direct or indirect remuneration from a third party must reveal that fact. See
OCR "Marketing"
Limiting Uses and Disclosures to the Minimum Necessary
Minimum Necessary
A central aspect of the Privacy Rule is the principle of minimum necessary
use and disclosure. A covered entity must make reasonable efforts to use,
disclose, and request only the minimum amount of protected health
information needed to accomplish the intended purpose of the use,
disclosure, or request. A covered entity must develop and implement
policies and procedures to reasonably limit uses and disclosures to the
minimum necessary. When the minimum necessary standard applies to a use
or disclosure, a covered entity may not use, disclose, or request the entire
medical record for a particular purpose, unless it can specifically justify the
whole record as the amount reasonably needed for the purpose.
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The minimum necessary requirement is not imposed in any of the following
circumstances: (a) disclosure to or a request by a health care provider for
treatment; (b) disclosure to an individual who is the subject of the
information, or the individuals personal representative; (c) use or disclosure
made pursuant to an authorization; (d) disclosure to HHS for complaint
investigation, compliance review or enforcement; (e) use or disclosure that is
required by law; or (f) use or disclosure required for compliance with the
HIPAA Transactions Rule or other HIPAA Administrative Simplification
Rules.
Access and Uses. For internal uses, a covered entity must develop and
implement policies and procedures that restrict access and uses of protected
health information based on the specific roles of the members of their
workforce. These policies and procedures must identify the persons, or
classes of persons, in the workforce who need access to protected health
information to carry out their duties, the categories of protected health
information to which access is needed, and any conditions under which they
need the information to do their jobs.
Disclosures and Requests for Disclosures. Covered entities must establish
and implement policies and procedures (which may be standard protocols)
for routine, recurring disclosures, or requests for disclosures, that limits the
protected health information disclosed to that which is the minimum amount
reasonably necessary to achieve the purpose of the disclosure. Individual
review of each disclosure is not required. For non-routine, non-recurring
disclosures, or requests for disclosures that it makes, covered entities must
develop criteria designed to limit disclosures to the information reasonably
necessary to accomplish the purpose of the disclosure and review each of
these requests individually in accordance with the established criteria.
Reasonable Reliance. If another covered entity makes a request for
protected health information, a covered entity may rely, if reasonable under
the circumstances, on the request as complying with this minimum necessary
standard. Similarly, a covered entity may rely upon requests as being the
minimum necessary protected health information from: (a) a public official,
(b) a professional (such as an attorney or accountant) who is the covered
entities business associate, seeking the information to provide services to or
for the covered entity; or (c) a researcher who provides the documentation or
representation required by the Privacy Rule for research.
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Notice and Other Individual Rights
Privacy Practices Notice
Each covered entity, with certain exceptions, must provide a notice of its
privacy practices. The Privacy Rule requires that the notice contain certain
elements. The notice must describe the ways in which the covered entity
may use and disclose protected health information. The notice must state the
covered entities duties to protect privacy, provide a notice of privacy
practices, and abide by the terms of the current notice. The notice must
describe individuals rights, including the right to complain to HHS and to
the covered entity if they believe their privacy rights have been violated. The
notice must include a point of contact for further information and for making
complaints to the covered entity. Covered entities must act in accordance
with their notices. The Rule also contains specific distribution requirements
for direct treatment providers, all other health care providers, and health
plans.
Acknowledgement of Notice Receipt
A covered health care provider with a direct treatment relationship with
individuals must make a good faith effort to obtain written
acknowledgement from patients of receipt of the privacy practices notice.
The Privacy Rule does not prescribe any particular content for the
acknowledgement. The provider must document the reason for any failure to
obtain the patients written acknowledgement. The provider is relieved of the
need to request acknowledgement in an emergency treatment situation.
Access
Except in certain circumstances, individuals have the right to review and
obtain a copy of their protected health information in a covered entities
designated record set. The designated record set is that group of records
maintained by or for a covered entity that is used, in whole or part, to make
decisions about individuals, or that is a providers medical and billing records
about individuals or a health plans enrollment, payment, claims adjudication,
and case or medical management record systems. The Rule excepts from the
right of access the following protected health information: psychotherapy
notes, information compiled for legal proceedings, laboratory results to
which the Clinical Laboratory Improvement Act (CLIA) prohibits access, or
information held by certain research laboratories. For information included
within the right of access, covered entities may deny an individual access in
certain specified situations, such as when a health care professional believes
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access could cause harm to the individual or another. In such situations, the
individual must be given the right to have such denials reviewed by a
licensed health care professional for a second opinion. Covered entities may
impose reasonable, cost-based fees for the cost of copying and postage.
Amendment
The Rule gives individuals the right to have covered entities amend their
protected health information in a designated record set when that
information is inaccurate or incomplete. If a covered entity accepts an
amendment request, it must make reasonable efforts to provide the
amendment to persons that the individual has identified as needing it, and to
persons that the covered entity knows might rely on the information to the
individual’s detriment. If the request is denied, covered entities must provide
the individual with a written denial and allow the individual to submit a
statement of disagreement for inclusion in the record. The Rule specifies
processes for requesting and responding to a request for amendment. A
covered entity must amend protected health information in its designated
record set upon receipt of notice to amend from another covered entity.
Disclosure Accounting
Individuals have a right to an accounting of the disclosures of their protected
health information by a covered entity or the covered entities business
associates. The maximum disclosure accounting period is the six years
immediately preceding the accounting request, except a covered entity is not
obligated to account for any disclosure made before its Privacy Rule
compliance date.
The Privacy Rule does not require accounting for disclosures: (a) for
treatment, payment, or health care operations; (b) to the individual or the
individuals personal representative; (c) for notification of or to persons
involved in an individual’s health care or payment for health care, for
disaster relief, or for facility directories; (d) pursuant to an authorization; (e)
of a limited data set; (f) for national security or intelligence purposes; (g) to
correctional institutions or law enforcement officials for certain purposes
regarding inmates or individuals in lawful custody; or (h) incident to
otherwise permitted or required uses or disclosures. Accounting for
disclosures to health oversight agencies and law enforcement officials must
be temporarily suspended on their written representation that an accounting
would likely impede their activities.
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Restriction Request
Individuals have the right to request that a covered entity restrict use or
disclosure of protected health information for treatment, payment or health
care operations, disclosure to persons involved in the individuals health care
or payment for health care, or disclosure to notify family members or others
about the individuals general condition, location, or death. A covered entity
is under no obligation to agree to requests for restrictions. A covered entity
that does agree must comply with the agreed restrictions, except for
purposes of treating the individual in a medical emergency.
Confidential Communications Requirements
Health plans and covered health care providers must permit individuals to
request an alternative means or location for receiving communications of
protected health information by means other than those that the covered
entity typically employs. For example, an individual may request that the
provider communicate with the individual through a designated address or
phone number. Similarly, an individual may request that the provider send
communications in a closed envelope rather than a post card. Health plans
must accommodate reasonable requests if the individual indicates that the
disclosure of all or part of the protected health information could endanger
the individual. The health plan may not question the individual’s statement
of endangerment. Any covered entity may condition compliance with a
confidential communication request on the individual specifying an
alternative address or method of contact and explaining how any payment
will be handled.
Administrative Requirements
HHS recognizes that covered entities range from the smallest provider to the
largest, multi-state health plan. Therefore the flexibility and scalability of the
Rule are intended to allow covered entities to analyze their own needs and
implement solutions appropriate for their own environment. What is
appropriate for a particular covered entity will depend on the nature of the
covered entities business, as well as the covered entities size and resources.
Privacy Policies and Procedures
A covered entity must develop and implement written privacy policies and
procedures that are consistent with the Privacy Rule.
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Privacy Personnel
A covered entity must designate a privacy official responsible for
developing and implementing its privacy policies and procedures, and a
contact person or contact office responsible for receiving complaints and
providing individuals with information on the covered entities privacy
practices.
Workforce Training and Management
Workforce members include employees, volunteers, trainees, and may also
include other persons whose conduct is under the direct control of the entity
(whether or not they are paid by the entity). A covered entity must train all
workforce members on its privacy policies and procedures, as necessary and
appropriate for them to carry out their functions. A covered entity must have
and apply appropriate sanctions against workforce members who violate its
privacy policies and procedures or the Privacy Rule.
Mitigation
A covered entity must mitigate, to the extent practicable, any harmful effect
it learns was caused by use or disclosure of protected health information by
its workforce or its business associates in violation of its privacy policies
and procedures or the Privacy Rule.
Data Safeguards
A covered entity must maintain reasonable and appropriate administrative,
technical, and physical safeguards to prevent intentional or unintentional use
or disclosure of protected health information in violation of the Privacy Rule
and to limit its incidental use and disclosure pursuant to otherwise permitted
or required use or disclosure. For example, such safeguards might include
shredding documents containing protected health information before
discarding them, securing medical records with lock and key or pass code,
and limiting access to keys or pass codes. See OCR Incidental Uses and
Disclosures.
Complaints
A covered entity must have procedures for individuals to complain about its
compliance with its privacy policies and procedures and the Privacy Rule.
The covered entity must explain those procedures in its privacy practices
notice.
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Among other things, the covered entity must identify to whom individuals
can submit complaints to at the covered entity and advise that complaints
also can be submitted to the Secretary of HHS.
Retaliation and Waiver
A covered entity may not retaliate against a person for exercising rights
provided by the Privacy Rule, for assisting in an investigation by HHS or
another appropriate authority, or for opposing an act or practice that the
person believes in good faith violates the Privacy Rule.
Documentation and Record Retention
A covered entity must maintain, until six years after the later of the date of
their creation or last effective date, its privacy policies and procedures, its
privacy practices notices, disposition of complaints, and other actions,
activities, and designations that the Privacy Rule requires to be documented.
Fully-Insured Group Health Plan Exception
The only administrative obligations with which a fully-insured group health
plan that has no more than enrollment data and summary health information
is required to comply are the (1) ban on retaliatory acts and waiver of
individual rights, and (2) documentation requirements with respect to plan
documents if such documents are amended to provide for the disclosure of
protected health information to the plan sponsor by a health insurance issuer
or HMO that services the group health plan.
Organizational Options
The Rule contains provisions that address a variety of organizational issues
that may affect the operation of the privacy protections.
Hybrid Entity
The Privacy Rule permits a covered entity that is a single legal entity and
that conducts both covered and non-covered functions to elect to be a hybrid
entity (The activities that make a person or organization a covered entity are
its covered functions ) To be a hybrid entity, the covered entity must
designate in writing its operations that perform covered functions as one or
more health care components. After making this designation, most of the
requirements of the Privacy Rule will apply only to the health care
components. A covered entity that does not make this designation is subject
in its entirety to the Privacy Rule.
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Affiliated Covered Entity
Legally separate covered entities that are affiliated by common ownership or
control may designate themselves (including their health care components)
as a single covered entity for Privacy Rule compliance. The designation
must be in writing. An affiliated covered entity that performs multiple
covered functions must operate its different covered functions in compliance
with the Privacy Rule provisions applicable to those covered functions.
Organized Health Care Arrangement
The Privacy Rule identifies relationships in which participating covered
entities share protected health information to manage and benefit their
common enterprise as organized health care arrangements. Covered entities
in an organized health care arrangement can share protected health
information with each other for the arrangement¡¦s joint health care
operations.
Covered Entities with Multiple Covered Functions
A covered entity that performs multiple covered functions must operate its
different covered functions in compliance with the Privacy Rule provisions
applicable to those covered functions.
The covered entity may not use or disclose the protected health information
of an individual who receives services from one covered function (e.g.,
health care provider) for another covered function (e.g., health plan) if the
individual is not involved with the other function.
Group Health Plan Disclosures to Plan Sponsors
A group health plan and the health insurer or HMO offered by the plan may
disclose the following protected health information to the plan sponsor, the
employer, union, or other employee organization that sponsors and
maintains the group health plan:
Enrollment or disenrollment information with respect to the group
health plan or a health insurer or HMO offered by the plan.
Requested by the plan sponsor, summary health information for the
plan sponsor to use to obtain premium bids for providing health
insurance coverage through the group health plan, or to modify,
amend, or terminate the group health plan. Summary health
information is information that summarizes claims history, claims
expenses, or types of claims experience of the individuals for whom
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the plan sponsor has provided health benefits through the group health
plan, and that is stripped of all individual identifiers other than five
digit zip code (though it need not qualify as de-identified protected
health information).
Protected health information of the group health plans enrollees for
the plan sponsor to perform plan administration functions. The plan
must receive certification from the plan sponsor that the group health
plan document has been amended to impose restrictions on the plan
sponsors use and disclosure of the protected health information. These
restrictions must include the representation that the plan sponsor will
not use or disclose the protected health information for any
employment-related action or decision or in connection with any other
benefit plan.
Other Provisions:
Personal Representatives and Minors Personal Representatives
The Privacy Rule requires a covered entity to treat a "personal
representative" the same as the individual, with respect to uses and
disclosures of the individuals protected health information, as well as the
individuals rights under the Rule. A personal representative is a person
legally authorized to make health care decisions on an individual’s behalf or
to act for a deceased individual or the estate. The Privacy Rule permits an
exception when a covered entity has a reasonable belief that the personal
representative may be abusing or neglecting the individual, or that treating
the person as the personal representative could otherwise endanger the
individual. Special case: Minors. In most cases, parents are the personal
representatives for their minor children. Therefore, in most cases, parents
can exercise individual rights, such as access to the medical record, on
behalf of their minor children. In certain exceptional cases, the parent is not
considered the personal representative. In these situations, the Privacy Rule
defers to State and other law to determine the rights of parents to access and
control the protected health information of their minor children. If State and
other law is silent concerning parental access to the minors protected health
information, a covered entity has discretion to provide or deny a parent
access to the minors health information, provided the decision is made by a
licensed health care professional in the exercise of professional judgment.
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State Law Preemption
In general, State laws that are contrary to the Privacy Rule are preempted by
the federal requirements, which means that the federal requirements will
apply. Contrary means that it would be impossible for a covered entity to
comply with both the State and federal requirements, or that the provision of
State law is an obstacle to accomplishing the full purposes and objectives of
the Administrative Simplification provisions of HIPAA.86 The Privacy Rule
provides exceptions to the general rule of federal preemption for contrary
State laws that (1) relate to the privacy of individually identifiable health
information and provide greater privacy protections or privacy rights with
respect to such information, (2) provide for the reporting of disease or
injury, child abuse, birth, or death, or for public health surveillance,
investigation, or intervention, or (3) require certain health plan reporting,
such as for management or financial audits.
A limited data set is protected health information that excludes the following
direct identifiers of the individual or of relatives, employers, or household
members of the individual: (i) Names; (ii) Postal address information, other
than town or city, State and zip code; (iii) Telephone numbers; (iv) Fax
numbers; (v) Electronic mail addresses: (vi) Social security numbers; (vii)
Medical record numbers; (viii) Health plan beneficiary numbers; (ix)
Account numbers; (x) Certificate/license numbers; (xi) Vehicle identifiers
and serial numbers, including license plate numbers; (xii) Device identifiers
and serial numbers; (xiii) Web Universal Resource Locators (URLs); (xiv)
Internet Protocol (IP) address numbers; (xv) Biometric identifiers, including
finger and voice prints; (xvi) Full face photographic images and any
comparable images.
A covered entity may condition the provision of health care solely to
generate protected health information for disclosure to a third party on the
individual giving authorization to disclose the information to the third party.
For example, a covered entity physician may condition the provision of a
physical examination to be paid for by a life insurance issuer on an
individual’s authorization to disclose the results of that examination to the
life insurance issuer. A health plan may condition enrollment or benefits
eligibility on the individual giving authorization, requested before the
individuals enrollment, to obtain protected health information (other than
psychotherapy notes) to determine the individuals eligibility or enrollment or
for underwriting or risk rating. A covered health care provider may
condition treatment related to research (e.g., clinical trials) on the individual
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giving authorization to use or disclose the individuals protected health
information for the research. 45 C.F.R. 508(b)(4). 46 45 CFR 164.532. OCR
Privacy Rule Summary 21 Last Revised 05/03.
Psychotherapy notes means notes recorded (in any medium) by a health care
provider who is a mental health professional documenting or analyzing the
contents of conversation during a private counseling session or a group,
joint, or family counseling session and that are separated from the rest of the
of the individuals medical record. Psychotherapy notes excludes medication
prescription and monitoring, counseling session start and stop times, the
modalities and frequencies of treatment furnished, results of clinical tests,
and any summary of the following items: diagnosis, functional status, the
treatment plan, symptoms, prognosis, and progress to date.( C.F.R. 164.501. 48 45
C.F.R. 164.508(a)(2). 49 45 C.F.R. 164.501 and 164.508(a)(3). 50 45 C.F.R. 164.502(b) and 164.514 (d).
51 45 C.F.R. 164.520(a) and (b)).
A group health plan, or a health insurer or HMO with respect to the group
health plan, that intends to disclose protected health information (including
enrollment data or summary health information) to the plan sponsor, must
state that fact in the notice. Special statements are also required in the notice
if a covered entity intends to contact individuals about health-related
benefits or services, treatment alternatives, or appointment reminders, or for
the covered entity’s own fundraising. (52 45 C.F.R. , 164.520(c). 53 45 C.F.R. 164.520(d).
54 45 C.F.R. 164.520(c). ,55 45 C.F.R. , 164.524. 56 45 C.F.R., 164.501).
A covered entity may deny an individual access, provided that the individual
is given a right to have such denials reviewed by a licensed health care
professional (who is designated by the covered entity and who did not
participate in the original decision to deny), when a licensed health care
professional has determined, in the exercise of professional judgment, that:
(a) the access requested is reasonably likely to endanger the life or physical
safety of the individual or another person; (b) the protected health
information makes reference to another person (unless such other person is a
health care provider) and the access requested is reasonably likely to cause
substantial harm to such other person; or (c) the request for access is made
by the individual’s personal representative and the provision of access to
such personal representative is reasonably likely to cause substantial harm to
the individual or another person.
A covered entity may deny access to individuals, without providing the
individual an opportunity for review, in the following protected situations:
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(a) the protected health information falls under an exception to the right of
access; (b) an inmate request for protected health information under certain
circumstances; (c) information that a provider creates or obtains in the
course of research that includes treatment for which the individual has
agreed not to have access as part of consenting to participate in the research
(as long as access to the information is restored upon completion of the
research); (d) for records subject to the Privacy Act, information to which
access may be denied under the Privacy Act, 5 U.S.C. , 552a; and (e)
information obtained under a promise of confidentiality from a source other
than a health care provider, if granting access would likely reveal the source.
45 C.F.R. , 164.524. 58 45 C.F.R. , 164.526., OCR Privacy Rule Summary
22 Last Revised 05/03.
Covered entities may deny an individual’s request for amendment only
under specified circumstances. A covered entity may deny the request if it:
(a) may exclude the information from access by the individual; (b) did not
create the information (unless the individual provides a reasonable basis to
believe the originator is no longer available); (c) determines that the
information is accurate and complete; or (d) does not hold the information in
its designated record set. 164.526(a)(2). 60 45 C.F.R. 164.528. 61 45 C.F.R.
164.522(a).
Common ownership exists if an entity possesses an ownership or equity
interest of five percent or more in another entity; common control exists if
an entity has the direct or indirect power significantly to influence or direct
the actions or policies of another entity. The Privacy Rule at 45 C.F.R.,
160.103 identifies several types of organized health care arrangements such
as a clinically-integrated setting where individuals typically receive health
care from more than one provider and an organized system of health care in
which the participating covered entities hold themselves out to the public as
part of a joint arrangement. OCR Privacy Rule Summary 23 Last Revised
05/03.
5. Continuing Education
The following information regarding continuing education is quoted directly
from the California Board of Behavioral Sciences written standards:
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MFT and LCSW CE Requirements
MFTs, LCSWs, LEPs, and LPCC’s must complete 36 hours of continuing
education within the preceding two years of their license renewal date.
Licensees renewing for the first time only need to complete a minimum of
18 hours of continuing education by the expiration date of the license. The
Continuing Education and License Renewal Information Brochure is a
helpful publication for keeping licensees informed of new continuing
education requirements. Continuing education must be taken from current
Board approved providers.
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Mandatory Coursework
MFTs and LCSWs are required to complete 6 hours of Law and Ethics
training with every renewal. All other mandatory courses are one-time
requirements. Please refer to the CE Chart for more information.
Auditing Information
If you are a licensee, you certify completion of continuing education on your
renewal application. Random CE audits ensure compliance. If audited, you
will receive a letter from the Board requesting copies of your continuing
education certificates or course documentation as proof of compliance.
Failure to comply with the Board’s audit may result in enforcement action.
Keep proof of completed coursework for at least four years.
Exceptions from the CE Requirements
A Request for Continuing Education Exception must be submitted to the
Board at least 60 days prior to license expiration. The Board will notify you
within 30 working days after receipt of the request for exception’s status. If
the request for exception is denied, you are responsible for completing the
full amount of continuing education required for license renewal. The Board
shall grant the exception if provided evidence, satisfactory to the Board, that:
 For at least one year during the licensee’s previous license renewal
period the licensee was absent from California due to military service.
 For at least one year during the licensee’s previous license renewal
period the licensee resided in another country; or
 During the licensee’s previous renewal period, the licensee or an
immediate family member where the licensee has primary
responsibility for the care of that family member was suffering from
or suffered a disability. A disability is a physical or mental impairment
that substantially limits one or more of the major life activities of an
individual. Verification of the disability must include all of the
following:
1. The nature and extent of the disability
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2. An explanation of how the disability would hinder the licensee
from completing the continuing education requirement.
3. The name, title, address, telephone number, professional license
or certification number, and original signature of the licensed
physician or psychologist verifying the disability
4. If the request for exception is approved, it shall be valid for one
renewal period.”
6. Professional Ethics
6A. CAMFT Ethical Standards Part II, Section II D
1) Any "member who knows of a violation of the CAMFT Ethical Standards
for Marriage and Family Therapists should bring this fact to the attention of
the Ethics Committee in the form of a complaint."
2) Thus a member must "know" of a violation (not suspect) and that upon
such knowledge, a member "should" bring a complaint (in other words, is
not required to bring a complaint).
d. NASW Ethical Standard 2.11 (d)
 "When necessary, social workers who believe that a colleague has
acted unethically should take action through appropriate formal
channels (such as contacting a state licensing board or regulatory
body, an NASW committee inquiry, or other professional ethics
committees)."
 In the case of sexual misconduct, a therapist is required to give the
client the brochure, "Professional Therapy Never Includes Sex."
D. Statute of limitations on BBS disciplinary actions
1. The BBS is required to file an accusation or statements of issues against
the respondent within three years from the date the BBS discovers an alleged
act or omission, or within seven years from the date such alleged act or
omission occurred, whichever comes first.
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2. This statute of limitation does not apply for accusations alleging the
procurement of a license by fraud or misrepresentation.
3. If the BBS allegation concerns a licensee or registrant’s act of omission
with a minor, the seven-year disciplinary limitation would not go into effect
until the minor reaches 18 years of age.
4. If the BBS allegation concerns sexual misconduct, an accusation shall be
filed within three years after the board discovers the act or within 10 years
after the act alleged occurred, which occurred first.
5. Apologies made by a therapist to a patient, where there is no wrongdoing
by the therapist, are no longer discoverable evidence in administrative
disciplinary actions. Examples that the law states are ”statements, writings,
or benevolent gestures expressing sympathy or a general sense of
benevolence relating to the pain, suffering, or death of a person involved in
an accident.”
Professional Negligence
1. California Approved Civil Instructions
a. A therapist is considered negligent if s/he fails to exercise a
standard of care.
b. In other words, what a reasonably competent therapist (licensee,
associate, intern, trainee, supervisor) would do under similar
circumstances (the expected level of care would vary in accordance to
the level of training and experience that each of these professionals
would possess).
c. A therapist who chooses a clinically accepted protocol that turns out
not be as productive a choice as another clinically accepted treatment
is not necessarily negligent (CACI 506).
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Legal Precedents
a. A mental health professional would not be considered negligent for a
reasonable error in response to a given set of circumstances. [Sanchez v.
Rodriguez (1964) 226 Cal. App. 2d 439, 449].
6B. Revised CAMFT Ethical Standards Effective 7-01-2008 Part 1Ethical Standards for Marriage and Family Therapists
The Revised CAMFT Ethical Standards became effective July 1st, 2008.
The revised ethical standards include twenty new sections, twelve of which
specifically address the activity of supervisors, supervisees, and students.
It is important for MFT’s to thoroughly read the revised ethical standards in
their entirety. However, the primary additions/changes will be highlighted
in yellow and discussed in the following paragraphs.
The following is quoted directly from CAMFT’s Revised Ethical Standards:
Introduction
“The Board of Directors of CAMFT hereby publishes pursuant to the
Association Bylaws, a Revised Code of Ethical Standards for Marriage and
Family Therapists. Members of CAMFT are expected to be familiar with
and abide by these standards and by applicable California laws and
regulations governing the conduct of licensed marriage, and family
therapists, supervisors, educators, interns, applicants, students, and trainees.
The effective date of these revised standards is July 1st, 2008.
The practice of marriage, and family therapy and psychotherapy is both an
art and a science. It is varied in its approach, technique, modality, and
method of service delivery. These ethical standards are to be read,
understood, and utilized as a guide for ethical behavior. The general
principles contained in this code of conduct are also used as a basis for the
adjudication of ethical issues and/or complaints (both within and outside of
CAMFT) that may arise. Ethical behavior must satisfy not only the judgment
of the individual marriage and family therapist, but also the judgment of
his/her peers, based upon a set of recognized norms.
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We recognize that the development of standards is an ongoing process, and
that every conceivable situation that may occur cannot be expressly covered
by any set of standards. The absence of a specific prohibition against a
particular kind of conduct does not mean that such conduct is either ethical
or unethical. While the specific wording of these standards is important, the
spirit and intent of the principles should be taken into consideration by those
utilizing or interpreting this code. The titles to the various sections of these
standards are not considered a part of the actual standard. Violations of these
standards may be brought to the attention of the CAMFT Ethics Committee,
in writing, at CAMFT's administrative office, 7901 Raytheon Road, San
Diego, CA 92111-1606, or at such other address as may be necessary
because of a change in location of the administrative office.”
1. RESPONSIBILITY TO PATIENTS: Marriage and family therapists
advance the welfare of families and individuals, respect the rights of those
persons seeking their assistance, and make reasonable efforts to ensure that
their services are used appropriately.
1.1 NON-DISCRIMINATION: Marriage and family therapists do not
condone or engage in discrimination, or refuse professional service to
anyone on the basis of race, gender, religion, national origin, age, sexual
orientation, disability, socioeconomic, or marital status. Marriage and family
therapists make reasonable efforts to accommodate patients who have
physical disabilities.
1.2 DUAL RELATIONSHIPS-DEFINITION: Marriage and family
therapists are aware of their influential position with respect to patients, and
they avoid exploiting the trust and dependency of such persons. Marriage
and family therapists therefore avoid dual relationships with patients that are
reasonably likely to impair professional judgment or lead to exploitation. A
dual relationship occurs when a therapist and his/her patient engage in a
separate and distinct relationship either simultaneously with the therapeutic
relationship, or during a reasonable period of time following the termination
of the therapeutic relationship. Not all dual relationships are unethical, and
some dual relationships cannot be avoided. When a concurrent or subsequent
dual relationship occurs, marriage and family therapists take appropriate
professional precautions to ensure that judgment is not impaired and that no
exploitation occurs.
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1.2.1 UNETHICAL DUAL RELATIONSHIPS: Other acts that would
result in unethical dual relationships include, but are not limited to,
borrowing money from a patient, hiring a patient, engaging in a business
venture with a patient, or engaging in a close personal relationship with a
patient. Such acts with a patient's spouse, partner or family member may
also be considered unethical dual relationships.
1.2.2 SEXUAL CONTACT: Sexual intercourse, sexual contact or sexual
intimacy with a patient, or a patient's spouse or partner, or a patient’s
immediate family member, during the therapeutic relationship, or during the
two years following the termination of the therapeutic relationship, is
unethical. Should a marriage and family therapist engage in sexual intimacy
with a former patient or a patient’s spouse or partner, or a patient’s
immediate family member, following the two years after termination or last
professional contact, the therapist shall consider the potential harm to or
exploitation of the former patient or to the patient’s family.
1.2.3 PRIOR SEXUAL RELATIONSHIP: A marriage and family
therapist does not enter into a therapeutic relationship with a person with
whom he/she has had a sexual relationship or with a partner or the
immediate family member of a person with whom he/she has had a sexual
relationship.
1.3 TREATMENT DISRUPTION: Marriage and family therapists are
aware of their professional and clinical responsibilities to provide consistent
care to patients and maintain practices and procedures that assure
undisrupted care. Such practices and procedures may include, but are not
limited to, providing contact information and specified procedures in case of
emergency or therapist absence, conducting appropriate terminations, and
providing for a professional will.
1.3.1 TERMINATION: Marriage and family therapists use sound clinical
judgment when terminating therapeutic relationships and do so in an
appropriate manner. Reasons for termination may include, but are not
limited to, the patient is not benefiting from treatment; continuing treatment
is not clinically appropriate; the therapist is unable to provide treatment due
to the therapist’s incapacity or extended absence, or in order to avoid an
ethical conflict or problem.
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1.3.2 ABANDONMENT: Marriage and family therapists do not abandon or
neglect patients in treatment. If a therapist is unable or unwilling to continue
to provide professional services, the therapist will assist the patient in
making clinically appropriate arrangements for continuation of treatment.
1.3.3 FINANCIAL GAIN: Marriage and family therapists do not maintain
therapeutic relationships solely for financial gain.
1.3.4 NON-PAYMENT OF FEES: Marriage and family therapists do not
terminate patient relationships for non-payment of fees except when the
termination is handled in a clinically appropriate manner.
1.4 PATIENT AUTONOMY: Marriage and family therapists respect the
right of patients to make decisions and help them to understand the
consequences of their decisions. When clinically appropriate, marriage and
family therapists advise their patients that decisions on the status of their
personal relationships, including dissolution, are the responsibilities of the
patient(s).
1.4.1 ELECTRONIC THERAPY: When patients are not physically
present (e.g., therapy by telephone or Internet) during the provision of
therapy, marriage and family therapists take extra precautions to meet their
responsibilities to patients. Prior to utilizing electronic therapy, marriage and
family therapists consider the appropriateness and suitability of this
therapeutic modality to the patient’s needs. When therapy occurs by
electronic means, marriage and family therapists inform patients of the
potential risks, consequences, and benefits, including but not limited to,
issues of confidentiality, clinical limitations, transmission difficulties, and
ability to respond to emergencies. Marriage and family therapists ensure that
such therapy complies with the informed consent requirements of the
California Telemedicine Act.
1.5 THERAPIST DISCLOSURES: Marriage and family therapists provide
adequate information to patients in clear and understandable language
so that patients can make meaningful decisions about their therapy.
1.5.1 RISKS AND BENEFITS: Marriage and family therapists inform
patients of the potential risks and benefits of therapy when utilizing novel or
experimental techniques or when there is a risk of physical harm that could
result from the utilization of any technique.
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1.5.2 EMERGENCIES/CONTACT BETWEEN SESSIONS: Marriage
and family therapists inform patients of the extent of their availability for
emergencies and for other contacts between sessions. When a marriage and
family therapist is not located in the same geographic area as the patient,
he/she shall provide the patient with appropriate resources in the patient's
locale for contact in case of emergency.
1.5.3 CONSENT FOR RECORDING/OBSERVATION: Marriage and
family therapists obtain written informed consent from patients before
videotaping, audio recording, or permitting third party observation.
1.5.4 LIMITS OF CONFIDENTIALITY: Marriage and family therapists
are encouraged to inform patients as to certain exceptions to confidentiality
such as child abuse reporting, elder and dependent adult abuse reporting, and
patients dangerous to themselves or others.
1.5.5 THERAPIST BACKGROUND: Marriage and family therapists are
encouraged to inform patients at an appropriate time and within the
context of the psychotherapeutic relationship of their experience,
education, specialties, and theoretical and professional orientation,
and any other information deemed appropriate by the therapist.
1.6 EXPLOITATION: Marriage and family therapists do not use their
professional relationships with patients to further their own interests.
1.7 PATIENT BENEFIT: Marriage and family therapists continually
monitor their effectiveness and take steps to improve when necessary.
Marriage and family therapists continue therapeutic relationships only so
long as it is reasonably clear that patients are benefiting from the
relationship.
1.8 EMPLOYMENT AND CONTRACTUAL TERMINATIONS: When
terminating employment or contractual relationships, marriage and family
therapists primarily consider the best interests of the patient when resolving
issues of continued responsibility for patient care.
1.9 FAMILY UNIT/CONFLICTS: When treating a family unit(s),
marriage and family therapists carefully consider the potential conflict that
may arise between the family unit(s) and each individual. Marriage and
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family therapists clarify, at the commencement of treatment, which person
or persons are clients and the nature of the relationship(s) the therapist will
have with each person involved in the treatment.
1.10 WITHHOLDING RECORDS/NON-PAYMENT: Marriage and
family therapists do not withhold patient records or information solely
because the therapist has not been paid for prior professional services.
1.11 CONSULTATION: When appropriate, marriage and family therapists
consult, collaborate with, and refer to physicians, other health care
professionals, and community resources in order to improve and protect the
health and welfare of the patient.
1.12 ADVOCATE WITH THIRD PARTY PAYERS: When appropriate,
marriage and family therapists advocate for mental health care they believe
will benefit their patients. In appropriate circumstances, they challenge
denials of care, or denials of payment for care, by managed care
organizations, insurers, or other payers.
1.13 TREATMENT ALTERNATIVES: Marriage and family therapists
discuss appropriate treatment alternatives with patients. Marriage and family
therapists do not limit their discussions of treatment alternatives to what is
covered by third-party payers.
1.14 POTENTIAL CONFLICTS: Marriage and family therapists carefully
consider potential conflicts when providing concurrent or sequential
individual, couple, family, and group treatment, and will take
reasonable care to avoid or minimize such conflicts.
1.15 DOCUMENTING TREATMENT DECISIONS: Marriage and
family therapists are encouraged to carefully document in their
records when significant decisions are made, e.g., determining
reasonable suspicion of child, elder or dependent adult abuse,
determining when a patient is a danger to self or others, when making
major changes to a treatment plan, or when changing the unit being
treated.
1.16 NON-THERAPIST ROLES: When marriage and family therapists
engage in professional roles other than treatment or supervision
(including, but not limited to, managed care utilization review,
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consultation, coaching, adoption service, or behavior analysis), they
act solely within that role and clarify, when necessary to avoid
confusion with consumers and employers, how that role is
distinguished from the practice of marriage and family therapy.
1.17 THIRD PARTY PAYER DISCLOSURES: Marriage and family
therapists advise patients of the information that will likely be
disclosed when submitting claims to managed care companies,
insurers, or other third party payers, such as dates of treatment,
diagnosis, prognosis, progress, and treatment plan.
2. CONFIDENTIALITY Marriage and family therapists have unique
confidentiality responsibilities because the "patient" in a therapeutic
relationship may be more than one person. The overriding principle is that
marriage and family therapists respect the confidences of their patient(s).
2.1 DISCLOSURES OF CONFIDENTIAL INFORMATION: Marriage
and family therapists do not disclose patient confidences, including the
names or identities of their patients, to anyone except a) as mandated by law
b) as permitted by law c) when the marriage and family therapist is a
defendant in a civil, criminal, or disciplinary action arising from the therapy
(in which case patient confidences may only be disclosed in the course of
that action), or d) if there is an authorization previously obtained in writing,
and then such information may only be revealed in accordance with the
terms of the authorization.
2.2 SIGNED AUTHORIZATIONS- RELEASE OF INFORMATION:
When there is a request for information related to any aspect of
psychotherapy or treatment, each member of the unit receiving such
therapeutic treatment must sign an authorization before a marriage and
family therapist will disclose information received from any member of the
treatment unit.
2.3 ELECTRONIC MEDIA: Marriage and family therapists are aware of
the possible adverse effects of technological changes with respect to the
dissemination of patient information, and take care when disclosing such
information. Marriage and family therapists are also aware of the limitations
regarding confidential transmission by Internet or electronic media and take
care when transmitting or receiving such information via these mediums.
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2.4 MAINTENANCE OF PATIENT RECORDSCONFIDENTIALITY: Marriage and family therapists store, transfer,
transmit, and/or dispose of patient records in ways that protect
confidentiality.
2.5 EMPLOYEES- CONFIDENTIALITY: Marriage and family therapists
take appropriate steps to ensure, insofar as possible, that the confidentiality
of patients is maintained by their employees, supervisees, assistants, and
volunteers.
2.6 USE OF CLINICAL MATERIALS- CONFIDENTIALITY:
Marriage and family therapists use clinical materials in teaching, writing,
and public presentations only if a written authorization has been previously
obtained in accordance with 2.1 d), or when appropriate steps have been
taken to protect patient identity.
2.7 GROUPS- CONFIDENTIALITY: Marriage and family therapists,
when working with a group, educate the group regarding the importance of
maintaining confidentiality, and are encouraged to obtain written agreement
from group participants to respect the confidentiality of other members of
the group.
3. PROFESSIONAL COMPETENCE AND INTEGRITY Marriage and
family therapists maintain high standards of professional competence and
integrity.
3.1 CONVICTION OF CRIME: Marriage and family therapists are in
violation of this Code and subject to termination of membership, or other
appropriate action, if they: a) are convicted of a crime substantially related to
their professional qualifications or functions; b) are expelled from or
disciplined by other professional organizations; c) have licenses or
certificates that are lapsed, suspended, or revoked or are otherwise
disciplined by regulatory bodies; d) if they continue to practice when they
are no longer competent to practice because they are impaired due to
physical or mental causes or the abuse of alcohol or other substances; or e)
fail to cooperate with the Association or the Ethics Committee at any point
from the inception of an ethical complaint through the completion of all
proceedings regarding that complaint.
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3.2 FINANCIAL INCENTIVES: Marriage and family therapists avoid
contractual arrangements that provide financial incentives to withhold or
limit medically/psychologically necessary care.
3.3 PATIENT RECORDS: Marriage and family therapists create and
maintain patient records, whether written, taped, computerized, or stored in
any other medium, consistent with sound clinical practice.
3.4 PROFESSIONAL ASSISTANCE: Marriage and family therapists seek
appropriate professional assistance for their personal problems or conflicts
that impair work performance or clinical judgment.
3.5 STAYING CURRENT: Marriage and family therapists remain abreast
of developments in their field through educational activities or clinical
experiences. Marriage and family therapists, when acting as teachers,
supervisors, and researchers, stay abreast of changes in the field, maintain
relevant standards of scholarship, and present accurate information.
3.6 CULTURAL SENSITIVITY: Marriage and family therapists actively
strive to identify and understand the diverse cultural backgrounds of their
clients by gaining knowledge, personal awareness, and developing
sensitivity and skills pertinent to working with a diverse client population.
3.7 THERAPIST CULTURAL VALUES: Marriage and family therapists
make continuous efforts to be aware of how their cultural/racial/ethnic
identity, values, and beliefs affect the process of therapy.
3.8 HARASSMENT OR EXPLOITATION: Marriage and family
therapists do not engage in sexual or other harassment or exploitation of
patients, students, supervisees, employees, or colleagues.
3.9 SCOPE OF COMPETENCE: Marriage and family therapists do not
assess, test, diagnose, treat, or advise on problems beyond the level of their
competence as determined by their education, training, and experience.
While developing new areas of practice, marriage and family therapists take
steps to ensure the competence of their work through education, training,
consultation, and/or supervision.
3.10 PATIENT SEEING TWO THERAPISTS: Marriage and family
therapists do not generally provide professional services to a person
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receiving treatment or therapy from another psychotherapist, except by
agreement with such other psychotherapist or after the termination of the
patient's relationship with the other psychotherapist.
3.11 ELECTRONIC SERVICES: Marriage and family therapists provide
services by Internet or other electronic media to patients located only in
jurisdictions where the therapist may lawfully provide such services.
3.12 RESEARCH FINDINGS: Marriage and family therapists take
reasonable steps to prevent the distortion or misuse of their clinical and
research findings.
3.13 PUBLIC STATEMENTS: Marriage and family therapists, because of
their ability to influence and alter the lives of others, exercise care when
making public their professional recommendations and opinions through
testimony or other public statements.
3.14 LIMITS OF PROFESSIONAL OPINIONS: Marriage and family
therapists do not express professional opinions about an individual's mental
or emotional condition unless they have treated or conducted an examination
of the individual, or unless they reveal the limits of the information upon
which their professional opinions are based, with appropriate cautions as to
the effects of such limited information upon their opinions.
4. SUPERVISOR, STUDENT, AND SUPERVISEE
RESPONSBILITIES: Marriage and family therapists do not exploit the
trust and dependency of students and supervisees.
4.1 DUAL RELATIONSHIPS: Marriage and family therapists are aware
of their influential position with respect to students and supervisees,
and they avoid exploiting the trust and dependency of such persons.
Marriage and family therapists therefore avoid dual relationships that
are reasonably likely to impair professional judgment or lead to
exploitation. Provision of therapy to students or supervisees is
unethical. Provision of marriage and family therapy supervision to
clients is unethical. Sexual intercourse, sexual contact or sexual
intimacy and/or harassment of any kind with students or supervisees is
unethical. Other acts which could result in unethical dual relationships
include, but are not limited to, borrowing money from a supervisee,
engaging in a business venture with a supervisee, or engaging in a
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close personal relationship with a supervisee. Such acts with a
supervisee's spouse, partner or family member may also be considered
unethical dual relationships.
4.2 COMPETENCE OF SUPERVISEES: Marriage and family therapists
do not permit students, employees, or supervisees to perform or to hold
themselves out as competent to perform professional services beyond their
training, level of experience, competence, or unlicensed status.
4.3 MAINTAINING SKILLS OF SUPERVISORS: Marriage and family
therapists who act as supervisors are responsible for maintaining the quality
of their supervision skills and obtaining consultation or supervision for their
work as supervisors whenever appropriate.
4.4 KNOWLEDGE OF SUPERVISORS: Supervisors and educators are
knowledgeable about supervision, relevant laws and regulations, and the
practice of marriage and family therapy. Supervisors and educators are
knowledgeable about and abide by the laws and regulations governing the
conduct of supervisors and supervisees.
4.5 CHANGES IN LAWS AND ETHICS: Supervisors and supervisees are
aware of and stay abreast of changes in professional and ethical standards
and legal requirements, and supervisors ensure that their supervisees are
aware of professional and ethical standards and legal responsibilities.
4.6 CULTURAL DIVERSITY: Supervisors and educators are aware of
and address the role that culture and diversity issues play in the supervisory
relationship, including, but not limited to, evaluating, terminating,
disciplining, or making decisions regarding supervisees or students.
4.7 POLICIES AND PROCEDURES: Supervisors and educators create
policies and procedures that are clear and that are disclosed to supervisees
and students at the commencement of supervision or education.
4.8 PERFORMANCE APPRAISALS: Supervisors and educators provide
supervisees with periodic performance appraisals and evaluative feedback
throughout the supervisory relationship and identify and address the
limitations of supervisees and students that might impede their performance.
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4.9 BUSINESS PRACTICES: Supervisors follow lawful business practices
and employer policies when employing and/or supervising interns, trainees,
applicants, and associates.
4.10 PERFORMANCE ASSISTANCE: Supervisors and educators guide
supervisees and students in securing assistance when needed for the
supervisee to maintain or improve performance, such as personal
psychotherapy, additional education, training, or consultation.
4.11 DISMISSAL: Supervisors shall document their decisions to dismiss
supervisees.
4.12 REVIEW OF TRAINEE AGREEMENTS: Supervisors are aware of
and review any trainee agreements with qualified educational institutions.
4.13 PATIENTS ARE PATIENTS OF EMPLOYER: Supervisees
understand that the patients seen by them are the patients of their employers.
4.14 KNOWLEDGE OF LAWS AND REGULATIONS: Supervisees
have a responsibility to be knowledgeable about relevant laws and
regulations pertaining to the license and practice of marriage and family
therapy.
4.15 MAINTAIN REGISTRATIONS: Supervisees maintain registrations
when required by law and/or regulation and function within this limited role
as permitted by the licensing law and/or regulations.
5. RESPONSIBILITY TO COLLEAGUES: Marriage and family
therapists treat and communicate with and about colleagues in a respectful
manner and with, courtesy, fairness, and good faith, and cooperate with
colleagues in order to promote the welfare and best interests of patients.
5.1 RESPECT CONFIDENCE OF COLLEAGUES: Marriage and family
therapists respect the confidences of colleagues that are shared in the course
of their professional relationships.
5.2 IMPAIRED COLLEAGUES: Marriage and family therapists are
encouraged to assist colleagues who are impaired due to substance abuse,
emotional problems, or mental illness.
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5.3 FRIVOLOUS COMPLAINTS: Marriage and family therapists do not
file or encourage the filing of ethics or other complaints that they know, or
reasonably should know, are frivolous.
5.4 SOLICITING OTHER THERAPISTS’ PATIENTS: Marriage and
family therapists do not agree to see or solicit the clients of other therapists
or encourage clients to leave other therapists, except as addressed in Section
3.10.
6. RESPONSIBILITY TO RESEARCH PARTICIPANTS: Researchers
respect the dignity and protect the welfare of participants in research and are
aware of federal and state laws and regulations and professional standards
governing the conduct of research.
6.1 SAFEGUARDS: Researchers are responsible for making careful
examinations of ethical acceptability in planning studies. To the extent that
services to research participants may be compromised by participation in
research, researchers seek the ethical advice of qualified professionals not
directly involved in the research and observe safeguards to protect the rights
of research participants.
6.2 DIMINISHED CONSENT WHEN RECEIVING SERVICES:
Researchers requesting participants' involvement in research inform them of
all aspects of the research that might reasonably be expected to influence
willingness to participate. Researchers are especially sensitive to the
possibility of diminished consent when participants are also receiving
clinical services, have impairments which limit understanding and/or
communication, or when participants are children.
6.3 DUAL RELATIONSHIPS WITH RESEARCH PARTICIPANTS:
Researchers respect participants' freedom to decline participation in or to
withdraw from a research study at any time. This obligation requires special
thought and consideration when researchers or other members of the
research team are in positions of authority or influence over participants.
Marriage and family therapists, therefore, make every effort to avoid dual
relationships with research participants that could impair professional
judgment or increase the risk of exploitation.
6.4 CONFIDENTIALITY: Information obtained about a research
participant during the course of a research project is confidential unless there
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is an authorization previously obtained in writing. When the possibility
exists that others, including family members, may obtain access to such
information, this possibility, together with the plan for protecting
confidentiality, is explained.
7. RESPONSIBILITY TO THE PROFESSION: Marriage and family
therapists respect the rights and responsibilities of professional colleagues
and participate in activities that advance the goals of the profession.
7.1 ACCOUNTABLE TO STANDARDS OF PROFESSION: Marriage
and family therapists remain accountable to the standards of the profession
when acting as members or employees of organizations.
7.2 PUBLICATION CREDIT: Marriage and family therapists assign
publication credit to those who have contributed to a publication in
proportion to their contributions and in accordance with customary
professional publication.
7.3 AUTHORS—CITING OTHERS: Marriage and family therapists who
are the authors of books or other materials that are published or distributed
appropriately cite persons to whom credit for original ideas is due.
7.4 AUTHORS—ADVERTISING BY OTHERS: Marriage and family
therapists who are the authors of books or other materials published or
distributed by an organization take reasonable steps to ensure that the
organization promotes and advertises the materials accurately.
7.5 PRO BONO SERVICES: Marriage and family therapists are
encouraged to participate in activities that contribute to a better community
and society, including devoting a portion of their professional activity to
services for which there is little or no financial return.
7.6 DEVELOPING PUBLIC POLICY: Marriage and family therapists are
concerned with developing laws and regulations pertaining to marriage and
family therapists that serve the public interest, and with altering such laws
and regulations that are not in the public interest.
7.7 FAILURE TO COOPERATE WITH COMMITTEE: Marriage and
family therapists cooperate with the Ethics Committee and truthfully
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represent facts to the Ethics Committee. Failure to cooperate with the Ethics
Committee is itself a violation of these standards.
8. RESPONSIBILITY TO THE LEGAL SYSTEM: Marriage and family
therapists recognize their role in the legal system and their duty to remain
objective and truthful.
8.1 TESTIMONY: Marriage and family therapists who give testimony in
legal proceedings testify truthfully and avoid making misleading statements.
8.2 EXPERT WITNESSES: Marriage and family therapists who act as
expert witnesses base their opinions and conclusions on appropriate data,
and are careful to acknowledge the limits of their data or conclusions in
order to avoid providing misleading testimony or reports.
8.3 CONFLICTING ROLES: Whenever possible, marriage and family
therapists avoid performing conflicting roles in legal proceedings and
disclose any potential conflicts. At the outset of the service to be provided
and as changes occur, marriage and family therapists clarify role
expectations and the extent of confidentiality to prospective clients, to the
courts, or to others as appropriate.
8.4 DUAL ROLES: Marriage and family therapists avoid providing both
treatment and evaluations for the same clients or treatment units in legal
proceedings such as child custody, visitation, dependency, or guardianship
proceedings, unless otherwise required by law or initially appointed pursuant
to court order.
8.5 IMPARTIALITY: Marriage and family therapists, regardless of their
role in a legal proceeding, remain impartial and do not compromise their
professional judgment or integrity.
8.6 MINORS AND PRIVILEGE: Marriage and family therapists confirm
the holder of the psychotherapist patient privilege on behalf of minor clients
prior to releasing information or testifying.
8.7 OPINIONS ABOUT PERSONS NOT EVALUATED: Marriage and
family therapists shall only express professional opinions about clients they
have treated or examined. Marriage and family therapists, when expressing
professional opinions, specify the limits of the information upon which their
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professional opinions are based. Such professional opinions include, but are
not limited to, mental or emotional conditions or parenting abilities.
8.8 CUSTODY EVALUATORS: Marriage and family therapists who are
custody evaluators (private or court-based) or special masters provide such
services only if they meet the requirements established by pertinent laws,
regulations, and rules of court.
8.9 CONSEQUENCES OF CHANGES IN THERAPIST ROLES:
Marriage and family therapists inform the patient or the treatment unit of
any potential consequences of therapist-client role changes. Such role
changes include, but are not limited to, child’s therapist, family’s therapist,
couple’s therapist, individual’s therapist, mediator, evaluator, and special
master.
8.10 FAMILIARITY WITH JUDICIAL AND ADMINISTRATIVE
RULES: Marriage and family therapists, when assuming forensic roles, are
or become familiar with the judicial and administrative rules governing their
roles.
9. FINANCIAL ARRANGEMENTS: Marriage and family therapists make
financial arrangements with patients and supervisees that are understandable,
and conform to accepted professional practices and legal requirements.
9.1 PAYMENT FOR REFERRALS: Marriage and family therapists do
not offer or accept payment for referrals, whether in the form of money or
otherwise.
9.2 FINANCIAL EXPLOITATION: Marriage and family therapists do
not financially exploit their patients.
9.3 DISCLOSURE OF FEES: Marriage and family therapists disclose, in
advance, their fees and the basis upon which they are computed, including,
but not limited to, charges for canceled or missed appointments and any
interest to be charged on unpaid balances, at the beginning of treatment and
give reasonable notice of any changes in fees or other charges.
9.4 COLLECTING ON UNPAID BALANCES: Marriage and family
therapists give reasonable notice to patients with unpaid balances of their
intent to sue or to refer for collection. Whenever legal action is taken,
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therapists will avoid disclosure of clinical information. Whenever unpaid
balances are referred to collection agencies, therapists will exercise care in
selecting collection agencies and will avoid disclosure of clinical
information.
9.5 BARTER: Marriage and family therapists ordinarily refrain from
accepting goods, services, or other non-monetary remuneration from patients
in return for professional services. Such arrangements often create conflicts
and may lead to exploitation or distortion of the professional relationship.
9.6 THIRD-PARTY PAYERS: Marriage and family therapists represent
facts regarding services rendered and payment for services fully and
truthfully to third-party payers and others.
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10. ADVERTISING Marriage and family therapists who advertise do so
appropriately. Their advertising enables consumers to choose professional services
based upon accurate information.
10.1 ACCURACY REGARDING QUALIFICATIONS: Marriage and family
therapists accurately represent their competence, education, training, and
experience relevant to their professional practice to patients and others.
10.2 ASSURING ACCURACY: Marriage and family therapists take reasonable
steps to assure that advertisements and publications, whether in directories,
announcement cards, newspapers, radio, television, Internet or any other media, are
formulated to accurately convey information to the public.
10.3 FICTITIOUS/OTHER NAMES: Marriage and family therapists do not use
a name that could mislead the public concerning the identity, responsibility,
source, and status of those practicing under that name, and do not hold themselves
out as being partners or associates of a firm if they are not.
10.4 FALSE, MISLEADING, OR DECEPTIVE: Marriage and family therapists
do not use any professional identification, including but not limited to: a business
card, office sign, letterhead, telephone, or association directory listing, Internet, or
any other media, if it includes a statement or claim that is false, fraudulent,
misleading, or deceptive. A statement is false, fraudulent, misleading, or deceptive
if it a) contains a material misrepresentation of fact; b) fails to state any material
fact necessary to make the statement, in light of all circumstances, not misleading;
or c) is intended to or is likely to create an unjustified expectation.
10.5 CORRECTIONS: Marriage and family therapists correct, wherever possible,
false, misleading, or inaccurate information and representations made by others
concerning the therapist's qualifications, services, or products.
10.6 SOLICITATION OF TESTIMONIALS: Marriage and family therapists do
not solicit testimonials from patients.
10.7 EMPLOYEE- ACCURACY: Marriage and family therapists make certain
that the qualifications of persons in their employ are represented in a manner that is
not false, misleading, or deceptive.
10.8 SPECIALIZATIONS: Marriage and family therapists may represent
themselves as either specializing or having expertise within a limited area of
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marriage and family therapy, but only if they have the education, training, and
experience that meets recognized professional standards to practice in that
specialty area.
10.9 ADVERTISING OF CAMFT MEMBERSHIP: CAMFT clinical, associate,
and pre-licensed members may identify such membership in CAMFT in public
information or advertising materials, but they must clearly and accurately represent
whether they are clinical, associate, or pre-licensed members.
10.10 USE OF “CAMFT”: Marriage and family therapists may not use the initials
CAMFT following their name in the manner of an academic degree.
10.11 USE OF CAMFT LOGO: Marriage and family therapists may use the
CAMFT logo only after receiving permission in writing from the Association.
Permission will be granted by the Association to CAMFT members in good
standing in accordance with Association policy on the use of CAMFT logo. The
Association (which is the sole owner of its name, logo, and the abbreviated initials
CAMFT) may grant permission to CAMFT committees and chartered chapters in
good standing, operating as such, to use the CAMFT logo. Such permission will be
granted in accordance with Association policy on use of the CAMFT logo.
10.12 CAMFT MEMBERSHIP: Marriage and family therapists, when
publicizing their membership in CAMFT, do not do so in a manner that implies
organizational endorsement of their activities.
Ethical Standards for Marriage and Family Therapists - Part II (Procedures for
Handling Complaints of Violations of the Ethical Standards for Marriage and
Family Therapists) is a publication of the California Association of Marriage and
Family Therapists, headquartered in San Diego, California
Ethical Standards for Marriage and Family Therapists - Part II (Procedures for
Handling Complaints of Violations of the Ethical Standards for Marriage and
Family Therapists) is a publication of the California Association of Marriage and
Family Therapists, headquartered in San Diego, California.
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Ethical Standards Part 2
PART II
PREAMBLE
In accepting membership in the Association, each member binds himself/herself to
abide by the CAMFT Ethical Standards for Marriage and Family Therapists. It is
the ethical responsibility of each member to safeguard the standards of ethical
practice and to see that violations of the Ethical Standards for Marriage and
Family Therapists are addressed. Members of the Association cooperate with duly
constituted bodies of the California Association of Marriage and Family
Therapists, and in particular, with the Ethics Committee, by responding to inquiries
promptly and completely.
I.
Basics and Scope of Authority of the Ethics Committee
II.
Membership and Meetings of The Committee
III. Initiation of Complaints
IV. Initial Action by Executive Director
V.
Preliminary Determination by Chair of Ethics Committee
with the Advice of Legal Counsel for the Association
VI. Investigation by Ethics Committee or Designees
VII. Action by the Full Ethics Committee
VIII. Procedures for Hearings Before Board of Directors
IX. Records and Disclosure of Information
I. Basics and Scope of Authority of the Ethics Committee
A. The Bylaws of the Association (Article IV, Section A) provide for three
categories of membership, as follows:
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1. clinical member - voting
2. student member - voting for one director only
3. associate member - nonvoting
B. The Association has authority only over these members. This authority is
derived from Article IV, Section C of the Bylaws of the Association which
requires that:
All members shall pay dues in accordance with the dues schedule of the
Association and shall abide by the Bylaws and the ethical standards of the
Association.
C. The Bylaws of the Association authorize the Ethics Committee to:
Maintain and review the ethical standards of the Association, interpret the ethical
standards to the membership and the public, conduct investigations of alleged
ethics violations, make recommendations to the Board of Directors regarding
members alleged to have violated the ethical standards, and from time to time
propose revisions, deletions and additions to the ethical standards to the Board of
Directors for its approval. (Article Vll, Section B3.)
D. The Bylaws of the Association, in Article IV, Section E3, also provide that:
Anyone in any class of membership who violates the ethical standards of the
Association may be expelled or suspended from membership in the Association
following an investigation and report by the Ethics Committee and a hearing
before the Board of Directors. A two thirds (2/3) majority of those Directors
present at the hearing shall be necessary in order to expel or suspend a member.
The member accused of the violation shall be given a reasonable opportunity to
defend against the charge and shall be entitled to be represented at all stages of the
proceedings. Any member to be expelled or suspended shall be entitled to at least
fifteen (15) days prior notice of the expulsion or suspension and the reasons
therefore, and shall be entitled to be heard, orally or in writing, not less than five
(5) days before the effective date of expulsion or suspension by the Board of
Directors. Notice may be given by any method reasonably calculated to provide
actual notice. Any notice given by mail shall be given by first-class or registered
mail sent to the last address of the member as shown on the Association's records.
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The ethical standards of the Association shall spell out further details of the
procedures for investigation and hearing of alleged violations not inconsistent with
these bylaw provisions.
E. One role of the Ethics Committee, therefore, is to investigate complaints of
violations of the Code of Ethical Standards for Marriage and Family Therapists.
II. Membership and Meetings of the Committee
A. Pursuant to Article Vll, Section B3 of the Bylaws, the Ethics Committee is
designated as a standing committee of CAMFT, and shall consist of not less than
five (5) nor more than seven (7) members, all of whom shall be clinical members
of the Association for at least two (2) years prior to appointment. The Committee
shall not contain any directors on its membership. The term of office shall be two
(2) years.
B. Pursuant to Article Vll, Section E of the Bylaws, committees shall meet at
such times as determined either by resolution of the Board of Directors, by
resolution of the committee, or by a committee chair with the prior approval of the
president of the Association.
C. Meetings of the committee shall be held upon not less than ten (10) days
written notice. Notice of a meeting need not be given to any committee member
who signed a waiver of notice or a written consent to holding the meeting or as
approved by the minutes thereof, whether before or after the meeting, or who
attends the meeting without protesting, prior thereto or at its commencement, the
lack of notice to such committee member.
D. A majority of the committee members of each committee shall constitute a
quorum of the committee for the transaction of business.
III. Initiation of Complaints
A. The Ethics Committee shall recognize and accept written complaints received
from both members and non-members of the Association.
B. All complaints must be in writing.
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C. Complaints must be signed by the complainant and accompanied by the
complainant's address. In addition, the Committee will only act on the basis of a
complaint that specifically names the person alleged to have been affected by the
member's conduct, and only if the affected person agrees to be identified to the
member.
D. Any member who knows of a violation of the CAMFT Ethical Standards for
Marriage and Family Therapists should bring this fact to the attention of the
Committee in the form of a complaint.
E. Anonymous complaints shall not be recognized as a basis for action.
F. The Ethics Committee may proceed on its own initiative when it has been
presented with enough facts which, if proven, would constitute a violation of the
Ethical Standards for Marriage and Family Therapists. For example, the
Committee could proceed on information received from another professional
organization or a state licensing board or committee. If the Committee decides to
proceed on its own initiative, it shall prepare a written statement concerning factual
allegations of a violation or violations of the Code.
G. The Ethics Committee may determine, in its discretion that a complaint
cannot be acted upon because the events complained about occurred too far in the
past.
IV. Initial Action by Executive Director
A. Upon receipt of a complaint, the Executive Director, or his/her designee
(hereafter "Executive Director") shall determine whether the person about whom
the complaint has been made is a member or applicant for membership in the
Association.
1. If the person is not a member or applicant for membership in the
Association, the Executive Director shall so inform the complainant in
writing and shall explain that the Association has no authority to proceed
against the person.
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2. If the person is an applicant for membership in the Association, the
complaint shall be immediately referred to the Chair of the Membership
Committee.
B. If the person is a member of the Association, the Executive Director shall
forward a copy of the complaint to the Chair of the Ethics Committee. A letter
shall be sent to the complainant acknowledging receipt of the complaint and
informing the complainant that the person complained against is a member. A copy
of the Ethical Standards (Part I) will be included with the letter.
V. Preliminary Determination by Chair of Ethics Committee with the Advice
of Legal Counsel for the Association
A. The Chair of the Ethics Committee, with the advice of Legal Counsel for the
Association, shall review the complaint and shall determine whether the complaint
warrants further action by the Committee or whether the matter shall be closed
without further action. In the event the Chair determines that the complaint shall be
closed without further action, the complainant shall be notified of such decision
and the reason for such decision. To aid in making such a determination, the Chair
of the Ethics Committee may request a written response to the letter of complaint
from the member.
B. If the Chair of the Ethics Committee requests a written response from the
member to aid in making the determination referred to in paragraph (A) above, or
if the Chair determines that the complaint warrants further action by the
Committee, the Chair shall request the complainant's permission for the use of
his/her name in the investigation and disclosure of his/ her name and all written or
other matter or evidence provided by the complainant. The Chair shall also request
that the complainant agree in writing to waive confidentiality and/or
psychotherapist/patient privilege available to him/her so that the Ethics Committee
may obtain information from the member and others.
C. If the complainant refuses permission for the use of his/her name in the
investigation or refuses permission for the disclosure of his/her name or any of the
written or other matter or evidence provided by the complainant, or if the
complainant refuses to sign a waiver of confidentiality and/or
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psychotherapist/patient privilege, then the Chair of the Ethics Committee, with the
advice of Legal Counsel, may do any of the following:
1. close the matter and notify the complainant
2. refer the matter to the full Committee for their action, or
3. decide whether the Committee may proceed with the complaint with an
investigation on the Committees' own initiative pursuant to III (F).
D. All correspondence to the complainant and to the member shall be marked
"Confidential" or "Personal and Confidential."
VI. Investigation by Ethics Committee or Designees
A. When the Chair of the Ethics Committee has decided that the complaint
warrants further investigation, copies of the complaint and any supporting
documentation/evidence shall be sent to all members of the Ethics Committee. Any
written response from the member shall also be sent to all members of the Ethics
Committee.
B. The Chair of the Ethics Committee shall cause an investigation of the
complaint to take place. This investigation may be carried out by the Chair of the
Committee in consultation with legal counsel, or by two or more members of the
Ethics Committee in consultation with legal counsel or the Chair, or by the entire
Committee.
C. The Chair of the Ethics Committee, in consultation with legal counsel, shall
prepare and send a letter to the accused member, prior to commencing the
investigation, specifying those sections of the Ethical Standards for Marriage and
Family Therapists which may have been violated by the member. The letter shall
contain a request that the member cooperate with the Ethics Committee in their
effort to obtain a full picture of the circumstances which led to the allegations, and
to provide in his/her behalf a written statement outlining his/her response to the
allegations or accusations made by the complainant.
D. Investigations may be pursued by corresponding with the parties involved in
the dispute, or by interviewing, personally or by telephone, such parties.
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E. During the investigation stage of the proceedings, the accused member shall
have the right to consult with his/her attorney and shall have the right to have
his/her attorney present at any investigatory meeting with the member.
F. If an accused member resigns from membership in the Association at any
stage of the investigation of the complaint, the Ethics Committee, in its discretion,
may continue its investigation. If inability to pay dues is cited as a reason for
voluntary resignation by a member under ethics investigation, the Ethics
Committee may suspend dues obligations until the ethics investigation is
completed.
G. After the investigation is completed, a full report shall be made to the Ethics
Committee detailing the findings.
H. The Ethics Committee, after receiving the report of the investigation, may
take such action as is authorized by Section VII of these procedures.
I. The accused member and the complainant shall be notified when the case has
been submitted to the full Ethics Committee.
J. The accused member shall be sent a copy of these procedures (Part II of the
CAMFT Ethical Standards for Marriage and Family Therapists) upon first being
contacted by the Ethics Committee.
VII. Action by the Full Ethics Committee
A. After reviewing the complaint, the response of the member, and the report of
the investigation, the Ethics Committee may attempt to settle the case by mutual
agreement with the member. While settlement by mutual agreement is favored, the
Ethics Committee is not required to attempt such a settlement.
1. In making such a settlement, the Committee may recommend to the member
that he/she agree to the Committee's request that the member cease and
desist, accept censure, be placed on probation and/or rehabilitation, be given
supervision, education, and/or therapy, termination of membership in the
Association, or any other action which the Committee deems appropriate.
The Ethics Committee may appropriately impose more stringent
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requirements upon members previously found to have violated the CAMFT
Ethical Standards for Marriage and Family Therapists, or any other relevant
professional or state code of professional conduct.
2. The mutual agreement shall be reduced to writing and shall detail the facts
upon which it is based and the manner in which it is to be instituted and/or
supervised.
3. The agreement shall be instituted and/or supervised by the Ethics Committee
and/or any member of the Association so designated in the agreement.
4. The agreement shall become final as soon as it is reduced to writing and
agreed to by the member and the Ethics Committee or at any other time
designated in the agreement. The Board of Directors shall be notified of the
agreement without disclosing the name of the member. The agreement shall
be filed in the membership file of the member.
B. If the Ethics Committee does not attempt settling by mutual agreement, it will
either drop the charges and close the case, or make a formal recommendation to the
Board of Directors that action should be taken. If the Committee recommends
formal action, it shall: (a) recommend action to be taken, including a request to
cease and desist, provide censure, probation, supervision, therapy, education, or
rehabilitation, or to terminate or suspend membership in the Association, or any
other action which the Association is authorized to take against a member; (b)
recommend the manner in which the action will be instituted and/or supervised: (c)
notify the member of the recommendation: (d) send the member a copy of the
report of the investigation and recommendations of the Ethics Committee; and (e)
inform the member, by certified mail, return receipt requested, that he/she has a
right to a hearing before the Board of Directors of the Association, and that if
he/she does not request a hearing before the Board of Directors within thirty (30)
days from receipt of notification, no hearing will be held and the Ethics Committee
recommendation for action will become final. The Ethics Committee may
appropriately impose more stringent sanctions upon members previously found to
have violated the CAMFT Ethical Standards for Marriage and Family Therapists,
or any other relevant professional or state code of professional conduct.
C. In the event that the Committee's recommendation for action becomes final
because the member does not request a hearing within thirty (30) days, the Ethics
Committee Chair shall thereafter forward a determination of the matter to the
executive director for execution.
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D. If the member requests a hearing before the Board of Directors, then the
Ethics Committee shall prepare and transmit to the Board of Directors, through the
president of the Association, the statement of charges against the member and the
action which the Ethics Committee recommends.
E. In any hearing before the Board of Directors of the Association, the Ethics
Committee, through its Chair or his/her designee, shall present the case against the
member.
F. If additional evidence of unethical conduct is brought to the attention of the
Committee after a matter has been closed, the case may be reopened and acted
upon under these procedures.
VIII. Procedures for Hearings Before Board of Directors
A. Upon receipt of the statement of charges and recommended action from the
Ethics Committee, the President of the Association shall inform the charged
member by certified mail, return receipt requested, that his/her request for a
hearing has been received and enclose a copy of the charges, the report of the
investigation, and the recommended action. The member shall be informed about
these procedures for hearings before the Board of Directors.
B. A hearing shall be scheduled at the next regularly scheduled meeting of the
Board of Directors or as soon thereafter as possible. The complainant and charged
member shall be notified promptly of the hearing date, time and place. All costs of
attendance at the hearing shall be borne by the complainant and the charged
member, respectively.
C. At least thirty (30) days before the hearing, the Ethics Committee shall furnish
the charged member and the Board of Directors with copies of all documents and
the names of witnesses who will appear in support of the charges.
D. The Ethics Committee, through the Chair of the Committee or his/her
designee, shall present the charges against the member and shall have the right to:
1. be represented by counsel for the Association
2. present witnesses and evidence to support the charge
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3. cross-examine witnesses who appear for the charged member
4. offer rebuttal evidence
5. make opening and closing statements.
E. The charged member shall have the right to:
1.
2.
3.
4.
5.
be represented by counsel
present witnesses and evidence
cross-examine witnesses against him/her
appear on his/her own behalf
make opening and closing statements.
F. All evidence which is relevant and reliable, as determined by the President of
the Association, shall be admissible. The formal rules of evidence shall not apply.
G. A tape recording of the hearing shall be made if requested by the Board or the
accused member. If the accused member makes the request, he/ she shall pay the
expense of recording the hearing.
H. The Ethics Committee shall have the burden of proving the charges by a
preponderance of the evidence.
I. The Board of Directors shall issue its decision within thirty (30) days after the
hearing.
J. The decision shall state:
1. the Board's findings of fact
2. whether a violation of the code was found and, if so, the section of the code
violated; and
3. the Board's decision:
a. if no violation of the code is found, the Board of Directors shall
order that the member be cleared of all charges
b. if a violation or violations of the Code are found, the Board shall
order action to be taken, including an order to cease and desist,
censure, therapy, probation, rehabilitation, supervision, education,
revocation or suspension of membership, or any other action which
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the board deems appropriate. The decision shall also specify the
manner in which the action is to be instituted and/or supervised.
K. The President of the Association shall inform the complainant and the Chair
of the Ethics Committee of the decision. Notice of the decision to the member shall
be by certified mail, return receipt requested.
L. There shall be no appeals from decisions of the Board of Directors, but the
Board, in its discretion, may reconsider its decision upon request of the accused
member. Any request for reconsideration shall be made in writing and within thirty
(30) days of receipt of the Board's decision.
IX. Records and Disclosure of Information
A. The permanent files of the Ethics Committee shall be maintained in the
central office of the Association.
B. All information obtained by the Ethics Committee, including any investigating
subcommittee, and all proceedings of the Ethics Committee, shall be confidential
except as follows:
1. Information may be disclosed by those investigating the complaint as is
necessary in order to pursue a thorough investigation.
2. The Ethics Committee may, in its discretion, authorize the Executive
Director to publicize settlements by mutual agreement without disclosing the
name of the complainant or the charged member.
3. In situations in which an accused member resigned from CAMFT
membership in the face of an Ethics Committee investigation, and a
violation of the code is subsequently proven, any publication shall include
the fact of the member's resignation.
4. Whenever the Board of Directors finds, after hearing, that a member has
violated the Code, and orders disciplinary action, the Board of Directors or
its designee is authorized to disclose the ethics violation and disciplinary
action to the membership of the Association. Publication shall be made of all
terminations or suspensions of membership. Publication may also be made
of other sanctions in the discretion of the Board of Directors. Publication of
the Board of Directors' findings and actions will be made in The California
Therapist and will include the member's full name, any earned degree,
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his/her geographical location, and the violation of the section of the Code
proven.
5. Whenever the Board of Directors finds, after hearing, that a member is not
guilty of the Code violations charged, that fact shall be disclosed to the
membership of the Association only upon the written request of the accused
member.
6. The complainant shall be informed of the status and progress of the
complaint in a timely manner and shall be notified of the conclusion of the
case.
7. The Board of Directors may inform state regulatory agencies and other
professional organizations, including chapters of CAMFT, of any
disciplinary action taken against a member for violating the CAMFT Ethical
Standards for Marriage and Family Therapists.
(Ethical Standards for Marriage and Family Therapists - Part II (Procedures for
Handling Complaints of Violations of the code of Ethical Standards for Marriage
and Family Therapists) is a publication of the California Association of Marriage
and Family Therapists, headquartered in San Diego, California.)
6C. NASW Ethical Standards
The following is an excerpt from NASW’s published ethical standards:
Ethical Standards
The following ethical standards are relevant to the professional activities of all
social workers. These standards concern (1) social workers’ ethical responsibilities
to clients, (2) social workers’ ethical responsibilities to colleagues, (3) social
workers’ ethical responsibilities in practice settings, (4) social workers’ ethical
responsibilities as professionals, (5) social workers’ ethical responsibilities to the
social work profession, and (6) social workers’ ethical responsibilities to the
broader society.
Some of the standards that follow are enforceable guidelines for professional
conduct, and some are aspirational. The extent to which each standard is
enforceable is a matter of professional judgment to be exercised by those
responsible for reviewing alleged violations of ethical standards.
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1. SOCIAL WORKERS’ ETHICAL RESPONSIBILITIES TO CLIENTS
1.01 Commitment to Clients
Social workers’ primary responsibility is to promote the wellbeing of clients. In
general, clients’ interests are primary. However, social workers’ responsibility to
the larger society or specific legal obligations may on limited occasions supersede
the loyalty owed clients, and clients should be so advised. (Examples include when
a social worker is required by law to report that a client has abused a child or has
threatened to harm self or others.)
1.02 Self Determination
Social workers respect and promote the right of clients to self determination and
assist clients in their efforts to identify and clarify their goals. Social workers may
limit clients’ right to self determination when, in the social workers’ professional
judgment, clients’ actions or potential actions pose a serious, foreseeable, and
imminent risk to themselves or others.
1.03 Informed Consent
(a) Social workers should provide services to clients only in the context of a
professional relationship based, when appropriate, on valid informed consent.
Social workers should use clear and understandable language to inform clients of
the purpose of the services, risks related to the services, limits to services because
of the requirements of a third party payer, relevant costs, reasonable alternatives,
clients’ right to refuse or withdraw consent, and the time frame covered by the
consent. Social workers should provide clients with an opportunity to ask
questions.
(b) In instances when clients are not literate or have difficulty understanding the
primary language used in the practice setting, social workers should take steps to
ensure clients’ comprehension. This may include providing clients with a detailed
verbal explanation or arranging for a qualified interpreter or translator whenever
possible.
(c) In instances when clients lack the capacity to provide informed consent, social
workers should protect clients’ interests by seeking permission from an appropriate
third party, informing clients consistent with the clients’ level of understanding. In
such instances social workers should seek to ensure that the third party acts in a
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manner consistent with clients’ wishes and interests. Social workers should take
reasonable steps to enhance such clients’ ability to give informed consent.
(d) In instances when clients are receiving services involuntarily, social workers
should provide information about the nature and extent of services and about the
extent of clients’ right to refuse service.
(e) Social workers who provide services via electronic media (such as computer,
telephone, radio, and television) should inform recipients of the limitations and
risks associated with such services.
(f) Social workers should obtain clients’ informed consent before audio taping or
videotaping clients or permitting observation of services to clients by a third party.
1.04 Competence
(a) Social workers should provide services and represent themselves as competent
only within the boundaries of their education, training, license, certification,
consultation received, supervised experience, or other relevant professional
experience.
(b) Social workers should provide services in substantive areas or use intervention
techniques or approaches that are new to them only after engaging in appropriate
study, training, consultation, and supervision from people who are competent in
those interventions or techniques.
(c) When generally recognized standards do not exist with respect to an emerging
area of practice, social workers should exercise careful judgment and take
responsible steps (including appropriate education, research, training, consultation,
and supervision) to ensure the competence of their work and to protect clients from
harm.
1.05 Cultural Competence and Social Diversity
(a) Social workers should understand culture and its function in human behavior
and society, recognizing the strengths that exist in all cultures.
(b) Social workers should have a knowledge base of their clients’ cultures and be
able to demonstrate competence in the provision of services that are sensitive to
clients’ cultures and to differences among people and cultural groups.
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(c) Social workers should obtain education about and seek to understand the nature
of social diversity and oppression with respect to race, ethnicity, national origin,
color, sex, sexual orientation, gender identity or expression, age, marital status,
political belief, religion, immigration status, and mental or physical disability.
1.06 Conflicts of Interest
(a) Social workers should be alert to and avoid conflicts of interest that interfere
with the exercise of professional discretion and impartial judgment. Social workers
should inform clients when a real or potential conflict of interest arises and take
reasonable steps to resolve the issue in a manner that makes the clients’ interests
primary and protects clients’ interests to the greatest extent possible. In some
cases, protecting clients’ interests may require termination of the professional
relationship with proper referral of the client.
(b) Social workers should not take unfair advantage of any professional
relationship or exploit others to further their personal, religious, political, or
business interests.
(c) Social workers should not engage in dual or multiple relationships with clients
or former clients in which there is a risk of exploitation or potential harm to the
client. In instances when dual or multiple relationships are unavoidable, social
workers should take steps to protect clients and are responsible for setting clear,
appropriate, and culturally sensitive boundaries. (Dual or multiple relationships
occur when social workers relate to clients in more than one relationship, whether
professional, social, or business. Dual or multiple relationships can occur
simultaneously or consecutively.)
(d) When social workers provide services to two or more people who have a
relationship with each other (for example, couples, family members), social
workers should clarify with all parties which individuals will be considered clients
and the nature of social workers’ professional obligations to the various individuals
who are receiving services. Social workers who anticipate a conflict of interest
among the individuals receiving services or who anticipate having to perform in
potentially conflicting roles (for example, when a social worker is asked to testify
in a child custody dispute or divorce proceedings involving clients) should clarify
their role with the parties involved and take appropriate action to minimize any
conflict of interest.
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1.07 Privacy and Confidentiality
(a) Social workers should respect clients’ right to privacy. Social workers should
not solicit private information from clients unless it is essential to providing
services or conducting social work evaluation or research. Once private
information is shared, standards of confidentiality apply.
(b) Social workers may disclose confidential information when appropriate with
valid consent from a client or a person legally authorized to consent on behalf of a
client.
(c) Social workers should protect the confidentiality of all information obtained in
the course of professional service, except for compelling professional reasons. The
general expectation that social workers will keep information confidential does not
apply when disclosure is necessary to prevent serious, foreseeable, and imminent
harm to a client or other identifiable person. In all instances, social workers should
disclose the least amount of confidential information necessary to achieve the
desired purpose; only information that is directly relevant to the purpose for which
the disclosure is made should be revealed.
(d) Social workers should inform clients, to the extent possible, about the
disclosure of confidential information and the potential consequences, when
feasible before the disclosure is made. This applies whether social workers disclose
confidential information on the basis of a legal requirement or client consent.
(e) Social workers should discuss with clients and other interested parties the
nature of confidentiality and limitations of clients’ right to confidentiality. Social
workers should review with clients circumstances where confidential information
may be requested and where disclosure of confidential information may be legally
required. This discussion should occur as soon as possible in the social worker
client relationship and as needed throughout the course of the relationship.
(f) When social workers provide counseling services to families, couples, or
groups, social workers should seek agreement among the parties involved
concerning each individual’s right to confidentiality and obligation to preserve the
confidentiality of information shared by others. Social workers should inform
participants in family, couples, or group counseling that social workers cannot
guarantee that all participants will honor such agreements.
(g) Social workers should inform clients involved in family, couples, marital, or
group counseling of the social worker’s, employer’s, and agency’s policy
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concerning the social worker’s disclosure of confidential information among the
parties involved in the counseling.
(h) Social workers should not disclose confidential information to third-party
payers unless clients have authorized such disclosure.
(i) Social workers should not discuss confidential information in any setting unless
privacy can be ensured. Social workers should not discuss confidential information
in public or semipublic areas such as hallways, waiting rooms, elevators, and
restaurants.
(j) Social workers should protect the confidentiality of clients during legal
proceedings to the extent permitted by law. When a court of law or other legally
authorized body orders social workers to disclose confidential or privileged
information without a client’s consent and such disclosure could cause harm to the
client, social workers should request that the court withdraw the order or limit the
order as narrowly as possible or maintain the records under seal, unavailable for
public inspection.
(k) Social workers should protect the confidentiality of clients when responding to
requests from members of the media.
(l) Social workers should protect the confidentiality of clients’ written and
electronic records and other sensitive information. Social workers should take
reasonable steps to ensure that clients’ records are stored in a secure location and
that clients’ records are not available to others who are not authorized to have
access.
(m) Social workers should take precautions to ensure and maintain the
confidentiality of information transmitted to other parties through the use of
computers, electronic mail, facsimile machines, telephones and telephone
answering machines, and other electronic or computer technology. Disclosure of
identifying information should be avoided whenever possible.
(n) Social workers should transfer or dispose of clients’ records in a manner that
protects clients’ confidentiality and is consistent with state statutes governing
records and social work licensure.
(o) Social workers should take reasonable precautions to protect client
confidentiality in the event of the social worker’s termination of practice,
incapacitation, or death.
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(p) Social workers should not disclose identifying information when discussing
clients for teaching or training purposes unless the client has consented to
disclosure of confidential information.
(q) Social workers should not disclose identifying information when discussing
clients with consultants unless the client has consented to disclosure of confidential
information or there is a compelling need for such disclosure.
(r) Social workers should protect the confidentiality of deceased clients consistent
with the preceding standards.
1.08 Access to Records
(a) Social workers should provide clients with reasonable access to records
concerning the clients. Social workers who are concerned that clients’ access to
their records could cause serious misunderstanding or harm to the client should
provide assistance in interpreting the records and consultation with the client
regarding the records. Social workers should limit clients’ access to their records,
or portions of their records, only in exceptional circumstances when there is
compelling evidence that such access would cause serious harm to the client. Both
clients’ requests and the rationale for withholding some or all of the record should
be documented in clients’ files.
(b) When providing clients with access to their records, social workers should take
steps to protect the confidentiality of other individuals identified or discussed in
such records.
1.09 Sexual Relationships
(a) Social workers should under no circumstances engage in sexual activities or
sexual contact with current clients, whether such contact is consensual or forced.
(b) Social workers should not engage in sexual activities or sexual contact with
clients’ relatives or other individuals with whom clients maintain a close personal
relationship when there is a risk of exploitation or potential harm to the client.
Sexual activity or sexual contact with clients’ relatives or other individuals with
whom clients maintain a personal relationship has the potential to be harmful to the
client and may make it difficult for the social worker and client to maintain
appropriate professional boundaries. Social workers—not their clients, their
clients’ relatives, or other individuals with whom the client maintains a personal
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relationship—assume the full burden for setting clear, appropriate, and culturally
sensitive boundaries.
(c) Social workers should not engage in sexual activities or sexual contact with
former clients because of the potential for harm to the client. If social workers
engage in conduct contrary to this prohibition or claim that an exception to this
prohibition is warranted because of extraordinary circumstances, it is social
workers—not their clients—who assume the full burden of demonstrating that the
former client has not been exploited, coerced, or manipulated, intentionally or
unintentionally.
(d) Social workers should not provide clinical services to individuals with whom
they have had a prior sexual relationship. Providing clinical services to a former
sexual partner has the potential to be harmful to the individual and is likely to
make it difficult for the social worker and individual to maintain appropriate
professional boundaries.
1.10 Physical Contact
Social workers should not engage in physical contact with clients when there is a
possibility of psychological harm to the client as a result of the contact (such as
cradling or caressing clients). Social workers who engage in appropriate physical
contact with clients are responsible for setting clear, appropriate, and culturally
sensitive boundaries that govern such physical contact.
1.11 Sexual Harassment
Social workers should not sexually harass clients. Sexual harassment includes
sexual advances, sexual solicitation, requests for sexual favors, and other verbal or
physical conduct of a sexual nature.
1.12 Derogatory Language
Social workers should not use derogatory language in their written or verbal
communications to or about clients. Social workers should use accurate and
respectful language in all communications to and about clients.
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1.13 Payment for Services
(a) When setting fees, social workers should ensure that the fees are fair,
reasonable, and commensurate with the services performed. Consideration should
be given to clients’ ability to pay.
(b) Social workers should avoid accepting goods or services from clients as
payment for professional services. Bartering arrangements, particularly involving
services, create the potential for conflicts of interest, exploitation, and
inappropriate boundaries in social workers’ relationships with clients. Social
workers should explore and may participate in bartering only in very limited
circumstances when it can be demonstrated that such arrangements are an accepted
practice among professionals in the local community, considered to be essential for
the provision of services, negotiated without coercion, and entered into at the
client’s initiative and with the client’s informed consent. Social workers who
accept goods or services from clients as payment for professional services assume
the full burden of demonstrating that this arrangement will not be detrimental to
the client or the professional relationship.
(c) Social workers should not solicit a private fee or other remuneration for
providing services to clients who are entitled to such available services through the
social workers’ employer or agency.
1.14 Clients Who Lack Decision-Making Capacity
When social workers act on behalf of clients who lack the capacity to make
informed decisions, social workers should take reasonable steps to safeguard the
interests and rights of those clients.
1.15 Interruption of Services
Social workers should make reasonable efforts to ensure continuity of services in
the event that services are interrupted by factors such as unavailability, relocation,
illness, disability, or death.
1.16 Termination of Services
(a) Social workers should terminate services to clients and professional
relationships with them when such services and
relationships are no longer required or no longer serve the clients’ needs or
interests.
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(b) Social workers should take reasonable steps to avoid abandoning clients who
are still in need of services. Social workers should withdraw services precipitously
only under unusual circumstances, giving careful consideration to all factors in the
situation and taking care to minimize possible adverse effects. Social workers
should assist in making appropriate arrangements for continuation of services
when necessary.
(c) Social workers in fee for service settings may terminate services to clients who
are not paying an overdue balance if the financial contractual arrangements have
been made clear to the client, if the client does not pose an imminent danger to self
or others, and if the clinical and other consequences of the current nonpayment
have been addressed and discussed with the client.
(d) Social workers should not terminate services to pursue a social, financial, or
sexual relationship with a client.
(e) Social workers who anticipate the termination or interruption of services to
clients should notify clients promptly and seek the transfer, referral, or
continuation of services in relation to the clients’ needs and preferences.
(f) Social workers who are leaving an employment setting should inform clients of
appropriate options for the continuation of services and of the benefits and risks of
the options.
2. SOCIAL WORKERS’ ETHICAL RESPONSIBILITIES TO
COLLEAGUES
2.01 Respect
(a) Social workers should treat colleagues with respect and should represent
accurately and fairly the qualifications, views, and obligations of colleagues.
(b) Social workers should avoid unwarranted negative criticism of colleagues in
communications with clients or with other professionals. Unwarranted negative
criticism may include demeaning comments that refer to colleagues’ level of
competence or to individuals’ attributes such as race, ethnicity, national origin,
color, sex, sexual orientation, gender identity or expression, age, marital status,
political belief, religion, immigration status, and mental or physical disability.
(c) Social workers should cooperate with social work colleagues and with
colleagues of other professions when such cooperation serves the wellbeing of
clients.
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2.02 Confidentiality
Social workers should respect confidential information shared by colleagues in the
course of their professional relationships and transactions. Social workers should
ensure that such colleagues understand social workers’ obligation to respect
confidentiality and any exceptions related to it.
2.03 Interdisciplinary Collaboration
(a) Social workers who are members of an interdisciplinary team should participate
in and contribute to decisions that affect the wellbeing of clients by drawing on the
perspectives, values, and experiences of the social work profession. Professional
and ethical obligations of the interdisciplinary team as a whole and of its individual
members should be clearly established.
(b) Social workers for whom a team decision raises ethical concerns should
attempt to resolve the disagreement through appropriate channels. If the
disagreement cannot be resolved, social workers should pursue other avenues to
address their concerns consistent with client wellbeing.
2.04 Disputes Involving Colleagues
(a) Social workers should not take advantage of a dispute between a colleague and
an employer to obtain a position or otherwise advance the social workers’ own
interests.
(b) Social workers should not exploit clients in disputes with colleagues or engage
clients in any inappropriate discussion of conflicts between social workers and
their colleagues.
2.05 Consultation
(a) Social workers should seek the advice and counsel of colleagues whenever such
consultation is in the best interests of clients.
(b) Social workers should keep themselves informed about colleagues’ areas of
expertise and competencies. Social workers should seek consultation only from
colleagues who have demonstrated knowledge, expertise, and competence related
to the subject of the consultation.
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(c) When consulting with colleagues about clients, social workers should disclose
the least amount of information necessary to achieve the purposes of the
consultation.
2.06 Referral for Services
(a) Social workers should refer clients to other professionals when the other
professionals’ specialized knowledge or expertise is needed to serve clients fully or
when social workers believe that they are not being effective or making reasonable
progress with clients and that additional service is required.
(b) Social workers who refer clients to other professionals should take appropriate
steps to facilitate an orderly transfer of responsibility. Social workers who refer
clients to other professionals should disclose, with clients’ consent, all pertinent
information to the new service providers.
(c) Social workers are prohibited from giving or receiving payment for a referral
when no professional service is provided by the referring social worker.
2.07 Sexual Relationships
(a) Social workers who function as supervisors or educators should not engage in
sexual activities or contact with supervisees, students, trainees, or other colleagues
over whom they exercise professional authority.
(b) Social workers should avoid engaging in sexual relationships with colleagues
when there is potential for a conflict of interest. Social workers who become
involved in, or anticipate becoming involved in, a sexual relationship with a
colleague have a duty to transfer professional responsibilities, when necessary, to
avoid a conflict of interest.
2.08 Sexual Harassment
Social workers should not sexually harass supervisees, students, trainees, or
colleagues. Sexual harassment includes sexual advances, sexual solicitation,
requests for sexual favors, and other verbal or physical conduct of a sexual nature.
2.09 Impairment of Colleagues
(a) Social workers who have direct knowledge of a social work colleague’s
impairment that is due to personal problems, psychosocial distress, substance
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abuse, or mental health difficulties and that interferes with practice effectiveness
should consult with that colleague when feasible and assist the colleague in taking
remedial action.
(b) Social workers who believe that a social work colleague’s impairment
interferes with practice effectiveness and that the colleague has not taken adequate
steps to address the impairment should take action through appropriate channels
established by employers, agencies, NASW, licensing and regulatory bodies, and
other professional organizations.
2.10 Incompetence of Colleagues
(a) Social workers who have direct knowledge of a social work colleague’s
incompetence should consult with that colleague when feasible and assist the
colleague in taking remedial action.
(b) Social workers who believe that a social work colleague is incompetent and has
not taken adequate steps to address the incompetence should take action through
appropriate channels established by employers, agencies, NASW, licensing and
regulatory bodies, and other professional organizations.
2.11 Unethical Conduct of Colleagues
(a) Social workers should take adequate measures to discourage, prevent, expose,
and correct the unethical conduct of colleagues.
(b) Social workers should be knowledgeable about established policies and
procedures for handling concerns about colleagues’ unethical behavior. Social
workers should be familiar with national, state, and local procedures for handling
ethics complaints. These include policies and procedures created by NASW,
licensing and regulatory bodies, employers, agencies, and other professional
organizations.
(c) Social workers who believe that a colleague has acted unethically should seek
resolution by discussing their concerns with the colleague when feasible and when
such discussion is likely to be productive.
(d) When necessary, social workers who believe that a colleague has acted
unethically should take action through appropriate formal channels (such as
contacting a state licensing board or regulatory body, an NASW committee on
inquiry, or other professional ethics committees).
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(e) Social workers should defend and assist colleagues who are unjustly charged
with unethical conduct.
3. SOCIAL WORKERS’ ETHICAL RESPONSIBILITIES IN PRACTICE
SETTINGS
3.01 Supervision and Consultation
(a) Social workers who provide supervision or consultation should have the
necessary knowledge and skill to supervise or consult appropriately and should do
so only within their areas of knowledge and competence.
(b) Social workers who provide supervision or consultation are responsible for
setting clear, appropriate, and culturally sensitive boundaries.
(c) Social workers should not engage in any dual or multiple relationships with
supervisees in whom there is a risk of exploitation of or potential harm to the
supervisee.
(d) Social workers who provide supervision should evaluate supervisees’
performance in a manner that is fair and respectful.
3.02 Education and Training
(a) Social workers who function as educators, field instructors for students, or
trainers should provide instruction only within their areas of knowledge and
competence and should provide instruction based on the most current information
and knowledge available in the profession.
(b) Social workers who function as educators or field instructors for students
should evaluate students’ performance in a manner that is fair and respectful.
(c) Social workers who function as educators or field instructors for students
should take reasonable steps to ensure that clients are routinely informed when
services are being provided by students.
(d) Social workers who function as educators or field instructors for students
should not engage in any dual or multiple relationships with students in which
there is a risk of exploitation or potential harm to the student. Social work
educators and field instructors are responsible for setting clear, appropriate, and
culturally sensitive boundaries.
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3.03 Performance Evaluation
Social workers who have responsibility for evaluating the performance of others
should fulfill such responsibility in a fair and considerate manner and on the basis
of clearly stated criteria.
3.04 Client Records
(a) Social workers should take reasonable steps to ensure that documentation in
records is accurate and reflects the services provided.
(b) Social workers should include sufficient and timely documentation in records
to facilitate the delivery of services and to ensure continuity of services provided to
clients in the future.
(c) Social workers’ documentation should protect clients’ privacy to the extent that
is possible and appropriate and should include only information that is directly
relevant to the delivery of services.
(d) Social workers should store records following the termination of services to
ensure reasonable future access. Records should be maintained for the number of
years required by state statutes or relevant contracts.
3.05 Billing
Social workers should establish and maintain billing practices that accurately
reflect the nature and extent of services provided and that identify who provided
the service in the practice setting.
3.06 Client Transfer
(a) When an individual who is receiving services from another agency or colleague
contacts a social worker for services, the social worker should carefully consider
the client’s needs before agreeing to provide services. To minimize possible
confusion and conflict, social workers should discuss with potential clients the
nature of the clients’ current relationship with other service providers and the
implications, including possible benefits or risks, of entering into a relationship
with a new service provider.
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(b) If a new client has been served by another agency or colleague, social workers
should discuss with the client whether consultation with the previous service
provider is in the client’s best interest.
3.07 Administration
(a) Social work administrators should advocate within and outside their agencies
for adequate resources to meet clients’ needs.
(b) Social workers should advocate for resource allocation procedures that are open
and fair. When not all clients’ needs can be met, an
allocation procedure should be developed that is nondiscriminatory and based on
appropriate and consistently applied principles.
(c) Social workers who are administrators should take reasonable steps to ensure
that adequate agency or organizational resources are available to provide
appropriate staff supervision.
(d) Social work administrators should take reasonable steps to ensure that the
working environment for which they are responsible is consistent with and
encourages compliance with the NASW Code of Ethics. Social work administrators
should take reasonable steps to eliminate any conditions in their organizations that
violate, interfere with, or discourage compliance with the Code.
3.08 Continuing Education and Staff Development
Social work administrators and supervisors should take reasonable steps to provide
or arrange for continuing education and staff development for all staff for which
they are responsible. Continuing education and staff development should address
current knowledge and emerging developments related to social work practice and
ethics.
3.09 Commitments to Employers
(a) Social workers generally should adhere to commitments made to employers and
employing organizations.
(b) Social workers should work to improve employing agencies’ policies and
procedures and the efficiency and effectiveness of their services.
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(c) Social workers should take reasonable steps to ensure that employers are aware
of social workers’ ethical obligations as set forth in the NASW Code of Ethics and
of the implications of those obligations for social work practice.
(d) Social workers should not allow an employing organization’s policies,
procedures, regulations, or administrative orders to interfere with their ethical
practice of social work. Social workers should take reasonable steps to ensure that
their employing organizations’ practices are consistent with the NASW Code of
Ethics.
(e) Social workers should act to prevent and eliminate discrimination in the
employing organization’s work assignments and in its employment policies and
practices.
(f) Social workers should accept employment or arrange student field placements
only in organizations that exercise fair personnel practices.
(g) Social workers should be diligent stewards of the resources of their employing
organizations, wisely conserving funds where appropriate and never
misappropriating funds or using them for unintended purposes.
3.10 Labor Management Disputes
(a) Social workers may engage in organized action, including the formation of and
participation in labor unions, to improve services to clients and working
conditions.
(b) The actions of social workers who are involved in labor management disputes,
job actions, or labor strikes should be guided by the profession’s values, ethical
principles, and ethical standards. Reasonable differences of opinion exist among
social workers concerning their primary obligation as professionals during an
actual or threatened labor strike or job action. Social workers should carefully
examine relevant issues and their possible impact on clients before deciding on a
course of action.
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4. SOCIAL WORKERS’ ETHICAL RESPONSIBILITIES AS
PROFESSIONALS
4.01 Competence
(a) Social workers should accept responsibility or employment only on the basis of
existing competence or the intention to acquire the necessary competence.
(b) Social workers should strive to become and remain proficient in professional
practice and the performance of professional functions. Social workers should
critically examine and keep current with emerging knowledge relevant to social
work. Social workers should routinely review the professional literature and
participate in continuing education relevant to social work practice and social work
ethics.
(c) Social workers should base practice on recognized knowledge, including
empirically based knowledge, relevant to social work and social work ethics.
4.02 Discrimination
Social workers should not practice, condone, facilitate, or collaborate with any
form of discrimination on the basis of race, ethnicity, national origin, color, sex,
sexual orientation, gender identity or expression, age, marital status, political
belief, religion, immigration status, or mental or physical disability.
4.03 Private Conduct
Social workers should not permit their private conduct to interfere with their ability
to fulfill their professional responsibilities.
4.04 Dishonesty, Fraud, and Deception
Social workers should not participate in, condone, or be associated with
dishonesty, fraud, or deception.
4.05 Impairment
(a) Social workers should not allow their own personal problems, psychosocial
distress, legal problems, substance abuse, or mental health difficulties to interfere
with their professional judgment and performance or to jeopardize the best
interests of people for whom they have a professional responsibility.
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(b) Social workers whose personal problems, psychosocial distress, legal problems,
substance abuse, or mental health difficulties interfere with their professional
judgment and performance should immediately seek consultation and take
appropriate remedial action by seeking professional help, making adjustments in
workload, terminating practice, or taking any other steps necessary to protect
clients and others.
4.06 Misrepresentation
(a) Social workers should make clear distinctions between statements made and
actions engaged in as a private individual and as a representative of the social work
profession, a professional social work organization, or the social worker’s
employing agency.
(b) Social workers who speak on behalf of professional social work organizations
should accurately represent the official and authorized positions of the
organizations.
(c) Social workers should ensure that their representations to clients, agencies, and
the public of professional qualifications, credentials, education, competence,
affiliations, services provided, or results to be achieved are accurate. Social
workers should claim only those relevant professional credentials they actually
possess and take steps to correct any inaccuracies or misrepresentations of their
credentials by others.
4.07 Solicitations
(a) Social workers should not engage in uninvited solicitation of potential clients
who, because of their circumstances, are vulnerable to undue influence,
manipulation, or coercion.
(b) Social workers should not engage in solicitation of testimonial endorsements
(including solicitation of consent to use a client’s prior statement as a testimonial
endorsement) from current clients or from other people who, because of their
particular circumstances, are vulnerable to undue influence.
4.08 Acknowledging Credit
(a) Social workers should take responsibility and credit, including authorship
credit, only for work they have actually performed and to which they have
contributed.
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(b) Social workers should honestly acknowledge the work of and the contributions
made by others.
5. SOCIAL WORKERS’ ETHICAL RESPONSIBILITIES TO THE SOCIAL
WORK PROFESSION
5.01 Integrity of the Profession
(a) Social workers should work toward the maintenance and promotion of high
standards of practice.
(b) Social workers should uphold and advance the values, ethics, knowledge, and
mission of the profession. Social workers should protect, enhance, and improve the
integrity of the profession through appropriate study and research, active
discussion, and responsible criticism of the profession.
(c) Social workers should contribute time and professional expertise to activities
that promote respect for the value, integrity, and competence of the social work
profession. These activities may include teaching, research, consultation, service,
legislative testimony, presentations in the community, and participation in their
professional organizations.
(d) Social workers should contribute to the knowledge base of social work and
share with colleagues their knowledge related to practice, research, and ethics.
Social workers should seek to contribute to the profession’s literature and to share
their knowledge at professional meetings and conferences.
(e) Social workers should act to prevent the unauthorized and unqualified practice
of social work.
5.02 Evaluation and Research
(a) Social workers should monitor and evaluate policies, the implementation of
programs, and practice interventions.
(b) Social workers should promote and facilitate evaluation and research to
contribute to the development of knowledge.
(c) Social workers should critically examine and keep current with emerging
knowledge relevant to social work and fully use evaluation and research evidence
in their professional practice.
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(d) Social workers engaged in evaluation or research should carefully consider
possible consequences and should follow guidelines developed for the protection
of evaluation and research participants. Appropriate institutional review boards
should be consulted.
(e) Social workers engaged in evaluation or research should obtain voluntary and
written informed consent from participants, when appropriate, without any implied
or actual deprivation or penalty for refusal to participate; without undue
inducement to participate; and with due regard for participants’ wellbeing, privacy,
and dignity. Informed consent should include information about the nature, extent,
and duration of the participation requested and disclosure of the risks and benefits
of participation in the research.
(f) When evaluation or research participants are incapable of giving informed
consent, social workers should provide an appropriate explanation to the
participants, obtain the participants’ assent to the extent they are able, and obtain
written consent from an appropriate proxy.
(g) Social workers should never design or conduct evaluation or research that does
not use consent procedures, such as certain forms of naturalistic observation and
archival research, unless rigorous and responsible review of the research has found
it to be justified because of its prospective scientific, educational, or applied value
and unless equally effective alternative procedures that do not involve waiver of
consent are not feasible.
(h) Social workers should inform participants of their right to withdraw from
evaluation and research at any time without penalty.
(i) Social workers should take appropriate steps to ensure that participants in
evaluation and research have access to appropriate supportive services.
(j) Social workers engaged in evaluation or research should protect participants
from unwarranted physical or mental distress, harm, danger, or deprivation.
(k) Social workers engaged in the evaluation of services should discuss collected
information only for professional purposes and only with people professionally
concerned with this information.
(l) Social workers engaged in evaluation or research should ensure the anonymity
or confidentiality of participants and of the data obtained from them. Social
workers should inform participants of any limits of confidentiality, the measures
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that will be taken to ensure confidentiality, and when any records containing
research data will be destroyed.
(m) Social workers who report evaluation and research results should protect
participants’ confidentiality by omitting identifying information unless proper
consent has been obtained authorizing disclosure.
(n) Social workers should report evaluation and research findings accurately. They
should not fabricate or falsify results and should take steps to correct any errors
later found in published data using standard publication methods.
(o) Social workers engaged in evaluation or research should be alert to and avoid
conflicts of interest and dual relationships with participants, should inform
participants when a real or potential conflict of interest arises, and should take
steps to resolve the issue in a manner that makes participants’ interests primary.
(p) Social workers should educate themselves, their students, and their colleagues
about responsible research practices.
6. SOCIAL WORKERS’ ETHICAL RESPONSIBILITIES TO THE
BROADER SOCIETY
6.01 Social Welfare
Social workers should promote the general welfare of society, from local to global
levels, and the development of people, their communities, and their environments.
Social workers should advocate for living conditions conducive to the fulfillment
of basic human needs and should promote social, economic, political, and cultural
values and institutions that are compatible with the realization of social justice.
6.02 Public Participation
Social workers should facilitate informed participation by the public in shaping
social policies and institutions.
6.03 Public Emergencies
Social workers should provide appropriate professional services in public
emergencies to the greatest extent possible.
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6.04 Social and Political Action
(a) Social workers should engage in social and political action that seeks to ensure
that all people have equal access to the resources, employment, services, and
opportunities they require to meet their basic human needs and to develop fully.
Social workers should be aware of the impact of the political arena on practice and
should advocate for changes in policy and legislation to improve social conditions
in order to meet basic human needs and promote social justice.
(b) Social workers should act to expand choice and opportunity for all people, with
special regard for vulnerable, disadvantaged, oppressed, and exploited people and
groups.
(c) Social workers should promote conditions that encourage respect for cultural
and social diversity within the United States and globally. Social workers should
promote policies and practices that demonstrate respect for difference, support the
expansion of cultural knowledge and resources, advocate for programs and
institutions that demonstrate cultural competence, and promote policies that
safeguard the rights of and confirm equity and social justice for all people.
(d) Social workers should act to prevent and eliminate domination of, exploitation
of, and discrimination against any person, group, or class on the basis of race,
ethnicity, national origin, color, sex, sexual orientation, gender identity or
expression, age, marital status, political belief, religion, immigration status, or
mental or physical disability.
6D. NBCC Code of Ethics
PREAMBLE
The National Board for Certified Counselors (NBCC) provides national
certifications that recognize individuals who have voluntarily met standards for
general and specialty areas of counseling practice. Counselors certified by NBCC
may also identify with different professional associations and are often licensed by
jurisdictions that promulgate standards of behavior. Regardless of any other
affiliation, this Code of Ethics is applicable to all NBCC applicants and National
Certified Counselors (NCCs). This Code establishes the minimum ethical
behaviors and provides an expectation of and assurance for the ethical practice for
all who use the professional services of NCCs. Furthermore, it provides an
enforceable set of directives and assures a resource for those served in the case of a
perceived violation. NCCs are required to adhere to all of the directives. Sanctions
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of applicants and credential holders under this Code are issued by NBCC only if
the provisions of the NBCC Code of Ethics are found to have been violated.
DIRECTIVES
NCCs take appropriate action to prevent harm.
1. NCCs, recognizing the potential for harm, shall not share information that is
obtained through the counseling process without specific written consent by the
client or legal guardian except to prevent clear, imminent danger to the client or
others or when required to do so by a court order.
2. NCCs shall respect client’s privacy and shall solicit only information that
contributes to the identified counseling goals.
3. NCCs generally shall not accept goods or services from clients in return for
counseling services in recognition of the possible negative effects, including
perceived exploitation. NCCs may accept goods, services or other nonmonetary
compensation from clients only in cases where no referrals are possible or
appropriate and if the arrangement is discussed with the client in advance, is an
exchange of a reasonable equivalent value, does not place the counselor in an
unfair advantage, is not harmful to the client or their treatment and is documented
in the
counseling services agreement.
4. NCCs shall not accept gifts from clients except in cases when it is culturally
appropriate or therapeutically relevant because of the potential confusion that may
arise. NCCs shall consider the value of the gift and the effect on the therapeutic
relationship when contemplating acceptance. This consideration shall be
documented in the client’s record.
5. NCCs shall not engage in harmful multiple relationships with clients. In the
event that a harmful multiple relationship develops in an unforeseen manner, the
NCC shall discuss the potential effects with the client and shall take reasonable
steps to resolve the situation, including the provision of referrals. This discussion
shall be documented in the client’s record.
6. NCCs shall discuss important considerations to avoid exploitation before
entering into a non-counseling relationship with a former client. Important
considerations to be discussed include amount of time since counseling service
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termination, duration of counseling, nature and circumstances of client’s
counseling, the likelihood that the client will want to resume counseling at some
time in the future; circumstances of service termination and possible negative
effects or outcomes.
7. NCCs shall not engage in any form of sexual or romantic intimacy with clients
or with former clients for two years from the date of counseling service
termination.
8. NCCs shall not engage in sexual harassment, which is defined as a single act or
multiple occurrences of verbal, nonverbal or physical actions that are known to be
unwelcome or that are of the severity to be perceived as harassment by a
reasonable person.
9. NCCs shall take proactive measures to avoid interruptions of counseling
services due to illness, vacations or unforeseen circumstances. To prevent the harm
that may occur if clients are unable to access professional assistance, such
measures shall identify other professionals with whom the NCC has a working
agreement or local emergency service agencies that can respond to clients in a
mental health crisis.
10. NCCs shall create written procedures regarding the handling of client records
in the event of their unexpected death or incapacitation. In recognition of the harm
that may occur if clients are unable to access professional assistance in these cases,
these procedures shall ensure that the confidentiality of client records is maintained
and shall include the identification of individual(s) who are familiar with ethical
and legal requirements regarding the counseling profession and who shall assist
clients in locating other professional mental health providers as well as
ensure the appropriate transfer of client records. These written procedures shall be
provided to the client, and the NCC shall provide an opportunity for the client to
discuss concerns regarding the process as it pertains to the transfer of his or her
record.
11. NCCs who act as counselor educators, field placement or clinical supervisors
shall not engage in sexual or romantic intimacy with current students or
supervisees. They shall not engage in any form of sexual or romantic intimacy with
former students or supervisees for two years from the date of last supervision
contact.
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12. NCCs who provide clinical supervision services shall keep accurate records of
supervision goals and progress and consider all information gained in supervision
as confidential except to prevent clear, imminent danger to the client or others or
when legally required to do so by a court or government agency order. In cases in
which the supervisor receives a court or governmental agency order requiring the
production of supervision records, the NCC shall make reasonable attempts to
promptly notify the supervisee. In cases in which the supervisee is a student of a
counselor education program, the supervisor shall release supervision records
consistent with the terms of the arrangement with the counselor education
program.
13. NCCs who provide clinical supervision services shall intervene in situations
where supervisees are impaired or incompetent and thus place client(s) at risk.
14. NCCs who provide clinical supervision services shall not have multiple
relationships with supervisees that may interfere with supervisors’ professional
judgment or exploit supervisees. Supervisors shall not supervise relatives.
15. NCCs who seek consultation (i.e., consultees) shall protect client’s
confidentiality and unnecessary invasion of privacy by providing only the
information relevant to the consultation and in a manner that protects the client’s
identity.
16. NCCs shall not release the results of tests and assessments to individuals other
than the client without prior written consent except as required to prevent clear,
imminent danger to the client or others; by written agreement with the client; or
when legally required to do so by a court order or governmental agency.
17. NCCs shall protect the welfare of research participants by taking reasonable
precautions to prevent negative psychological or physical effects.
18. NCCs shall protect the identities of research participants by appropriately
disguising data except when there is a detailed written authorization.
19. NCCs shall recognize the potential harm of informal uses of social media and
other related technology with clients, former clients and their families and personal
friends. After carefully considering all of the ethical implications, including
confidentiality, privacy and multiple relationships, NCCs shall develop written
practice procedures in regard to social media and digital technology, and these
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shall be incorporated with the information provided to clients before or during the
initial session. At a minimum, these social media procedures shall specify
that personal accounts will be separate and isolated from any used for professional
counseling purposes including those used with prospective or current clients. These
procedures shall also address “friending” and responding to material posted.
20. NCCs shall not use social media sources (e.g., updates, tweets, blogs, etc.) to
provide confidential information regarding client cases that have not been
consented to by the client. To facilitate the secure provision of information, NCCs
shall inform clients prior to or during the initial session about appropriate ways to
communicate with them. Furthermore, NCCs shall advise clients about the
potential risks of sending messages through digital technology and social media
sources.
21. NCCs who use digital technology (e.g., social media) for professional purposes
shall limit information posted to that which does not create multiple relationships
or which may threaten client confidentiality.
NCCs provide only those services for which they have education and qualified
experience.
22. NCCs shall perform only those professional services for which they are
qualified by education and supervised experience.
23. NCCs shall seek professional assistance or withdraw from the practice of
counseling if their mental or physical condition makes it unlikely that the
counselor will be able to provide appropriate services.
24. NCCs shall seek supervision and consultation with other qualified
professionals when unsure about client treatment or professional practice
responsibilities.
25. NCCs shall use or interpret only the specific tests and assessments for which
they have the required education and supervised experience.
26. NCCs shall demonstrate multicultural competence and shall not use techniques
that discriminate against or show hostility towards individuals or groups based on
gender, ethnicity, race, national origin, sexual orientation, disability, religion or
any other legally prohibited basis. Techniques shall be based on established theory.
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NCCs shall discuss appropriate considerations and obtain written consent from the
client(s) prior to the use of any experimental approach.
NCCs promote the welfare of clients, students, supervisees or the recipients of
professional services provided.
27. NCCs shall discuss with prospective clients the appropriateness of counseling
services offered and shall not offer services if there is reasonable cause to believe
clients will not benefit.
28. NCCs who provide supervision services shall present supervisees with
feedback according to a schedule with identified evaluation dates as well as on
appropriate occasions throughout the process.
29. NCCs shall promote the welfare of supervisees by discussing ethical practices
relating to supervision as well as the legal standards that regulate the practice of
counseling.
30. NCCs who provide supervision services shall establish with their supervisees
procedures for responding to crisis situations or expressing concerns regarding the
supervision process. This information shall be provided in verbal and written
formats.
31. NCCs who seek consultation (i.e., consultees) shall promote welfare by
selecting appropriate professionals who can specifically respond to the identified
issue with the client, supervisee or student.
32. NCCs who provide consultative services (i.e., consultants) shall establish a
written plan with the professional seeking assistance. This plan shall include the
identification of the primary client concern or issue, consultation goals, potential
consequences of actions, evaluation and other future steps. The consultant shall
document this information in their professional records. Brief collaborative
conversations between an NCC and other professionals are not considered
consultations as long as no identifying client information is provided.
33. NCCs shall limit the use of tests and assessments to those that are current,
specifically necessary for the provision of quality services, and that have been
carefully considered in terms of the instrument’s validity, reliability, psychometric
limitations and appropriateness for use in a given situation or with a particular
client.
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34. NCCs shall protect the confidentiality and security of tests or assessments,
reports, data and any transmission of information in any form.
35. NCCs shall recognize results that are outside the norms for a given test and
assessment, and shall document in the client’s record how those results will be
appropriately used in the counseling process.
36. NCCs who develop tests or assessments for measuring personal characteristics,
development, diagnoses, goal attainment or other similar clinical uses shall provide
test users with written information regarding the benefits and limitations of test
instruments, including appropriate use, test results and interpretation.
37. NCCs who develop tests and assessments for measuring personal
characteristics, development, diagnoses, goal attainment or other similar clinical
uses shall identify other potential sources of appropriate information and shall
emphasize to test users the importance of basing decisions on multiple sources
rather than a single criterion.
NCCs communicate truthfully.
38. NCCs shall accurately represent their current qualifications and credentials in
counseling or closely related disciplines. NCCs shall not use doctorate degrees
with relation to professional counseling duties unless they are specific to
counseling or mental health disciplines.
39. NCCs shall identify only earned degrees in counseling or closely related
disciplines when it comes to all counseling work including publications. Listed
degrees from programs in the United States must be from colleges and universities
that were accredited at the time of graduation by one of the regional accrediting
organizations recognized by the Council for Higher Education Accreditation
(CHEA).
40. NCCs who have been awarded honorary degrees shall clearly distinguish these
from earned degrees.
41. NCCs shall correct known misrepresentations of their qualifications and
credentials by others and shall not allow such information to be used in a
misleading way.
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42. NCCs shall take credit only for work that they have performed, and when
quoting the work of others, shall provide appropriate references.
43. NCCs shall provide accurate reports which are based on direct experiences
with individual(s) or documentation from other professionals when providing
opinions. NCCs shall limit opinions to areas within their expertise.
44. NCCs shall accurately note in the client’s or supervisee’s records all
information necessary for the provision of quality services or as required by laws,
regulations or institutional procedures.
45. NCCs who provide supervision services shall present accurate written
information to supervisees regarding the NCC’s credentials as well as information
regarding the process of supervision. This information shall include any conditions
of supervision, supervision goals, case management procedures, confidentiality and
its limitations, appraisal methods and timing of evaluations.
46. NCCs who provide consultative services (i.e., consultants) shall use accurate
information regarding their qualifications in relation to the identified concerns or
situations.
47. NCCs who seek case consultation services from another professional shall
document consultation in clients’ records.
48. NCCs shall accurately report test and assessment results and limit conclusions
to those based on evidence, taking into consideration any influences that may
affect results such as health, motivation and multicultural factors. NCCs shall
generally avoid making decisions based on a single test or assessment result.
49. NCCs shall note in the results and interpretation when tests and assessments
are not administered under standard conditions or when unusual behavior or
irregularities occur during the testing session.
50. NCCs shall not misrepresent a test or the results and shall provide accurate
information in the event that he or she becomes aware of any false statements.
51. NCCs shall report to participants the subject and features of the study after
research data is collected, as well as clarify any misconceptions about the research.
52. NCCs shall accurately report results of research, including limitations and
variables that may have impacted the outcomes.
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53. NCCs shall take reasonable steps to publicly correct errors in their published
research if any are discovered.
54. NCCs shall include all electronic communications exchanged with clients and
supervisees, including those through digital technology and social media methods,
as a part of the record, even when strictly related to clerical issues such as change
of contact information or scheduling appointments. All electronic therapeutic
communication methods shall use encryption and password security.
NCCs recognize that their behavior reflects on the integrity of the profession as a
whole, and thus, they avoid actions which can reasonably be expected to damage
trust.
55. NCCs shall retain client records for a minimum of five years unless state or
federal laws require additional time. After the required retention period, NCCs
shall dispose of records in a manner that protects client confidentiality.
56. NCCs shall act in a professional manner by protecting against unauthorized
access to confidential information. This includes data contained in electronic
formats. NCCs shall inform any subordinates who have physical or electronic
access to information of the importance of maintaining privacy and confidentiality.
57. NCCs shall make all reasonable efforts to inform clients and former clients
prior to the court-ordered release of confidential client information. In the event
that the client seeks to prevent the release, the NCC shall request that a court
withdraw any order to release confidential information due to the potential harm to
the client or the counseling relationship. When ordered to disclose confidential
client information by a court or governmental agency, NCCs shall release only the
required information. Any release of information shall be appropriately
documented in accordance with the practice setting.
58. NCCs shall not provide forensic evaluation services concerning current or past
clients or client’s family members. Also, NCCs shall not provide forensic
evaluation services regarding their own family members, friends or professional
associates.
59. NCCs who are retiring or departing from an established practice with other
mental health professionals shall notify current and former clients as appropriate
regarding their pending departure from the practice. Such notifications should
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include information about record availability and access, and contact information
of appropriate referrals within the established practice.
60. NCCs who practice in multiple settings (e.g., agencies and private practice
settings) shall not increase their private practices by referring clients from the
setting of contact unless by specific prior arrangement with authorized individuals
in the agency or group setting. In such situations, clients shall be instructed of their
right to request to be referred to another professional in the original setting of
contact.
61. NCCs shall not misuse their professional influence or meet their own needs at
the expense of clients or their welfare. This shall include the promotion of products
developed by the NCC.
62. NCCs shall not solicit testimonials from current clients or their families and
close friends. Recognizing the possibility of future requests for services, NCCs
shall not solicit testimonials from former clients within two years from the date of
service termination.
63. NCCs shall not provide references if they have reasonable belief that the
individual counselor is not qualified, is not able to provide competent professional
services or presents a risk of harm to others.
64. NCCs who provide supervision services to supervisee’s who have more than
one supervisor (e.g., field placement and university) shall exchange contact
information and communicate regularly about the shared supervisee’s
performance.
65. NCCs who develop tests or assessments for measuring personal characteristics,
development, diagnoses, goal attainment or other similar clinical uses shall provide
written evidence that technical features (e.g., reliability, validity) are consistent
with the identified purposes.
66. NCCs shall limit use of information obtained through digital technology and
social media sources (e.g., Facebook, LinkedIn, Twitter, etc.) in accordance with
established practice procedures provided to clients at the initiation of services.
NCCs recognize the importance of and encourage active participation of clients,
students or supervisees.
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67. NCCs conducting counseling with more than one client at a time (e.g., group or
family counseling) shall discuss with clients the nature, the rights and
responsibilities as well as the possible additional limitations of confidentiality.
NCCs shall also describe the steps that they will take in the event that having
multiple clients in session creates issues between or concerning clients.
68. NCCs who learn that a client is receiving additional mental health services
from other professionals shall discuss with the client the importance of developing
clear agreements to avoid client confusion and conflict. Following this discussion,
NCCs shall request the client’s written consent to inform the other professional(s)
of the counseling relationship and to collaborate on the provision of mental health
services. This discussion and the client’s response to the request shall be
documented in the client’s record.
69. NCCs shall inform clients of the purposes, goals, procedures, limitations,
potential risks and benefits of services and techniques either prior to or during the
initial session. NCCs also shall provide information about client’s rights and
responsibilities including billing arrangements, collection procedures in the event
of nonpayment, confidentiality and its limitations, records and service termination
policies as appropriate to the counseling setting. This professional information
shall be provided to the client in verbal and written forms (i.e., the
counseling services agreement). NCCs shall have a reasonable basis for believing
that the information provided is understood. NCCs shall document any client
concerns related to the information provided in the client’s record.
70. NCCs shall respond to client requests for access to or copies of records within
a practical timeframe. Additionally, NCCs shall provide an opportunity for the
client to discuss the content of the record. If there is a reasonable basis to believe
that providing such access will cause harm, the NCC shall discuss the request and
possible effects; however, the information ultimately belongs to the client, and thus
must be released. Records requests and any discussion regarding the provision
shall be documented in the client’s record.
71. NCCs who become aware of another mental health professional’s unethical
behavior shall first attempt to resolve issues through reasonable means except
when state regulations require immediate reporting. In the event that it cannot be
resolved, the NCC shall report the matter to all appropriate professional regulatory
organizations and agencies.
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72. NCCs shall obtain a client’s consent prior to the provision of services. In
private practice or other similar situations, this consent shall be documented in
writing in a counseling services agreement. This counseling services agreement
shall become a part of the client’s record.
73. NCCs shall work collaboratively with clients in the creation of written plans of
treatment that offer attainable goals and use appropriate techniques consistent with
client’s psychological and physical needs and abilities.
74. NCCs shall update the client’s record throughout the counseling relationship
when changes occur in the treatment plan, including those relating to goals, roles
and techniques. The NCC shall obtain the client’s written approval on such
updates.
75. NCCs shall clearly designate in writing the primary client in the record. NCCs
shall also identify in the record individuals who are receiving related professional
services in connection with such client relationship. In the event of working with
minors or individuals who are unable to give informed consent, NCCs shall discuss
relevant considerations regarding the preferences of the individuals receiving
services and legal guardian’s rights and obligations. This information shall become
a part of the client’s record. NCCs shall discuss service termination with clients
when there is a reasonable belief that the clients are no longer benefiting from or
are unlikely to benefit from future services. NCCs shall not abruptly terminate
counseling services without good cause or significant justification, and in such
cases, shall provide appropriate referrals.
77. NCCs shall provide referrals if the client cannot afford services, at the client’s
request or as appropriate at the conclusion of a professional counseling service
relationship.
78. NCCs who act as university, field placement or clinical supervisors shall
ensure that supervisees provide accurate information to clients about the
supervisee’s professional status (i.e., intern, licensed, etc.)
79. NCCs shall provide complete information regarding the format (electronic or
otherwise), administration purpose, and the desired outcome, risks and limitations
prior to the use of a test or assessment. NCCs shall have a reasonable basis for
believing that the information provided is understood.
80. NCCs shall seek information, such as limitations, regarding a client which may
affect the administration or interpretation of results prior to use of a test or
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assessment. If appropriate, the NCC may provide a referral to another professional
who specializes in the evaluation of individuals with similar conditions. This
discussion shall be documented in the client’s record.
81. NCCs shall provide critical information to potential research subjects that will
assist them in reaching a determination about participation. This information shall
include the research’s purpose, process, duration, potential consequences, and
procedures as well as the participant’s right to refuse or withdraw participation.
82. NCCs shall obtain prior consent from all research participants. This consent
process shall contain relevant information with regard to the recording of voices or
images of participants. In the event of conducting research with individuals who
are unable to give informed consent, NCCs shall document considerations between
the potential subject’s desire to participate and the legal guardian’s consent.
83. NCCs shall not employ deceptive techniques in research unless there are no
alternatives and there is significant prospective scientific, educational or clinical
value. In all cases, NCCs shall review potential techniques and shall not use any
that can be reasonably expected to cause harm, as well as provide an explanation to
participants during the debriefing.
84. NCCs shall carefully consider ethical implications, including confidentiality
and multiple relationships, prior to conducting research with students, supervisees
or clients. NCCs shall not convey that participation is required or will otherwise
negatively affect academic standing, supervision or counseling services.
NCCs are accountable in their actions and adhere to recognized professional
standards and practices.
85. NCCs shall comply with all NBCC policies, procedures and agreements,
including all disclosure requirements.
86. NCCs shall adhere to legal standards and state board regulations.
87. NCCs shall not engage in unlawful discrimination.
88. NCCs who make statements in a public manner shall state that their opinions
represent their personal views and not another organization unless officially
authorized to do otherwise.
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89. NCCs providing public presentations by any means, shall ensure that
statements are consistent with this Code of Ethics.
90. NCCs who act as university, field placement or clinical supervisors shall
require that supervisees provide the supervising NCC’s name, credentials and
contact information to the supervisee’s clients.
91. NCCs shall follow administration and interpretation protocols for tests and
assessments, including the use of appropriate software if using electronic
measures.
92. NCCs shall comply with identified security protocols when using published
tests and assessments.
93. NCCs shall comply with intellectual property laws and other accepted
publication guidelines.
94. NCCs shall comply with applicable guidelines when designing, conducting or
reporting research, including those of an institutional review board.
95. NCCs shall credit the work of others who have contributed to research or
publication either through joint authorship, acknowledgment or other appropriate
means.
6E. The American Mental Health Counselors Association (AMHCA) Code of
Ethics
Preamble
The American Mental Health Counselors Association (AMHCA) represents mental
health counselors. As the professional counseling organization of mental health
counselors, AMHCA subscribes to rigorous standards for education, training and
clinical practice. Mental health counselors are committed to increasing knowledge
of human behavior and understanding of themselves and others. AMHCA
members are highly skilled professionals who provide a full range of counseling
services in a variety of settings. Members believe in the dignity and worth of the
individual and make every reasonable effort to protect human welfare. To this end,
AMHCA establishes and promotes the highest professional standards. Mental
health counselors subscribe to and pledge to abide by the principles identified in
the Code of Ethics. This code is a document intended as a guide to: assist members
to make sound ethical decisions; to define ethical behaviors and best practices for
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Association members; to support the mission of the Association; and to educate
members, students and the public at large regarding the ethical standards of mental
health counselors. Mental health counselors are expected to utilize carefully
considered ethical-decision making processes when faced with ethical dilemmas.
I. Commitment to Clients
A. Counselor-Client Relationship
1. Primary Responsibility
Mental health counselors value objectivity and integrity in their commitment to
understanding human behavior, and they maintain the highest standards in
providing mental health counseling services.
a) The primary responsibility of mental health counselors is to respect client
dignity and promote client welfare.
b) Mental health counselors are clear with clients about the parameters of the
counseling relationship. In a professional disclosure statement, they provide
information about expectations and responsibilities of both counselor and client in
the counseling process, their professional orientation and values regarding the
counseling process, emergency procedures, supervision (as applicable) and
business practices. Information is also provided regarding client rights and contact
information for the state counseling licensure authority.
2. Confidentiality
Mental health counselors have a primary obligation to safeguard information about
individuals obtained in the course of practice, teaching, or research. Personal
information is communicated to others only with the person's consent, preferably
written, or in those circumstances, as dictated by state laws. Disclosure of
counseling information is restricted to what is necessary, relevant and verifiable.
a) the onset of the counseling relationship, mental health counselors inform clients
of these rights including legal limitations and exceptions.
b) The information in client records belongs to the client and shall not be shared
without permission granted through a formal release of information. In the event
that a client requests that information in his or her record be shared, mental health
counselors educate clients to the implications of sharing the materials.
c) The release of information without consent of the client may only take place
under the most extreme circumstances: the protection of life (suicidality or
homicidality), child abuse, and/or abuse of incompetent persons and elder abuse.
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Above all, mental health counselors are required to comply with state and federal
statutes concerning mandated reporting.
d) Mental health counselors (or their staff members) do not release information by
request unless accompanied by a specific release of information or a valid court
order. Mental health counselors make every attempt to release only information
necessary to comply with the request or valid court order. Mental health counselors
are advised to seek legal advice upon receiving a subpoena in order to respond
appropriately.
e) The anonymity of clients served in public and other agencies is preserved, if at
all possible, by withholding names and personal identifying data. If external
conditions require reporting such information, the client shall be so informed.
f) Information received in confidence by one agency or person shall not be
forwarded to another person or agency without the client's written permission.
g) Mental health counselors have the responsibility to ensure the accuracy of, and
to indicate the validity of, data shared with other parties.
h) Case reports presented in classes, professional meetings, or publications shall be
disguised so that no identification is possible. Permission must be obtained from
clients prior to disclosing their identity.
i) Counseling reports and records are maintained under conditions of security, and
provisions are made for their destruction after five (5) years post termination or as
specified by state regulations. Mental health counselors ensure that all persons in
their employ, and volunteers, supervisees and interns, maintain confidentiality of
client information.
j) Sessions with clients may be taped or otherwise recorded only with written
permission of the client or guardian. Even with a guardian's written consent,
mental health counselors should not record a session against the expressed wishes
of a client. Such tapes shall be destroyed after five (5) years post termination or as
specified by state regulations.
k) The primary client owns the rights to confidentiality; however, in the case where
primary clients are minors or are adults who have been legally determined to be
incompetent, parents and guardians have legal access to client information. Where
appropriate, a parent(s) or guardian(s) may be included in the counseling process;
however, mental health counselors must take measures to safeguard client
confidentiality within legal limits.) Confidentiality is a right granted to all clients
of mental health counseling services.
l) In working with families or groups, the rights to confidentiality of each member
should be safeguarded. Mental health counselors must make clear that each
member of the group has individual rights to confidentiality and that each member
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of a family, when seen individually, has individual rights to confidentiality within
legal limits.
m) When using a computer to store confidential information, mental health
counselors take measures to control access to such information. After five (5) years
post termination or as specified by state regulations, the information should be
deleted from the system.
n) Mental health counselors may justify disclosing information to identifiable third
parties if clients disclose that they have a communicable or life threatening illness.
However, prior to disclosing such information, mental health counselors must
confirm the diagnosis with a medical provider. The intent of clients to inform a
third party about their illness and to engage in possible behaviors that could be
harmful to an identifiable third party must be assessed as part of the process of
determining whether a disclosure should be made to identifiable third parties.
o) Mental health counselors take necessary precautions to ensure client
confidentiality of information transmitted electronically through the use of a
computer, e-mail, fax, telephone, voice mail, answering machines, or any other
electronic means.
p) Mental health counselors protect the confidentiality of deceased clients in
accordance with legal requirements and agency or organizational policy.
q) Mental health counselors may disclose information to third-party payers only
after clients have authorized such disclosure.
3. Dual/multiple Relationships
Mental health counselors are aware of their influential position with respect to their
clients and avoid exploiting the trust and fostering dependency of the client.
a) Mental health counselors make every effort to avoid dual/multiple relationships
with clients that could impair professional judgment or increase the risk of harm.
Examples of such relationships may include, but are not limited to: familial, social,
financial, business, or close personal relationships with the clients.
b) When deciding whether to enter a dual/multiple relationship with a client,
former client or close relationship to the client, mental health counselors will seek
consultation and adhere to a credible decision-making process prior to entering this
relationship.
c) When a dual/multiple relationship cannot be avoided, mental health counselors
take appropriate professional precautions such as informed consent, consultation,
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supervision and documentation to ensure that judgment is not impaired and no
exploitation has occurred
d) Mental health counselors do not accept as clients, individuals with whom they
are involved in an administrative, supervisory or other relationship of an evaluative
nature.
4. Exploitive Relationships
Mental health counselors are aware of the intimacy and responsibilities inherent in
the counseling relationship. They maintain respect for the client and avoid actions
that seek to meet their personal needs at the expense of the client.
a) Romantic or sexual relationships with clients are strictly prohibited. Mental
health counselors do not counsel persons with whom they have had a previous
sexual relationship.
b) Mental health counselors are strongly discouraged from engaging in romantic or
sexual relationships with former clients. Counselors may not enter into an intimate
relationship until five years post termination or longer as specified by state
regulations. Documentation of supervision or consultation for exploring the risk of
exploitation is strongly encouraged.
c) Determining the risk of exploitive relationships includes but is not limited to
factors such as duration of counseling, amount of time since counseling,
termination circumstances the client’s personal history and mental status, and the
potential adverse impact on the former client.
d) Mental health counselors are aware of their own values, attitudes, beliefs and
behaviors, as well as how these apply in a society with clients from diverse ethnic,
social, cultural, religious, and economic backgrounds.
B. Counseling Process
1. Counseling Plans
Mental health counselors use counseling plans to direct their work with clients.
a) Mental health counselors and their clients work jointly in devising integrated,
individual counseling plans that offer reasonable promise of success and are
consistent with the abilities, ethnic, social, cultural, and values backgrounds, and
circumstances of the clients.
b) Mental health counselors and clients regularly review counseling plans to ensure
their continued viability and effectiveness, respecting the clients’ autonomy.
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2. Informed Consent
Clients have the right to know and understand what is expected, how the
information divulged will be used, and the freedom to choose whether, and with
whom, they will enter into a counseling relationship.
a) Mental health counselors provide information that allows clients to make an
informed choice when selecting a provider. Such information includes but is not
limited to: counselor credentials, issues of confidentiality, the use of tests and
inventories, diagnosis, reports, billing, and therapeutic process. Restrictions that
limit clients' autonomy are fully explained.
b) Informed Consent includes the mental health counselor's professional disclosure
statement and client bill of rights.
c) When a client is a minor or is unable to give informed consent mental health
counselors nature of the counseling relationship. Mental health counselors embrace
the diversity of the family system and the inherent rights and responsibilities
parents/guardians have for the welfare of their children. Mental health counselors
therefore strive to establish collaborative relationships with parents/guardians to
best serve their minor clients.
d) Informed consent is ongoing and needs to be reassessed throughout the
counseling relationship.
e) Mental health counselors inform the client of specific limitations, potential risks,
and/or potential benefits relevant to the client's anticipated use of on-line
counseling services.
3. Multiple Clients
When working with multiple clients, mental health counselors respect individual
client rights and maintain objectivity.
a) When mental health counselors agree to provide counseling services to two or
more persons who have a relationship (such as husband and wife, or parents and
children), counselors clarify at the outset, the nature of the relationship they will
have with each involved person.
b) Collateral consent informs family members or significant others involved in
counseling, of the parameters and limitations of confidentiality.
c) If it becomes apparent that mental health counselors are unable to maintain
objectivity resulting in conflicting roles, they must appropriately clarify, adjust, or
withdraw from roles.
d) Rules of confidentiality extend to all clients who receive services, not just those
identified as primary clients.
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e) When working in groups, mental health counselors screen prospective group
counseling/therapy participants. Every effort is made to select members whose
needs and goals are compatible with goals of the group, who will not impede the
group process, and whose wellbeing will not be jeopardized by the group
experience.
f) In the group setting, mental health counselors take reasonable precautions to
protect clients from physical, emotional, and psychological harm or trauma.
4. Clients Served by Others
Mental health counselors do not enter into counseling relationships with a person
being served by another mental health professional unless all parties have been
informed and agree.
a) When clients choose to change professionals but have not terminated services
with the former professional, it is important to encourage the individual to first
deal with that termination prior to entering into a new therapeutic relationship.
b) When clients work with multiple providers, it is important to secure permission
to work collaboratively with the other professional involved.
5. Termination and Referral
Mental health counselors do not abandon or neglect their clients in counseling.
a) Assistance is given in making appropriate arrangements for the continuation of
treatment, when necessary, during interruptions such as vacation and following
termination.
b) Mental health counselors terminate a counseling relationship when it is
reasonably clear that the client is no longer benefiting, when services are no longer
required, when counseling no longer serves the needs and/or interests of the client,
or when agency or institution limits do not allow provision of further counseling
services.
c) Mental health counselors may terminate a counseling relationship when clients
do not pay fees charged or when insurance denies treatment. In such cases,
appropriate referrals are offered to the clients.
d) If mental health counselors determine that services are not beneficial to the
client, they avoid entering or terminate immediately the counseling relationship. In
such situations, appropriate referrals are made. If clients decline the suggested
referral, mental health counselors discontinue the relationship.
e) When mental health counselors refer clients to other professionals, open and
collaborative communication is important to ensure an appropriate transition.
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f) If clients are in danger, such as domestic violence or suicidality, mental health
counselors take steps to secure a safety plan, refer to appropriate resources, and if
necessary contact appropriate support.
6. Technology-Assisted Counseling
Technology-assisted counseling includes but is not limited to computer, telephone,
internet and other communication devices. Mental health counselors take
reasonable steps to protect patients, clients, students, research participants and
others from harm. Mental health counselors performing technology assisted
counseling comply with all other provisions of this Ethics Code. Mental health
counselors:
a) establish methods to ascertain the client’s identity and obtain alternative
methods of contacting the client in an electronic emergency.
b) electronically transfer client confidential information to authorized third-party
recipients only when both the mental health counselor and the authorized recipient
have secure transfer and acceptance capabilities as state and federal laws regulate.
c) ensure that clients are intellectually, emotionally, and physically capable of
using technology-assisted counseling services, and of understanding the potential
risks and/or limitations of such services.
d) provide technology-assisted counseling services only in practice areas within
their expertise. Mental health counselors do not provide services to clients in states
where doing so would violate local licensure laws or regulations.
e) confirm that the provision of technology-assisted counseling services are not
prohibited by or otherwise violate any applicable state or local statutes, rules,
regulations or ordinances, codes of professional membership organizations and
certifying boards, and/or codes of state licensing boards.
7. Clients' Rights
In all mental health services, wherever and however they are delivered, clients
have the right to be treated with dignity, consideration and respect at all times.
Clients have the right:
a) to expect quality service provided by concerned, trained, professional and
competent staff.
b) to expect complete confidentiality within the limits of the law, and to be
informed about the legal exceptions to confidentiality; and to expect that no
information will be released without the client's knowledge and written consent.
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c) to a clear working contract in which business items, such as time of sessions,
payment plans/fees, absences, access, emergency procedures, third-party
reimbursement procedures, termination and referral procedures, and advanced
notice of the use of collection agencies, are discussed.
d) to a clear statement of the purposes, goals, techniques, rules limitations, and all
other pertinent information that may affect the ongoing mental health counseling
relationship.
e) to appropriate information regarding the mental health counselor's education,
training, skills, license and practice limitations and to request and receive referrals
to other clinicians when appropriate.
f) to full, knowledgeable, and responsible participation in the ongoing treatment
plan to the maximum extent feasible.
g) to obtain information about their case record and to have this information
explained clearly and directly.
h) to request information and/or consultation regarding the conduct and progress of
their therapy.
i) to refuse any recommended services and to be advised of the consequences of
this action.
j) to a safe environment for counseling free of emotional, physical, or sexual abuse.
k) to a client grievance procedure, including requests for consultation and/or
mediation; and to file a complaint with the mental health counselor's supervisor
(where relevant), and/or the appropriate credentialing body.
l) to a clearly defined ending process, and to discontinue therapy at any time.
8. End-of-Life Care for Terminally Ill Clients
a) Mental health counselors ensure that clients receive quality end-of-life care for
their physical, emotional, social, and spiritual needs. This includes providing
clients with an opportunity to participate in informed decision making regarding
their end-of-life care, and a thorough assessment, from a qualified end-of-life care
professional, of clients’ ability to make competent decisions on their behalf.
b) Mental health counselors are aware of their own personal, moral, and
competency issues as it relates to end-of-life decisions. When mental health
counselors assess that they are unable to work with clients on the exploration of
end-of-life options, they make appropriate referrals to ensure clients receive
appropriate help.
c) Depending upon the applicable state laws, the circumstances of the situation,
and after seeking consultation and supervision from competent professional and
legal entities, mental health counselors have the options of breaking or not
breaking confidentiality of terminally ill clients who plan on hastening their deaths.
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C. Counselor Responsibility and Integrity
1. Competence
The maintenance of high standards of professional competence is a responsibility
shared by all mental health counselors in the best interests of the client, the public,
and the profession.
Mental health counselors:
a) recognize the boundaries of their particular competencies and the limitations of
their expertise.
b) provide only those services and use only those techniques for which they are
qualified by education, techniques or experience.
c) maintain knowledge of relevant scientific and professional information related
to the services rendered, and recognize the need for on-going education.
d) represent accurately their competence, education, training, and experience
including licenses and certifications.
e) perform their duties, as teaching professionals, based on careful preparation in
order that their instruction is accurate, up-to-date and educational.
f) recognize the importance of continuing education and remain open to new
counseling approaches and procedures documented by peer-reviewed scientific and
professional literature.
g) recognize the important need to be competent in regard to cultural diversity and
are sensitive to the diversity of varying populations as well as to changes in
cultural expectations and values over time.
h) recognize that their effectiveness is dependent on their own mental and physical
health. Should their involvement in any activity, or any mental, emotional, or
physical health problem, compromise sound professional judgment and
competency, they seek capable professional assistance to determine whether to
limit, suspend, or terminate services to their clients.
i) have a responsibility to maintain high standards of professional conduct at all
times.
j) take appropriate steps to rectify ethical issues with colleagues by using
procedures developed by employers and/or state licensure boards.
k) are aware of the intimacy of the counseling relationship, maintain a healthy
respect for the integrity of the client, and avoid engaging in activities that seek to
meet the mental health counselor's personal needs at the expense of the client.
l) will actively attempt to understand the diverse cultural backgrounds of the
clients with whom they work. This includes learning how the mental health
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counselor's own cultural/ethical/racial/religious identity impacts his or her own
values and beliefs about the counseling process.
m) are responsible for continuing education and remaining abreast of current trends
and changes in the field including the professional literature on best practices.
n) develop a plan for termination of practice, death or incapacitation by assigning a
colleague or records custodian to handle transfer of clients and files.
2. Non-discrimination
Mental health counselors do not condone or engage in any discrimination based on
age, color, culture, disability, ethnic group, gender, race, religion, sexual
orientation, marital status, or socioeconomic status.
Mental health counselors do not condone or engage in sexual harassment. Sexual
harassment is defined as any solicitation, physical, or verbal or nonverbal conduct
that is sexual in nature that occurs in connection with professional activities or
roles, and that is either unwelcome or offensive, or creates a hostile workplace or
learning environment, or is sufficiently severe or intense to be perceived as
harassment to a reasonable person in the context in which the behavior occurred.
Sexual harassment can consist of a single intense or severe act or multiple
persistent or pervasive acts.
3. Conflict of Interest
Mental health counselors are aware of possible conflicts of interests that may arise
between the counselor and the client, the employer, consultant and other
professionals. Mental health counselors may choose to consult with any other
professionally competent person about a client assuring that no conflict of interest
exists. When conflicts occur, mental health counselors clarify the nature of the
conflict and inform all parties of the nature and direction of their loyalties and
responsibilities, and keep all parties informed of their commitments.
D. Assessment and Diagnosis
1. Selection and Administration
Mental health counselors utilize tests (herein references educational,
psychological, and career assessment instruments), interviews, and other
assessment techniques and diagnostic tools in the counseling process for the
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purpose of determining the client’s particular needs in the context of his/her
situation.
a) Mental health counselors choose assessment methods that are reliable, valid and
appropriate based on the age, gender, race, ability and other client characteristics.
If tests must be used in the absence of information regarding the aforementioned
factors, the limitations of generalizability should be duly noted
b) In selecting assessment tools, mental health counselors justify the logic of their
choices in relation to the client’s needs and the clinical context in which the
assessment occurs.
c) Mental health counselors avoid using outdated or obsolete tests, and remain
current regarding test publication and revision.
d) Mental health counselors use assessments only in the context of professional,
academic, or training relationships.
e) Mental health counselors provide the client with appropriate information
regarding the reason for assessment, the approximate length of time required, and
to whom the report will be distributed.
f) Mental health counselors provide an appropriate assessment environment with
regard to temperature, privacy, comfort, and freedom from distractions.
2. Interpretation and Reporting
Mental health counselors respects the rights and dignity of the client in assessment,
interpretation, and diagnosis of mental disorders and makes every effort to assure
that the client receives the appropriate treatment.
a) Mental health counselors base diagnoses and other assessment summaries on
multiple sources of data whenever possible.
b) Mental health counselors are careful not to draw conclusions unless empirical
evidence is present.
c) Mental health counselors consider multicultural factors (including but not
limited to gender, race, religion, age, ability, culture, class, ethnicity, sexual
orientation) in test recommendations.
d) Mental health counselors are responsible for evaluating the quality of computer
software interpretations of test data. Mental health counselors should obtain
information regarding validity of computerized test interpretation before utilizing
such an approach.
e) Mental health counselors clearly explain computerized test results in their
summaries and reports.
f) Mental health counselors write reports in a style that is clear, concise and easily
accessible to the lay reader.
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g) To the extent possible mental health counselors provide test results in a neutral
and nonjudgmental manner.
h) Mental health counselors are responsible for ensuring the confidentiality and
security of assessment reports, test data, and test materials regardless of how the
material is maintained or transmitted.
i) Mental health counselors train their staff to respect the confidentiality of test
reports in the context of typing, filing, or mailing them.
j) Mental health counselors (or their staff members) do not release an assessment
or evaluation report by request unless accompanied by a specific release of
information or a valid court order. A subpoena is insufficient to release a report. In
such a case, the counselor must inform his or her client of the situation. If the client
refuses release, the mental health counselor coordinates between the client's
attorney and the requesting attorney to protect client confidentiality and the
counselor’s legal welfare.
3. Competence
Mental health counselors employ only those diagnostic tools and assessment
instruments they are trained to use by education, or supervised training and clinical
experience.
a) Mental health counselors seek appropriate workshops, supervision and training
to familiarize themselves with assessment techniques and the use of specific
assessment instruments.
b) Mental health counselor supervisors ensure that their supervisees have adequate
training in interpretation before allowing them to evaluate tests independently.
4. Forensic Activity
Mental health counselors who are requested or required to perform forensic
functions, such as assessments, interviews, consultations, report writing,
responding to subpoenas, or offering expert testimony, comply with all provisions
of this Ethics Code and act in accordance with applicable state law.
a) Mental health counselors who engage in forensic activity must possess
appropriate knowledge and competence, including specialized knowledge about
special populations, specialized testing and specialized interview techniques.
b) When conducting interviews, writing reports or offering testimony mental health
counselors objectively offers their findings without bias, personal opinion or
investment in the ultimate outcome.
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b) The client, in a forensic evaluation will be informed about the limits of
confidentiality, the role of the mental health counselor, the purpose of the
assessment and potential for unfavorable findings.
c) Mental health counselors’ forensic written reports and recommendations are
based upon information and techniques appropriate to the evaluation.
d) Mental health counselors do not provide written conclusions or forensic
testimony regarding any individual without assessment of that individual adequate
to support any statements or conclusions offered in the forensic setting.
e) When testifying, the mental health counselors clearly present their qualifications
and specialized training. They describe fairly the basis for their professional
judgment, conclusions, and testimony. Counselors remain cognizant of the social
responsibility they bear.
f) In general, mental health counselors do not evaluate, for forensic purposes,
individuals whom they are currently counseling or have counseled in the past. In
addition, in general, mental health counselors do not counsel individuals they are
currently evaluating, or have evaluated in the past, for forensic purposes.
g) Forensic mental health counselors do not act as an advocate for the legal system,
perpetrators, or victims of criminal activity.
E. Record-Keeping, Fee Arrangements, and Bartering
1. Recordkeeping
Mental health counselors create and maintain accurate and adequate clinical and
financial records.
a) Mental health counselors create, maintain, store, transfer, and dispose of client
records in ways that protect confidentiality and are in accordance with applicable
regulations or laws.
b) Mental health counselors establish a plan for the transfer, storage, and disposal
of client records in the event of withdrawal from practice or death of the counselor
that maintains confidentiality and protects the welfare of the client.
2. Fee Arrangements, Bartering, and Gifts
Mental health counselors are cognizant of cultural norms in relation to fee
arrangements, bartering, and gifts. Mental health counselors clearly explain to
clients, early in the counseling relationship, all financial arrangements related to
counseling.
a) In establishing professional counseling fees, mental health counselors take into
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consideration the financial situation of clients and locality. If the usual fees create
undue hardship for the client, the counselor may adjust fees or assist the client to
locate comparable, affordable services.
b) Mental health counselors usually refrain from accepting goods or services from
clients in return for counseling services because such arrangements may create the
potential for conflicts, exploitation and distortion of the professional relationship.
However, bartering may occur if the client requests it, there is no exploitation, and
the cultural implications and other concerns of such practice are discussed with the
client and agreed upon in writing.
c) Mental health counselors contribute to society by providing pro bono services.
d) When accepting gifts, mental health counselors take into consideration the
therapeutic relationship, motivation of giving, the counselor’s motivation for
receiving or declining, cultural norms, and the value of the gift.
F. Other Roles
1. Consultant
Mental health counselors acting as consultants have a high degree of selfawareness of their own values, knowledge, skills and needs in entering a helping
relationship that involves human and/or organizational change.
a) The focus of the consulting relationship is on the issues to be resolved and not
on the personal characteristics of those presenting the consulting issues.
b) Mental health counselors develop an understanding of the problem presented by
the client and secure an agreement with the client, specifying the terms and nature
of the consulting relationship.
c) Mental health counselors are reasonably certain that they and their clients have
the competencies and resources necessary to follow the consultation plan.
d) Mental health counselors encourage adaptability and growth toward selfdirection.
e) Mental health counselors keep all proprietary information confidential.
f) Mental health counselors avoid conflicts of interest in selecting consultation
clients.
2. Advocate
Mental health counselors may serve as advocates at the individual, institutional,
and/or societal level in an effort to foster sociopolitical change that meets the needs
of the client or the community.
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a) Mental health counselors are aware of and make every effort to avoid pitfalls of
advocacy including conflicts of interest, inappropriate relationships and other
negative consequences. Mental health counselors remain sensitive to the potential
personal and cultural impact on clients of their advocacy efforts. b) Mental health
counselors may encourage clients to challenge familial, institutional, and societal
obstacles to their growth and development and they may advocate on the clients’
behalf. Mental health counselors remain aware of the potential dangers of
becoming overly involved as an advocate.
II. Commitment to Other Professionals
A. Relationship with colleagues
Mental health counselors act with due regard for the needs and feelings of their
colleagues in counseling and other professions. Mental health counselors respect
the rights and obligations of the institutions or organizations with which they
associate.
1. Mental health counselors understand how related professions complement their
work and make full use of other professional, technical, and administrative
resources that best serve the interests of clients.
2. Mental health counselors know and take into account the traditions and practices
of other professional groups with which they work and cooperate fully in working
for the benefit of public welfare.
3. Mental health counselors treat professional colleagues with the same dignity and
respect afforded to clients. Professional discourse should be free of personal
attacks.
4. Mental health counselors respect the viability, reputation, and proprietary rights
of organizations that they serve.
5. Credit is assigned to those who have contributed to a publication, in proportion
to their contribution.
6. Mental health counselors do not accept or offer referral fees from other
professionals.
7. When mental health counselors have knowledge of the impairment,
incompetence, or unethical conduct of a mental health professional, they are
obliged to attempt to rectify the situation. Failing an informal solution, mental
health counselors should bring such unethical activities to the attention of the
appropriate state licensure board and/or the ethics committee of the professional
association.
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B. Clinical Consultation
Mental health counselors may offer or seek clinical consultation from another
mental health professional. In clinical consulting mental health counselors provide
critical and supportive feedback. Clinical consultation does not imply hierarchy or
responsibility for client outcome.
III. Commitment to Students, Supervisees and Employee Relationships
Mental health counselors have an ethical concern for the integrity and welfare of
supervisees, students, and employees. These relationships typically include an
evaluative component and therefore need to be maintained on a professional and
confidential basis. Mental health counselors recognize the influential position they
have with regard to both current and former supervisees, students and employees
and avoid exploiting their trust and dependency.
1. Mental health counselors do not engage in ongoing counseling relationships
with current supervisees, students and employees.
2. All forms of sexual behavior with supervisees, students and employees are
unethical.
3. Mental health counselors do not engage in any form of harassment of
supervisees, students, employees or colleagues.
4. Mental health counselor supervisors advise their supervisees, students and
employees against holding themselves out to be competent to engage in
professional services beyond their training, experience, or credentials.
5. With supervisees, students and employees, mental health counselors make every
effort to avoid dual/multiple relationships that could bias their judgment or
increase the risk of personal or financial exploitation. When a dual/multiple
relationship cannot be avoided, mental health counselors take appropriate
professional precautions to make sure that detrimental effects are minimized.
Examples of such dual/multiple relationships include, but are not limited
to, a supervisee who receives supervision as a benefit of employment.
6. Mental health counselors do not disclose supervisee confidences regarding client
information except:
a) To prevent clear and eminent danger to a person or persons
b) As mandated by law
i) As in mandated child or senior abuse reporting or
ii) Where the counselor is a defendant in a civil, criminal, or disciplinary action or
iii) Where there is a waiver of confidentiality obtained, in writing, prior to such a
release of information
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c) In educational or training settings where only other professionals who will share
responsibility for the training of the supervisee are present and formal written
client consent has been obtained for such disclosures for training purposes.
7. In the informed consent statement, students and mandated supervisees notify the
client they are in supervision and provide their clients with the name and
credentials of their supervisor, if requested.
8. Students and supervisees have the same ethical obligations to clients as those
required of mental health counselors.
9. The primary obligation of supervisors is to monitor services provided by
supervisees to ensure client welfare.
10. Supervisors are expected to monitor clinical performance of supervisees;
including but not limited to regular meetings, review of case notes and records,
direct observation of supervisee’s clinical work via audio/video records, or live
supervision .
11. Supervisors provide written informed consent prior to beginning a supervision
relationship that documents business address and telephone number; list of
degrees, license, and credentials/certifications held; areas of competence in clinical
mental health counseling; training in supervision and experience providing
supervision; model of or approach to supervision, including the role, objectives and
goals of supervision, and modalities; evaluation procedures in the supervisory
relationship; the limits and scope of confidentiality and privileged
communication within the supervisory relationship; procedures for supervisory
emergencies and supervisor absences; use of supervision agreements; and
procedures for supervisee endorsement for certification and/or licensure, or
employment to those whom are competent, ethical, and qualified.
IV. Commitment to the Profession
Mental health counselors promote the mission, goals, values, and knowledge of the
profession. They engage in activities that maintain and increase the respect,
integrity, and knowledge base of the counseling profession and human welfare.
Such activities include but are not limited to teaching, research, serving on
professional boards and membership in professional associations.
A. Teaching
As teaching professionals, mental health counselors perform their duties based on
careful preparation in order that their instruction is accurate, current, and
educational.
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B. Research and Publications
Mental health counselors, as researchers, conduct investigations and publish
findings with respect for dignity and welfare of the participants and integrity of the
profession.
1. The ethical researcher seeks advice from other professionals if any plan of
research suggests a deviation from any ethical principle of research with human
subjects. Such deviation protects the dignity and welfare of the client and places on
the researcher a special burden to act in the subject's interest.
2. The ethical researcher is open and honest in the relationship with research
participants.
3. The ethical researcher protects participants from physical and mental
discomfort, harm, and danger. If the risks of such consequences exist, the
investigator is required to inform participants of that fact, secure consent before
proceeding, and take all possible measures to minimize the distress.
4. The ethical researcher instructs research participants that they are free to
withdraw from participation at any time.
5. The ethical researcher understands that information obtained about research
participants during the course of an investigation is confidential. When the
possibility exists that others may obtain access to such information, participants are
made aware of the possibility and the plan for protecting confidentiality and for
storage and disposal of research records.
6. The ethical researcher gives sponsoring agencies, host institutions, and
publication channels the same respect and opportunity for informed consent that
they accord to individual research participants.
7. The ethical researcher is aware of his or her obligation to future research and
ensures that host institutions are given feedback information and proper
acknowledgement.
C. Service on public or private boards and other organizations
When serving as members of governmental or other organizational bodies, mental
health counselors represent the mental health counseling profession and are
accountable as individuals to the Code of Ethics of the American Mental Health
Counselors Association.
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V. Commitment to the Public
Mental health counselors recognize they have a moral, legal, and ethical
responsibility to the community and to the general public. Mental health
counselors are aware of the prevailing community and cultural values, and the
impact of professional standards on the community.
A. Public Statements
Mental health counselors in their professional roles may be expected or required to
make public statements providing counseling information or professional opinions,
or supply information about the availability of counseling products and services. In
making such statements, mental health counselors accurately present their
education, professional qualifications, licenses and credentials, expertise,
affiliations, and functions, as well as those of the institutions or organizations with
which the statements may be associated. Public statements serve the purpose of
providing information to aid the public in making informed judgments and choices.
All public statements will be consistent with this Code of Ethics.
B. Advertising
Mental health counselors advertise the following: highest counseling-related
degree, type and level of certification or license, and type and/or description of
services or other relevant information concerning areas of clinical competence.
These statements will not be false, inaccurate, misleading, or out of context.
VI. Resolution of Ethical Problems
Members are encouraged to consult with the AMHCA Ethics Committee regarding
processes to resolve ethical dilemmas which may arise in clinical practice.
Members are also encouraged to use commonly recognized procedures for ethical
decision-making to resolve ethical conflicts. Sources for examples of such ethical
decision-making procedures are attached to this code.
The American Mental Health Counselors Association, its Board of Directors, and
its National Committee on Ethics do not investigate or adjudicate ethical
complaints. In the event a member has his or her license suspended or revoked by
an appropriate state licensure board, the AMHCA Board of Directors may then act
in accordance with AMHCA's National By-Laws to suspend or revoke his or her
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membership. Any member so suspended may apply for reinstatement upon the
reinstatement of his or her licensure.
6E. The ACA Code of Ethics
ACA Code of Ethics Preamble
The American Counseling Association is an educational, scientific, and
professional organization whose members are dedicated to the enhancement of
human development throughout the life-span. Association members recognize
diversity in our society and embrace a cross- cultural approach in support of the
worth, dignity, potential, and uniqueness of each individual.
The specification of a code of ethics enables the association to clarify to current
and future members, and to those served by members, the nature of the ethical
responsibilities held in common by its members. As the code of ethics of the
association, this document establishes principles that define the ethical behavior of
association members. All members of the American Counseling Association are
required to adhere to the Code of Ethics and the Standards of Practice. The Code of
Ethics will serve as the basis for processing ethical complaints initiated against
members of the association.
ACA Code of Ethics
Section A: The Counseling Relationship
Section B: Confidentiality
Section C: Professional Responsibility
Section D: Relationships with Other Professionals
Section E: Evaluation, Assessment, and Interpretation
Section F: Teaching, Training, and Supervision
Section G: Research and Publication
Section H: Resolving Ethical Issues
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Section A: The Counseling Relationship
A.1. Client Welfare
Primary Responsibility
The primary responsibility of counselors is to respect the dignity and to promote
the welfare of clients.
Positive Growth and Development
Counselors encourage client growth and development in ways that foster the
clients' interest and welfare; counselors avoid fostering dependent counseling
relationships.
Counseling Plans
Counselors and their clients work jointly in devising integrated, individual
counseling plans that offer reasonable promise of success and are consistent with
abilities and circumstances of clients. Counselors and clients regularly review
counseling plans to ensure their continued viability and effectiveness, respecting
clients' freedom of choice. (See A.3.b.)
Family Involvement
Counselors recognize that families are usually important in clients' lives and strive
to enlist family understanding and involvement as a positive resource, when
appropriate.
Career and Employment Needs
Counselors work with their clients in considering employment in jobs and
circumstances that are consistent with the clients' overall abilities, vocational
limitations, physical restrictions, general temperament, interest and aptitude
patterns, social skills, education, general qualifications, and other relevant
characteristics and needs. Counselors neither place nor participate in placing
clients in positions that will result in damaging the interest and the welfare of
clients, employers, or the public.
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A.2. Respecting Diversity
Nondiscrimination
Counselors do not condone or engage in discrimination based on age, color,
culture, disability, ethnic group, gender, race, religion, sexual orientation, marital
status, or socioeconomic status. (See C.5.a., C.5.b., and D.1.i.)
Respecting Differences
Counselors will actively attempt to understand the diverse cultural backgrounds of
the clients with whom they work. This includes, but is not limited to, learning how
the counselor's own cultural/ethnic/racial identity impacts her or his values and
beliefs about the counseling process. (See E.8. and F.2.i.)
A.3. Client Rights
Disclosure to Clients
When counseling is initiated, and throughout the counseling process as necessary,
counselors inform clients of the purposes, goals, techniques, procedures,
limitations, potential risks, and benefits of services to be performed, and other
pertinent information. Counselors take steps to ensure that clients understand the
implications of diagnosis, the intended use of tests and reports, fees, and billing
arrangements. Clients have the right to expect confidentiality and to be provided
with an explanation of its limitations, including supervision and/or treatment team
professionals; to obtain clear information about their case records; to participate in
the ongoing counseling plans; and to refuse any recommended services and be
advised of the consequences of such refusal. (See E.5.a. and G.2.)
Freedom of Choice. Counselors offer clients the freedom to choose whether to
enter into a counseling relationship and to determine which professional(s) will
provide counseling. Restrictions that limit choices of clients are fully explained.
(See A.1.c.)
Inability to Give Consent
When counseling minors or persons unable to give voluntary informed consent,
counselors act in these clients' best interests. (See B.3.)
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A.4. Clients Served by Others
If a client is receiving services from another mental health professional,
counselors, with client consent, inform the professional persons already involved
and develop clear agreements to avoid confusion and conflict for the client. (See
C.6.c.)
A.5. Personal Needs and Values
Personal Needs
In the counseling relationship, counselors are aware of the intimacy and
responsibilities inherent in the counseling relationship, maintain respect for clients,
and avoid actions that seek to meet their personal needs at the expense of clients.
Personal Values
Counselors are aware of their own values, attitudes, beliefs, and behaviors and how
these apply in a diverse society, and avoid imposing their values on clients. (See
C.5.a.)
A.6. Dual Relationships
Avoid When Possible
Counselors are aware of their influential positions with respect to clients, and they
avoid exploiting the trust and dependency of clients. Counselors make every effort
to avoid dual relationships with clients that could impair professional judgment or
increase the risk of harm to clients. (Examples of such relationships include, but
are not limited to, familial, social, financial, business, or close personal
relationships with clients.) When a dual relationship cannot be avoided, counselors
take appropriate professional precautions such as informed consent, consultation,
supervision, and documentation to ensure that judgment is not impaired and no
exploitation occurs. (See F.1.b.)
Superior/Subordinate Relationships
Counselors do not accept as clients superiors or subordinates with whom they have
administrative, supervisory, or evaluative relationships.
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A.7. Sexual Intimacies with Clients
Current Clients
Counselors do not have any type of sexual intimacies with clients and do not
counsel persons with whom they have had a sexual relationship.
Former Clients
Counselors do not engage in sexual intimacies with former clients within a
minimum of 2 years after terminating the counseling relationship. Counselors who
engage in such relationship after 2 years following termination have the
responsibility to examine and document thoroughly that such relations did not have
an exploitative nature, based on factors such as duration of counseling, amount of
time since counseling, termination circumstances, client's personal history and
mental status, adverse impact on the client, and actions by the counselor suggesting
a plan to initiate a sexual relationship with the client after termination.
A.8. Multiple Clients
When counselors agree to provide counseling services to two or more persons who
have a relationship (such as husband and wife, or parents and children), counselors
clarify at the outset which person or persons are clients and the nature of the
relationships they will have with each involved person. If it becomes apparent that
counselors may be called upon to perform potentially conflicting roles, they
clarify, adjust, or withdraw from roles appropriately. (See B.2. and B.4.d.)
A.9. Group Work
Screening
Counselors screen prospective group counseling/therapy participants. To the extent
possible, counselors select members whose needs and goals are compatible with
goals of the group, who will not impede the group process, and whose well-being
will not be jeopardized by the group experience.
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Protecting Clients
In a group setting, counselors take reasonable precautions to protect clients from
physical or psychological trauma.
A.10. Fees and Bartering (See D.3.a. and D.3.b.)
Advance Understanding
Counselors clearly explain to clients, prior to entering the counseling relationship,
all financial arrangements related to professional services including the use of
collection agencies or legal measures for nonpayment. (A.11.c.)
Establishing Fees
In establishing fees for professional counseling services, counselors consider the
financial status of clients and locality. In the event that the established fee structure
is inappropriate for a client, assistance is provided in attempting to find comparable
services of acceptable cost. (See A.10.d., D.3.a., and D.3.b.)
Bartering Discouraged
Counselors ordinarily refrain from accepting goods or services from clients in
return for counseling services because such arrangements create inherent potential
for conflicts, exploitation, and distortion of the professional relationship.
Counselors may participate in bartering only if the relationship is not exploitative,
if the client requests it, if a clear written contract is established, and if such
arrangements are an accepted practice among professionals in the community. (See
A.6.a.)
Pro Bono Service
Counselors contribute to society by devoting a portion of their professional activity
to services for which there is little or no financial return (pro bono).
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A.11. Termination and Referral
Abandonment Prohibited
Counselors do not abandon or neglect clients in counseling. Counselors assist in
making appropriate arrangements for the continuation of treatment, when
necessary, during interruptions such as vacations, and following termination.
Inability to Assist Clients
If counselors determine an inability to be of professional assistance to clients, they
avoid entering or immediately terminate a counseling relationship. Counselors are
knowledgeable about referral resources and suggest appropriate alternatives. If
clients decline the suggested referral, counselors should discontinue the
relationship.
Appropriate Termination
Counselors terminate a counseling relationship, securing client agreement when
possible, when it is reasonably clear that the client is no longer benefiting, when
services are no longer required, when counseling no longer serves the client's needs
or interests, when clients do not pay fees charged, or when agency or institution
limits do not allow provision of further counseling services. (See A.10.b. and
C.2.g.)
A.12. Computer Technology
Use of Computers
When computer applications are used in counseling services, counselors ensure
that (1) the client is intellectually, emotionally, and physically capable of using the
computer application; (2) the computer application is appropriate for the needs of
the client; (3) the client understands the purpose and operation of the computer
applications; and (4) a follow-up of client use of a computer application is
provided to correct possible misconceptions, discover inappropriate use, and assess
subsequent needs.
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Explanation of Limitations
Counselors ensure that clients are provided information as a part of the counseling
relationship that adequately explains the limitations of computer technology.
c. Access to Computer Applications. Counselors provide for equal access to
computer applications in counseling services. (See A.2.a.)
Section B: Confidentiality
B.1. Right to Privacy
Respect for Privacy
Counselors respect their clients right to privacy and avoid illegal and unwarranted
disclosures of confidential information. (See A.3.a. and B.6.a.)
Client Waiver
The right to privacy may be waived by the client or his or her legally recognized
representative.
Exceptions
The general requirement that counselors keep information confidential does not
apply when disclosure is required to prevent clear and imminent danger to the
client or others or when legal requirements demand that confidential information
be revealed. Counselors consult with other professionals when in doubt as to the
validity of an exception.
Contagious, Fatal Diseases
A counselor who receives information confirming that a client has a disease
commonly known to be both communicable and fatal is justified in disclosing
information to an identifiable third party, who by his or her relationship with the
client is at a high risk of contracting the disease. Prior to making a disclosure the
counselor should ascertain that the client has not already informed the third party
about his or her disease and that the client is not intending to inform the third party
in the immediate future. (See B.1.c and B.1.f.)
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Court-Ordered Disclosure
When court ordered to release confidential information without a client's
permission, counselors request to the court that the disclosure not be required due
to potential harm to the client or counseling relationship. (See B.1.c.)
Minimal Disclosure
When circumstances require the disclosure of confidential information, only
essential information is revealed. To the extent possible, clients are informed
before confidential information is disclosed.
Explanation of Limitations
When counseling is initiated and throughout the counseling process as necessary,
counselors inform clients of the limitations of confidentiality and identify
foreseeable situations in which confidentiality must be breached. (See G.2.a.)
Subordinates. Counselors make every effort to ensure that privacy and
confidentiality of clients are maintained by subordinates including employees,
supervisees, clerical assistants, and volunteers. (See B.1.a.)
Treatment Teams
If client treatment will involve a continued review by a treatment team, the client
will be informed of the team's existence and composition.
B.2. Groups and Families
Group Work
In group work, counselors clearly define confidentiality and the parameters for the
specific group being entered, explain its importance, and discuss the difficulties
related to confidentiality involved in group work. The fact that confidentiality
cannot be guaranteed is clearly communicated to group members.
Family Counseling
In family counseling, information about one family member cannot be disclosed to
another member without permission. Counselors protect the privacy rights of each
family member. (See A.8., B.3., and B.4.d.)
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B.3. Minor or Incompetent Clients
When counseling clients who are minors or individuals who are unable to give
voluntary, informed consent, parents or guardians may be included in the
counseling process as appropriate. Counselors act in the best interests of clients
and take measures to safeguard confidentiality. (See A.3.c.)
B.4. Records
Requirement of Records
Counselors maintain records necessary for rendering professional services to their
clients and as required by laws, regulations, or agency or institution procedures.
Confidentiality of Records
Counselors are responsible for securing the safety and confidentiality of any
counseling records they create, maintain, transfer, or destroy
whether the records are written, taped, computerized, or stored in any other
medium. (See B.1.a.)
Permission to Record or Observe
Counselors obtain permission from clients prior to electronically recording or
observing sessions. (See A.3.a.)
Client Access
Counselors recognize that counseling records are kept for the benefit of clients, and
therefore provide access to records and copies of records when requested by
competent clients, unless the records contain information that may be misleading
and detrimental to the client. In situations involving multiple clients, access to
records is limited to those parts of records that do not include confidential
information related to another client. (See A.8., B.1.a., and B.2.b.)
Disclosure or Transfer
Counselors obtain written permission from clients to disclose or transfer records to
legitimate third parties unless exceptions to confidentiality exist as listed in Section
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B.1. Steps are taken to ensure that receivers of counseling records are
sensitive to their confidential nature.
B.5. Research and Training
Data Disguise Required. Use of data derived from counseling relationships for
purposes of training, research, or publication is confined to content that is
disguised to ensure the anonymity of the individuals involved. (See B.1.g. and
G.3.d.)
Agreement for Identification
Identification of a client in a presentation or publication is permissible only when
the client has reviewed the material and has agreed to its presentation or
publication. (See G.3.d.)
B.6. Consultation
Respect for Privacy. Information obtained in a consulting relationship is discussed
for professional purposes only with persons clearly concerned with the case.
Written and oral reports present data germane to the purposes of the consultation,
and every effort is made to protect client identity and avoid undue invasion of
privacy.
Cooperating Agencies
Before sharing information, counselors make efforts to ensure that there are
defined policies in other agencies serving the counselor's clients that effectively
protect the confidentiality of information.
Section C: Professional Responsibility
C.1. Standards Knowledge
Counselors have a responsibility to read, understand, and follow the Code of Ethics
and the Standards of Practice.
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C.2. Professional Competence
Boundaries of Competence
Counselors practice only within the boundaries of their competence, based on their
education, training, supervised experience, state and national professional
credentials, and appropriate professional experience. Counselors will demonstrate
a commitment to gain knowledge, personal awareness, sensitivity, and skills
pertinent to working with a diverse client population.
New Specialty Areas of Practice
Counselors practice in specialty areas new to them only after appropriate
education, training, and supervised experience. While developing skills in new
specialty areas, counselors take steps to ensure the competence of their work and to
protect others from possible harm.
Qualified for Employment
Counselors accept employment only for positions for which they are qualified by
education, training, supervised experience, state and national professional
credentials, and appropriate professional experience. Counselors hire for
professional counseling positions only individuals who are qualified and
competent.
Monitor Effectiveness
Counselors continually monitor their effectiveness as professionals and take steps
to improve when necessary. Counselors in private practice take reasonable steps to
seek out peer supervision to evaluate their efficacy as counselors.
Ethical Issues Consultation
Counselors take reasonable steps to consult with other counselors or related
professionals when they have questions regarding their ethical obligations or
professional practice. (See H.1.)
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Continuing Education
Counselors recognize the need for continuing education to maintain a reasonable
level of awareness of current scientific and professional information in their fields
of activity. They take steps to maintain competence in the skills they use, are open
to new procedures, and keep current with the diverse and/or special populations
with whom they work.
Impairment
Counselors refrain from offering or accepting professional services when their
physical, mental, or emotional problems are likely to harm a client or others. They
are alert to the signs of impairment, seek assistance for problems, and, if necessary,
limit, suspend, or terminate their professional responsibilities. (See A.11.c.)
C.3. Advertising and Soliciting Clients
Accurate Advertising
There are no restrictions on advertising by counselors except those that can be
specifically justified to protect the public from deceptive practices. Counselors
advertise or represent their services to the public by identifying their credentials in
an accurate manner that is not false, misleading, deceptive, or fraudulent.
Counselors may only advertise the highest degree earned which is in counseling or
a closely related field from a college or university that was accredited when the
degree was awarded by one of the regional accrediting bodies recognized by the
Council on Postsecondary Accreditation.
Testimonials
Counselors who use testimonials do not solicit them from clients or other persons
who, because of their particular circumstances, may be vulnerable to undue
influence.
Statements by Others
Counselors make reasonable efforts to ensure that statements made by others about
them or the profession of counseling are accurate.
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Recruiting Through Employment
Counselors do not use their places of employment or institutional affiliation to
recruit or gain clients, supervisees, or consultees for their private practices. (See
C.5.e.)
Products and Training Advertisements
Counselors who develop products related to their profession or conduct workshops
or training events ensure that the advertisements concerning these products or
events are accurate and disclose adequate information for consumers to make
informed choices.
Promoting to Those Served
Counselors do not use counseling, teaching, training, or supervisory relationships
to promote their products or training events in a manner that is deceptive or would
exert undue influence on individuals who may be vulnerable. Counselors may
adopt textbooks they have authored for instruction purposes.
Professional Association Involvement
Counselors actively participate in local, state, and national associations that foster
the development and improvement of counseling.
C.4. Credentials
Credentials Claimed
Counselors claim or imply only professional credentials possessed and are
responsible for correcting any known misrepresentations of their credentials by
others. Professional credentials include graduate degrees in counseling or closely
related mental health fields, accreditation of graduate programs, national voluntary
certifications, government-issued certifications or licenses, ACA professional
membership, or any other credential that might indicate to the public specialized
knowledge or expertise in counseling.
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ACA Professional Membership
ACA professional members may announce to the public their membership status.
Regular members may not announce their ACA membership in a manner that
might imply they are credentialed counselors.
Credential Guidelines
Counselors follow the guidelines for use of credentials that have been established
by the entities that issue the credentials.
Misrepresentation of Credentials
Counselors do not attribute more to their credentials than the credentials represent,
and do not imply that other counselors are not qualified because they do not
possess certain credentials.
Doctoral Degrees from Other Fields
Counselors who hold a master's degree in counseling or a closely related mental
health field, but hold a doctoral degree from other than counseling or a closely
related field, do not use the title "Dr." in their practices and do not announce to the
public in relation to their practice or status as a counselor that they hold a
doctorate.
C.5. Public Responsibility
Nondiscrimination
Counselors do not discriminate against clients, students, or supervisees in a manner
that has a negative impact based on their age, color, culture, disability, ethnic
group, gender, race, religion, sexual orientation, or socioeconomic status, or for
any other reason. (See A.2.a.)
Sexual Harassment
Counselors do not engage in sexual harassment. Sexual harassment is defined as
sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual
in nature, that occurs in connection with professional activities or roles, and that
either (1) is unwelcome, is offensive, or creates a hostile workplace environment,
and counselors know or are told this; or (2) is sufficiently severe or intense to be
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perceived as harassment to a reasonable person in the context. Sexual harassment
can consist of a single intense or severe act or multiple persistent or pervasive acts.
Reports to Third Parties
Counselors are accurate, honest, and unbiased 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. (See B.1.g.)
Media Presentations
When counselors provide advice or comment by means of public lectures,
demonstrations, radio or television programs, prerecorded tapes, printed articles,
mailed material, or other media, they take reasonable precautions to ensure that (1)
the statements are based on appropriate professional counseling literature and
practice; (2) the statements are otherwise consistent with the Code of Ethics and
the Standards of Practice; and (3) the recipients of the information are not
encouraged to infer that a professional counseling relationship has been
established. (See C.6.b.)
Unjustified Gains
Counselors do not use their professional positions to seek or receive unjustified
personal gains, sexual favors, unfair advantage, or unearned goods or services.
(See C.3.d.)
C.6. Responsibility to Other Professionals
Different Approaches
Counselors are respectful of approaches to professional counseling that differ from
their own. Counselors know and take into account the traditions and practices of
other professional groups with which they work.
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Personal Public Statements
When making personal statements in a public context, counselors clarify that they
are speaking from their personal perspectives and that they are not speaking on
behalf of all counselors or the profession. (See C.5.d.)
Clients Served by Others
When counselors learn that their clients are in a professional relationship with
another mental health professional, they request release from clients to inform the
other professionals and strive to establish positive and collaborative professional
relationships. (See A.4.)
Section D: Relationships with Other Professionals
D.1. Relationships with Employers and Employees
Role Definition
Counselors define and describe for their employers and employees the parameters
and levels of their professional roles.
Agreements
Counselors establish working agreements with supervisors, colleagues, and
subordinates regarding counseling or clinical relationships, confidentiality,
adherence to professional standards, distinction between public and private
material, maintenance and dissemination of recorded information, work load, and
accountability. Working agreements in each instance are specified and made
known to those concerned.
Negative Conditions
Counselors alert their employers to conditions that may be potentially disruptive or
damaging to the counselor's professional responsibilities or that may limit their
effectiveness.
Evaluation
Counselors submit regularly to professional review and evaluation by their
supervisor or the appropriate representative of the employer.
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In-Service
Counselors are responsible for in-service development of self and staff.
Goals
Counselors inform their staff of goals and programs.
Practices
Counselors provide personnel and agency practices that respect and enhance the
rights and welfare of each employee and recipient of agency services. Counselors
strive to maintain the highest levels of professional services.
Personnel Selection and Assignment
Counselors select competent staff and assign responsibilities compatible with their
skills and experiences.
Discrimination
Counselors, as either employers or employees, do not engage in or condone
practices that are inhumane, illegal, or unjustifiable (such as considerations based
on age, color, culture, disability, ethnic group, gender, race, religion, sexual
orientation, or socioeconomic status) in hiring, promotion, or training. (See A.2.a.
and C.5.b.)
Professional Conduct
Counselors have a responsibility both to clients and to the agency or institution
within which services are performed to maintain high standards of professional
conduct.
Exploitative Relationships
Counselors do not engage in exploitative relationships with individuals over whom
they have supervisory, evaluative, or instructional control or authority. l. Employer
Policies. The acceptance of employment in an agency or institution implies that
counselors are in agreement with its general policies and principles. Counselors
strive to reach agreement with employers as to acceptable standards of conduct that
allow for changes in institutional policy conducive to the growth and development
of clients.
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Consultation as an Option
Counselors may choose to consult with any other professionally competent persons
about their clients. In choosing consultants, counselors avoid placing the consultant
in a conflict of interest situation that would preclude the consultant being a proper
party to the counselor's efforts to help the client. Should counselors be engaged in a
work setting that compromises this consultation standard, they consult with other
professionals whenever possible to consider justifiable alternatives.
Consultant Competency
Counselors are reasonably certain that they have or the organization represented
has the necessary competencies and resources for giving the kind of consulting
services needed and that appropriate referral resources are available.
Understanding with Clients
When providing consultation, counselors attempt to develop with their clients a
clear understanding of problem definition, goals for change, and predicted
consequences of interventions selected.
Consultant Goals
The consulting relationship is one in which client adaptability and growth toward
self-direction are consistently encouraged and cultivated. (See A.1.b.)
D.3. Fees for Referral
Accepting Fees from Agency Clients
Counselors refuse a private fee or other remuneration for rendering services to
persons who are entitled to such services through the counselor's employing
agency or institution. The policies of a particular agency may make explicit
provisions for agency clients to receive counseling services from members of its
staff in private practice. In such instances, the clients must be informed of other
options open to them should they seek private counseling services. (See A.10.a.,
A.11.b., and C.3.d.)
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Referral Fees
Counselors do not accept a referral fee from other professionals.
D.4. Subcontractor Arrangements
When counselors work as subcontractors for counseling services for a third party,
they have a duty to inform clients of the limitations of confidentiality that the
organization may place on counselors in providing counseling services to clients.
The limits of such confidentiality ordinarily are discussed as part of the intake
session. (See B.1.e. and B.1.f.)
Section E: Evaluation, Assessment, and Interpretation
E.1. General
Appraisal Techniques
The primary purpose of educational and psychological assessment is to provide
measures that are objective and interpretable in either comparative or absolute
terms. Counselors recognize the need to interpret the statements in this section as
applying to the whole range of appraisal techniques, including test and non-test
data.
Client Welfare
Counselors promote the welfare and best interests of the client in the development,
publication, and utilization of educational and psychological assessment
techniques. They do not misuse assessment results and interpretations and take
reasonable steps to prevent others from misusing the information these techniques
provide. They respect the client's right to know the results, the interpretations
made, and the bases for their conclusions and recommendations.
E.2. Competence to Use and Interpret Tests
Limits of Competence
Counselors recognize the limits of their competence and perform only those testing
and assessment services for which they have been trained. They are familiar with
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reliability, validity, related standardization, error of measurement, and proper
application of any technique utilized. Counselors using computer-based test
interpretations are trained in the construct being measured and the specific
instrument being used prior to using this type of computer application. Counselors
take reasonable measures to ensure the proper use of psychological assessment
techniques by persons under their supervision.
Appropriate Use
Counselors are responsible for the appropriate application, scoring, interpretation,
and use of assessment instruments, whether they score and interpret such tests
themselves or use computerized or other services.
Decisions Based on Results
Counselors responsible for decisions involving individuals or policies that are
based on assessment results have a thorough understanding of educational and
psychological measurement, including validation criteria, test research, and
guidelines for test development and use.
Accurate Information
Counselors provide accurate information and avoid false claims or misconceptions
when making statements about assessment instruments or techniques. Special
efforts are made to avoid unwarranted connotations of such terms as IQ and grade
equivalent scores. (See C.5.c.)
E.3. Informed Consent
Explanation to Clients
Prior to assessment, counselors explain the nature and purposes of assessment and
the specific use of results in language the client (or other legally authorized person
on behalf of the client) can understand, unless an explicit exception to this right has
been agreed upon in advance. Regardless of whether scoring and interpretation are
completed by counselors, by assistants, or by computer or other outside services,
counselors take reasonable steps to ensure that appropriate explanations are given
to the client.
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Recipients of Results
The examinee's welfare, explicit understanding, and prior agreement determine the
recipients of test results. Counselors include accurate and appropriate
interpretations with any release of individual or group test results. (See B.1.a. and
C.5.c.)
E.4. Release of Information to Competent Professionals
Misuse of Results
Counselors do not misuse assessment results, including test results, and
interpretations, and take reasonable steps to prevent the misuse of such by others.
Release of Raw Data
Counselors ordinarily release data (e.g., protocols, counseling or interview notes,
or questionnaires) in which the client is identified only with the consent of the
client or the client's legal representative. Such data are usually released only to
persons recognized by counselors as competent to interpret the data. (See B.1.a.)
E.5. Proper Diagnosis of Mental Disorders
Proper Diagnosis
Counselors take special care to provide proper diagnosis of mental disorders.
Assessment techniques (including personal interview) used to determine client care
(e.g., locus of treatment, type of treatment, or recommended follow-up) are
carefully selected and appropriately used. (See A.3.a. and C.5.c.)
Cultural Sensitivity
Counselors recognize that culture affects the manner in which clients' problems are
defined. Clients' socioeconomic and cultural experience is considered when
diagnosing mental disorders.
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E.6. Test Selection
Appropriateness of Instruments
Counselors carefully consider the validity, reliability, psychometric limitations,
and appropriateness of instruments when selecting tests for use in a given situation
or with a particular client.
Culturally Diverse Populations
Counselors are cautious when selecting tests for culturally diverse populations to
avoid inappropriateness of testing that may be outside of socialized behavioral or
cognitive patterns.
E.7. Conditions of Test Administration
Administration Conditions
Counselors administer tests under the same conditions that were established in
their standardization. When tests are not administered under standard conditions or
when unusual behavior or irregularities occur during the testing session, those
conditions are noted in interpretation, and the results may be designated as invalid
or of questionable validity.
Computer Administration
Counselors are responsible for ensuring that administration programs function
properly to provide clients with accurate results when a computer or other
electronic methods are used for test administration. (See A.12.b.)
Unsupervised Test Taking
Counselors do not permit unsupervised or inadequately supervised use of tests or
assessments unless the tests or assessments are designed, intended, and validated
for self-administration and/or scoring.
Disclosure of Favorable Conditions
Prior to test administration, conditions that produce most favorable test results are
made known to the examinee.
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E.8. Diversity in Testing
Counselors are cautious in using assessment techniques, making evaluations, and
interpreting the performance of populations not represented in the norm group on
which an instrument was standardized. They recognize the effects of age, color,
culture, disability, ethnic group, gender, race, religion, sexual orientation, and
socioeconomic status on test administration and interpretation and place test results
in proper perspective with other relevant factors. (See A.2.a.)
E.9. Test Scoring and Interpretation
Reporting Reservations
In reporting assessment results, counselors indicate any reservations that exist
regarding validity or reliability because of the circumstances of the assessment or
the inappropriateness of the norms for the person tested.
Research Instruments
Counselors exercise caution when interpreting the results of research instruments
possessing insufficient technical data to support respondent results. The specific
purposes for the use of such instruments are stated explicitly to the examinee.
Testing Services
Counselors 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 consultee, but the
ultimate and overriding responsibility is to the client.
E.10. Test Security
Counselors maintain the integrity and security of tests and other assessment
techniques consistent with legal and contractual obligations. Counselors do not
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appropriate, reproduce, or modify published tests or parts thereof without
acknowledgment and permission from the publisher.
E.11. Obsolete Tests and Outdated Test Results
Counselors do not use data or test results that are obsolete or outdated for the
current purpose. Counselors make every effort to prevent the misuse of obsolete
measures and test data by others.
E.12. Test Construction
Counselors 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.
Section F: Teaching, Training, and Supervision
F.1. Counselor Educators and Trainers
Educators as Teachers and Practitioners
Counselors who are responsible for developing, implementing, and supervising
educational programs are skilled as teachers and practitioners. They are
knowledgeable regarding the ethical, legal, and regulatory aspects of the
profession, are skilled in applying that knowledge, and make students and
supervisees aware of their responsibilities. Counselors conduct counselor education
and training programs in an ethical manner and serve as role models for
professional behavior. Counselor educators should make an effort to infuse
material related to human diversity into all courses and/or workshops that are
designed to promote the development of professional counselors.
Relationship Boundaries with Students and Supervisees
Counselors clearly define and maintain ethical, professional, and social
relationship boundaries with their students and supervisees. They are aware of the
differential in power that exists and the student's or supervisee's possible
incomprehension of that power differential. Counselors explain to students and
supervisees the potential for the relationship to become exploitive.
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Sexual Relationships
Counselors do not engage in sexual relationships with students or supervisees and
do not subject them to sexual harassment. (See A.6. and C.5.b)
Contributions to Research
Counselors give credit to students or supervisees for their contributions to research
and scholarly projects. Credit is given through co-authorship, acknowledgment,
footnote statement, or other appropriate means, in accordance with such
contributions. (See G.4.b. and G.4.c.)
Close Relatives
Counselors do not accept close relatives as students or supervisees.
Supervision Preparation
Counselors who offer clinical supervision services are adequately prepared in
supervision methods and techniques. Counselors who are doctoral students serving
as practicum or internship supervisors to master's level students are adequately
prepared and supervised by the training program.
Responsibility for Services to Clients
Counselors who supervise the counseling services of others take reasonable
measures to ensure that counseling services provided to clients are professional.
Endorsement
Counselors do not endorse students or supervisees for certification, licensure,
employment, or completion of an academic or training program if they believe
students or supervisees are not qualified for the endorsement. Counselors take
reasonable steps to assist students or supervisees who are not qualified for
endorsement to become qualified.
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F.2. Counselor Education and Training Programs
Orientation
Prior to admission, counselors orient prospective students to the counselor
education or training program's expectations, including but not limited to the
following: (1) the type and level of skill acquisition required for successful
completion of the training, (2) subject matter to be covered, (3) basis for
evaluation, (4) training components that encourage self-growth or self-disclosure
as part of the training process, (5) the type of supervision settings and requirements
of the sites for required clinical field experiences, (6) student and supervisee
evaluation and dismissal policies and procedures, and (7) up-to-date employment
prospects for graduates.
Integration of Study and Practice. Counselors establish counselor education and
training programs that integrate academic study and supervised practice.
Evaluation
Counselors clearly state to students and supervisees, in advance of training, the
levels of competency expected, appraisal methods, and timing of evaluations for
both didactic and experiential components. Counselors provide students and
supervisees with periodic performance appraisal and evaluation feedback
throughout the training program.
Teaching Ethics
Counselors make students and supervisees aware of the ethical responsibilities and
standards of the profession and the students' and supervisees' ethical
responsibilities to the profession. (See C.1. and F.3.e.)
Peer Relationships
When students or supervisees are assigned to lead counseling groups or provide
clinical supervision for their peers, counselors take steps to ensure that students
and supervisees placed in these roles do not have personal or adverse relationships
with peers and that they understand they have the same ethical obligations as
counselor educators, trainers, and supervisors. Counselors make every effort to
ensure that the rights of peers are not compromised when students or supervisees
are assigned to lead counseling groups or provide clinical supervision.
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Varied Theoretical Positions
Counselors present varied theoretical positions so that students and supervisees
may make comparisons and have opportunities to develop their own positions.
Counselors provide information concerning the scientific bases of professional
practice. (See C.6.a.)
Field Placements
Counselors develop clear policies within their training program regarding field
placement and other clinical experiences. Counselors provide clearly stated roles
and responsibilities for the student or supervisee, the site supervisor, and the
program supervisor. They confirm that site supervisors are qualified to provide
supervision and are informed of their professional and ethical responsibilities in
this role.
Dual Relationships as Supervisors
Counselors avoid dual relationships such as performing the role of site supervisor
and training program supervisor in the student's or supervisee's training program.
Counselors do not accept any form of professional services, fees, commissions,
reimbursement, or remuneration from a site for student or supervisee placement.
Diversity in Programs
Counselors are responsive to their institution's and program's recruitment and
retention needs for training program administrators, faculty, and students with
diverse backgrounds and special needs. (See A.2.a.)
F.3. Students and Supervisees
Limitations
Counselors, through ongoing evaluation and appraisal, are aware of the academic
and personal limitations of students and supervisees that might impede
performance. Counselors assist students and supervisees in securing remedial
assistance when needed, and dismiss from the training program supervisees who
are unable to provide competent service due to academic or personal limitations.
Counselors seek professional consultation and document their decision to dismiss
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or refer students or supervisees for assistance. Counselors ensure that students and
supervisees have recourse to address decisions made to require them to seek
assistance or to dismiss them.
Self-Growth Experiences
Counselors use professional judgment when designing training experiences
conducted by the counselors themselves that require student and supervisee selfgrowth or self-disclosure. Safeguards are provided so that students and supervisees
are aware of the ramifications their self-disclosure may have on counselors whose
primary role as teacher, trainer, or supervisor requires acting on ethical obligations
to the profession. Evaluative components of experiential training experiences
explicitly delineate predetermined academic standards that are separate and do not
depend on the student's level of self-disclosure. (See A.6.)
Counseling for Students and Supervisees
If students or supervisees request counseling, supervisors or counselor educators
provide them with acceptable referrals. Supervisors or counselor educators do not
serve as counselor to students or supervisees over whom they hold administrative,
teaching, or evaluative roles unless this is a brief role associated with a training
experience. (See A.6.b.)
Clients of Students and Supervisees
Counselors make every effort to ensure that the clients at field placements are
aware of the services rendered and the qualifications of the students and
supervisees rendering those services. Clients receive professional disclosure
information and are informed of the limits of confidentiality. Client permission is
obtained in order for the students and supervisees to use any information
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. Counselors design
concerning the counseling relationship in the training process. (See B.1.e.)
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Standards for Students and Supervisees
Students and supervisees preparing to become counselors adhere to the Code of
Ethics and the Standards of Practice. Students and supervisees have the same
obligations to clients as those required of counselors. (See H.1.)
Section G: Research and Publication
G.1. Research Responsibilities
Use of Human Subjects
Counselors and conduct research that reflects cultural sensitivity appropriateness.
Deviation from Standard Practices
Counselors seek consultation and observe stringent safeguards to protect the rights
of research participants when a research problem suggests a deviation from
standard acceptable practices. (See B.6.)
Precautions to Avoid Injury
Counselors 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.
Principal Researcher Responsibility
The ultimate responsibility for ethical research practice lies with the principal
researcher. All others involved in the research activities share ethical obligations
and full responsibility for their own actions.
Minimal Interference
Counselors take reasonable precautions to avoid causing disruptions in subjects'
lives due to participation in research. f. Diversity. Counselors are sensitive to
diversity and research issues with special populations. They seek consultation
when appropriate. (See A.2.a. and B.6.)
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G.2. Informed Consent
Topics Disclosed. In obtaining informed consent for research, counselors use
language that is understandable to research participants and that (1) accurately
explains the purpose and procedures to be followed; (2) identifies any procedures
that are experimental or relatively untried; (3) describes the attendant discomforts
and risks; (4) describes the benefits or changes in individuals or organizations that
might be reasonably expected; (5) discloses appropriate alternative procedures that
would be advantageous for subjects; (6) offers to answer any inquiries concerning
the procedures; (7) describes any limitations on confidentiality; and (8) instructs
that subjects are free to withdraw their consent and to discontinue participation in
the project at any time. (See B.1.f.)
Deception
Counselors do not conduct research involving deception unless alternative
procedures are not feasible and the prospective value of the research justifies the
deception. When the methodological requirements of a study necessitate
concealment or deception, the investigator is required to explain clearly the reasons
for this action as soon as possible.
Voluntary Participation
Participation in research is typically voluntary and without any penalty for refusal
to participate. Involuntary participation is appropriate only when it can be
demonstrated that participation will have no harmful effects on subjects and is
essential to the investigation.
Confidentiality of Information
Information obtained about research participants during the course of an
investigation is confidential. When the possibility exists that others may obtain
access to such information, ethical research practice requires that the possibility,
together with the plans for protecting confidentiality, be explained to participants
as a part of the procedure for obtaining informed consent. (See B.1.e.)
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Persons Incapable of Giving Informed Consent
When a person is incapable of giving informed consent, counselors provide an
appropriate explanation, obtain agreement for participation, and obtain appropriate
consent from a legally authorized person.
Commitments to Participants
Counselors take reasonable measures to honor all commitments to research
participants.
Explanations after Data Collection
After data are collected, counselors provide participants with full clarification of
the nature of the study to remove any misconceptions. Where scientific or human
values justify delaying or withholding information, counselors take reasonable
measures to avoid causing harm.
Agreements to Cooperate
Counselors who agree to cooperate with another individual in research or
publication incur an obligation to cooperate as promised in terms of punctuality of
performance and with regard to the completeness and accuracy of the information
required.
Informed Consent for Sponsors
In the pursuit of research, counselors give sponsors, institutions, and publication
channels the same respect and opportunity for giving informed consent that they
accord to individual research participants. Counselors are aware of their obligation
to future research workers and ensure that host institutions are given feedback
information and proper acknowledgment.
G.3. Reporting Results
Information Affecting Outcome
When reporting research results, counselors explicitly mention all variables and
conditions known to the investigator that may have affected the outcome of a study
or the interpretation of data.
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Accurate Results
Counselors plan, conduct, and report research accurately and in a manner that
minimizes the possibility that results will be misleading. They provide thorough
discussions of the limitations of their data and alternative hypotheses. Counselors
do not engage in fraudulent research, distort data, misrepresent data, or deliberately
bias their results.
Obligation to Report Unfavorable Results
Counselors communicate to other counselors the results of any research judged to
be of professional value. Results that reflect unfavorably on institutions, programs,
services, prevailing opinions, or vested interests are not withheld.
Identity of Subjects
Counselors who supply data, aid in the research of another person, report research
results, or make original data available take due care to disguise the identity of
respective subjects in the absence of specific authorization from the subjects to do
otherwise. (See B.1.g. and B.5.a.)
Replication Studies
Counselors are obligated to make available sufficient original research data to
qualified professionals who may wish to replicate the study.
G.4. Publication
Recognition of Others
When conducting and reporting research, counselors are familiar with and give
recognition to previous work on the topic, observe copyright laws, and give full
credit to those to whom credit is due. (See F.1.d. and G.4.c.)
Contributors
Counselors give credit through joint authorship, acknowledgment, footnote
statements, or other appropriate means to those who have contributed significantly
to research or concept development in accordance with such contributions. The
principal contributor is listed first and minor technical or professional contributions
are acknowledged in notes or introductory statements.
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Student Research
For an article that is substantially based on a student's dissertation or thesis, the
student is listed as the principal author. (See F.1.d. and G.4.a.)
Duplicate Submission
Counselors submit manuscripts for consideration to only one journal at a time.
Manuscripts that are published in whole or in substantial part in another journal or
published work are not submitted for publication without acknowledgment and
permission from the previous publication.
Professional Review
Counselors who review material submitted for publication, research, or other
scholarly purposes respect the confidentiality and proprietary rights of those who
submitted it.
Section H: Resolving Ethical Issues
H.1. Knowledge of Standards
Counselors are familiar with the Code of Ethics and the Standards of Practice and
other applicable ethics codes from other professional organizations of which they
are member, or from certification and licensure bodies. Lack of knowledge or
misunderstanding of an ethical responsibility is not a defense against a charge of
unethical conduct. (See F.3.e.)
H.2. Suspected Violations
Ethical Behavior Expected
Counselors expect professional associates to adhere to the Code of Ethics. When
counselors possess reasonable cause that raises doubts as to whether a counselor is
acting in an ethical manner, they take appropriate action. (See H.2.d. and H.2.e.)
Consultation
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When uncertain as to whether a particular situation or course of action may be in
violation of the Code of Ethics, counselors consult with other counselors who are
knowledgeable about ethics, with colleagues, or with appropriate authorities.
Organization Conflicts
If the demands of an organization with which counselors are affiliated pose a
conflict with the Code of Ethics, counselors specify the nature of such conflicts
and express to their supervisors or other responsible officials their commitment to
the Code of Ethics. When possible, counselors work toward change within the
organization to allow full adherence to the Code of Ethics.
Informal Resolution
When counselors have reasonable cause to believe that another counselor is
violating an ethical standard, they attempt to first resolve the issue informally with
the other counselor if feasible, providing that such action does not violate
confidentiality rights that may be involved.
Reporting Suspected Violations
When an informal resolution is not appropriate or feasible, counselors, upon
reasonable cause, take action such as reporting the suspected ethical violation to
state or national ethics committees, unless this action conflicts with confidentiality
rights that cannot be resolved.
Unwarranted Complaints
Counselors do not initiate, participate in, or encourage the filing of ethics
complaints that are unwarranted or intend to harm a counselor rather than to
protect clients or the public.
H.3. Cooperation with Ethics Committees
Counselors assist in the process of enforcing the Code of Ethics. Counselors
cooperate with investigations, proceedings, and requirements of the ACA Ethics
Committee or ethics committees of other duly constituted associations or boards
having jurisdiction over those charged with a violation. Counselors are familiar
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with the ACA Policies and Procedures and use it as a reference in assisting the
enforcement of the Code of Ethics.
6G. NAADAC Code of Ethics
The Revised Code of Ethics is divided under major headings and standards. The
sections utilized are:
I. The Counseling Relationship
II. Evaluation, Assessment and Interpretation of Client Data
III. Confidentiality/Privileged Communication and Privacy
IV. Professional Responsibility
V. Working in a Culturally Diverse World
VI. Workplace Standards
VII. Supervision and Consultation
VIII. Resolving Ethical Issues
IX. Communication and Published Works
X. Policy and Political Involvement
I. The Counseling Relationship
It is the responsibility of the addiction professional to safeguard the integrity of the
counseling relationship and to ensure that the client is provided with services that
are most beneficial. The client will be provided access to effective treatment and
referral giving consideration to individual educational, legal and financial
resources needs. Addiction professionals also recognize their responsibility to the
larger society and any specific legal obligations that may, on limited occasions,
supersede loyalty to clients. The addiction professional shall provide the client
and/or guardian with accurate and complete information regarding the extent of the
potential professional relationship. In all areas of function, the addiction
professional is likely to encounter individuals who are vulnerable and exploitable.
In such relationships he/she seeks to nurture and support the development of a
relationship of equals rather than to take unfair advantage. In personal
relationships, the addiction professional seeks to foster self-sufficiency and healthy
self-esteem in others. In relationships with clients he/she provides only that level
and length of care that is necessary and acceptable.
Standard 1: Client Welfare
The addiction professional understands that the ability to do good is based on an
underlying concern for the well being of others. The addiction professional will act
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for the good of others and exercise respect, sensitivity and insight. The addiction
professional understands that the primary professional responsibility and loyalty is
to the welfare of his or her clients, and will work for the client irrespective of who
actually pays his/her fees.
1. The addiction professional understands and supports actions that will assist
clients to a better quality of life, greater freedom and true independence.
2. The addiction professional will support clients in accomplishing what they can
readily do for themselves. Likewise, the addiction professional will not insist on
pursuing treatment goals without incorporating what the client perceives as good
and necessary.
3. The addiction professional understands that suffering is unique to a specific
individual and not of some generalized or abstract suffering, such as might be
found in the understanding of the disorder. On that basis, the action taken to relieve
suffering must be uniquely suited to the suffering individual and not simply some
universal prescription.
4. Services will be provided without regard to the compensation provided by the
client or by a third party and shall render equally appropriate services to
individuals whether they are paying a reduced fee or a full fee or are waived from
fees.
Standard 2: Client Self Determination
The addiction professional understands and respects the fundamental human right
of all individuals to self-determination and to make decisions that they consider in
their own best interest. In that regard, the counselor will be open and clear about
the nature, extent, probable effectiveness and cost of those services to allow each
individual to make an informed decision about his or her care. The addiction
professional works toward increased competence in all areas of professional
functioning; recognizing that at the heart of all roles is an ethical commitment
contributing greatly to the well-being and happiness of others. He/she is especially
mindful of the need for faithful competence in those relationships that are termed
fiduciary - relationships of special trust in which the clients generally do not have
the resources to adequately judge competence.
1. The addiction professional will provide the client and/or guardian with accurate
and complete information regarding the extent of the potential professional
relationship, including the Code of Ethics and documentation regarding
professional loyalties and responsibilities.
2. Addiction professionals will provide accurate information about the efficacy of
treatment and referral options available to the client.
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3. The addiction professional will terminate work with a client when services are
no longer required or no longer serve the client’s best interest.
4. The addiction professional will take reasonable steps to avoid abandoning
clients who are in need of services. Referral will be made only after careful
consideration of all factors to minimize adverse effects.
5. The addiction professional recognizes that there are clients with whom he/she
cannot work effectively. In such cases, arrangements for consultation, co-therapy
or referral are made
6. The addiction professional may terminate services to a client for nonpayment if
the financial contractual arrangements have been made clear to the client and if the
client does not pose an imminent danger to self or others. The addiction
professional will document discussion of the consequences of nonpayment with the
client.
7. When an addiction professional must refuse to accept the client due to inability
to pay for services, ethical standards support the addiction professional in
attempting to identify other care options. Funding constraints might interfere with
this standard.
8. The addiction professional will refer a client to an appropriate resource when the
client’s mental, spiritual, physical or chemical impairment status is beyond the
scope of the addiction professional's expertise.
9. The addiction professional will foster self-sufficiency and healthy self-esteem in
others. In relationships with clients, students, employees and supervisors, he/she
strives to develop full creative potential and mature, independent functioning.
10. Informed Consent: The addiction professional understands the client’s right to
be informed about treatment. Informed consent information will be presented in
clear and understandable language that informs the client or guardian of the
purpose of the services, risks related to the services, limits of services due to
requirements from a third party payer, relevant costs, reasonable alternatives and
the client’s right to refuse or withdraw consent within the time frames covered by
the consent. When serving coerced clients, the addiction professional will
provide information about the nature and extent of services, treatment options and
the extent to which the client has the right to refuse services. When services are
provided via technology such as computer, telephone or web-based counseling,
clients are fully informed of the limitations and risks associated with these
services. Client questions will be addressed within a reasonable time frame.
11. Clients will be provided with full disclosure including the guarantee of
confidentiality if and when they are to receive services by a supervised person in
training. The consent to treat will outline the boundaries of the client-supervisee
relationship, the supervisee’s training status and confidentiality issues. Clients will
have the option of choosing not to engage in services provided by a trainee as
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determined by agency policies. Any disclosure forms will provide information
about grievance procedures.
Standard 3: Dual Relationships
The addiction professional understands that the goal of treatment services is to
nurture and support the development of a relationship of equals of individuals to
ensure protection and fairness of all parties. Addiction professionals will provide
services to clients only in the context of a professional setting. In rural settings and
in small communities, dual relationships are evaluated carefully and avoided as
much as possible.
1. Because a relationship begins with a power differential, the addiction
professional will not exploit relationships with current or former clients, current or
former supervisees or colleagues for personal gain, including social or business
relationships.
2. The addiction professional avoids situations that might appear to be or could be
interpreted as a conflict of interest. Gifts from clients, other treatment
organizations or the providers of materials or services used in the addiction
professional's practice will not be accepted, except when refusal of such gift would
cause irreparable harm to the client relationship. Gifts of value over $25 will not be
accepted under any circumstances.
3. The addiction professional will not engage in professional relationships or
commitments that conflict with family members, friends, close associates or others
whose welfare might be jeopardized by such a dual relationship.
4. The addiction professional will not, under any circumstances, engage in sexual
behavior with current or former clients.
5. The addiction professional will not accept as clients anyone with whom they
have engaged in romantic or sexual relationships.
6. The addiction professional makes no request of clients that does not directly
pertain to treatment (giving testimonials about the program or participating in
interviews with reporters or students).
7. The addiction professional recognizes that there are situations in which dual
relationships are difficult to avoid. Rural areas, small communities and other
situations necessitate discussion of the counseling relationship and take steps to
distinguish the counseling relationship from other interactions.
8. When the addiction professional works for an agency such as department of
corrections, military, an HMO or as an employee of the client’s employer, the
obligations to external individuals and organizations are disclosed prior to
delivering any services.
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9. The addiction professional recognizes the challenges resulting from increased
role of the criminal justice system in making referrals for addiction treatment.
Consequently he/she strives to remove coercive elements of such referrals as
quickly as possible to encourage engagement in the treatment and recovery
process.
10. The addiction professional encourages self-sufficiency among clients in
making daily choices related to the recovery process and self care.
11. The addiction professional shall avoid any action that might appear to impose
on others’ acceptance of their religious/spiritual, political or other personal beliefs
while also encouraging and supporting participation in recovery support groups.
Standard 4: Group Standards
Much of the work conducted with substance use disorder clients is performed in
group settings. Addiction professionals shall take steps to provide the required
services while providing clients physical, emotional, spiritual and psychological
health and safety.
1. Confidentiality standards are established for each counseling group by involving
the addiction professional and the clients in setting confidentiality guidelines.
2. To the extent possible, addiction professionals will match clients to a group in
which other clients have similar needs and goals.
Standard 5: Preventing Harm
The addiction professional understands that every decision and action has ethical
implication leading either to benefit or harm, and will carefully consider whether
decisions or actions have the potential to produce harm of a physical,
psychological, financial, legal or spiritual nature before implementing them. The
addiction professional recognizes that even in a life well lived, harm may be done
to others by thoughtless words and actions, If he/she becomes aware that
any word or action has done harm to anyone, he/she readily admits it and does
what is possible to repair or ameliorate the harm except where doing so might
cause greater harm.
1. The addiction professional counselor will refrain from using any methods that
could be considered coercive such as threats, negative labeling and attempts to
provoke shame or humiliation.
2. The addiction professional develops treatment plans as a negotiation with the
client, soliciting the client’s input about the identified issues/needs, the goals of
treatment and the means of reaching treatment goals.
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3. The addiction professional will make no requests of clients that are not
necessary as part of the agreed treatment plan. At the beginning of each session,
the client will be informed of the intent of the session. Collaborative effort between
the client and the addiction professional will be maintained as much as possible.
4. The addiction professional will terminate the counseling or consulting
relationship when it is reasonably clear that the client is not benefiting from the
exchange.
5. The addiction professional understands the obligation to protect individuals,
institutions and the profession from harm that might be done by others.
Consequently there is awareness when the conduct of another individual is an
actual or likely source of harm to clients, colleagues, institutions or the profession.
The addiction professional will assume an ethical obligation to report such conduct
to competent authorities.
6. The addiction professional defers to review by a human subjects committee
(Institutional Review Board) to ensure that research protocol is free of coercion
and that the informed consent process is followed. Confidentiality and deceptive
practices are avoided except when such procedures are essential to the research
protocol and are approved by the designated review board or committee.
7. When research is conducted, the addiction professional is careful to ensure that
compensation to subjects is not as great or attractive as to distort the client’s ability
to make free decisions about participation.
II. Evaluation, Assessment and Interpretation of Client Data
The Counseling/treatment process takes into account the client’s personal and
cultural background. The assessment process promotes the well-being of individual
clients or groups. Addiction professionals base their recommendations/reports on
approved evaluation instruments and procedures. The designated assessment
instruments are ones for which reliability has been verified by research.
Standard 1: Scope of Competency
The addiction professional uses only those assessment instruments for which they
have been adequately trained to administer and interpret.
Standard 2: Informed Consent
Addiction professionals obtain informed consent documentation prior to
conducting the assessment except when such assessment is mandated by
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governmental or judicial entities and such mandate eliminates the requirement for
informed consent. When the services of an interpreter are required, addiction
professionals must obtain informed consent documents and verification of
confidentiality from the interpreter and client. Addiction professionals shall respect
the client’s right to know the results of assessments and the basis for conclusions
and recommendations. Explanation of assessment results is provided to the client
and/or guardian unless the reasons for the assessment preclude such disclosure or
if it is deemed that such disclosure will cause harm to the client
Standard 3: Screening
The formal process of identifying individuals with particular issues/needs or those
who are at risk for developing problems in certain areas is conducted as a
preliminary procedure to determine whether or not further assessment is warranted
at that time.
Standard 4: Basis for Assessment
Assessment tools are utilized to gain needed insight in the formulation of the most
appropriate treatment plan. Assessment instruments are utilized with the goal of
gaining an understanding of the extent of a person’s issues/needs and the extent of
addictive behaviors.
Standard 5: Release of Assessment Results
Addiction professionals shall consider the examinee’s welfare, explicit
understanding of the assessment process and prior agreements in determining
where and when to report assessment results. The information shared shall include
accurate and appropriate interpretations when individual or group assessment
results are reported to another entity.
Standard 6: Release of Data to Qualified Professionals
Information related to assessments is released to other professionals only with a
signed release of information form or such a release from the client’s legal
representative. Such information is released only to persons recognized as qualified
to interpret the data.
Standard 7: Diagnosis of Mental Health Disorders
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Diagnosis of mental health disorders shall be performed only by an authorized
mental health professional licensed or certified to conduct mental health
assessments or by a licensed or certified addictions counselor who has completed
graduate level specific education on diagnosis of mental health disorders.
Standard 8: Unsupervised Assessments
Unless the assessment instrument being used is designed, intended and validated
for self-administration and/or scoring, Addiction professional administered tests
will be chosen and scored following the recommended methodology.
Standard 9: Assessment Security
Addiction professionals maintain the integrity and security of tests and other
assessment procedures consistent with legal and contractual obligations.
Standard 10: Outdated Assessment Results
Addiction professionals avoid reliance on outdated or obsolete assessment
instruments. Professionals will seek out and engage in timely training and/or
education on the administration, scoring and reporting of data obtained through
assessment and testing procedures. Intake data and other documentation obtained
from clients to be used in recommending treatment level and in treatment planning
are reviewed and approved by an authorized mental health professional
or a licensed or qualified addiction professional with specific education on
assessment and testing.
Standard 11: Cultural Sensitivity Diagnosis
Addiction professionals recognize that cultural background and socioeconomic
status impact the manner in which client issues/needs are defined. These factors are
carefully considered when making a clinical diagnosis. Assessment procedures are
chosen carefully to ensure appropriate assessment of specific client populations
During assessment the addiction professional shall take appropriate steps to
evaluate the assessment results while considering the culture and ethnicity of the
persons being evaluated
Standard 12: Social Prejudice
Addiction professionals recognize the presence of social prejudices in the
diagnosis of substance use disorders and are aware of the long term impact of
recording such diagnoses. Addiction professionals refrain from making and/or
reporting a diagnosis if they think it would cause harm to the client or others.
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III. Confidentiality/Privileged Communication and Privacy
Addiction professionals shall provide information to clients regarding
confidentiality and any reasons for releasing information in adherence with
confidentiality laws. When providing services to families, couples or groups, the
limits and exceptions to confidentiality must be reviewed and a written document
describing confidentiality must be provided to each person. Once private
information is obtained by the addiction professional, standards of confidentiality
apply. Confidential information is disclosed when appropriate with valid consent
from a client or guardian. Every effort is made to protect the confidentiality of
client information, except in very specific cases or situations.
1. The addiction professional will inform each client of the exceptions to
confidentiality and only make a disclosure to prevent or minimize harm to another
person or group, to prevent abuse of protected persons, when a legal court order is
presented, for purpose of research, audit, internal agency communication or in a
medical emergency. In each situation, only the information essential to satisfy the
reason for the disclosure is provided.
2. The addiction professional will do everything possible to safeguard the privacy
and confidentiality of client information, except where the client has given
specific, written, informed and limited consent or when the client poses a risk of
harm to themselves or others.
3. The addiction professional will inform the client of his/her confidentiality rights
in writing as a part of informing the client of any areas likely to affect the client’s
confidentiality.
4. The addiction professional will explain the impact of electronic records and use
of electronic devices to transmit confidential information via fax, email or other
electronic means. When client information is transmitted electronically, the
addiction professional will, as much as possible, utilize secure, dedicated telephone
lines or encryption programs to ensure confidentiality.
5. Clients are to be notified when a disclosure is made, to whom the disclosure was
made and for what purposes.
6. The addiction professional will inform the client and obtain the client's
agreement in areas likely to affect the client's participation including the recording
of an interview, the use of interview material for training purposes and/or
observation of an interview by another person.
7. The addiction professional will inform the client(s) of the limits of
confidentiality prior to recording an interview or prior to using information from a
session for training purposes.
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IV. Professional Responsibility
The addiction professional espouses objectivity and integrity and maintains the
highest standards in the services provided. The addiction professional recognizes
that effectiveness in his/her profession is based on the ability to be worthy of trust.
The professional has taken time to reflect on the ethical implications of clinical
decisions and behavior using competent authority as a guide. Further, the addiction
professional recognizes that those who assume the role of assisting others to live a
more responsible life take on the ethical responsibility of living a life that is more
than ordinarily responsible. The addiction professional recognizes that even in a
life well-lived, harm might be done to others by words and actions. When he/she
becomes aware that any work or action has done harm, he/she admits the error and
does what is possible to repair or ameliorate the harm except when to do so would
cause greater harm. Professionals recognize the many ways in which they
influence clients and others within the community and take this fact into
consideration as they make decisions in their personal conduct.
Standard 1: Counselor Attributes
1. Addiction professionals will maintain respect for institutional policies and
management functions of the agencies and institutions within which the services
are being performed, but will take initiative toward improving such policies when
it will better serve the interest of the client.
2. The addiction professional, as an educator, has a primary obligation to help
others acquire knowledge and skills in treating the disease of substance use
disorders.
3. The addiction professional, as an advocate for his or her clients, understands that
he/she has an obligation to support legislation and public policy that recognizes
treatment as the first intervention of choice for non-violent substance-related
offenses.
4. The addiction professional practices honesty and congruency in all aspects of
practice including accurate billing for services, accurate accounting of expenses,
faithful and accurate reporting of interactions with clients and accurate reporting of
professional activities.
5. The addiction professional recognizes that much of the property in the substance
use disorder profession is intellectual in nature. In this regard, the addiction
professional is careful to give appropriate credit for the ideas, concepts and
publications of others when speaking or writing as a professional and as an
individual.
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6. The addiction professional is aware that conflicts can arise among the duties and
rights that are applied to various relationships and commitments of his/her life.
Priorities are set among those relationships and family, friends and associates are
informed to the priorities established in order to balance these relationships and the
duties flowing from them.
7. When work involves addressing the needs of potentially violent clients, the
addiction professional will ensure that adequate safeguards are in place to protect
clients and staff from harm.
8. Addiction professionals shall continually seek out new and effective approaches
to enhance their professional abilities including continuing education research, and
participation in activities with professionals in other disciplines. Addiction
professionals have a commitment to lifelong learning and continued education and
skills to better serve clients and the community.
9. The addiction professional respects the differing perspectives that might arise
from professional training and experience other than his/her own. In this regard,
common ground is sought rather than striving for ascendance of one opinion over
another.
10. Addiction professionals, whether they profess to be in recovery or not, must be
cognizant of ways in which their use of psychoactive chemicals in public or in
private might adversely affect the opinion of the public at large, the recovery
community, other members of the addiction professional community or, most
particularly, vulnerable individuals seeking treatment for their own problematic
use of psychoactive chemicals. Addiction professionals who profess to be in
recovery will avoid impairment in their professional or personal lives due to
psychoactive chemicals. If impairment occurs, they are expected to immediately
report their impairment, to take immediate action to discontinue professional
practice and to take immediate steps to address their impairment through
professional assistance. (See Standard 2, item 3below).
Standard 2: Legal and Ethical Standards
Addiction professionals will uphold the legal and ethical standards of the
profession by being fully cognizant of all federal laws and laws that govern
practice of substance use disorder counseling in their respective state. Furthermore,
addiction professionals will strive to uphold not just the letter of the law and the
Code, but will espouse aspirational ethical standards such as autonomy,
beneficence, non-malfeasance, justice, fidelity and veracity.
1. Addiction professionals will honestly represent their professional qualifications,
affiliations, credentials and experience.
2. Any services provided shall be identified and described accurately with no
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unsubstantiated claims for the efficacy of the services. Substance use disorders are
to be described in terms of information that has been verified by scientific inquiry.
3. The addiction professional strives for a better understanding of substance use
disorders and refuses to accept supposition and prejudice as if it were the truth.
4. The impact of impairment on professional performance is recognized; addiction
professionals will seek appropriate treatment for him/herself or for a colleague.
Addiction professionals support the work of peer assistance programs to assist in
the recovery of colleagues or themselves.
5. The addiction professional will ensure that products or services associated with
or provided by the member by means of teaching, demonstration, publications or
other types of media meet the ethical standards of this code.
6. The addiction professional who is in recovery will maintain a support system
outside the work setting to enhance his/her own well-being and personal growth as
well as promoting continued work in the professional setting.
7. The addiction professional will maintain appropriate property, life and
malpractice insurance policies that serve to protect personal and agency assets.
Standard 3: Records and Data
The addiction professional maintains records of professional services rendered,
research conducted, interactions with other individuals, agencies, legal and medical
entities regarding professional responsibilities to clients and to the profession as a
whole.
1. The addiction professional creates, maintains, disseminates, stores, retains and
disposes of records related to research, practice, payment for services, payment of
debts and other work in accordance with legal standards and in a manner that
permits/satisfies the ethics standards established. Documents will include data
relating to the date, time and place of client contact, the services provided, referrals
made, disclosures of confidential information, consultation regarding the client,
notation of supervision meetings and the outcome of every service provided.
2. Client records are maintained and disposed of in accordance with law and in a
manner that meets the current ethical standards.
3. Records of client interactions including group and individual counseling services
are maintained in a document separate from documents recording financial
transactions such as client payments, third party payments and gifts or donations.
4. Records shall be kept in a locked file cabinet or room that is not easily accessed
by professionals other than those performing essential services in the care of
clients or the operation of agency.
5. Electronic records shall be maintained in a manner that assures consistent
service and confidentiality to clients.
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6. Steps shall be taken to ensure confidentiality of all electronic data and
transmission of data to other entities.
7. Notes kept by the addiction professional that assist the professional in making
appropriate decisions regarding client care but are not relevant to client services
shall be maintained in separate, locked locations.
Standard 4: Inter-professional Relationships
The addiction professional shall treat colleagues with respect, courtesy, fairness
and good faith and shall afford the same to other professionals.
1. Addiction professionals shall refrain from offering professional services to a
client in counseling with another professional except with the knowledge of the
other professional or after the termination of the client's relationship with the other
professional.
2. The addiction professional shall cooperate with duly constituted professional
ethics committees and promptly supply necessary information unless constrained
by the demands of confidentiality.
3. The addiction professional shall not in any way exploit relationships with
supervisees, employees, students, research participants or volunteers.
V. Working in a Culturally Diverse World
Addiction professionals, understand the significance of the role that ethnicity and
culture plays in an individual’s perceptions and how he or she lives in the world.
Addiction professionals shall remain aware that many individuals have disabilities
which may or may not be obvious. Some disabilities are invisible and unless
described might not appear to inhibit expected social, work and health care
interactions. Included in the invisible disabled category are those persons who
are hearing impaired, have a learning disability, have a history of brain or physical
injuries and those affected by chronic illness. Persons having such limitations
might be younger than age 65. Part of the intake and assessment must then include
a question about any additional factor that must be considered when working with
the client.
1. Addiction professionals do not discriminate either in their professional or
personal lives against other persons with respect to race, ethnicity, national origin,
color, gender, sexual orientation, veteran status, gender identity or expression, age,
marital status, political beliefs, religion, immigration status and mental or physical
challenges.
2. Accommodations are made as needed for clients who are physically, mentally,
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educationally challenged or are experiencing emotional difficulties or speak a
different language than the clinician.
VI. Workplace Standards
The addiction professional recognizes that the profession is founded on national
standards of competency which promote the best interests of society, the client, the
individual addiction professional and the profession as a whole. The addiction
professional recognizes the need for ongoing education as a component of
professional competency and development.
1. The addiction professional recognizes boundaries and limitations of their own
competencies and does not offer services or use techniques outside of their own
professional competencies.
2. Addiction professionals recognize the impact of impairment on professional
performance and shall be willing to seek appropriate treatment for oneself or for a
colleague.
Working Environment
Addiction professionals work to maintain a working/therapeutic environment in
which clients, colleagues and employees can be safe. The working environment
should be kept in good condition through maintenance, meeting sanitation needs
and addressing structural defects.
1. The addiction professional seeks appropriate supervision/consultation to ensure
conformance with workplace standards.
2. The clerical staff members of the treatment agency hired and supervised by
addiction professionals are competent, educated in confidentiality standards and
respectful of clients seeking services.
3. Private work areas that ensure confidentiality will be maintained.
VII. Supervision and Consultation
Addiction professionals who supervise others accept the obligation to facilitate
further professional development of these individuals by providing accurate and
current information, timely evaluations and constructive consultation. Counseling
supervisors are aware of the power differential in their relationships with
supervisees and take precautions to maintain ethical standards. In relationships
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with students, employees and supervisees he/she strives to develop full creative
potential and mature independent functioning.
1. Addiction professionals must take steps to ensure appropriate resources are
available when providing consultation to others. Consulting counselors use clear
and understandable language to inform all parties involved of the purpose and
expectations related to consultation.
2. Addiction professionals who provide supervision to employees, trainees and
other counselors must have completed education and training specific to clinical
and/or administrative supervision. The addiction professional who supervises
counselors in training shall ensure that counselors in training adhere to policies
regarding client care.
3. Addiction professionals serving as supervisors shall clearly define and maintain
ethical professional, personal and social relationships with those they supervise. If
other professional roles must be assumed, standards must be established to
minimize potential conflicts.
4. Sexual, romantic or personal relationships with current supervisees are
prohibited.
5. Supervision of relatives, romantic partners or friends is prohibited.
6. Supervision meetings are conducted at specific regular intervals and
documentation of each meeting is maintained.
7. Supervisors are responsible for incorporating the principles of informed consent
into the supervision relationship.
8. Addiction professionals who serve as supervisors shall establish and
communicate to supervisees the procedures for contacting them, or in their absence
alternative on-call supervisors.
9. Supervising addiction professionals will assist those they supervise in
identifying counter-transference and transference issues. When the supervisee is in
need of counseling to address issues related to professional work or personal
challenges, appropriate referrals shall be provided.
VIII. Resolving Ethical Issues
The addiction professional shall behave in accordance with legal, ethical and moral
standards for his or her work. To this end, professionals will attempt to resolve
ethical dilemmas with direct and open communication among all parties involved
and seek supervision and/or consultation as appropriate.
1. When ethical responsibilities conflict with law, regulations or other governing
legal authority, addiction professionals should take steps to resolve the issue
through consultation and supervision.
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2. When addiction professionals have knowledge that another counselor might be
acting in an unethical manner, they are obligated to take appropriate action based,
as appropriate, on the standards of this code of ethics, their state ethics committee
and the National Certification Commission.
3. When an ethical dilemma involving a person not following the ethical standards
cannot be resolved informally, the matter shall be referred to the state ethics
committee and the National Certification Commission.
4. Addiction professionals will cooperate with investigations, proceedings and
requirements of ethics committees.
IX. Communication and Published Works
The addiction professional who submits for publication or prepares handouts for
clients, students or for general distribution shall be aware of and adhere to
copyright laws.
1. The addiction professional honestly respects the limits of present knowledge in
public statements related to alcohol and drug abuse. Statements of fact will be
based on what has been empirically validated as fact. Other opinions, speculations
and conjectures related to the addictive process shall be represented as less than
scientifically validated.
2. The addiction professional recognizes contributions of other persons to their
written documents.
3. When a document is based on cooperative work, all contributors are recognized
in documents or during a presentation.
4. The addiction professional who reviews material submitted for publication,
research or other scholarly purposes must respect the confidentiality and
proprietary rights of the authors.
X. Policy and Political Involvement
Standard 1: Societal Obligations
The addiction professional is strongly encouraged to the best of his/her ability,
actively engage the legislative processes, educational institutions and the general
public to change public policy and legislation to make possible opportunities and
choice of service for all human beings of any ethnic or social background whose
lives are impaired by alcoholism and drug abuse.
1. The addiction professional understands that laws and regulations exist for the
good ordering of society and for the restraint of harm and evil and will follow
them, while reserving the right to commit civil disobedience.
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2. The one exception to this principle is a law or regulation that is clearly unjust,
where compliance leads to greater harm than breaking a law.
3. The addiction professional understands that the determination that a law or
regulation is unjust is not a matter of preference or opinion but a matter of rational
investigation, deliberation and dispute, and will willingly accept that there may be
a penalty for justified civil disobedience.
Standard 2: Public Participation
The addiction professional is strongly encouraged to actively participate in
community activities designed to shape policies and institutions that impact on
substance use disorders. Addiction professionals will provide appropriate
professional services in public emergencies to the greatest extent possible.
Standard 3: Social and Political Action
The addiction professional is strongly encouraged to understand that personal and
professional commitments and relationships create a network of rights and
corresponding duties and will work to safeguard the natural and consensual rights
of each individual within their community.
The addiction professional, understands that social and political actions and
opinions are an individual’s right and will not work to impose their social or
political views on individuals with whom they have a professional relationship.
This resource was designed to provide an ethics code and ethical standards that
will be used by counseling professionals. These principles of ethical conduct
outline the importance of having ethical standards and the importance of adhering
to those standards. These principles can help professionals face ethical dilemmas in
their practice and explore ways to avoid them. Please use this resource and share it
with your colleagues. For more information contact [email protected] or
800.548.0497.
CCBADC-ALCOHOL/DRUG COUNSELORS
CODE OF ETHICS/CONDUCT
(For all Alcohol/Drug Counselors: Certificants and Registrants)
Principle 1: Non-discrimination
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The alcoholism and drug abuse counselor/registrant must not discriminate against
clients or professionals based upon race, religion, age, sex, handicaps, national
ancestry, sexual orientation or economic condition.
Principle 2: Responsibility
The alcoholism and drug abuse counselor/registrant must espouse objectivity and
integrity, and maintain the highest standards in the services the counselor offers.
a. The alcoholism and drug counselor/registrant, as teacher, must recognize the
counselor's primary obligation to help others acquire knowledge and skill in
dealing with the disease of chemical dependency.
b. The alcoholism and drug abuse counselor/registrant, as practitioner, must accept
the professional challenge and responsibility deriving from the counselor's work.
c. The alcoholism and drug counselor/registrant, who supervises others, accepts the
obligation to facilitate further professional development of these individuals by
providing accurate and current information, timely evaluations and constructive
consultation.
Principle 3: Competence
The alcoholism and drug abuse counselor/registrant must recognize that the
profession is founded on national standards of competence which promote the best
interests of society, of the client, of the counselor and of the profession as a whole.
The counselor/registrant must recognize the need for ongoing education as a
component of professional competency.
a. The alcoholism and drug abuse counselor/registrant must prevent the
practice of alcoholism and drug abuse counseling by unqualified and
unauthorized persons.
b. The alcoholism and drug abuse counselor/registrant who is aware of
unethical conduct or of unprofessional modes of practice must report such
violations to the appropriate certifying authority.
c. The alcoholism and drug abuse counselor/registrant must recognize
boundaries and limitations of counselor's competencies and not offer
services or use techniques outside of these professional competencies.
d. The alcoholism and drug abuse counselor/registrant must recognize the
effect of professional impairment on professional performance and must be
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willing to seek appropriate treatment for oneself or for a colleague. The
counselor/registrant must support peer assistance programs in this respect.
Principle 4: Legal Standards and Moral Standards
The alcoholism and drug abuse counselor/registrant must uphold the legal and
accepted moral codes, which pertain to professional conduct.
a. The alcoholism and drug abuse counselor/registrant must not claim
directly or by implication, professional qualifications/affiliations that the
counselor does not possess.
b. The alcoholism and drug abuse counselor/registrant must not use the
affiliation with the California Certification Board of Alcohol/Drug
Counselors (and/or CAADAC) for purposes that are not consistent with the
stated purposes of the Association.
c. The alcoholism and drug abuse counselor/registrant must not associate
with or permit the counselor's name to be used in connection with any
services or products in a way that is incorrect or misleading.
d. The alcoholism and drug abuse counselor/registrant must not associate
with the development or promotion of books or other products offered for
commercial sale must be responsible for ensuring that such books or
products are presented in a professional and factual way.
e. The alcoholism and drug abuse counselor/registrant must not attempt to
secure certification or registration (or certification renewal) by fraud, deceit,
or misrepresentation on any application or other documents submitted to the
certifying organization whether engaged in by an applicant for certification
or registration or in support of any application for certification or
registration. Any altered documents as identified by staff in the application
or renewal process will be denied immediately and
reapplication may be required and the CCBADC Chairperson may deny
application or reapplication as a result of such fraudulent activity.
f. The alcoholism and drug abuse counselor/registrant must not violate,
attempt to violate, or conspire to violate any regulation or law adopted by
the California Alcohol and Drug Program Administration or CCBADC
Policies and/or Code of Ethics.
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5: Public Statements
The alcoholism and drug abuse counselor/ registrant must respect the limits of
present knowledge in public statements concerning alcoholism and other forms of
drug addiction.
a. The alcoholism and drug abuse counselor/registrant who represents the
field of AOD counseling to clients, other professionals, or to the general
public must report fairly and accurately the appropriate information.
b. The alcoholism and drug abuse counselor/registrant must acknowledge
and document materials and techniques used.
c. The alcoholism and drug abuse counselor/registrant who conducts training
in alcoholism or drug abuse counseling skills or techniques must indicate to
the audience the requisite training/qualifications required to properly
perform these skills and techniques.
Principle 6: Publication Credit
The alcoholism and drug abuse counselor/registrant must assign credit to all who
have contributed to the published material and for the work upon which the
publication is based.
a. The alcoholism and drug abuse counselor/registrant must recognize joint
authorship, major contributions of a professional character, made by several
persons to a common project. The author who has made the principle
contribution to a publication must be identified as a first listed.
b. The alcoholism and drug abuse counselor/registrant must acknowledge in
footnotes or an introductory statement minor contributions of a professional
character, extensive clerical or similar assistance and other minor
contributions.
d. The alcoholism and drug abuse counselor/registrant must acknowledge,
through specific citations, unpublished, as well as published material, that
has directly influences the research or writing.
e. The alcoholism and drug abuse counselor/registrant who complies and
edits for publication the contributions of others must list oneself as editor,
along with the names of those who have contributed.
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Principle 7: Client Welfare
The alcoholism and drug abuse counselor/registrant must respect the integrity and
protect the welfare of the person or group with whom the counselor is working.
a. The alcoholism and drug abuse counselor/registrant must define for self
and others the nature and direction of loyalties and responsibilities and keep
all parties concerned informed of these commitments.
b. The alcoholism and drug abuse counselor/registrant, in the presence of
professional conflict must be concerned primarily with the welfare of the
client.
c. The alcoholism and drug abuse counselor/registrant must terminate a
counseling or consulting relationship when it is reasonably clear that the
client is not benefiting from it.
d. The alcoholism and drug abuse counselor/registrant, in referral cases,
must assume the responsibility for the client's welfare either by termination
by mutual agreement and/or by the client becoming engaged with another
professional. In situations when a client refuses treatment, referral or
recommendations, the alcohol and drug abuse counselor/registrant must
carefully consider the welfare of the client by weighing the benefits of
continued treatment or termination and must act in the best interest of the
client.
e. The alcoholism and drug abuse counselor/registrant who asks a client to
reveal personal information from other professionals or allows information
to be divulged must inform the client of the nature of such transactions. The
information released or obtained with informed consent must be used for
expressed purposes only.
f. The alcoholism and drug abuse counselor/registrant must not use a client
in a demonstration role in a workshop setting where such participation
would potentially harm the client.
g. The alcoholism and drug abuse counselor/registrant must ensure the
presence of an appropriate setting for clinical work to protect the client from
harm and the counselor and the profession from censure.
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h. The alcoholism and drug abuse counselor/registrant must collaborate with
other health care professional(s) in providing a supportive environment for
the client who is receiving prescribed medications.
Principle 8: Confidentiality
The alcoholism and drug abuse counselor/registrant must embrace, as a primary
obligation, the duty of protecting the privacy of clients and must not disclose
confidential information acquired, in teaching, practice or investigation.
a. The alcoholism and drug abuse counselor/registrant must inform the client
and obtain agreement in areas likely to affect the client's participation
including the recording of an interview, the use of interview material for
training purposes, and observation of an interview by another person.
b. The alcoholism and drug abuse counselor/registrant must make provisions
for the maintenance of confidentiality and the ultimate disposition of
confidential records.
c. The alcoholism and drug abuse counselor/registrant must reveal
information received in confidence only when there is clear and imminent
danger to the client or to other persons, and then only to appropriate
professional workers or public authorities.
d. The alcoholism and drug abuse counselor/registrant must discuss the
information obtained in clinical or consulting relationships only in
appropriate settings, and only for professional purposes clearly concerned
with the case. Written and oral reports must present only data germane to the
purpose of the evaluation and every effort must be made to avoid undue
invasion of privacy.
e. The alcoholism and drug abuse counselor/registrant must use clinical and
other material in classroom teaching and writing only when the identity of
the persons involved is adequately disguised.
Principle 9: Client Relationships
The alcoholism and drug abuse counselor/registrant must inform the prospective
client of the important aspects of the potential relationship.
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a. The alcoholism and drug abuse counselor/registrant must inform the client
and obtain the client's agreement in areas likely to affect the client's
participation including the recording of an interview, the use of interview
material for training purposes, and/or observation of an interview by another
person.
b. The alcoholism and drug abuse counselor/registrant must inform the
designated guardian or responsible person of the circumstances, which may
influence the relationship, when the client is a minor or incompetent.
c. Dual Relationships:
i. The alcoholism and drug abuse counselor/registrant must seek to
nurture and support the development of a relationship with clients as
equals rather than to take advantage of individuals who are vulnerable
and exploitable.
ii. The alcoholism and drug abuse counselor/registrant must not
engage in professional relationships or commitments that conflict with
family members, friends, close associates or others whose welfare
might be jeopardized by such a dual relationship.
iii. Because all relationship begins with a power differential, the
alcoholism and drug abuse counselor/registrant must not exploit
relationships with current or former clients for personal gain,
including social or business relationships.
iv. Engaging in sexual relations with a client or with a former client
within two years from the termination date of therapy with the client,
soliciting sexual relations with a client, or committing an act of sexual
abuse, or sexual misconduct with a client, or committing an act
punishable as a sexually related crime, if that act or solicitation is
substantially related to the qualifications, functions, or duties of an
alcohol and other drug counselor/registrant.
v. The alcoholism and drug abuse counselor/registrant must not accept
gifts from clients, other treatment organizations or the providers of
materials or services used in practice.
Principle 10: Inter-professional Relationships
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The alcoholism and drug abuse counselor/registrant must treat colleagues with
respect, courtesy and fairness, and must afford the same professional courtesy to
other professionals.
a. The alcoholism and drug abuse counselor/registrant must not offer
professional services to a client in counseling with another professional
except with the knowledge of the other professional or after the termination
of the client's relationship with the other professional.
b. The alcoholism and drug abuse counselor/registrant must cooperate with
duly constituted professional ethics committees, staff requests and promptly
supply necessary information unless constrained by the demands of
confidentiality. Failure to cooperate with the committee or staff may result
in immediate suspension until such time cooperation is given. Additionally,
the alcoholism and drug abuse counselor/registrant may not use threatening
gestures, behaviors or other forms of coercion with the committee,
colleagues, members, staff or other individuals.
c. The alcoholism and drug abuse counselor/registrant must not in any way
exploit relationships with supervisees, employees, students, research
participants or volunteers.
Principle 11: Remuneration
The alcoholism and drug abuse counselor/registrant must establish financial
arrangements in professional practice and in accordance with the professional
standards that safeguard the best interests of the client, of the counselor and of the
profession.
a. The alcoholism and drug abuse counselor/registrant must inform the client
of all financial policies. In circumstances where an agency dictates explicit
provisions with its staff for private consultations, clients must be made fully
aware of these policies.
b. The alcoholism and drug abuse counselor/registrant must not send or
receive any commission or rebate or any other form of remuneration for
referral of clients for professional services. The counselor must not engage
in fee splitting.
c. The alcoholism and drug abuse counselor/registrant in clinical or
counseling practice must not use one's relationship with clients to promote
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personal gain or the profit of an agency or commercial enterprise of any
kind.
d. The alcoholism and drug abuse counselor/registrant must not accept a
private fee or any other gift or gratuity for professional work with a person
who is entitled to such services though an institution or agency. The policy
of a particular agency may make explicit provisions for private work with its
client by members of its staff, and in such instances the client must be fully
apprised of all policies affecting the client.
Principle 12: Societal Obligations CCBADC
The alcoholism and drug abuse counselor/registrant must advocate changes in
public policy and legislation to afford opportunity and choice for all persons whose
lives are impaired by alcoholism and other forms of drug addiction. The counselors
must inform the public through active civic and professional participation in
community affairs of the effects of alcoholism and drug addiction and must act to
guarantee that all persons, especially the needy and disadvantaged, have access to
the necessary resources and services. The alcoholism and drug abuse
counselor/registrant must adopt a personal and professional stance, which
promotes the well being of all human beings. The CCBADC is comprised of
certified counselors who, as responsible health care professionals, believe in the
dignity and worth of human beings. In practice of their profession they assert that
the ethical principles of autonomy, beneficence and justice must guide their
professional conduct. As professionals dedicated to the treatment of alcohol and
drug dependent clients and their families, they believe that they can effectively
treat its individual and families manifestations. CCBADC certified counselors
dedicate themselves to promote the best interest of their society, of their clients, of
their profession, and of their colleagues.
CALIFORNIA AOD COUNSELORS: CERTIFICANTS AND
REGISTRANTS–UNIFORM CODE OF CONDUCT
FINAL VERSION JUNE 29, 2009
Note: This code of conduct does not replace the existing Code of Ethics as defined
by the CCBADC it merely enhances it. Additionally, the CCBADC requires the
most stringent rules be applied whether defined by CCBADC Code of Ethics or
ADP’s Uniform Code of Conduct.
This Code of Conduct shall prohibit registrants and certified alcohol and other drug
(AOD) counselors from:
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1. Securing a certification or registration by fraud, deceit, or misrepresentation on
any application submitted to the certifying organization whether engaged in by an
applicant for certification or registration or in support of any application for
certification or registration.
2. Administering to himself or herself any controlled substance as defined in
section 4021 of the Business and Professions Code, or using any of the dangerous
drugs or devices specified in section 4022 of the Business and Professions Code or
using any alcoholic beverage to the extent, or in a manner, as to be dangerous or
injurious to the person applying for a certification or holding a registration or
certification, or to any other person, or to the public, or, to the extent that the use
impairs the ability of the person applying for or holding a registration or
certification to conduct with safety to the public the counseling authorized by the
registration or certification.
3. Gross negligence or incompetence in the performance of alcohol and other drug
counseling.
4. Violating, attempting to violate, or conspiring to violate any regulation adopted
by ADP.
5. Misrepresentation as to the type or status of certification or registration held by
the person, or otherwise misrepresenting or permitting misrepresentation of his or
her education, professional qualifications, or professional affiliations to any person
or entity, and failure to state proper certification or licensure initials and numbers
on business cards, brochures, websites, etc.
6. Impersonation of another by any counselor or registrant, or applicant for a
certification or registration, or, in the case of a counselor, allowing any other
person to use his or her certification or registration.
7. Aiding or abetting any uncertified or unregistered person to engage in conduct
for which certification or registration is required.
8. Providing services beyond the scope of his/he registration or certification as an
AOD counselor or his or her professional license, if the individual is a licensed
counselor as defined in Secton13015.
9. Intentionally or recklessly causing physical or emotional harm to any client.
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10. The commission of any dishonest, corrupt, or fraudulent act substantially
related to the qualifications, functions, or duties of a counselor or registrant.
11. Engaging in sexual relations with a client or with a former client within two
years from the termination date of therapy with the client, soliciting sexual
relations with a client, or committing an act of sexual abuse, or sexual misconduct
with a client, or committing an act punishable as a sexually related crime, if that
act or solicitation is substantially related to the qualifications, functions, or duties
of an alcohol and other drug counselor.
12. Engaging in a social or business relationship with clients, program participants,
patients, or residents or other persons significant to them while they are in
treatment and exploiting former clients, program participants, patients, or residents.
13. Verbally, physically or sexually harassing, threatening, or abusing any
participant, patient, resident, their family members, other persons who are
significant to them, or other staff members.
14. Failure to maintain confidentiality, except as otherwise required or permitted
by law, including but not limited to Code of Federal Regulations, Title 42, Part 2.
15. Advertising that in reasonable probability will cause an ordinarily prudent
person to misunderstand or be deceived; makes a claim either of professional
superiority or of performing services in a superior manner, unless that claim is
relevant to the service being performed and can be substantiated with objective
scientific evidence; makes a scientific claim that cannot be substantiated by
reliable, peer reviewed, published scientific studies.
16. Failure to keep records consistent with sound professional judgment, the
standards of the profession, and the nature of the services being rendered.
17. Willful denial of access to client records as otherwise provided by law.
8. Ethics and Confidentiality with HIV/AIDS
Ethical and Legal Issues
Do you or your staff ever ask: Are we making the correct decision?
Legally? Ethically? Have we done the right thing? Have we protected
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our clients? What is our responsibility with regard to others
who may be harmed by a client s behavior? TIP 37 (below) helps you and
your staff answer these difficult, complex questions. Here are
some of the topics covered:
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
Duty-to-treat, duty-to-warn, and end-of-life issues
Allocation decisions when resources are scarce
Discrimination
Confidentiality and disclosure of client information
A step-by-step model for making ethical decisions
Decision tree to help determine if a duty exists to warn clients
sexual or needle-sharing partners of their HIV infection
Sample codes of ethics.
A number of legal issues can affect HIV-infected clients and the operations of
substance abuse treatment programs. With multiple sets of rules governing HIV/
AIDS as well as substance abuse treatment, compliance can be tricky. This chapter
examines legal issues (many of them with ethical implications) in two main areas:
1. Access to services and programs, as well as employment opportunities
for recovering substance abusers and persons living with HIV/AIDS
2. Confidentiality, or the protection of clients' right to privacy
Both of these areas are covered by Federal and State laws, which are often attempts
to address the ethical concerns involved.
Access to Treatment--Issues of Discrimination
Substance abuse treatment providers may encounter discrimination against their
clients as they try to connect them with services. Although people have come a
long way from the early days of the AIDS pandemic (when people were afraid to
have any contact with someone infected with HIV), there are still many instances
in which people living with HIV/AIDS are shunned, excluded from services, or
offered services under discriminatory conditions. As recently as 1998, the United
States Supreme Court considered a case against a dentist who refused to treat a
patient in his office. He stated he would only treat her in a hospital (although her
situation did not warrant an admission) and that she would have to incur those
costs herself.
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People in substance abuse treatment also may encounter outright rejection or
discrimination because of their history of drug or alcohol use. A hospital might be
unwilling to admit a client who relapses periodically. Or a long-term care facility
may be reluctant to accommodate a client who is maintained on methadone.
Individuals living with HIV/AIDS and persons in substance abuse treatment may
also encounter discrimination in employment. A school may refuse to hire a
teacher who is HIV positive, or a business may fire a secretary when it discovers
she once was treated for alcoholism.
This section outlines the protections Federal law currently affords people with
substance abuse problems and people living with HIV/AIDS, as well as the
limitations of those protections. State laws that outlaw discrimination against
individuals with disabilities are also mentioned.
Federal Statutes Protecting People With Disabilities
Two Federal statutes protect people with disabilities: the Federal Rehabilitation
Act (29 United States Code [U.S.C.] §791 et seq. [1973]) and the Americans With
Disabilities Act (ADA) (42 U.S.C. 12101 et seq. [1992]). (In this section these are
referred to collectively as "the acts.") Together, these laws prohibit discrimination
based on disability by private and public entities that provide most of the benefits,
programs, and services a substance abuser or person living with HIV/AIDS is
likely to need or seek. They also outlaw discrimination by a wide range of
employers. For a general discussion about these Federal statutes, see TIP 29,
Substance Use Disorder Treatment for People With Physical and Cognitive
Disabilities.
Protections for substance abusers and persons living with HIV/AIDS
The issue for treatment providers is whether substance abusers and people living
with HIV/AIDS are included in the definition of "individual with a disability." The
answer is yes in many, but not all, instances.
Alcohol abuse
In general, these acts protect alcohol abusers who are seeking benefits or services
from an organization or agency covered by one of the statutes (29 U.S.C.
§706(8)(C)(iii) and 42 U.S.C. §12110(c)), if they are "qualified" and do not pose a
direct threat to the health or safety of others (28 Code of Federal Regulations
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[CFR] §36.208(a)). This means that an organization or program cannot refuse to
serve an individual unless
 The individual's alcohol use is so severe, or has resulted in other
debilitating conditions, that he no longer "meets the essential
eligibility requirements for the receipt of services or the participation
in programs with or without reasonable modifications to rules,
policies, or practices" (42 U.S.C. 12131(2)).
 The individual poses "a significant risk to the health or safety of
others that cannot be eliminated by a modification of policies,
practices, or procedures, or by the provision of auxiliary aids or
services" (36 CFR §36.208(b); Supplemental Information 28 CFR
Part 35, Section-by-Section Analysis, 35.104).
For example, a hospital might take the position that an alcohol-dependent client
with dementia was not "qualified" to participate in occupational therapy because he
could not follow directions. Or an alcohol abuser whose drinking results in
assaultive episodes that endanger elderly residents in a long-term care facility
might pose the kind of "direct threat" to the health or safety of others that would
permit his exclusion.
The Rehabilitation Act also permits programs and activities providing services of
an educational nature to discipline students who use or possess alcohol (29 U.S.C.
706(8)(C)(iv)).
Abuse of illegal drugs
The acts divide abuse of illegal drugs into two groups: former abuse and current
abuse.
Former abuse. Individuals who no longer are engaged in illegal use of drugs and
have completed or are participating in a drug rehabilitation program are protected
from discrimination to the same extent as alcohol abusers (29 U.S.C. 706(8)(C)(ii);
42 U.S.C. 12210(b)). In other words, they are protected so long as they are
"qualified" for the program, activity, or service and do not pose a "direct threat" to
the health or safety of others. Service providers may administer drug tests to ensure
that an individual who once used illegal drugs no longer does so (28 CFR
36.209(c); 28 CFR 35.131(c)).
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Current abuse. Individuals currently engaging in illegal use of drugs are offered
full protection only in connection with health and drug rehabilitation services (28
CFR 36.209(b) and 28 CFR 35.131(b)). (However, drug treatment programs may
deny participation to individuals who continue to use illegal drugs while they are in
the program (28 CFR 36.209(b)(2)).) The laws explicitly withdraw protection with
regard to other services, programs, or activities (29 U.S.C. 706(8)(C)(i) and 42
U.S.C. 2210(a)). Current illegal use of drugs is defined as "illegal use of drugs that
occurred recently enough to justify a reasonable belief that a person's drug use is
current or that continuing use is a real and ongoing problem" (28 CFR §35.104 and
28 CFR 35.104).
For example, a hospital that specializes in treating burn victims could not refuse to
treat a burn victim because he uses illegal drugs, nor could it impose a surcharge
on him because of his addiction. However, the hospital is not required to provide
services that it does not ordinarily provide; for example, drug abuse treatment
(Appendix B to 28 CFR Part 36, Section-by-Section Analysis, 36.302). On the
other hand, a homeless shelter could refuse to admit an abuser of illegal drugs,
unless the individual has stopped and is participating in or has completed drug
treatment.
The Rehabilitation Act also permits programs and activities providing educational
services to discipline students who use or possess illegal drugs (29 U.S.C.
706(8)(C)(iv)).
Individuals living with HIV/AIDS
Although alcohol and drug abuse are mentioned in both of the acts, HIV/AIDS is
not. However, on June 25, 1998, the United States Supreme Court held that
asymptomatic HIV infection is a "disability" under the ADA (Bragdon v. Abbott,
524 U.S. 624 . See also 28 CFR §35.104 and §36.104; 28 CFR Part 35, Section-bySection Analysis, 35.104 and Appendix B to 28 CFR Part 36, Section-by-Section
Analysis, 36.104). In this case, a woman with asymptomatic HIV disease sued a
dentist who denied her equal service.
The Bragdon v. Abbott decision means that individuals living with HIV/AIDS are
protected from discrimination under both of the acts, so long as they are "qualified"
for the service, program, or benefit and do not pose a "direct threat" to the health or
safety of others. (See also 28 CFR 36.208; Supplemental Information 28 CFR Part
35, Section-by-Section Analysis, 35.104.) An individual who is too ill to
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participate in a program, even with reasonable modifications, might not be
"qualified."
The "direct threat" question has received the most public attention. Can a "public
accommodation," a restaurant, hospital, school, or funeral home, refuse to provide
services to someone living with HIV/AIDS because the person poses a "direct
threat" to the health and safety of others? Because HIV is not transmitted by casual
contact, and most programs and services provided by "public accommodations"
involve only casual contact, the answer in most cases should be "no." Even when
contact with bodily fluids is likely to occur, public health authorities advise health
care professionals to treat HIV-positive clients in the normal setting and to use
universal precautions with all clients. Moreover, in those cases where a public
accommodation could argue that an HIV-positive individual poses a direct threat, it
would also have to show that the threat could not be eliminated by a modification
of policies, practices, or procedures, or by the provision of auxiliary aids or
services.
Confidentiality of Information About Clients
Programs providing substance abuse treatment for clients living with HIV/AIDS
frequently must communicate with individuals and organizations as they gather
information, refer clients for services the program does not provide, and coordinate
care with other service providers. On occasion, they are required to report
information to the State. This section outlines the laws protecting client
confidentiality and examines how staff can continue to provide appropriate
treatment services, comply with State reporting laws, and protect client privacy.
Information about clients in substance abuse treatment who are living with
HIV/AIDS is subject to two sets of laws:
 Federal statutes and regulations that guarantee the confidentiality of
information about all persons applying for or receiving alcohol and
drug abuse prevention, screening, assessment, and treatment services
(42 U.S.C. 290dd-2; 42 CFR, Part 2)
 State laws governing the confidentiality of HIV/AIDS-related
information. (State laws protecting HIV-related information vary in
the protection they offer; some guard clients' privacy closely, others
are more lenient. State laws also protect the confidentiality of other
medical and mental health information. These laws, however, are
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likely to be less stringent than statutes dealing specifically with
information about HIV/AIDS.)
The remainder of this chapter describes what these laws require and examines their
impact on substance abuse treatment programs. The first section contains an
overview of the Federal law protecting the right to privacy of any person who
seeks or receives substance abuse treatment services. Because the Federal law
applies throughout the country and preempts less restrictive State laws, this
discussion focuses on how the Federal rules apply in a variety of situations, then
addresses related State laws in those contexts. Next is an examination of the rules
surrounding the use of consent forms to obtain a client's permission to release
information, including ways to handle requests for disclosure when the client's file
contains both substance abuse and HIV/AIDS information.
The third section reviews situations that commonly arise when a client in substance
abuse treatment is living with HIV/AIDS, including how communications among
agencies providing services to the client can be managed. The fourth section
discusses exceptions in the Federal confidentiality rules that, in limited
circumstances, permit disclosure of information about clients (e.g., reporting child
abuse or neglect). The chapter ends with a few additional points concerning the
requirement that clients receive a notice about the confidentiality regulations,
clients' right to review their own records, and security of records.
Federal and State Laws Protect the Client's Right to Privacy
A Federal law and a set of regulations guarantee strict confidentiality of
information about all persons who seek or receive alcohol and substance abuse
assessment and treatment services. The legal citations for the laws and regulations
are 42 U.S.C. 290dd-2 and 42 CFR Part 2. (Citations below in the form "2..." refer
to specific sections of 42 CFR Part 2.)
The Federal law and regulations are designed to protect clients' privacy rights in
order to attract people into treatment. The regulations restrict communications
tightly; unlike either the doctor-patient or the attorney-client privilege, the
substance abuse treatment provider is prohibited from disclosing even the client's
name. Violating the regulations is punishable by a fine of up to $500 for a first
offense or up to $5,000 for each subsequent offense (2.4).
The Federal rules apply to any program that specializes, in whole or in part, in
providing treatment, counseling, or assessment and referral services for people
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with alcohol or drug problems (42 CFR 2.12(e)). Although the Federal regulations
apply only to programs that receive Federal assistance, this includes indirect forms
of Federal aid such as tax-exempt status, or State or local government funding
coming (in whole or in part) from the Federal Government. Whether the Federal
regulations apply to a particular program depends on the kinds of services the
program offers, not the label the program chooses. Calling itself a "prevention
program" or "outreach program" or "screening program" does not absolve a
program from adhering to the confidentiality rules.
In the wake of the HIV/AIDS pandemic, many States have adopted laws protecting
HIV/AIDS information. These laws are designed to encourage people at risk for
HIV/AIDS to be tested, determine their HIV/AIDS status, begin medical treatment
early, and change risky behaviors. Many State laws were passed with the concern
that those who are seropositive will suffer discrimination in employment, medical
care, insurance, housing, and other areas if their status becomes known. (Other
State laws protect information about individuals' health, mental health status, or
treatment, as well as information about other infectious diseases.)
The primary aim of confidentiality rules is to allow the client (and not the
provider) to determine when and to whom information about medical or mental
health, substance abuse, or HIV infection will be disclosed. Most of the nettlesome
problems that may crop up under the State and Federal laws and regulations can be
avoided through planning ahead. Familiarity with the rules will ease
communication. It can also reduce the confidentiality-related conflicts among
program, client, and outside agency or person to a few relatively rare situations.
General rules pertaining to confidentiality
Federal protections for substance abuse-related information
The Federal confidentiality law and regulations protect any information about a
client who has applied for or received any service related to substance abuse
treatment from a program that is covered under the law. Services can include
screening, referral, assessment, diagnosis, individual counseling, group counseling,
or treatment. The regulations are in effect from the time the client applies for or
receives services or the program first conducts an assessment or begins to counsel
the client. The restrictions on disclosure apply to any information that would
identify the client as an alcohol or drug abuser, either directly or by implication.
They also apply to former clients or patients. The rules apply whether or not the
person making an inquiry about the client already has the information, has other
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ways of getting it, has some form of official status, is authorized by State law, or
comes armed with a subpoena or search warrant. It should be noted, however, that
if the person requesting information has a "special authorizing court order," he
does have the right to receive confidential information according to 42 CFR, Part
2.
State protections for HIV/AIDS-related information
Whereas the Federal confidentiality rules apply throughout the country, each State
has a different set of rules regarding disclosure of HIV/AIDS information. When
substance abuse treatment programs hold HIV/AIDS-related information about
clients, that information is protected by the Federal confidentiality regulations as
well as by State law protecting HIV/AIDS-related information.
State protections for other medical and mental health-related information
State laws also offer general protection to some medical and mental health
information. While any HIV/AIDS-specific confidentiality law is likely to be more
stringent, providers should be aware of these more general statutes. 2
When may confidential information be shared with others?
Although Federal and State law protect information about clients, the laws do
contain exceptions. The most commonly used exception is the client's written
consent. Although the Federal law protecting information about clients in
substance abuse treatment and State laws protecting HIV/AIDS-related
information both permit a client to consent to a disclosure, the consent
requirements are likely to differ. Therefore, whenever providers contemplate
making a disclosure of information about a client in substance abuse treatment that
is living with HIV/AIDS, they must consider both Federal and State laws.
Federal Rules about Consent
The Federal regulations regarding consent are strict, somewhat unusual, and must
be carefully followed. A proper consent form must be in writing and must contain
each of the items below (2.31):
The name or general description of the program(s) making the disclosure
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1. The name or title of the individual or organization that will receive the
disclosure
2. The name of the client who is the subject of the disclosure
3. The purpose or need for the disclosure
4. How much and what kind of information will be disclosed
5. A statement that the client may revoke (take back) the consent at any
time, except to the extent that the program has already acted on it
6. The date, event, or condition upon which the consent expires if not
previously revoked
7. The signature of the client
8. The date on which the consent is signed
A general medical release form, or any consent form that does not contain all of
the elements listed above, is not acceptable. (See sample consent form in Figure 91.) Most disclosures of information about a client in substance abuse treatment are
permissible if the client has signed a valid consent form that has not expired or
been revoked. (One exception to this statement may be when a client's file contains
HIV/AIDS information, as discussed below.)
Purpose of the disclosure and how much and what kind of information will be
disclosed
These two items are closely related. All disclosures, and especially those made
pursuant to a consent form, must be limited to the information necessary to
accomplish the need or purpose for the disclosure (2.13(a)). It is improper to
disclose everything in a client's file if the recipient of the information needs only
one specific piece of information.
A key step in completing the consent form is specifying the purpose or need for the
communication of information. Once the purpose has been identified, it is easier to
determine how much and what kind of information will be disclosed and to tailor it
to what is essential to accomplish that particular purpose or need.
Client's right to revoke consent
Federal regulations permit the client to revoke consent at any time, and the consent
form must include a statement to this effect. Revocation need not be in writing. If a
program has already made a disclosure prior to the revocation, the program has
acted in reliance on the consent and is not required to retrieve the information it
has already disclosed.
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Expiration of consent form
The Federal rules require that the consent form contain a date, event, or condition
on which it will expire if not previously revoked. A consent form must last "no
longer than reasonably necessary to serve the purpose for which it is given"
(2.31(a)(9)). If the purpose of the disclosure is expected to be accomplished in 5 or
10 days, it is better to fill in that amount of time rather than a longer period. It is
best to determine how long each consent form should run rather than impose a set
time period such as 60 or 90 days. When uniform expiration dates are used,
agencies can find themselves in a situation requiring disclosure, after the client's
consent form has expired. This means at the least that the client must return to the
agency to sign a new consent form. At worst, the client has left or is unavailable
(e.g., hospitalized), and the agency will not be able to make the disclosure.
The consent form need not contain a specific expiration date, but may instead
specify an event or condition. For example, a form could expire after a client has
seen a specific referred health care provider, or a consent form permitting
disclosures to an employer might expire at the end of the client's probationary
period.
The signature when the client is a minor (and the issue of parental consent) 3
Minors must always sign the consent form in order for a program to release
information, even with a parent's or guardian's consent. The program must obtain
the parent's signature in addition to the minor's signature only if the program is
required by State law to obtain parental permission before providing treatment to
minors (2.14). ("Parent" includes parent, guardian, or other person legally
responsible for the minor.)
In other words, if State law does not require the program to obtain parental consent
to provide services to a minor, then parental consent is not required to make
disclosures (§2.14(b)). If State law requires parental consent to provide services to
a minor, then parental consent is required to make any disclosures. The program
must always obtain the minor's consent for disclosures and cannot rely on the
parent's signature alone. Substance abuse treatment programs should consult with
their Single State Authority or a local lawyer to determine whether they need
parental consent to provide services to minors. For more information about minors,
see TIP 31, Screening and Assessing Adolescents for Substance Use Disorders
(CSAT, 1999A), and TIP 32, Treatment of Adolescents With Substance Use
Disorders.
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Required notice against re-disclosing information
Once the consent form is properly completed, one last requirement remains. Any
disclosure made with client consent must be accompanied by a written statement
that the information disclosed is protected by Federal law and that the recipient of
the information cannot further disclose it unless permitted by the regulations
(§2.32). This statement, not the consent form itself, should be delivered and
explained to the recipient at the time of disclosure or earlier.
The prohibition on redisclosure is clear and strict. Those who receive the notice are
prohibited from re-releasing information except as permitted by the regulations.
(Of course, a client may sign a consent form authorizing such a redisclosure.)
Note on the effect of a signed consent form
Programs may not disclose information when a consent form has expired, is
deficient, is invalid or has been revoked (§2.31(c)). The other rules about how
programs should respond to a signed consent form depend upon whether the
disclosure will be to a third party or to the client himself and whether the client is a
minor.
Disclosures to third parties
Programs subject to the Federal confidentiality rules are not required to disclose
information to a third party about a client who has signed a consent form
authorizing release of information unless the program has also been served with a
subpoena or court order that meets the requirements of §2.3(b) and §2.61(a)(b). If
the client consenting to disclosure is a minor (an issue governed by State law), the
same rule applies. However, whether a consent form signed by a minor is valid
depends upon whether State law permits a minor to enter treatment without
parental consent. If State law permits a minor to enter treatment without parental
consent, the program can rely on the minor client's signature on the consent form to
make a disclosure to a third party. If State law requires parental consent for minors
to enter treatment, then the program must get the signature of both parent and
client. The minor must always sign the form.
Whenever a program releases information to a third party, it should disclose only
what is necessary, and only as long as necessary, keeping in mind the purpose of
the communication.
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Disclosures to clients
If a client signs a consent form authorizing the program to disclose records directly
to the client and State law requires the program to honor such a request, then the
program must release the records to the client. (Note that the Federal law does not
require clients to sign a proper consent form to obtain their own records, but State
law may.) If the client signing the consent form authorizing release of information
is a minor and the disclosure will be to his parent, guardian or other person or
entity legally responsible for him, the program should make the disclosure. State
law may mandate the disclosure and once the minor has consented, the program
must follow the State rule. Even in States without such a rule mandating
disclosure, only extraordinary circumstances could justify withholding information
from a parent or guardian once the minor has consented to its release.
Special consent rules for clients mandated into treatment by the justice system
Substance abuse treatment programs treating clients who are involved in the
criminal justice system (CJS) must also follow the Federal confidentiality
regulations. However, some special rules apply when a client comes for assessment
or treatment as an official condition of probation, sentence, dismissal of charges,
release from detention, or other disposition of a criminal justice proceeding.
A consent form (or court order) is still required before a program can disclose
information about a client who is the subject of CJS referral. For more detailed
information about consent for clients within the CJS, see TIP 17, Planning for
Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice
System (CSAT, 1995c).
State Rules about Consent
State laws that protect disclosure of HIV/AIDS-related information also contain an
exception permitting most disclosures when the client consents. However, some
States have strict requirements governing the content of the consent form. It is
important, therefore, that programs providing substance abuse treatment to people
living with HIV/AIDS become familiar with those requirements.
Which set of rules applies when a substance abuse treatment client with HIV/AIDS
consents to a disclosure? This depends on what information is to be released, as
illustrated in the following examples.
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Example 1. Suppose a client's file contains both substance abuse treatment
information and HIV/AIDS information, and the client wants to consent to
disclosure of information about substance abuse to an outside agency but not
information about HIV/AIDS status. This problem could be handled in several
ways:
 The federally required consent form can be drafted narrowly so that
the purpose for the disclosure and the kind of information to be
disclosed are limited to substance abuse treatment.
 The program can maintain a filing system that isolates substance
abuse and HIV/AIDS-related information in two different
"treatment" or "medical" files and discloses only information from
the "treatment" file. (This solution may not be practical, however, in
States that regulate how and where HIV/AIDS-related information
must be charted.)
 The program can send the client's file without the HIV/AIDS-related
information to the outside agency and include the following notice
(with the federally required notice of the prohibition on redisclosure):
Example 2. If the client wants the program to release information about his
HIV/AIDS status, the answer will be different. Clearly the State's form must be
used. However, if the disclosure of the client's HIV/AIDS-related information will
by implication or otherwise reveal that the client is in substance abuse treatment,
the Federal form must also be used. For example, if the Satellite City Drug and
Alcohol Program is the agency releasing HIV/AIDS-related information with a
client's consent, the fact that the information came from a substance abuse
treatment program will alert the recipient that the client is not only HIV positive
but is also in substance abuse treatment. The program, therefore, must use a
consent form that complies with both Federal and State requirements. It should not
be necessary for clients to sign two separate forms in this kind of situation; a form
that complies with both sets of requirements should be drafted.
Example 3. Finally, what happens when a client signs a proper consent form
permitting disclosure of information about her substance abuse treatment, and the
information she consents to release would also disclose her HIV/AIDS status? Can
the program release the information? Not unless the program has complied with
State consent requirements. Even if a client has signed a consent form permitting
disclosure of substance abuse information, the program may not release
information about HIV/AIDS unless it has also satisfied State requirements.
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Strategies for Communication With Others About Clients
Some of the practical questions that affect program operations include the
following:
 How can substance abuse treatment providers seek information from
collateral sources about clients they are screening, assessing, or
treating?
 How can providers comply with State mandatory reporting laws?
 How should providers deal with insurance companies and other thirdparty payors?
 How can providers respond to requests for information about clients
who have died or become incompetent?
 How should programs deal with clients' risk-taking behavior? Do
programs have a duty to warn potential victims or law enforcement
agencies of clients' threats to plan to infect someone else with
HIV/AIDS, and if so, how do they communicate the warning?
 Can staff members of substance abuse treatment programs comply with
mandatory State child abuse reporting laws?
Seeking information from collateral sources
Making inquiries of family members, employers, schools, doctors, and other health
care entities might seem to pose no risk to a client's right to confidentiality. This is
not the case. When program staff seek information from other sources, they are
letting these sources know that the client has asked for substance abuse treatment
services. The Federal regulations generally prohibit this kind of disclosure unless
the client consents.
How should a substance abuse treatment program proceed? The easiest way is to
obtain the client's consent to contact the employer, family member, school, health
care facility, etc. Or, the program could ask the client to sign a consent form that
permits it to make a disclosure for the purpose of seeking information from other
sources to any one of a number of organizations or persons listed on the consent
form. Note that this combination form must still include "the name or title of the
individual or the name of the organization" for each source the program contacts.
Whichever method the program chooses, it must use the consent form required by
the regulations, not a general medical release form.
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If the client is living with HIV/AIDS, the program must check State laws to see
whether they impose additional requirements. For example, an alcohol and drug
counselor wishing to talk to a client's primary care physician must first find out
whether State law protecting HIV/AIDS-related information requires that
additional provisions be added to the consent form the client signs.
Making mandatory reports to public health authorities
All States require that AIDS and tuberculosis (TB) be reported to public health
authorities, and some States also require that new cases of HIV infection be
reported. The reports are forwarded to the Centers for Disease Control and
Prevention (CDC). All States also use the TB report to perform contact tracing, or
finding others to whom an infected person may have spread the disease; some
States use HIV/AIDS reporting similarly.
In each State, what must be reported for which diseases, who must report, and the
purposes for which the information is used vary. Therefore, providers must be
familiar with their State laws regarding (1) whether they or any of their staff
members are mandated to report, (2) when reporting is required, (3) what
information must be reported and whether it includes client-identifying
information, and (4) what will be done with the information reported.
Reporting HIV/AIDS and TB cases
If client-identifying information must be reported, how can programs comply with
State laws mandating the reporting of TB and HIV/AIDS cases? Several ways are
listed below.
Reporting with consent
The easiest way to comply is to obtain the client's consent. Note that if the public
health authority plans to re-disclose the information to the CDC, the consent form
must be drafted to permit such re-disclosure. The consent form can also be drafted
to authorize the program to communicate on an ongoing basis with the public
health department to help them find, counsel, monitor, or treat a client or
coordinate a client's TB care.
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Reporting without making a client-identifying disclosure
If State law permits the use of a code rather than the client's name, the program can
make the report without the client's consent because no client-identifying
information is being revealed. If the program is part of another health care facility,
general hospital, or a mental health program, the report can include the client's
name, if it does so under the name of the parent agency and releases no
information that links the client with substance abuse treatment. (See the
discussion below in "Communications that do not disclose client-identifying
information.")
Reporting through a Qualified Service Organization Agreement
A substance abuse treatment program can enter into a Qualified Service
Organization Agreement (QSOA) with the State or local public health department
charged with receiving mandatory reports. The QSOA (explained in more detail
later in this chapter) permits the program to report names of clients to the health
department and, if properly drafted, allows ongoing communication between the
program and public health officials.
A program that is required to report TB or AIDS cases to a public health
department can also enter into a QSOA with a general medical care facility or a
laboratory that conducts testing or provides care to the program's clients. The
QSOA would permit the program to report the names of clients to the medical care
facility or laboratory, which can then report the information (including the clients'
names) to the public health department, without any information that would link
those names with substance abuse treatment. Note that State confidentiality laws
might impose additional requirements. Also, an agreement with a medical care
facility or laboratory would not permit public health authorities to follow up on
cases with the treatment program.
Reporting under the audit and evaluation exception
One exception to the general rule prohibiting disclosure without a client's consent
permits programs under certain conditions to disclose information to auditors and
evaluators (§2.53). (For an explanation of the requirements of §2.53, see TIP 14,
Developing State Outcomes Monitoring Systems for Alcohol and Other Drug
Abuse Treatment [CSAT].) DHHS has written two opinion letters that approve the
use of the audit and evaluation exception to report HIV/AIDS-related information
to public health authorities. Together, these two letters suggest that substance
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abuse treatment programs may report client-identifying information even if that
information will be used by the public health department to conduct contact
tracing, so long as the health department does not disclose the name of the client to
"contacts" it approaches. The letters also suggest that public health authorities
could use the information to contact the infected substance abuse disorder client
directly.
However, some authorities may not agree with these opinion letters. As its title
"audit and evaluation" implies, §2.53 is intended to permit an outside entity, such
as a peer review organization or an accounting firm, to examine a program's
records to determine whether it is operating appropriately. It is not intended to
permit an outside entity such as the public health authority to gain information for
other social ends, such as tracing the spread of disease. It can be argued that such
use distorts the purpose of the audit and evaluation exception.
Getting a court order
A program could apply to a court for an order authorizing it to disclose information
to a public health department. The court order provision is discussed further under
"Exceptions that permit disclosures," below. Since obtaining a court order requires
drawing up legal papers, it is not likely to be a program's first choice.
Using the medical emergency exception
The Federal regulations permit a program to disclose information without client
consent to medical personnel "who have a need for information about a client for
the purpose of treating a condition which poses an immediate threat to the health"
of the client or any other individual. The regulations define "medical emergency"
as a situation that poses an immediate threat to health and requires immediate
medical intervention (§2.51). (This exception is explained more fully later in this
chapter.) Because any disclosure under this exception is limited to true
emergencies, a program cannot routinely use the medical emergency exception to
make mandatory reports. Because immediate medical intervention is unlikely to
prevent or cure HIV infection, it is not an advisable way to make mandatory
HIV/AIDS reports to public health departments.
For a more complete exploration of these options see TIP 18, The Tuberculosis
Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment
Providers (CSAT).
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Dealing with client risk-taking behavior
Does a program have a "duty to warn" others when it knows that a client is infected
with HIV? When would that "duty" arise? Even where no duty exists, should
providers warn others at risk about a client's HIV status? Finally, how can others
be warned without violating the Federal confidentiality regulations and State
confidentiality laws?
These questions raise complex legal issues that are discussed below. But first it
must be noted that "warning" someone about a client's HIV status without his
consent has potential consequences. Successful substance abuse treatment depends
on clients' willingness to expose shameful things about themselves to program
staff. The news that the program has "warned" a spouse, lover, or someone else
that a client is HIV positive will spread quickly among the client population. Such
news could destroy clients' trust in the program and its staff. Any counselor or
program considering "warning" someone of a client's HIV status without the
client's consent should carefully analyze whether there is, in fact, a "duty to warn"
and whether it is possible to persuade the client to discharge this responsibility
himself or consent to the program's doing so.
Is there a duty?
The answer is a matter of State law. Courts in some States hold that health care
providers have a duty to warn third parties of behavior of persons under their care
that poses a potential danger to others. In addition to these court decisions, some
States have laws that either permit or require health care providers to warn certain
third parties. Usually, these State laws prohibit disclosure of the infected person's
identity but allow the provider to tell the person at risk that she may have been
exposed. It is important that providers consult with an attorney familiar with State
law to learn whether the law imposes a duty to warn, as well as whether State law
prescribes the ways a provider can notify the person at risk. The law in this area is
still developing and may expand; thus, it is important to keep abreast of changes.
One source of information about State codes with regard to the duty to warn is
each State's Web site (available at http://janus.state.me.us/states.htm). (If there is
no State statute or court decision on this issue, it is best to consult with a lawyer or
someone with expertise in this area who can help the program determine the best
course to take. Such a consultation is particularly helpful because of the competing
obligations the program may have to protect a third party who may be in danger
and to safeguard its client's confidentiality.)
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When does the duty arise?
Two behaviors of infected persons can put others at risk of infection: unprotected
sex involving the exchange of bodily fluids and syringe sharing. Because HIV is
not transmitted by casual contact, the simple fact that a client is infected would not
give rise to a duty to warn the client's family or acquaintances who are not engaged
in sex or syringe sharing with the client.
This still leaves open the question as to when duty arises. Is it when a client tells a
counselor that he wants to or plans to infect others? Or when a client tells the
counselor that he has already exposed others to HIV? These are two different
questions.
Threat to expose others
A counselor whose client threatens to infect others should consider four questions
in determining whether there is a "duty to warn":
1. Is the client making a threat or "blowing off steam?" Sometimes, wild
threats are a way of expressing anger. However, for example, if the
client has a history of violence or of sexually abusing others, the threat
should be taken seriously.
2. Is there an identifiable potential victim? Most States that impose a "duty
to warn" do so only when there is an identifiable victim or class of
victims. However, unless public health authorities have the power to
detain someone in these circumstances there is little reason to inform
them.
3. Does a State statute or court decision impose a duty to warn in this
particular situation?
4. Even if there is no State legal requirement that the program warn an
intended victim or the police, does the counselor feel a moral obligation
to do so?
Clearly, there are no definitive answers in this area. Each case depends on the
particular facts presented and on State law. If a provider believes she has a "duty to
warn" under State law, or that there is real danger to a particular individual, she
should do so in a way that complies with both the Federal confidentiality
regulations and any State law or regulation regarding disclosure of medical or
HIV/AIDS-related information. Because a client is unlikely to consent to
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disclosure to the potential victim, to comply with the Federal regulations a provider
could act as follows:
 Seek a court order authorizing the disclosure. The program must
take care that the court abide by the requirements of the Federal
confidentiality regulations, which are discussed below in detail. It
should also consult State law to determine whether it imposes
additional requirements.
 Make a disclosure that does not identify the person as a client in
substance abuse treatment. This can be accomplished either by
making an anonymous report or, for a program that is part of a
larger nonsubstance abuse treatment facility, by making the report
in the larger facility's name. Counselors at freestanding alcohol or
drug programs cannot give the name of the program. (Non-clientidentifying disclosures are discussed more fully under
"Exceptions that permit disclosure," below.)
In these circumstances, the counselor should also limit the way he makes the
warning to minimize the exposure of the client's identity as HIV positive.
Recounting an exposure
Suppose an HIV-infected client tells his counselor that he has had unprotected sex
or shared syringes with someone. If the counselor knows who the person is, does
she have a "duty to warn" that person (or law enforcement)? This is not a true duty
to warn case because the exposure has already occurred. The purpose of the
"warning" is not to prevent a criminal act but to notify an individual so that she can
take steps to monitor health status. Thus, it is probably not helpful to call a law
enforcement agency. Rather, the counselor might want to let the public health
authorities know, particularly in States with mandatory partner notification laws.
Public health officials can then find the person at risk and provide appropriate
counseling.
How can programs notify the public health department without violating
confidentiality regulations? In some areas of the country, programs have signed
QSOAs with public health departments that provide services to the program. A
QSOA enables providers to report exposures to the department in situations like
these. The public health department can then not only help the person the
counselor believes was exposed but also trace other contacts the client may have
exposed. In doing so, the public health department often does not identify the
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person who has put his contacts at risk. The public health department would not
have to tell the contact that the person is in substance abuse treatment, and the
QSOA would prohibit it from doing so. (A treatment program must also make sure
that reporting an exposure by a client through a QSOA complies with any State
law protecting medical or HIV/AIDS-related information.)
If the provider does not have a QSOA with the public health department, it might
try one of the following methods:
 Consent. The provider could inform the health department with
the client's consent. The consent form must comply with both the
Federal confidentiality regulations and any State requirements
governing client consent to release of HIV/AIDS information, as
well as any other State law governing consent (e.g., whether a
parent also must consent).
 "Anonymous" notification. If the program notifies the public
health department in a way that does not identify the client as a
substance abuser, this constitutes complying with the Federal
regulations.
 Court order. Again, State law must be consulted to determine
whether it imposes requirements in addition to those imposed by
the Federal regulations.
One of the above methods should enable the provider to alert the public health
department, which is the most effective way to notify someone who may have been
exposed.
The program should document the factors that impelled the decision to warn an
individual of impending danger of exposure or to report an exposure to the public
health department. If the decision is later questioned, notes made at the time of the
decision could prove invaluable.
As noted earlier, whenever a program proceeds without a client's consent to warn
someone of a threat the client made or to report an exposure that has already
occurred, the program may be undermining the trust of other clients and thus its
effectiveness. This may be particularly true for a program serving HIV-positive
clients. This is not to say that a disclosure should not be made, particularly when
the law requires it. It is to say that a disclosure should not be made without careful
thought.
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Circumstances in which a "duty to warn" or "duty to notify" arises may change
over time, as scientists learn more about the virus and its transmission and as more
effective treatments are developed. There is little doubt that the law also will
change, as States adopt new statutes and their courts apply statutes to new
situations.
Programs should develop a protocol about "duty to warn" cases, so that staff
members are not left to make decisions on their own about when and how to report
threats or past occurrences of HIV transmission. Ongoing training and discussions
can also assist staff in sorting out what should be done in any particular situation.
Disclosures to insurers, HMOs, and other third-party payors
Traditional health insurance companies offering reimbursement to clients for
treatment expenses require clients to sign claim forms containing language
consenting to the release of information about their care. Can a program release
information after a client has signed one of these standard consent forms? It cannot
do so unless the form contains all the elements required by §2.31 of the
regulations. Also, when the disclosure includes any HIV/AIDS-related
information, the consent form must comply with State law.
Health maintenance organizations (HMOs) do not require clients to submit claim
forms with language consenting to the release of information. Instead, clients in
systems run by managed care organizations (MCOs) generally agree when they
enter the "system" that the HMO or MCO can review records or request
information about treatment at any time.
A substance abuse treatment program cannot rely on the fact that the client agreed
when he signed on with the HMO that it could review his records and talk to
doctors and other care providers whose fees it is covering. Federal regulations
prohibit any communication unless the client has signed a proper consent form or
the communication fits within another of the regulatory exceptions. State laws
protecting HIV/AIDS-related information may also prohibit release of information
in such circumstances.
As managed care becomes more prevalent, substance abuse treatment providers
(and other professionals in the field of counseling and mental health) are finding
that in order to monitor care and contain costs, third-party payors are demanding
more information about clients and about the treatment provided them. The
demand for information or records often comes when a provider requests
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authorization to continue or extend treatment. Providers are becoming all too
familiar with the kinds of information they need to supply to HMOs and MCOs to
obtain authorization to treat (or continue to treat) a client.
In many instances, simply getting the client's signature on a consent form that
complies with the Federal rules and any State law governing the release of
HIV/AIDS-related information will not resolve the ethical dilemma raised by the
demand for greater and more detailed information. Providers faced with the
question, "To disclose or not to disclose?" can be torn between their client's real
need for continued treatment and the client's right to privacy. Should the provider
disclose all information the HMO requests, perhaps shading it to ensure
authorization, or should the provider protect the client's privacy, thereby
jeopardizing the client's opportunity to obtain needed treatment services?
The better practice is to discuss the dilemma frankly with the client and to allow
the client to decide whether and how much to disclose. To make an informed
decision, the client will have to know what information the provider is being asked
to disclose to obtain authorization to treat or continue treatment. The client and
provider should discuss the likely consequences of the alternatives open to the
client--disclosure and refusal to disclose. The client should understand that
disclosure of the information the HMO seeks may be the only way to get the HMO
to cover his treatment. Refusal to comply with the request for information will
likely result in the HMO's refusal to cover at least some of the services the client
needs.
On the other hand, the client may be more concerned that once his insurer learns
she has a substance abuse problem or is HIV positive, she will lose her insurance
coverage and be unable to obtain other coverage. For example, if in response to a
demand from an HMO the provider releases information that the client's substance
abuse has included use of both alcohol and illegal drugs, the HMO may deny
benefits, arguing that since its policy does not cover treatment for abuse of drugs
other than alcohol, it will not reimburse treatment when abuse of both alcohol and
drugs is involved. A client whose employer is self-insured may fear being fired,
demoted, or disciplined if the employer suspects he has abused substances or is
HIV positive.
The process of helping the client weigh the available choices allows the client to
make a decision based on his understanding of his own best interests.
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Even a decision as simple as whether to submit a claim for HIV testing should be
preceded by a discussion about the pros and cons of requesting coverage from an
insurance company or HMO. The insurance company or HMO may infer from the
fact that the client has had a test that he has engaged in risky behavior.
A client who fears the loss of employment or insurance may decide to pay for HIV
testing or substance abuse treatment out of pocket. Or she may agree to a limited
disclosure and ask the provider to inform her if more information is requested. If a
client does not want the insurance carrier or HMO to be notified and is unable to
pay for treatment, the program may refer her to a publicly funded program, if one
is available. Programs should consult State law to learn whether they may refuse to
admit a client who is unable to pay and who will not consent to the necessary
disclosures to her insurance carrier.
Disclosing information about clients who have died or become incompetent
The Federal regulations apply to any disclosure of information that would identify
a deceased client as a substance abuser, and programs may not release information
unless an executor, administrator, or other personal representative appointed under
State law has signed a consent form authorizing the release of information. If no
such appointment has been made, the client's spouse, or if there is no spouse, any
responsible member of the client's family can sign a consent form (§2.15(b)(2)).
An exception is that the regulations do permit a program to disclose clientidentifying information that relates to a client's cause of death pursuant to laws
requiring the collection of death or other vital statistics or permitting an inquiry
into the cause of death (§2.15(b)(1)).
How can programs handle disclosures about incompetent clients? If the client has
been adjudicated as lacking the capacity to manage his affairs, a consent form can
be signed by his guardian or other individual authorized by State law to act on his
behalf. If the client has not been adjudicated incompetent but suffers from "a
medical condition that prevents knowing or effective action on his own behalf," the
program director can sign a consent form but only for the purpose of getting
payment for services from a third-party payor (§2.15(a)).
Exceptions that permit disclosures
The Federal confidentiality regulations' general rule prohibiting disclosure of
client-identifying information has a number of exceptions. Reference has already
been made to some of these exceptions: consent, disclosures that do not identify
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someone as a client in substance abuse treatment, disclosures pursuant to a QSOA,
disclosures during a medical emergency, disclosures authorized by special court
order, and disclosures of information to auditors. The rules governing these
exceptions are described in the pages that follow. Also explained is another
exception, not yet mentioned, that permits disclosure of information among
program staff.
Communications that do not disclose client-identifying information
The Federal regulations permit programs to disclose information about a client if
the program reveals no client-identifying information. "Client-identifying"
information identifies someone as an alcohol or drug abuser. Thus, a program may
disclose information about a client if that information does not identify her as an
alcohol or drug abuser or support anyone else's identification of the client as an
alcohol or drug abuser.
A program may make such a disclosure in two basic ways. First, a program can
report aggregate data about its population (summary information that gives an
overview of the clients served in the program) or some portion of its populations.
Thus, for example, a program could tell the newspaper that in the last 6 months it
screened 43 clients, 10 female and 33 male.
The second way was mentioned above: A program can communicate information
about a client in a way that does not reveal the client's status as a substance abuse
disorder client (§2.12(a)(i)). For example, a program that provides services to
clients with other problems or illnesses as well as substance abuse may disclose
information about a particular client as long as the fact that the client has a
substance abuse problem is not revealed. More specifically, a program that is part
of a general hospital could ask a counselor to call the police about a violent threat
made by a client, as long as the counselor does not disclose that the client has a
substance abuse problem or is a client of the treatment program.
Programs that provide only alcohol or drug services cannot disclose information
that identifies a client under this exception--letting someone know a counselor is
calling from the "Capital City Drug Program" automatically identifies the client as
someone who received services from the program. However, a free-standing
program can sometimes make "anonymous" disclosures, that is, disclosures that do
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not mention the name of the program or otherwise reveal the client's status as an
alcohol or drug abuser.
Programs using this exception to disclose HIV/AIDS-related information about a
client must also consult State law to determine if this kind of disclosure is
permitted.
Disclosures to an outside agency that provides services to the program: QSOA
If a program routinely needs to share certain information with an outside agency
that provides services to the program, it can enter into what is known as a qualified
service organization agreement, or "QSOA." This is a written agreement between
a program and a person providing services to the program, in which that person
 Acknowledges that in receiving, storing, processing, or otherwise
dealing with any client records from the program, she is fully bound
by the Federal confidentiality regulations
 Promises that, if necessary, she will resist in judicial proceedings any
efforts to obtain access to client records except as permitted by these
regulations (§2.11, §2.12(c)(4))
A QSOA should be used only when an agency or official outside of the program
provides a service to the program itself. An example is when laboratory analyses
or data processing are performed for the program by an outside agency.
A QSOA is not a substitute for individual consent in other situations. Disclosures
under a QSOA must be limited to information needed by others so that the
program can function effectively. QSOAs may not be used between programs
providing alcohol and drug services. Programs that share information with outside
agencies by using the QSOA must take care that any information about HIV/AIDS
or other infectious diseases is transmitted in accordance with State law.
Medical emergencies
A program may make disclosures to public or private medical personnel "who have
a need for information about a client for the purpose of treating a condition which
poses an immediate threat to the health" of the client or any other individual. The
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regulations define "medical emergency" as a situation that poses an immediate
threat to health and requires immediate medical intervention (2.51).
The medical emergency exception permits only disclosure to medical personnel.
This means that this exception cannot be used as the basis for a disclosure to
family, the police, or other nonmedical personnel.
Whenever a disclosure is made to cope with a medical emergency, the program
must document the following information in the client's records:
 The
name and affiliation of the recipient of the information
 The name of the individual making the disclosure
 The date and time of the disclosure
 The nature of the emergency
Programs using the medical emergency exception to disclose information about a
client's infectious disease or infection with HIV must also consult State law to
determine if a disclosure is permitted.
Disclosures authorized by court order
A State or Federal court may issue an order that will permit a program to make a
disclosure about a client that would otherwise be forbidden. A court may issue one
of these authorizing orders, however, only after it follows certain procedures and
makes particular determinations required by the regulations. A subpoena, search
warrant, or arrest warrant, even when signed by a judge, is not sufficient, standing
alone, to require or even to permit a program to disclose information (§2.61).
Before a court can issue a court order authorizing a disclosure about a client, the
program and any clients whose records are sought must be given notice of the
application for the order and some opportunity to make an oral or written statement
to the court. (However, if the information is being sought to investigate or
prosecute a client for a crime, only the program need be notified (§2.65). Also, if
the information is sought to investigate or prosecute the program, no prior notice at
all is required (§2.66).) Generally, the application and any court order must use
fictitious names for any known client, and all court proceedings in connection with
the application must remain confidential unless the client requests otherwise
(§2.64(a), (b), §2.65, §2.66). Before issuing an authorizing order, the court must
find "good cause" for the disclosure. A court can find "good cause" only if it
determines that the public interest and the need for disclosure outweigh any
negative effect that the disclosure will have on the client, or the doctor-patient or
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counselor-client relationship, and the effectiveness of the program's treatment
services. Before it may issue an order, the court must also find that other ways of
obtaining the information are not available or would be ineffective (§2.64(d)). The
judge may examine the records before making a decision (§2.64(c)).
There are also limits on the scope of the disclosure a court may authorize, even
when it finds good cause. The disclosure must be limited to information essential
to fulfill the purpose of the order, and it must be restricted to those persons who
need the information for that purpose. The court should also take any other steps
that are necessary to protect the client's confidentiality, including sealing court
records from public scrutiny (§2.64(e)).
 The
court may order disclosure of "confidential communications" by a
client to the program only if the disclosure
 Is necessary to protect against a threat to life or of serious bodily injury
 Is necessary to investigate or prosecute an extremely serious crime
(including child abuse)
 Is in connection with a proceeding at which the client has already
presented evidence concerning confidential communications (e.g., "I
told my counselor_")
Again, programs using the court order exception to disclose identity or HIV/AIDS
information about a client must also consult State law to determine if a disclosure
is permitted.
Research, audit, or evaluation
The confidentiality regulations also permit programs to disclose client-identifying
information to researchers, auditors, and evaluators without client consent,
provided certain safeguards are met (§2.52, §2.53). For a more complete
explanation of the requirements of §2.52 and §2.53, see Chapter 6 of TIP 14,
Developing State Outcomes Monitoring Systems for Alcohol and Other Drug
Abuse Treatment (CSAT, 1995a).
Again, State law must be consulted to see that any audit that inspects HIV/AIDS
information about a client is conducted in accordance with State law.
Internal program communications
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The Federal regulations permit some information to be disclosed to staff members
within the same program:
The restrictions on disclosure in these regulations do not apply to communications
of information between or among personnel having a need for the information in
connection with their duties that arise out of the provision of diagnosis, treatment,
or referral for treatment of alcohol or drug abuse if the communications are (i)
within a program or (ii) between a program and an entity that has direct
administrative control over that program (§2.12(c)(3)).
In other words, staff who have access to client records because they work for or
administratively direct the program, "including full- or part-time employees and
unpaid volunteers," may consult among themselves or otherwise share information
if their substance abuse treatment work so requires (§2.12(c)(3)). After consent,
this is the most commonly invoked exception.
Some States have enacted laws that restrict the staff who are permitted access to
HIV/AIDS-related information. Programs should consult a lawyer familiar with
State law and implement a policy that complies with any restrictions on staff
access to this information.
Other rules regarding confidentiality
Client notice
The Federal confidentiality regulations require programs to notify clients of their
right to confidentiality and to give them a written summary of the regulations'
requirements. The notice and summary should be handed to clients when they
begin participating in the program or soon thereafter (§2.22(a)). The regulations
contain a sample notice.
Client access to records
Programs can decide when to permit clients to view or obtain copies of their
records, unless State law grants clients the right of access to records. The Federal
regulations do not require programs to obtain written consent from clients before
permitting them to see their own records. Programs serving clients living with
HIV/AIDS should educate themselves about any State laws or regulations
requiring notice to clients and access to records.
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Security of records
The Federal regulations require programs to keep written records in a secure room,
a locked file cabinet, a safe, or other similar container. The program should
establish written procedures that regulate access to and use of client records. Either
the program director or a single staff person should be designated to process
inquiries and requests for information (§2.16).
Computerization of medical and treatment records complicates the problem of
keeping sensitive information private. Currently, protection is afforded by the
cumbersome and inefficient paper files that many, if not most, medical, mental
health, and social services still store and send from one provider to another. When
records are stored in computers, retrieval can be far more efficient, but
computerized records may allow anyone with access to the computer in which the
information is stored to copy information without constraint or accountability.
Modems that allow communication about clients among different components of a
managed care network extend the possibility of unauthorized access. The ease with
which computerized information can be accessed can lead to casual gossip about a
client, particularly if it is someone of importance in the community, making
privacy difficult to preserve. For a brief discussion of some of the issues that
computerization raises, see TIP 23, Treatment Drug Courts: Integrating Substance
Abuse Treatment with Legal Case Processing (CSAT), pp. 52, 53.
Conclusion
For providers of substance abuse treatment to clients living with HIV/AIDS, the
rules regarding confidentiality of clients' information are very specific. State laws
address disclosure of HIV/AIDS-related information as well as other medical and
mental health information. Overlaid on these are the Federal law and regulations
regarding confidentiality of substance abuse treatment information.
Generally, no more than two sets of laws apply in any given situation. If only
substance abuse treatment information will be disclosed, a program is generally
safe in following Federal rules. If HIV/AIDS-related information will be disclosed,
and the disclosure will reveal the client is in drug treatment, the program must
comply with both sets of laws. When in doubt, the best practice is to follow the
more restrictive rules. Whenever possible, providers should try to find resources
familiar with State laws to help sort out their responsibilities. The State
Department of Health, the Single State Authority, the State Attorney General,
professional associations, a member of the agency's board who is an attorney,
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advocacy groups for people living with HIV/AIDS, or a local law school or bar
association might provide the necessary information.
Footnotes
1. If the purpose of seeking the court order is to obtain authorization to
disclose information in order to investigate or prosecute a client for a crime,
the court must also find that (1) the crime involved is extremely serious,
such as an act causing or threatening to cause death or serious injury; (2) the
records sought are likely to contain information of significance to the
investigation or prosecution; (3) there is no other practical way to obtain the
information; and (4) the public interest in disclosure outweighs any actual or
potential harm to the client.
2. For a discussion of these kinds of State confidentiality laws, see TIP 24, A
Guide to Substance Abuse Services for Primary Care Clinicians (CSAT),
Appendix B.
3. There is an exception that allows the director of a substance abuse
treatment program to communicate with a minor's parents without the
minor's consent, when (1) the minor is applying for services; (2) the
program director believes that the minor, because of extreme substance
abuse or medical condition, does not have the capacity to decide rationally
whether to consent to the notification of her parents or guardian; and (3) the
program director believes that the disclosure is necessary to cope with a
substantial threat to the life or well-being of the minor or someone else.
Thus, if a minor applies for services in a State where parental consent is
required to provide services, but the minor refuses to consent to the
program's notifying his parents or guardian, the regulations permit the
program to contact a parent without the minor's consent, if these conditions
are met. Otherwise, the program must explain to the minor that although he
has the right to refuse to consent to any communication with a parent, the
program can provide no services without such communication and parental
consent (§2.14(d)). The regulations add a warning, however, that such
action might violate a State or local law (§2.14(b)).
8. Clinical Supervision Law and Ethics Considerations
Some of the underlying assumptions of incorporating ethical issues into clinical
supervision include:
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



Ethical decision-making is a continuous, active process.
Ethical standards are not a cookbook. They tell you what to do, not always
how.
Each situation is unique. Therefore, it is imperative that all personnel learn
how to ―think ethically and how to make sound legal and ethical decisions.
 The most complex ethical issues arise in the context of two ethical behaviors
that conflict; for instance, when a counselor wants to respect the privacy and
confidentiality of a client, but it is in the client’s best interest for the
counselor
to contact someone else about his or her care.
 Therapy is conducted by fallible beings; people make mistakes hopefully,
minor ones.
 Sometimes the answers to ethical and legal questions are elusive. Ask a
dozen people, and you’ll likely get twelve different points of view.
Helpful resources on legal and ethical issues for supervisors include; Beauchamp
and Childress, Falvey; Gutheil and Brodsky (2008); Pope, Sonne, and Greene
(2006); and Reamer (2006)
Legal and ethical issues that are critical to clinical supervisors include (1) vicarious
liability (or respondeat superior), (2) dual relationships and boundary concerns, (4)
informed consent, (5) confidentiality, and (6) supervisor ethics.
Direct Versus Vicarious Liability
An important distinction needs to be made between direct and vicarious liability.
Direct liability of the supervisor might include dereliction of supervisory
responsibility, such as ―not making a reasonable effort to supervise (defined
below). In vicarious liability, a supervisor can be held liable for damages incurred
as a result of negligence in the supervision process. Examples of negligence
include providing inappropriate advice to a counselor about a client (for instance,
discouraging a counselor from conducting a suicide screen on a depressed client),
failure to listen carefully to a supervisee’s comments about a client, and the
assignment of clinical tasks to inadequately trained counselors. The key legal
question is: ―Did the supervisor conduct him - or herself in a way that would be
reasonable for someone in his position? or ―Did the supervisor make a reasonable
effort to supervise? A generally accepted time standard for a ―reasonable effort to
supervise in the behavioral health field is 1 hour of supervision for every 20–40
hours of clinical services. Of course, other variables (such as the quality and
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content of clinical supervision sessions) also play a role in a reasonable effort to
supervise.
Supervisory vulnerability increases when the counselor has been assigned too
many clients, when there is no direct observation of a counselor’s clinical work,
when staff are inexperienced or poorly trained for assigned tasks, and when a
supervisor is not involved or not available to aid the clinical staff. In legal texts,
vicarious liability is referred to as ―respondent superior.
Dual Relationships and Boundary Issues
Dual relationships can occur at two levels: between supervisors and supervisees
and between counselors and clients. You have a mandate to help your supervisees
recognize and manage boundary issues. A dual relationship occurs in supervision
when a supervisor has a primary professional role with a supervisee and, at an
earlier time, simultaneously or later, engages in another relationship with the
supervisee that transcends the professional relationship. Examples
of dual relationships in supervision include providing therapy for a current or
former supervisee, developing an emotional relationship with a supervisee or
former supervisee, and becoming an Alcoholics Anonymous sponsor for a former
supervisee. Obviously, there are varying degrees of harm or potential harm that
might occur as a result of dual relationships, and some negative effects of dual
relationships might not be apparent until later. Therefore, firm, always-or-never
rules aren’t applicable. You have the responsibility of weighing with the counselor
the anticipated and unanticipated effects of dual relationships, helping the
supervisee’s self-reflective awareness when boundaries become blurred, when he
or she is getting close to a dual relationship, or when he or she is crossing the line
in the clinical relationship. Exploring dual relationship issues with counselors in
clinical supervision can raise its own professional dilemmas. For instance, clinical
supervision involves unequal status, power, and expertise between a supervisor and
supervisee. Being the evaluator of a counselor’s performance and gatekeeper for
training programs or credentialing bodies also might involve a dual relationship.
Further, supervision can have therapy-like qualities as you explore
countertransferential issues with supervisees, and there is an expectation of
professional growth and self-exploration. What makes a dual relationship
unethical in supervision is the abusive use of power by either party, the likelihood
that the relationship will impair or injure the supervisor’s or supervisee’s
judgment, and the risk of exploitation
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The most common basis for legal action against counselors (20 percent of claims)
and the most frequently heard complaint by certification boards against counselors
(35 percent) is some form of boundary violation or sexual impropriety.
Codes of ethics for most professions clearly advise that dual relationships between
counselors and clients should be avoided. Dual relationships between counselors
and supervisors are also a concern and are addressed in the substance abuse
counselor codes and those of other professions as well. Problematic dual
relationships between supervisees and supervisors might include intimate
relationships (sexual and non-sexual) and therapeutic relationships, wherein the
supervisor becomes the counselor’s therapist. Sexual involvement between the
supervisor and supervisee can include sexual attraction, harassment, consensual
(but hidden) sexual relationships, or intimate romantic relationships. Other
common boundary issues include asking the supervisee to do favors, providing
preferential treatment, socializing outside the work setting, and using emotional
abuse to enforce power. It is imperative that all parties understand what constitutes
a dual relationship between supervisor and supervisee and avoid these dual
relationships. Sexual relationships between supervisors and supervisees and
counselors and clients occur far more frequently than one might realize (Falvey,
2002b). In many States, they constitute a legal transgression as well as an ethical
violation.
Informed Consent
Informed consent is key to protecting the counselor and/or supervisor from legal
concerns, requiring the recipient of any service or intervention to be sufficiently
aware of what is to happen, and of the potential risks and alternative approaches,
so that the person can make an informed and intelligent decision about
participating in that service. The supervisor must inform the supervisee about the
process of supervision, the feedback and evaluation criteria, and other expectations
of supervision. The supervision contract should clearly spell out these issues.
Supervisors must ensure that the supervisee has informed the client about the
parameters of counseling and supervision (such as the use of live observation,
video- or audio taping).
Confidentiality
In supervision, regardless of whether there is a written or verbal contract between
the supervisor and supervisee, there is an implied contract and duty of care because
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of the supervisor’s vicarious liability. Informed consent and concerns for
confidentiality should occur at three levels: client consent to treatment, client
consent to supervision of the case, and supervisee consent to supervision (Bernard
& Goodyear, 2004). In addition, there is an implied consent and commitment to
confidentiality by supervisors to assume their supervisory responsibilities and
institutional consent to comply with legal and ethical parameters of supervision.
(See also the Code of Ethics of the Association for Counselor Education and
Supervision [ACES], available online at
http://www.acesonline.net/ethical_guidelines.asp).
With informed consent and confidentiality comes a duty not to disclose certain
relational communication. Limits of confidentiality of supervision session content
should be stated in all organizational contracts with training institutions and
credentialing bodies. Criteria for waiving client and supervisee privilege should be
stated in institutional policies and discipline-specific codes of ethics and clarified
by advice of legal counsel and the courts. Because standards of confidentiality are
determined by State legal and legislative systems, it is prudent for supervisors
to consult with an attorney to determine the State codes of confidentiality and
clinical privileging.
In the substance abuse treatment field, confidentiality for clients is clearly defined
by Federal law: 42 CFR, Part 2 and the Health Insurance Portability and
Accountability Act (HIPAA). Key information is available at
http://www.hipaa.samhsa.gov. Supervisors need to train counselors in
confidentiality regulations and to adequately document their supervision, including
discussions and directives, especially relating to duty-to-warn situations.
Supervisors need to ensure that counselors provide clients with appropriate dutyto-warn information early in the counseling process and inform clients of the limits
of confidentiality as part of the agency’s informed consent procedures. Under dutyto-warn requirements (e.g., child abuse, suicidal or homicidal ideation),
supervisors need to be aware of and take action as soon as possible in situations in
which confidentiality may need to be waived. Organizations should have a policy
stating how clinical crises will be handled (Falvey). What mechanisms are in place
for responding to crises? In what timeframe will a supervisor be notified of a crisis
situation? Supervisors must document all discussions with counselors concerning
duty-to-warn and crises. At the onset of supervision, supervisors should ask
counselors if there are any duty-to-warn issues of which the supervisor should be
informed.
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New technology brings new confidentiality concerns. Websites now dispense
information about substance abuse treatment and provide counseling services.
With the growth in online counseling and supervision, the following concerns
emerge: (a) how to maintain confidentiality of information, (b) how to ensure the
competence and qualifications of counselors providing online services, and (c) how
to establish reporting requirements and duty to warn when services are conducted
across State and international boundaries. New standards will need to be written to
address these issues. (The National Board for Certified Counselors has guidelines
for counseling by Internet at
http://www.nbcc.org/AssetManagerFiles/ethics/internetcounseling.pdf.)
Supervisor Ethics
The standards and ethics regard to dual relationship and other boundary violations
include that supervisors will:
 Uphold the highest professional standards of the field.
 Seek professional help (outside the work setting) when personal issues
interfere with their clinical and/or supervisory functioning.
 Conduct themselves in a manner that models and sets an example for agency
mission, vision, philosophy, wellness, recovery, and consumer satisfaction.
 Reinforce zero tolerance for interactions that are not professional, courteous,
and compassionate.
 Treat supervisees, colleagues, peers, and clients with dignity, respect, and
honesty.
 Adhere to the standards and regulations of confidentiality as dictated by the
field. This applies to the supervisory as well as the counseling relationship.
10. Self-Disclosure and Its Impact on Individuals Who Receive Mental Health
Services
Factors that may facilitate self-disclosing include the following:
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 The need to become educated about one’s own condition so that one can
educate others as needed
 The importance of first disclosing to someone one trusts
 The recognition that one can decide to share less with those people who
may appear judgmental
 The need to pick and choose when to disclose and under what
circumstances
 The importance of feeling safe when one self-discloses
 The essential fact that each of us should be in control of how much to tell;
we do not let anyone manipulate us into sharing more than we feel
comfortable sharing.
What else do we know about self-disclosure?
A number of individuals who are professionals in the mental health field have
themselves received mental health services. These professionals have offered a
variety of strategies about disclosing in general and disclosing to consumers with
whom they work. One such professional offered, “I’ve asked many of my patients
what it has meant for them to know about my history, and there is one consistent
and resounding refrain: HOPE!” If a person feels that the therapist has made
progress with his or her own mental health issues, disclosure by the therapist may
be beneficial to the consumers.
A number of individuals not associated professionally with the mental health field
also have written about their disclosure experiences. Much of the literature
indicates that disclosing to others about one’s own mental illness is positive,
although difficult.
People with other illnesses and life situations also have to make decisions about
self-disclosure. Examining the literature about these issues provides useful
suggestions. For example, tailor your information to fit the person you are telling:
your child, your neighbor, and your oldest friend. It helps to remember that it will
take time for the person you tell to absorb what you have said.
Many people find disclosing their mental illnesses or other illnesses or personal
situations gratifying, beneficial to their own recoveries, and often helpful to others.
It appears that the more open one can be and the more people disclose, the more
possible it is to overcome discrimination and stigma in the greater society.
The findings from interviews of mental health consumers, some of whom are
mental health professionals, others in the clergy, and another in politics, indicated
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that hiding information and worrying that someone will discover one’s secrets
consumes a lot of personal energy. A number of individuals felt it was important to
tell their stories. In fact, they saw self-disclosing as a mission to give others hope,
increase public awareness, and help make it easier for others to reveal their
experiences with mental illnesses.
Recommendations
1. SAMHSA/CMHS should support consumer workshops, meetings, and
seminars to address self-disclosure in further examining the pros and cons to
disclosure and offering a dialogue for other consumers to hear how and
when individuals have disclosed.
2. On the basis of these findings, SAMHSA/CMHS should develop guidelines
on self-disclosure that will inform persons with mental illness about the pros
and cons of disclosure. The guidelines should help individuals learn how and
when to disclose in a way that is comfortable and beneficial within
employment, social, family, and other arenas.
3. Once these guidelines have been established, educational programs should
be supported to further understand the significance of contact strategies on
reducing discrimination and stigma. Educational programs should be
consumer driven with the goal to encourage and teach individuals how and
when to disclose appropriately.
4. Professional and provider groups should join with consumers and family
advocates in developing strategies for individuals with mental illnesses to
self-disclose.
5. SAMHSA/CMHS Resource Center to Address Discrimination and Stigma
(ADS Center) should offer Web site information and training in disclosure.
6. Public and private mental health organizations should promote dialogues on
the topic of self-disclosure. These dialogues will provide vital information to
individuals receiving mental health services who are contemplating or
preparing to self-disclose and support to those who have already done so.
The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s)
Center for Mental Health Services (CMHS) provides Federal leadership to improve
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mental health services. Transforming Mental Health Care in America—The
Federal Action Agenda: First Steps identified discrimination and stigma as having
a central impact on access to mental health services, and on the quality of life for
individuals with mental illnesses (U.S. Department of Health and Human Services
[HHS], 2005).
The final report of the President’s New Freedom Commission on Mental Health,
Achieving the Promise: Transforming Mental Health Care in America, defines
stigma as a cluster of negative attitudes and beliefs that motivate the general public
to fear, reject, avoid, and discriminate against individuals with mental illnesses
(New Freedom Commission on Mental Health).
The stigma associated with mental illness is one of the most persistent problems
people face. It is fundamental to discrimination in housing, employment, and
health insurance. It prevents treatment, and it impedes recovery.
In this monograph, CMHS examines the role self-disclosure plays in reducing
stigma and discrimination associated with mental illness.
Research has shown that public attitudes about mental illness improve when people
have contact, or interactions, with people with mental illnesses. Meeting
individuals who have received mental health services and who are productive
members of the community challenges stigmatizing attitudes (Corrigan and
Lundin). For these contact strategies to work, individuals must self-disclose or
identify that they have received mental health services.
Researchers have begun compiling extensive information on the benefits of contact
as a way to reduce discrimination and stigma.
Patrick Corrigan, Psy.D., a researcher on this topic, states that “contact between the
public and people who have mental illnesses produces the greatest results with
regard to positive change. Hence the more interaction between people with mental
illnesses and the public, the more stigma will be torn down. This poses a challenge
because the stigma of mental illness, like that experienced by gay men and
lesbians, is largely hidden. People with mental illnesses need to weigh the real
costs of coming out against the benefits to the community at large as well as
themselves” (Corrigan).
Research shows that the greatest effects occur when the average person comes out.
Although there is some benefit when people with notoriety tell their stories of
recovery from mental illness, public attitudes are most challenged when neighbors,
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coworkers, and fellow churchgoers admit that they, too, have struggled with and
beaten mental illness stigma (Spikol, 2003).
Corrigan states that “contact effects should improve when the following
elements are present:
1. Equal status among participants
2. Cooperative tasks define the interaction
3. Institutional support for contact
4. High levels of intimacy
5. The person with severe mental illness does not greatly differ from the
stereotype.”
The following examines current literature related to self-disclosure and provides
the findings from a series of key informant interviews to examine the factors that
promote or hinder self-disclosure. Books, articles, and Web sites were analyzed in
order to glean key findings and implications regarding the disclosure of mental
illness in various arenas.
Some of the questions examined included the following:
 Why should a person disclose that he or she has received mental health
services?
 What are the advantages and risks of disclosure?
 What factors facilitate disclosure?
 Is there a safe way to disclose?
 What impact does self-disclosure have personally and systemically?
In addition, the monograph also examines techniques used by other individuals and
groups who have disclosed private issues to others. For instance, individuals with
HIV/AIDS have had significant experience in this area. Individuals who are gay
and lesbian have coined the phrase “coming out” to define when they tell others
about their sexual orientation. Individuals with disabilities other than mental illness
face disclosure issues as well. How do they address self-disclosure?
Current Selected Literature
The selections cited in this monograph include a compilation of references from
books, magazine articles, research projects, and various Web sites addressing
disclosure of mental illnesses (see Appendix B, References and Resources).
Although much of the literature reviewed focuses on disclosure in the employment
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arena, consumers working in the mental health field made a number of significant
statements about self-disclosure.
To Disclose or Not to Disclose?
“Disclosure is not a black and white choice. Mental illness is a complex
experience. People need to decide which parts of this experience to disclose,”
states the opening page of a chapter titled “To Disclose or Not To Disclose” in the
book, Don’t Call Me Nuts!: Coping With the Stigma of Mental Illness, by Patrick
Corrigan, Psy.D., and Robert Lundin.
Some benefits of disclosure that the authors list and discuss include
 Not having to worry about hiding experiences with mental illness and
being more open about day-to-day affairs
 Finding others who express approval, including those with similar
experiences
 Finding someone who can provide assistance in the future
 Promoting a sense of personal power and acting as living testimony
against stigma and discrimination.
Some costs discussed include
 Encountering disapproval of your mental illness or your disclosure,
including the risks of social ostracism and gossip
 Being discriminated against in employment, housing, and other
opportunities
 Having increased anxiety due to perceptions that people are thinking
about you or pitying you
 Thinking that future relapses may be more stressful because others will
be “watching”
 Experiencing anger from family members and others because you selfdisclosed.
Corrigan and Lundin discuss two levels of disclosure: selective and what they call
indiscriminate disclosure. Selective disclosure refers to choosing who specifically
to tell about one’s mental illness and when to tell. Indiscriminate disclosure, the
authors suggest, requires a change of attitude by the person who no longer conceals
a mental illness in general. They suggest that “you have successfully changed your
attitude about disclosure when talking about mental illness no longer evokes a
sense of hesitancy or shame.” The book offers sample questions to determine
whether an individual is able to cope with indiscriminate disclosure.
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Disclosure does not have to be all or nothing. Disclosing one’s mental illness is a
very personal, subjective decision. It is important to look at your own feelings
about mental illness before disclosing your personal information to others. Not
everyone needs to know about a person’s struggles, but sharing your mental illness
diagnosis may garner support. It is also important to brace yourself for possible
negative responses from people when you do disclose. You can agree to disagree,
or you can try to educate the person. Many educational materials are available to
assist you (Albert, 2005).
Michael S. Finkle, executive director of a statewide consumer advocacy group,
said, “While the consumer movement consumes my life, I usually don’t disclose
one-on-one, unless there is a purpose to it. I don’t disclose to strangers. If they ask
what I do, I tell them, and if they seem interested, and ask more questions, then I
make a judgment call. I tend not to disclose unless it would be beneficial and
comfortable doing so.” (Finkle, personal communication, 2005.)
Disclosure among Mental Health Field Professionals
Daniel Fisher, M.D., in his article, “A Psychiatrist’s Gradual Disclosure,” writes,
“A person’s freedom to disclose is also contingent upon the individual’s power,
status, and position.” He did not disclose his illness or hospitalization until he
completed his residency. He advises prudence in disclosure. “Pick someone you
can trust—someone who is tolerant, understanding, and fearless about the
experiences. More often, this will be a peer who has been through a similar
experience and is in the process of recovery. Try to discuss your thoughts and
feelings about past episodes and the treatment you received. Try to gain enough
understanding and objectivity that you can then develop a strategy for further
disclosure” (Fisher).
Fisher notes that another benefit of disclosure is that it promotes one’s recovery
process by allowing one to form or join a self-help group and begin the
relationships and conversations needed to reconstruct one’s self-image in a positive
light. The more open one can be, the more possible it is to overcome stigma and
discrimination in the greater society.
In addressing the issues of also working in the mental health community, Fisher
states, “Disclosure, when it is geared to the needs of the client rather than the
provider, can nourish hope and add a valuable human dimension to the
relationship. The questions of how and when to make such disclosures are best
addressed through discussions with peers.”
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Fisher’s comment about consumers working in the mental health community led to
a further examination of literature on that topic. The following article focusing on
self-disclosure of therapists with personal histories of eating disorders appeared in
a special edition of the publication, Perspectives: A Professional Journal of the
Renfrew Center Foundation.
“With regard to self-disclosure, the question is more when and how, rather than
whether I tell my patients,” states Beth McGilley, Ph.D., psychiatrist. “I have no
pat formula, no hard and fast rules for sharing this part of my history. It only
makes sense not to lock myself into any rigid guidelines, because the therapeutic
relationship, as I conceive it, is a dynamic, unique, and intimate connection in
which exchanges occur as the relationship allows and demands.”
She further states that “coming out to my professional colleagues then outweighed
any experience I’ve had dealing with the same considerations with my
patients.…I’ve asked many of my patients what it has meant for them to know
about my history, and there is one consistent and resounding refrain: HOPE!”
In the same issue of Perspectives, Andrea Bloomgarden, Ph.D., states that she was
initially afraid that if she disclosed with her clients, it would get back to her
colleagues, and that they would not respect her if they heard about her past. Since
becoming outspoken with her colleagues, Bloomgarden feels free to really think
about what is best for her clients. She says, “I am open to the possibility that
sharing some information about my eating disorder experience might be helpful,
but would still prefer to err on the side of caution. In general, it seems extremely
important to consider whether sharing or disclosing personal information will be
attuned to the client’s needs.…Since I don’t believe there is a clear decision-tree to
guide self-disclosure, I use those therapists who’ve helped me the most as a model
in my therapeutic work. For the most part, I’ve chosen to self-disclose in response
to a specific question and after I’ve explored with the client the ramifications of
answering the question” (Bloomgarden).
“The recovering therapist is in a unique position to help this patient,” states
Thomas Holbrook, M.D. “His knowing what it’s like to be eating-disordered gives
him an intuitive sense of what’s going on with his patient. He has a chance of
establishing a trust early on…self-disclosure is a useful tool, but it calls for a word
of caution.…Self-disclosure could unwittingly be used more for the therapist’s
recovery than for the patient’s. The timing of self-disclosure is also critically
important. The choice of what’s disclosed will determine whether it’s a meaningful
and helpful offering, and not just an ‘I’ve been there too’ story” (Holbrook).
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Marion Bilich, Ph.D., in another article in this publication, states that some 20
years ago, she disclosed her eating disorder in the Daily News. “Overall,” she said
that “the therapist who self-discloses through the media must always be prepared
to deal with the issues that may arise out of that disclosure.” She also points out
that by disclosing “publicly through the media—newspaper articles, books,
television appearances—we lose control over timing.” She further says that “as
long as I have kept in mind the possible pitfalls of my personal revelations in the
media, the therapeutic good that has resulted has far outweighed any harmful
consequences” (Bilich).
Fred Frese, Ph.D., in an online discussion, notes that a “small but growing number
of psychiatrists, psychologists, social workers, and other mental health
professionals who are in recovery from mental illness have decided to openly
identify themselves as such. If these professionals could begin to be more open
about their experiences, those of their family members and consumer
advocates could better realize that mental health policy and research decisions are
not being made as much in isolation from consumer influence as it may appear”
(Frese, Stanley, Kress, and Vogel-Scibilia).
Notable among mental health professionals, Kay Redfield Jamison, Ph.D., has
published a number of books disclosing her mental illness. In An Unquiet Mind: A
Memoir of Moods and Madness, which is a first-person account of manicdepression, Jamison states:
I have had many concerns about writing a book that so explicitly describes my
own attacks of mania, depression, and psychosis, as well as my problems
acknowledging the need for ongoing medications. Clinicians have been, for
obvious reasons of licensing and hospital privileges, reluctant to make their
psychiatric problems known to others. These concerns are often well warranted.
I have no idea what the long-term effects of discussing such issues so openly
will be on my personal and professional life, but, whatever the consequences,
they are bound to be better than continuing to be silent. I am tired of hiding,
tired of misspent and knotted energies, tired of the hypocrisy, and tired of acting
as though I have something to hide. One is what one is, and the dishonesty of
hiding behind a degree, or a title, or any manner and collection of words, is still
that: dishonest.
She further relates:
There is no easy way to tell other people that you have manic-depressive illness; if
there is, I haven’t found it. So despite the fact that most people that I have told
have been very understanding—some remarkably so—I remain haunted by those
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occasions when the response was unkind, condescending, or lacking in even a
semblance of empathy.
Other Disclosure Experiences
A number of individuals not associated professionally with the mental health field
also have written about their disclosure experiences. Some of the individuals are
famous, and some are not. Overall, the literature seems to indicate that disclosing
to others about one’s own mental illness is positive, although difficult.
Author William Styron, in his book, Darkness Visible: A Memoir of Madness he
was so annoyed about the press coverage of the suicide of Primo Levi, a famous
Italian writer, that he wrote a short article for the op-ed page of the New York
Times. Styron states:
The overwhelming reaction made me feel that inadvertently I had helped unlock
a closet from which many souls were eager to come out and proclaim that they,
too, had experienced the feelings I had described. It is the only time in my life I
have felt it worthwhile to have invaded my own privacy, and to make that
privacy public. And I thought that, given such momentum, and with my
experience in Paris as a detailed example of what occurs during depression, it
would be useful to try to chronicle some of my own experiences with the illness
and in the process perhaps establish a frame of reference out of which one or more valuable
conclusions might be drawn.
The Noonday Demon: An Atlas of Depression, by Andrew Solomon, discusses
disclosure and stigma in a chapter titled “Politics.” Solomon states, “I would have
to say, however, that talking about my depression has made it easier to bear the
illness and easier to forestall its return. I’d recommend coming out about
depression. Having secrets is burdensome and exhausting, and deciding exactly
when to convey the information you have kept in check is really troublesome”
(Solomon).
Until the time of his death, Ken Steele was a mental health advocate and editor and
publisher of New York City Voices: A Consumer Journal for Mental Health
Advocacy. His book, The Day the Voices Stopped: A Memoir of Madness and
Hope, relates his personal story of illness and recovery. “Most striking about New
York City Voices, however, has been the inclusion of personal stories by people
with mental illness,” Steele states, “written in our own words and under our own
bylines (often accompanied by a photograph of the contributor). A bold but
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necessary move, self-disclosure is a first step toward successfully addressing the
stigma associated with being mentally ill. Before we can reveal ourselves to others,
we have to come out of our own dark closets” (Steele and Berman).
Along the lines of Steele’s New York program, NAMI (formerly known as the
National Alliance for Mental Illness) has a program titled “In Our Own Voice” that
offers opportunities for consumers to speak to the community. The Web site offers
information on this outreach program in which consumers make presentations to
various audiences. It also presents an explanation of how the program works and
testimonials of the program. NAMI notes that “it is also an opportunity for
consumers to gain self-confidence, self-esteem, and income while serving as role
models for the community.”
Mindy Lewis, author of Life Inside: A Memoir, found herself speaking in public at
grand rounds to more than 100 mental health professionals at a hospital where she
lived from age 15 to 18. She was invited to talk about what it was like to be
hospitalized as an adolescent. In an article in Newsweek, she discusses the
experience and says, “I am overcome by a surreal ecstasy at unlikelihood and
privilege of this my prodigal return. But I also know that this day will pass, and
many of my questions will go unanswered. All I can do is tell my story, and in so
doing, make reparations to myself” (Lewis, 2003).
The power of self-disclosure is chronicled in a Maine newspaper article about a 46year-old man, Tom Shumate. His mental illness had been mentioned in a local
paper. After his initial reaction to being “outed,” Shumate decided to share his
experiences with others at a local coffee shop. He had concluded that he would
neither conceal his experiences nor apologize for them. Shumate emphasized that it
is important for individuals who are having symptoms to tell someone so that they
can get the best treatment. He commented, “It’s hard enough as it is—when you try
to hide it, it gets even harder.” This article points out that sometimes disclosure
comes out whether a person is ready for it or not, but one can turn the disclosure
into something good and set an example for others (Nemitz, 2004).
Jeffrey Widom smiles in a picture featured in the Washington Post. In an
accompanying article, Widom describes how he tries to educate friends and
colleagues about attention deficit hyperactivity disorder (ADHD) and depression
by being a standup comic. For him, finding the right therapy has helped, as well as
practicing coping skills like the self-deprecating humor he uses on stage. He tosses
a challenge to society: “Take the time to say hi and ask what I’m going through,
and have a laugh with me” (Guzy, 2004).
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Liz Spikol in her article, “Mad as Well: People Need Labels. Now You Have
Mine,” gives her first-person account about writing a column in a Philadelphia
newspaper in which she “comes out” about her mental illness and describes the
reactions she received. She said that there were a number of inquiries about her
specific diagnosis. She contended that people were more comfortable with labels
(Spikol, 2003).
Although the subject of mental illness is not as taboo as it once was, stigma and
discrimination are still highly prevalent. But the brave individuals who either have
been forced or pushed to self-disclose, or have volunteered to tell their stories,
seem to find it liberating and an important part of their recovery.
10. Legal and Ethical Issues in Emergencies
While national or regional disasters are well-known for causing an array of harms
to physical health, they can also have a significant impact on individuals’ mental
and behavioral health. Existing mental health conditions, such as schizophrenia
and depression, may be exacerbated by an emergency. New conditions, such as
post-traumatic stress disorder, may emerge in some persons as a result of the
emergency. Large-scale emergencies may affect the mental and behavioral health
of first responders, public health officials, health care workers, and others involved
in response efforts. The mental health of certain vulnerable populations, including
children, the elderly, individuals in group facilities, and persons from socially or
economically disadvantaged groups, may also be impacted. Depending on the
particular mental and behavioral health issues that arise, individuals may need to
access mental health services during and/or after a declared emergency.
In September 2008, the Centers for Disease Control and Prevention (CDC)
established a Preparedness and Emergency Response Research Center (PERRC) at
the Johns Hopkins Bloomberg School of Public Health. One of the Center’s goals
is to identify, research, and analyze the legal and ethical issues that arise during
emergencies relative to mental and behavioral health. As part of this effort,
scholars and researchers at the Johns Hopkins PERRC, in collaboration with the
Sandra Day O’Connor College of Law at Arizona State University, have created a
series of translational tools on relevant legal and ethical issues.
Purpose
This tool is intended as a resource for health care providers and administrators,
public health officials, emergency planners, clergy, and their public and private
sector partners who seek an enhanced understanding of the ethical issues that may
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arise during and after emergencies relative to mental and behavioral health.
Information about additional resources is provided at the end of the document.
Acknowledgment
This document, prepared by Nancy Kass, ScD, Larry Wissow, MD, MPH, and
Lainie Rutkow, JD, PhD, MPH, is supported by CDC through a project entitled
“Legal and Ethical Assessments Concerning Mental and Behavioral Health
Preparedness” at the Johns Hopkins Bloomberg School of Public Health and the
Sandra Day O’Connor College of Law at Arizona State University.
Disclaimer
While this document was prepared with support from CDC (5P01TP000288), its
contents do not represent the official position of CDC or other project partners.
This document does not provide specific legal advice. Practitioners should consult
with their legal counsel for a more detailed understanding of federal laws and to
understand the implications of relevant state laws.
1) What ethical principles guide a response when considering preparedness for
individuals with serious mental disorders during emergencies?
a. Minimizing of harm: Many individuals with serious mental disorders live on
the margin. Their lives are marked by high rates of unemployment, precarious
financial status, and social isolation. Further, mental health remains stigmatized in
our society, leading individuals living with mental disorders often to be shunned by
others or treated with less compassion than those living with equally serious
physical disorders. Individuals with mental disorders may be particularly
vulnerable to disruptions in normal routines inherent in an emergency and less
likely than others to prepare or shelter themselves from significant harms.
Anticipating their needs and developing strategies to minimize the harms that
persons with mental health disorders may face in an emergency is an ethical
requirement.
b. Equity: Although the U.S. mental health care system has experienced
significant reforms, treatment of mental disorders remains, in many contexts,
subject to a lesser, or inequitable, standard of care when compared to physical
impairments. Expenditures for mental health care lag behind those for care of
physical disorders. Individuals with mental disorders are sometimes viewed as
being less worthy of care. Mental health treatments may be perceived as “less
scientific” or less essential than treatments for physical disorders. Emergency
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planners and responders must sustain commitments to equity by (1) ensuring that
the needs of those with mental health disorders are given their fair attention during
emergencies and (2) engaging in effective planning and training exercises to
prepare for the mental health challenges that individuals with pre-existing and
emerging mental health conditions will face.
c. Effectiveness: A core value of public health ethics is implementing policies,
actions, interventions, and strategies only when there is evidence, or high
suspicion, that they are effective. Even in an emergency, when the standard of care
shifts and changes arise related to who will provide care, where it is delivered, and
what treatments may be available, commitments to effective treatment must be
sustained to the greatest degree possible. Those with mental health conditions may
be particularly at risk of exposure to ineffective interventions or constraints during
an emergency. Maintaining commitments, even in times of crisis, to foundational
principles of effectiveness and necessity in a response is critical—particularly for
those who have been stigmatized and, importantly, may not always understand the
purpose of particular actions.
d. Respecting of choice: Emergency mental health responses should respect the
choices and preferences of those affected to the greatest degree possible, consistent
with ensuring an effective public health response. Any constraints on choice
should be necessary for achieving a successful public health outcome, should only
constrain choices proportionally to what is required to achieve the outcome and no
further, or for no longer than necessary, and should be applied equally across
populations. For example, in the context of mental health, if there is evidence that
an individual is not complying with a public health order, then constraints may be
justified if a similar constraint is applied to all non-complying individuals and if it
is based on actual evidence of lack of cooperation rather than stigma or suspicions
that lack of cooperation might occur. While respecting choice, public health
responses should, in addition, choose the intervention or strategy that provides the
least infringement to achieve the desired effect. In the context of mental health, this
is a particularly important commitment to sustain.
e. Right to privacy: Rights to informational privacy often may be compromised in
the context of an emergency. Routine systems or processes for protecting
information and maintaining confidentially may have broken down. Identifiable
health information regarding sensitive medical conditions may need to be shared to
help those in need. In normal times, special mechanisms are in place to protect
confidentiality of diagnosis and treatment, but these are subject to disruption
during an emergency. Concerns about health information privacy may be
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heightened for those with a history of mental health disorders. Public health and
emergency responders should work to protect the privacy of mental health data
even during emergencies and operate consistent with a “need to know” basis (i.e.,
information should be shared to provide assistance or, in rare cases, protection)
related to health data exchanges.
f. Duty to provide care: Health care providers have special duties to respond
during an emergency. Professional codes of ethics reinforce the duty to continue to
provide care during an emergency. This duty extends to those with mental health
needs, physical needs, and the least well off. Many persons with mental health
needs are also disadvantaged in other ways, including living in poverty or being
unable to advocate adequately for themselves. Ethics requires attention to those
who are less well off, including a duty to plan for and provide care during times of
emergency.
g. Transparency: Emergency response teams must communicate to the public
why they are responding the way they are, how they are setting priorities, and what
their strategies are. Significant opportunities for misunderstanding arise when
individuals feel their needs are not being met, even when the response strategies
are ethically sound and reasonable. Maintaining transparency includes identifying
effective strategies for communication about how and why responses are
proceeding in a particular way. Such commitment to transparency is respectful and
can minimize individual and societal anxieties and other harms.
2. Why do emergencies create ethical challenges in caring for persons with
serious mental disorders?
Serious mental disorders are chronic conditions and are highly susceptible to
deterioration with disruptions in care. Specialty mental health care is in short
supply under normal circumstances, and access can be easily disrupted during
emergencies. Knowing when to provide care—and what types of care can be
provided—when specialists are not available can create challenges to principles of
professional ethics, particularly if healthcare providers assist with care functions
outside of their specialty. Because serious mental disorders are often highly
stigmatized, they may evoke fear or avoidance even among professionals. Finally,
serious mental disorders can be associated with decreased decisional capacity or
the perception by caregivers that capacity is diminished (even if it is not). In
normal times, special mechanisms are in place to optimize individual autonomy
while reducing ill persons’ risks to themselves or others. These mechanisms may
not be feasible or there may be a lack of trained personnel to implement them
during an emergency. Balancing commitments to individuals in need with
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commitments to quickly and fairly assuring the safety and wellbeing of the public
can create ethical challenges; determining what it means for someone with mental
health needs to receive their fair due, particularly when the responder has limited
expertise in this area, also can create ethical challenges.
3. Do different ethical issues arise for persons with pre-existing mental disorders
compared to persons who acutely develop mental disorders during an
emergency? Persons with pre-existing disorders are more likely to depend on a
particular treatment regimen that is believed to optimally balance benefits and
risks. The obligation to try to maintain this particular regimen differs from a duty
to provide the safest mental health “first aid” for an individual with an acute
mental disorder. Persons with pre-existing disorders may also have mental health
advance directives or other plans that set out their preferences should they suffer a
deterioration and a loss of capacity. Family members may also be aware of their
preferences and norms. Ideally, these directives would be respected. For those with
acute disorders that result in a loss of capacity, a “best interest” or substituted
judgment standard may apply.
4. How can the ethical duty to provide care—balancing effectiveness and risk—
be respected where optimal medications, facilities, and trained staff are scarce?
As with other considerations in emergency response, anticipating needs during
preparedness phases (i.e., before an event occurs) is critically important. First, to
the extent that general medical and emergency personnel receive basic training in
recognition and first line management of mental disorders, harms will be
minimized and respectful interactions increased. Unfortunately, even in ordinary
times, this type of training is lacking in the basic curriculum of most medical
professionals, despite considerable overlap in the skills required for mental health
and general medical care. Planning may also involve developing ways to use
available communication channels to allow front-line providers access to mental
health specialists for consultation. Additionally, mental health topics (maintenance
as well as emergency) should be included in emergency/disaster treatment
handbooks.
Like medical preparedness, mental health preparedness requires advance
stockpiling of essential medicines at the patient and population levels. For many
individuals with serious mental health conditions, taking medication continuously
is essential. Although most classes of mental health medications include several
medications that in theory have similar actions and potency, many patients do
better with one particular medication or experience distress or deterioration when
switching. Individuals may want to have extra supplies of their own medication on
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hand to ensure continuous access to the particular medicine that works best for
them. Central stockpiles should include medications thought to be in widest use for
the most serious and common mental health disorders.
Individuals with chronic mental health problems—and persons who serve as
caregivers for these individuals—may want to work with their treatment team to
rehearse non-pharmacologic ways of staying healthy in times of emergency. They
can also identify appropriate ways to make emergency treatment information
available, should it be needed by caregivers not familiar with an individual’s needs
or desires.
5. How can ethical duties to respect privacy and maintain confidentiality be met
during emergencies?
Individuals with mental disorders should not be segregated from patients with
other illnesses unless there are risks related to these individuals’ own or others’
health and safety, or unless their needs could be better met in a separate facility.
Further, emergency health care facilities should make mental health surveillance
and support universal components of intake and ongoing care (just as universal
infection control precautions are taken to avoid singling out particular individuals
and to ensure that cases are not missed). Identifiable medical records should not be
“flagged” in a way that makes it externally obvious that they contain psychiatric
records, and only the minimal information needed for emergency treatment should
be recorded and disclosed. Whenever possible, emergency facilities should have an
area to which any patient can be brought, however briefly, for private discussion.
6. How can ethical duties to provide care in the least restrictive setting be
respected during emergencies?
Standards for compulsory evaluation, treatment, and hospitalization should be
defined in emergency training manuals, including explanations of the need to
provide the least restrictive care consistent with safety. Administrative personnel
who facilitate emergency responses should be familiar with these standards.
Security personnel should be trained to recognize individuals with mental disorders
and to provide support and a safe environment in calming, non-threatening ways.
These skills are likely to be of use among the many individuals caught up in an
emergency, not just those with identifiable mental disorders.
11. Domestic Violence and the Law
All jurisdictions in the United States have implemented regulations and laws
designed to protect victims of domestic violence. The Violence against Women
Act (VAWA), which was signed into law by President Clinton in September 1994,
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strengthens many of these protections and outlines Federal as well as State
enforcement provisions and penalties. This legislation demonstrated the Federal
government's commitment to address domestic violence. The Federal penalties
mandated by VAWA are more stringent than existing State penalties: The bill, for
example, makes it a Federal offense to cross State lines in violation of a civil
protection order. In order to provide useful advice and support, substance abuse
treatment providers should be familiar with VAWA and with relevant State and
local regulations as well as with the legal resources available to victims of
domestic violence (Source: Center for Substance Abuse Treatment. Substance
Abuse Treatment and Domestic Violence. Rockville (MD): Substance Abuse and
Mental Health Services Administration (US); Treatment Improvement Protocol
(TIP) Series).
There are four titles within the Act—the Safe Street Act, Safe Homes for Women,
Civil Rights for Women and Equal Justice for Women in the Courts, and
Protections for Battered Immigrant Women and Children—and each act addresses
domestic violence, sexual assault, stalking, and protection against gendermotivated violence. The provisions of VAWA call for improving law enforcement
and criminal justice responses, creating new criminal offenses and tougher
penalties, mandating victim restitution, and requiring system reform geared
towards protecting victims of domestic violence during prosecution of the
perpetrator. VAWA also authorized support for increased prevention and education
programs, victim services, domestic violence training of community professionals,
and protections from deportation for battered immigrant women (Source: Center
for Substance Abuse Treatment. Substance Abuse Treatment and Domestic
Violence. Rockville (MD): Substance Abuse and Mental Health Services
Administration (US); Treatment Improvement Protocol (TIP) Series)
Besides strengthening prevention and prosecution of violent crimes against women
and children, the law made domestic violence a civil rights violation. What this
means is that a victim of "crimes of violence motivated by gender" can bring a suit
for damages in civil court in addition to any charges made in criminal court.
Some of the more important provisions of the law include
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Greater penalties for sex crimes
Funding for States to improve law enforcement, prosecution, and services
for female victims of violent crimes
Increased security in public transportation systems and national and urban
parks
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Funding for rape prevention and education programs, targeted to, among
others, middle and senior high school students
Enhanced treatment for released sex offenders
The development of model confidentiality legislation
Funding for programs for victims of child abuse as well as for individuals
who are homeless, for runaways, and for street youth at risk of abuse
The creation of a national domestic violence hotline
Funding to improve mandatory arrest or proarrest (a policy stating that
police will make arrests in domestic violence incidents) programs, to
improve tracking of domestic violence cases, to increase coordination of
services, to strengthen legal advocacy, and to educate judges
The prohibition of the purchase of firearms by individuals subject to a final
civil protection order
The implementation of more protections for battered immigrant women and
children, including liberalization of the "battered spouse waiver" enforced
by the Immigration and Naturalization Service (INS).
Some provisions of VAWA may be particularly important to women in substance
abuse treatment who are also survivors of domestic violence. Under VAWA,

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Past sexual behavior or alleged sexual predisposition of the victim is no
longer admissible evidence in civil or criminal proceedings involving sexual
misconduct.
New Federal criminal penalties apply to anyone who crosses a State line in
order to commit domestic violence or to violate a civil protection order.
Anyone who forces a spouse or domestic partner to cross a State line for
these purposes also is subject to penalties.
States are required to enforce civil protection orders issued by the courts of
other States.
Victims must have the opportunity to testify regarding the potential danger
of the pretrial release of a defendant.
Defendants are required to make financial restitution to victims.
The U.S. Postal Service is required to maintain the confidentiality of shelters
and individual abuse victims by not disclosing addresses or other locating
information.
One of the most important aspects of VAWA is the civil rights remedy for gendermotivated violence mentioned above. Relief in civil court may include monetary
damages, injunctions, or declaratory judgment to redress the civil rights violation.
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(Source: Center for Substance Abuse Treatment. Substance Abuse Treatment and
Domestic Violence. Rockville (MD): Substance Abuse and Mental Health Services
Administration (US). Treatment Improvement Protocol (TIP) Series)
Local Laws: Civil Protection and Restraining Orders
The most common and easily obtainable mechanism of relief for victims of
domestic violence is the civil protection order. This general term includes any
injunction or other order (such as a restraining order) that is issued for the purpose
of preventing violent or threatening acts against another person. Generally, these
orders prohibit harassment, contact, communication, or physical proximity.
Protection orders may be temporary or final and may be issued by a civil or a
criminal court. Protection orders can be issued independently or as part of another
proceeding, such as a divorce or criminal complaint, but are separate from support
or child custody orders.
Statutes and case law in all States and the District of Columbia allow an abused
adult to petition the court for an order of protection, and in most State courts, a
parent or another adult can file for a civil protection order on behalf of a minor
child. Depending on the relevant statutes and case law on the books of any given
jurisdiction, conduct sufficient to support issuance of a civil protection order can
include.
(Source: Center for Substance Abuse Treatment. Substance Abuse Treatment and
Domestic Violence. Rockville (MD): Substance Abuse and Mental Health Services
Administration (US). Treatment Improvement Protocol (TIP) Series)
Family Violence Prevention and Services Act of 1984 (P.L. 98-457)
The Family Violence Prevention and Services Act of 1984 (FVPSA) was Congress'
first attempt to address domestic violence in the country. The legislation was
designed to assist States with their efforts to increase public awareness about
domestic violence and to provide Federal funding for domestic violence shelters
and victim services. States and nonprofit organizations also were awarded grants to
develop domestic violence and child maltreatment programs and to provide
training and technical assistance for law enforcement officers and community
service providers.
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The Office on Violence against Women is a component of the United States
Department of Justice. In recognition of the severity of the crimes associated with
domestic violence, sexual assault, and stalking, Congress passed the Violence
against Women Act of 1994 (VAWA 1994) as part of the Violent Crime Control
and Law Enforcement Act of 1994. VAWA is a comprehensive legislative package
designed to end violence against women and was reauthorized in both 2000 and
2005. The legislative history of VAWA indicates that Congress seeks to remedy
the legacy of laws and social norms that serve to justify violence against women.
Since the passage of VAWA, there has been a paradigm shift in how the issue of
violence against women is addressed.
The Office on Violence against Women (OVW) was created specifically to
implement (VAWA) and subsequent legislation. OVW administers financial and
technical assistance to communities around the country to facilitate the creation of
programs, policies, and practices aimed at ending domestic violence, dating
violence, sexual assault, and stalking.
VAWA was designed to improve criminal justice responses to domestic violence,
sexual assault, and stalking and to increase the availability of services for victims
of these crimes. VAWA requires a coordinated community response (CCR) to
domestic violence, sexual assault, and stalking, encouraging jurisdictions to bring
together players from diverse backgrounds to share information and to use their
distinct roles to improve community responses to violence against women. These
players include, but are not limited to: victim advocates, police officers,
prosecutors, judges, probation and corrections officials, health care professionals,
leaders within faith communities, and survivors of violence against women. The
federal law takes a comprehensive approach to violence against women by
combining tough new penalties to prosecute offenders while implementing
programs to aid the victims of such violence.
The Violence Against Women Act of 2000 (VAWA 2000) and the Violence
Against Women and Department of Justice Reauthorization Act of 2005 (VAWA
2005) reauthorized the grant programs created by the original VAWA and
subsequent legislation, as well as established new programs. Specifically, the new
programs of VAWA 2005 include the Court Training and Improvements, Child
Witness, and Culturally Specific programs. The VAWA 2000 reauthorization
strengthened the original law by improving protections for battered immigrants,
sexual assault survivors, and victims of dating violence. In addition, it enabled
victims of domestic violence that flee across state lines to obtain custody orders
without returning to jurisdictions where they may be in danger. Furthermore, it
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improved the enforcement of protection orders across state and tribal lines. VAWA
2005 continued to improve upon these laws by providing an increased focus on the
access to services for underserved populations.
In 2002, legislation was passed that made OVW a permanent part of the
Department of Justice with a Presidentially-appointed, Senate-confirmed Director.
Since 1994, OVW has awarded more than $3 billion in grant funds to state, tribal,
and local governments, non-profit victim services providers, and universities.
(Source: Center for Substance Abuse Treatment. Substance Abuse Treatment and
Domestic Violence. Rockville (MD): Substance Abuse and Mental Health Services
Administration (US). Treatment Improvement Protocol (TIP) Series)
Gathering Documentation
All States have mandatory reporting laws for child abuse, but only some have or
are developing such laws for reporting domestic violence. Some battered women's
advocates support such laws because they "take the pressure off" the victims to
report their batterers. Some domestic violence service providers also believe that it
is the community's responsibility -- not the victim's -- to stop the batterer's
behavior. Some States mandate the arrest of batterers whether or not their victims
press charges, and some are proposing mandatory physician reporting of battering.
Concerns have been raised, however, about preserving victims' ability to decide
whether they want to become involved in the criminal justice system or in domestic
violence programs. For this reason, such laws are opposed by some batteredwomen's groups, who believe they put women at greater risk.
Regardless of whether a survivor elects to pursue legal remedies, she is welladvised to document the nature and extent of the domestic violence she and her
family have experienced by compiling copies of
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Criminal justice reports, including prior legal actions (e.g., restraining
orders) against batterers
Any previous CPS reports that can be obtained
Hospital records and health history of the client
Complete criminal justice and medical records may be difficult to obtain. In the
case of medical records, for example, survivors may have made visits to numerous
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institutions (e.g., clinics and emergency rooms) in order to avoid raising the
suspicion of domestic violence. Issues of confidentiality also may be an
impediment to obtaining these records. (See Appendix B for more information on
confidentiality.) When clients are unsuccessful in compiling information from
standard sources, their self-reports to substance abuse treatment providers,
documented in their program records, can be used to fill in the gaps and to help
support their claims. When entering notes into the client's record, however, it is
important to include the facts as presented or observed. Records can be subpoenaed
and "gratuitous comments or opinions" may be used against survivors in custody
cases (Source: Center for Substance Abuse Treatment. Substance Abuse Treatment
and Domestic Violence. Rockville (MD): Substance Abuse and Mental Health
Services Administration (US); Treatment Improvement Protocol (TIP) Series;
Minnesota Coalition for Battered Women).
12. Child Abuse Reporting
Statistics
Recently a study conducted by the Center for Disease Control and Prevention
found that 1 in 50 infants in the United States are victims of nonfatal neglect or
abuse. In the US, neglect is defined as the failure to meet the basic needs of
children including housing, clothing, food and access to medical care. Researchers
found over 91,000 cases of neglect over the course of one year (from October
2005- September 30, 2006) with their information coming from a database of cases
verified by protective services agencies (Source: Centers for Disease Control and
Prevention).
Child sexual abuse occurs frequently in Western society. The rate of prevalence
can be difficult to determine. In the UK it is estimated at about 8% for boys and
12% for girls. The estimates for the United States vary widely. A literature review
of 23 studies found rates of 3% to 37% for males and 8% to 71% for females,
which produced an average of 17% for boys and 28% for girls, while a statistical
analysis based on 16 cross-sectional studies estimated the rate to be 7.2% for males
and 14.5% for females. The US Department of Health and Human Services
reported 83,600 substantiated reports of sexually abused children in 2005.Including
incidents which were not reported would make the total number even larger.
Surveys have shown that one fifth to one third of all women reported some sort of
childhood sexual experience with a male adult. One study found that professionals
failed to report approximately 40% of the child sexual abuse cases they
encountered. A study by Lawson & Chaffin indicated that many children who were
sexually abused were "identified solely by a physical complaint that was later
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diagnosed as a venereal disease...Only 43% of the children who were diagnosed
with venereal disease made a verbal disclosure of sexual abuse during the initial
interview." It has been found in the epidemiological literature on CSA that there is
no identifiable demographic or family characteristic of a child that can be used to
bar the prospect that a child has been sexually abused (Centers for Disease Control
and Prevention, 2005). Adverse Childhood Experiences Study: Data and Statistics.
Atlanta, GA: Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control)
In US schools, according to the US Department of Education, "nearly 9.6% of
students are targets of educator sexual misconduct sometime during their school
career." In studies of student sex abuse by male and female educators, male
students were reported as targets in ranges from 23% to 44%. In U.S. school
settings same-sex (female and male) sexual misconduct against students by
educators "ranges from 18-28% of reported cases, depending on the study"
Significant under reporting of sexual abuse of boys by both women and men is
believed to occur due to sex stereotyping, social denial, the minimization of male
victimization, and the relative lack of research on sexual abuse of boys. Sexual
victimization of boys by their mothers or other female relatives is especially rarely
researched or reported. Sexual abuse of girls by their mothers, and other related
and/or unrelated adult females is beginning to be researched and reported despite
the highly taboo nature of female-female child sex abuse. In studies where students
are asked about sex offenses, they report higher levels of female sex offenders than
found in adult reports. This under-reporting has been attributed to cultural denial of
female-perpetrated child sex abuse, because "males have been socialized to believe
they should be flattered or appreciative of sexual interest from a female" and
because female sexual abuse of males is often seen as 'desirable' and/or beneficial
by judges, mass media pundits and other authorities (Centers for Disease Control
and Prevention. (2005). Adverse Childhood Experiences Study: Data and
Statistics. Atlanta, GA: Centers for Disease Control and Prevention, National
Center for Injury Prevention and Control)
In 2007 the Ministry of Women and Child Development published the "Study on
Child Abuse: India 2007." It sampled 12447 children, 2324 young adults and 2449
stakeholders across 13 states. It looked at different forms of child abuse: Physical
Abuse, Sexual Abuse and Emotional Abuse and Girl Child Neglect in five evidence
groups, namely, children in a family environment, children in school, children at
work, children on the street and children in institutions. The study's main findings
included: 53.22% of children reported having faced sexual abuse. Among them
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52.94% were boys and 47.06% girls. Andhra Pradesh, Assam, Bihar and Delhi
reported the highest percentage of sexual abuse among both boys and girls, as well
as the highest incidence of sexual assaults. 21.90% of child respondents faced
severe forms of sexual abuse, 5.69% had been sexually assaulted and 50.76%
reported other forms of sexual abuse. Children on the street, at work and in
institutional care reported the highest incidence of sexual assault. The study also
reported that 50% of abusers are known to the child or are in a position of trust and
responsibility and most children had not reported the matter to anyone (Ministry of
Women and Child Development (2007) “Study on Child Abuse: India”)
Mandated Reporters
The criteria in identifying suspected child abuse and when a mandatory reporter
should report varies among states. Typically, a report must be made when the
reporter, in his or her official capacity, suspects that a child has been abused.
Another standard frequently used is when the reporter has knowledge of, or
observes a child being subjected to, conditions that would reasonably result in harm
to the child (Mandated Reporter video and online training resource - 'Recognizing
and Reporting Child Abuse and Child Sexual Abuse')
State Reporting Laws
All 50 States and the District of Columbia have statutes that protect children from
abuse and neglect by their parents or others. There are criminal statutes prohibiting
certain acts (or failures to act), violation of which may lead to imprisonment. There
are also civil statutes that prohibit abuse and neglect. If these statutes are violated,
the court may impose requirements that parents accept certain kinds of help (such
as substance abuse treatment, parenting classes, or anger management training),
that their children be removed from the home, or that their parental rights be
terminated (Source: SAMHSA)
Most States define abuse as an act or failure to act that result in non-accidental
physical injury or sexual abuse of a child. Neglect generally includes the denial of
adequate food, shelter, supervision, clothing, or medical care when such resources
or services are available. Each state defines abuse and neglect differently, and the
conditions considered to be neglect or abuse in one state may not be the same in
others. Because state law often requires that treatment providers report suspected
abuse and neglect, treatment staff should become familiar with their state's
definitions of abuse and neglect. Staff can contact the State's CPS agency for
information on current laws. (If the abuse occurred in another state, or if the
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perpetrator is currently living in another state, it is wise to check on the laws in the
other state to ensure compliance. At times, there may be a need to report in both
states.) Readers can also find state statutory child abuse and neglect definitions on
the Internet at http://www.calib.com/nccanch/services/statutes.htm. Federal
definitions of these terms appear in the Child Abuse Prevention and Treatment Act,
42 U.S.C. §5106(g). In some cases, the CPS agency can be consulted regarding
whether or not a report must be made in a particular situation without divulging
confidential (i.e., identifying) information. Consultation with the CPS agency must
be done with great care, and this communication can be noted in the client's chart
(Source: SAMHSA).
Although each state's laws are different, the following conditions are reportable in
most states:
 The child has been seriously physically injured by a parent or other
adult by other than accidental means.
 The child appears injured or ill to the point that a reasonable person
would seek medical attention, but the parent has not sought medical
attention, refuses to consider it, or fails to follow medical advice,
putting the child at risk.
 An adult has sexually touched (or made the child sexually touch the
adult), abused, or exploited the child.
 The child is not registered for or attending school, and the parent
refuses to remedy the situation (home schooling must be adequately
documented).
Although the behaviors outlined above are the most blatant examples of child
abuse or neglect, other parental behaviors or practices may put children at risk. For
example, the following may also constitute child abuse or neglect:
 Leaving
a young child alone and unsupervised
 Inappropriate punishment that puts a child at risk (e.g., locking a
young child out of the house as a punishment)
 Depriving a young child of food for an extended period of time
 Treating one child, the "bad one," far more harshly than others
Whether behaviors like these are reportable depends, in part, on how State statutes
define abuse and neglect, the seriousness of the behavior or incident, its impact on
the child, and the counselor's perception of the client's overall behavior with the
child and of the client's willingness to correct inappropriate behavior (Source:
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SAMSHA).
Mandated reporters are those who, in the course of their work and because they
have regular contact with children, are required to make a suspected child abuse
report whenever physical, sexual or other types of abuse has been observed or is
suspected, or when there is evidence of neglect, knowledge of an incident, or an
imminent risk of serious harm. Abuse occurs when a victim has suffered physical
injury inflicted other than by accidental means, has injuries, or is in a condition
resulting from mistreatment, such as malnutrition, sexual molestation or
exploitation, deprivation of necessities, emotional abuse or cruelty. Neglect may
be defined as abandonment, denial of proper care and attention physically,
emotionally, or morally, or living under conditions, circumstances or associations
injurious to well-being (Mandated Reporter video and online training resource 'Recognizing and Reporting Child Abuse and Child Sexual Abuse').
Mandated reporters also include persons who have assumed full or intermittent
responsibility for the care or custody of a child, dependent adult, or elder, whether
or not they are compensated for their services. The report must be made to a "child
protective agency." Including 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 (Mandated Reporter video and online training
resource - 'Recognizing and Reporting Child Abuse and Child Sexual Abuse').
Mandated reporters may not make an anonymous report. 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. A client’s self-report does not negate the therapist's mandate
to report. The role of a mandated reporter is to report and not investigate the
allegation(s). Any attempts to investigate may have a negative clinical impact on
the child and family. If a mandated reporter learns about suspected child abuse
from a third party (hearsay), and reasonable suspicion exists, the therapist must
make a report if the information was revealed to the therapist within their
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professional capacity (Mandated Reporter video and online training resource 'Recognizing and Reporting Child Abuse and Child Sexual Abuse').
The identity of all reporters is considered confidential and is disclosed only
between child protective agencies. 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.
The Child Abuse Reporting Law takes precedence over laws governing the
psychotherapist-patient privilege. 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
(Mandated Reporter video and online training resource - 'Recognizing and
Reporting Child Abuse and Child Sexual Abuse').
RAINN maintains a database of mandatory reporting regulations regarding children
and the elderly by state, including who is required to report, standards of
knowledge, definitions of a victim, to whom the report must be made, information
required in the report, and regulations regarding timing and other procedures.
Summary of State Laws
Alabama
Professionals Required to Report: Doctors, medical examiners, dentists, nurses, or
pharmacists, school teachers or officials, law enforcement officials, daycare
workers or social workers, members of the clergy, and any other person called
upon to render aid or medical assistance to a child
Reporting by Other Persons: Any other person who has reasonable cause to
suspect that a child is being abused or neglected may report.
Standards for Making a Report: A report must be made when the child is known or
suspected of being a victim of abuse or neglect.
Privileged Communications: Only the clergy-penitent and attorney-client privileges
are permitted.
Inclusion of Reporter’s Name in Report: Not specifically required by statute
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Disclosure of Reporter Identity. The department will not release the identity of the
reporter except under court order when the court has determined that the reporter
knowingly made a false report.
Alaska
Professionals Required to Report: Health practitioners, administrative officers of
institutions, school teachers and administrators, childcare providers, paid
employees of domestic violence and sexual assault programs, and crisis
intervention and prevention programs; paid employees of organizations that
provide counseling or treatment to individuals seeking to control their use of drugs
or alcohol, peace officers; officers of the Department of Corrections, persons who
process or produce visual or printed matter, either privately or commercially,
members of a child fatality review team or the multidisciplinary child protection
team
Mandated reporters may report cases that come to their attention in their nonoccupational capacities: Any other person who has reasonable cause to suspect
that a child has been harmed may report.
Standards for Making a Report: When, in the performance of their occupational
duties, they have reasonable cause to suspect that a child has suffered harm as a
result of abuse or neglect, when they have reasonable cause to suspect that visual or
printed matter depicts a child engaged in the unlawful exploitation of a minor.
Privileged Communications: Neither the physician-patient nor the husband-wife
privilege is recognized.
Inclusion of Reporter’s Name in Report: Not specifically required by statute
disclosure of reporter identity not addressed in statutes reviewed
Arizona
Professionals Required to Report: Physicians, physician’s assistants, optometrists,
dentists, behavioral health professionals, nurses, psychologists, counselors or social
workers, peace officers, members of the clergy, priests, or Christian Science
practitioners parents, stepparents, or guardians, school personnel or domestic
violence victim advocates, and any other person who has responsibility for the care
or treatment of the minor.
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Reporting by Other Persons: Any other person who reasonably believes that a
minor is a victim of abuse or neglect may report.
Standards for Making a Report: When they reasonably believe that a minor is a
victim of abuse or neglect
Privileged Communications: Only the attorney-client and the clergy-penitent
privileges are recognized.
Inclusion of Reporter’s Name in Report: Not specifically required by statute
Disclosure of Reporter Identity: Not addressed in statutes reviewed
Arkansas
Professionals Required to Report: Physicians, surgeons, osteopaths, resident
interns, coroners, dentists, nurses, or medical personnel, teachers, school officials
or counselors, daycare center workers, childcare workers, foster care workers,
social workers, foster parents, or department employees, mental health
professionals, domestic violence shelter employees or volunteers, law enforcement
personnel, peace officers, prosecuting attorneys, domestic abuse advocates, judges,
Court Appointed Special Advocate (CASA) program staff or volunteers, juvenile
intake or probation officers, any members of clergy, including ministers, priests,
rabbis, accredited Christian Science practitioners, or other similar functionary of a
religious organization
Reporting by Other Persons: Any other person with reasonable cause to suspect
child maltreatment may report.
Standards for Making a Report: When they have reasonable cause to suspect child
maltreatment. When they have observed the child being subjected to conditions or
circumstances that would reasonably result in child maltreatment.
Privileged Communications: No privilege is granted except the attorney-client and
clergy-penitent (including a Christian Science practitioner).
Inclusion of Reporter’s Name in Report: Not specifically required in statute
Disclosure of Reporter Identity: The identity of the reporter shall not be disclosed
unless a court determines that the reporter knowingly made a false report.
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California
Professionals Required to Report: Penal Code 11166; 11165.7: Teachers, teacher’s
assistants, administrative officers, certificated pupil personnel employees of any
public or private school administrators and employees of public or private day
camps, youth centers, youth recreation programs, or youth organizations,
employees of childcare institutions, including, but not limited to, foster parents,
group home personnel, and personnel of residential care facilities. Social workers,
probation officers, or parole officers. Any person who is an administrator or a
counselor in a child abuse prevention program in any public or private school.
District attorney investigators, peace officers, firefighters, except for volunteer
firefighters. Physicians, surgeons, psychiatrists, psychologists, dentists, licensed
nurses, dental hygienists, optometrists, marriage counselors, family and child
counselors and clinical social workers. Emergency medical technicians I or II or
paramedics, state or county public health employees, coroners or medical
examiners, commercial film and photographic print processors, child visitation
monitors, animal control officers or humane society officers, clergy members,
which includes priests, ministers, rabbis, religious practitioners, or similar
functionary of a church, temple, or recognized denomination or organization. Any
custodian of records of a clergy member. Employees or volunteers of Court
Appointed Special Advocate programs
Reporting by Other Persons: Penal Code 11166: Any other person who reasonably
suspects that a child is a victim of abuse or neglect may report.
Standards for Making a Report: Penal Code 11166; 11165.7
When in his or her professional capacity, he or she has knowledge of or observes a
child whom the reporter knows or reasonably suspects is the victim of abuse or
neglect. Commercial film and photographic print processors when they have
knowledge of or observe any film, photograph, videotape, negative, or slide
depicting a child under the age of 16 years engaged in an act of sexual conduct.
Privileged Communications: Penal Code 11166: Only the clergy-penitent privilege
is permitted.
Inclusion of Reporter’s Name in Report: Penal Code 11167: Reports of mandated
reporters shall include: The name, business address, and telephone number of the
mandated reporter; The capacity that makes the person a mandated reporter;
Reports of other persons do not require the reporter’s name.
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Disclosure of Reporter Identity: Penal Code 11167: The identity of the reporter
shall be confidential, and shall be disclosed only to agencies investigating the
report, when the person waives confidentiality, and/or by court order
Colorado
Professionals Required to Report: Physicians, surgeons, physicians in training,
child health associates, medical examiners, coroners, dentists, osteopaths,
optometrists, chiropractors, podiatrists, nurses, hospital personnel, dental
hygienists, physical therapists, pharmacists, registered dieticians, public or private
school officials or employees, social workers, Christian Science practitioners,
mental health professionals, psychologists, professional counselors, marriage and
family therapists, veterinarians, peace officers, firefighters, or victim’s advocates,
commercial film and photographic print processors, counselors, marriage and
family therapists, or psychotherapists, clergy members, including priests; rabbis;
duly ordained, commissioned, or licensed ministers of a church; members of
religious orders; or recognized leaders of any religious bodies, and workers in the
state department of human services
Reporting by Other Persons: Any other person may report known or suspected
child abuse or neglect.
Standards for Making a Report: When they have reasonable cause to know or
suspect child abuse or neglect, when they have observed a child being subjected to
circumstances or conditions that would reasonably result in abuse or neglect.
Commercial film and photographic print processors when they have knowledge of
or observe any film, photograph, videotape, negative, or slide depicting a child
engaged in an act of sexual conduct.
Privileged Communications: 19-3-304; 19-3-311, the clergy-penitent privilege is
permitted. The physician-patient, psychologist-client, and husband-wife privileges
are not allowed as grounds for not reporting.
Inclusion of Reporter‘s Name in Report: 19-3-307, the report shall include the
name, address, and occupation of the person making the report.
Disclosure of Reporter Identity: 19-1-307, the identity of the reporter shall be
protected.
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Connecticut
Professionals Required to Report: 17a-101, physicians or surgeons, nurses,
medical examiners, dentists, dental hygienists, physician assistants, pharmacists, or
physical therapists, psychologists or other mental health professionals, school
teachers, principals, guidance counselors, or coaches, social workers, police
officers, juvenile or adult probation officers, or parole officers, members of the
clergy, alcohol and drug counselors, marital and family therapists, professional
counselors, sexual assault counselors, or battered women’s counselors, emergency
medical services providers, any person paid to care for a child in any public or
private facility, child daycare center, group daycare home, or family daycare home
that is licensed by the State Employees of the Department of Children and Families
and the Department of Public Health who are responsible for the licensing of child
daycare center, group daycare homes, family daycare homes, or
youth camps, the Child Advocate and any employee of the Office of Child
Advocate.
Reporting by Other Persons: 17a-103, any mandated reporter acting outside his or
her professional capacity or any other person having reasonable cause to suspect
that a child is being abused or neglected may report.
Standards for Making a Report: 17a-101a, when, in the ordinary course of their
employment or profession, they have reasonable cause to suspect or believe that a
child has been abused or neglected.
Inclusion of Reporter’s Name in Report: 17a-101d; 17a-103, the reporter is not
specifically required by statute to include his or her name in the report. The
Commissioner shall use his or her best efforts to obtain the name and address of the
reporter.
Disclosure of Reporter Identity: 17a-28, the identity of the reporter shall not be
released to the subject of the report unless there is reasonable cause to believe that
the reporter knowingly made a false report.
Delaware
Professionals Required to Report: Tit. 16, 903, physicians, dentists, interns,
residents, osteopaths, nurses, or medical examiners, school employees, social
workers or psychologists.
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Reporting by Other Persons: Tit. 16, 903, any person who knows or in good faith
suspects child abuse or neglect shall make a report.
Standards for Making a Report: Tit. 16, 903, when they know or in good faith
suspect child abuse or neglect.
Privileged Communications: Tit. 16, 909, only the attorney-client and clergypenitent privileges are recognized.
Inclusion of Reporter’s Name in Report: Tit. 16, 905, although reports may be
made anonymously, the division shall request the name and address of any person
making a report.
Disclosure of Reporter Identity: Not addressed in statutes reviewed.
Florida
Professionals Required to Report: 39.201, physicians, osteopaths, medical
examiners, chiropractors, nurses, or hospital personnel, other health or mental
health professionals, practitioners who rely solely on spiritual means for healing,
school teachers or other school officials or personnel, social workers, daycare
center workers, or other professional childcare, foster care, residential, or
institutional workers, law enforcement officers or judges.
Reporting by Other Persons: 39.201, any person who knows or has reasonable
cause to suspect that a child is abused, abandoned, or neglected shall report.
Standards for Making a Report: 39.201, when they know or have reasonable cause
to suspect that a child is abused, abandoned, or neglected.
Privileged Communications: 39.204, only the attorney-client and clergy-penitent
privileges are permitted.
Inclusion of Reporter’s Name in Report: 39.201, the professionals who are
mandated reporters are required to provide their names to hotline staff.
Disclosure of Reporter Identity: 39.201; 39.202, the names of reporters are held
confidential and may be released only: To the department, the central abuse
hotline, law enforcement, or the appropriate State attorney (if the reporter consents
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to release in writing).
Georgia
Professionals Required to Report: 19-7-5; 16-12-100, physicians, hospital and
medical personnel, podiatrists, dentists, or nurses, school teachers, administrators,
guidance counselors, school social workers, or psychologists, counselors, social
workers, or marriage and family therapists, child welfare agency personnel
(including any child-caring institution, child-placing agency, maternity home,
family daycare home, group daycare home, and daycare center), child-counseling
personnel, or child service organization personnel, law enforcement personnel,
persons who process or produce visual or printed matter.
Reporting by Other Persons: 19-7-5, any other person who has reasonable cause to
believe that a child has been abused may report.
Standards for Making a Report: 19-7-5; 16-12-100, when they have reasonable
cause to believe that a child has been abused, when they have reasonable cause to
believe that the visual or printed matter submitted for processing or producing
depicts a minor engaged in sexually explicit conduct.
Privileged Communications: 19-7-5, no privileged communications are permitted
for mandatory reporters.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 49-5-41, any release of records shall protect the
identity of any person reporting child abuse.
Hawaii
Professionals Required to Report: 350-1.1, physicians, physicians in training,
psychologists, dentists, nurses, osteopathic physicians and surgeons, optometrists,
chiropractors, podiatrists, pharmacists, and other health-related professionals,
medical examiners or coroners. employees or officers of any public or private
school; childcare employees; employees or officers of any licensed or registered
childcare facility, foster home, or similar institution. Employees or officers of any
public or private agency or institution, or other individuals, providing social,
medical, hospital, or mental health services, including financial assistance.
Employees or officers of any law enforcement agency, including, but not limited
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to, the courts, police departments, correctional institutions, and parole or probation
offices. Employees of any public or private agency providing recreational or sports
activities.
Reporting by Other Persons: 350-1.3, any other person who becomes aware of
facts or circumstances that cause the person to believe that child abuse or neglect
has occurred may report.
Standards for Making a Report: 350-1.1, when, in their professional or official
capacity, they have reason to believe that child abuse or neglect has occurred or
that there exists a substantial risk that child abuse or neglect may occur in the
reasonably foreseeable future.
Privileged Communications: § 350-5, the physician-patient, psychologist-client,
husband-wife, and the victim-counselor privileges are not grounds for failing to
report.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 350-1.4, every reasonable good faith effort shall be
made by the department to maintain the confidentiality of the name of a reporter
who requests that his or her name be confidential.
Idaho
Professionals Required to Report: 16-1619, physicians, residents on hospital staffs,
interns, nurses, or coroners, school teachers or daycare personnel, social workers or
law enforcement personnel.
Reporting by Other Persons: 16-1619, any person who has reason to believe that a
child has been abused, abandoned, or neglected is required to report.
Standards for Making a Report: 16-1619, when they have reason to believe that a
child has been abused, abandoned, or neglected. When they observe a child being
subjected to conditions or circumstances which would reasonably result in abuse,
abandonment, or neglect.
Privileged Communications:, 16-1619; 16-1620, any privilege between a husband
and wife and any professional and client, except for the clergy-penitent or
attorney-client privilege, shall not be grounds for failure to report.
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Inclusion of Reporter’s Name in Report: Not addressed in statutes reviewed.
Disclosure of Reporter Identity: Not addressed in statutes reviewed.
Illinois
Professionals Required to Report: Ch. 325, 5/4; Ch. 720, 5/11-20.2, physicians,
hospital administrators and personnel, surgeons, physician assistants, osteopaths,
chiropractors, genetic counselors, dentists, coroners, medical examiners,
emergency medical technicians, nurses, acupuncturists, respiratory care
practitioners, or home health aides. School personnel, directors or staff of nursery
schools or child daycare centers, recreational program or facility personnel,
childcare workers, or homemakers. Substance abuse treatment personnel, crisis line
or hotline personnel, social workers, domestic violence program personnel,
psychologists, psychiatrists, or counselors, social services administrators, foster
parents, or field personnel of the Illinois Department of Public Aid, Public Health,
Human Services, Corrections, Human Rights, or Children and Family Services,
truant officers, law enforcement officers, probation officers, funeral home directors
or employees, clergy members, commercial film and photographic print processors.
Reporting by Other Persons: Ch. 325, 5/4, any other person who has reasonable
cause to believe that a child is abused or neglected may report.
Standards for Making a Report: Ch. 325, 5/4; Ch. 720, 5/11-20.2, when they have
reasonable cause to believe that a child known to them in their professional
capacity may be abused or neglected, commercial film and photographic print
processors when they have knowledge of or observe any film, photograph,
videotape, negative, or slide that depicts a child engaged in any sexual conduct.
Privileged Communications: Ch. 325, 5/4; Ch. 735, 5/8-803, the privileged quality
of communication between any professional person required to report and his
patient or client shall not apply to situations involving abused or neglected children
and shall not constitute grounds for failure to report. A member of the clergy shall
not be compelled to disclose a confession or admission made to him or her apart of
the discipline of the religion.
Inclusion of Reporter’s Name in Report: Ch. 325, 5/7.9, the report shall include the
name, occupation, and contact information of the person making the report.
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Disclosure of Reporter Identity: Ch. 325, 5/11.1a, any disclosure of information
shall not identify the person making the report.
Indiana
Professionals Required to Report: 31-33-5-2. Any staff member of a medical or
other public or private institution, school, facility, or agency.
Reporting by Other Persons: 31-33-5-1. Any person who has reason to believe that
a child is a victim of abuse or neglect must report.
Standards for Making a Report: 31-33-5-1; 31-33-5-2. When they have reason to
believe that a child is a victim of abuse or neglect.
Privileged Communications: 31-32-11-1. The following privileges are not
permitted, and shall not be grounds for failing to report:
 Husband-wife privilege
 Health care provider-patient privilege
 Therapist-client privilege between a certified social worker, certified clinical
social worker, or certified marriage and family therapist and a client of any
of these professionals
 Any privilege between a school counselor or psychologist and a student
Inclusion of Reporter’s Name in Report: 31-33-7-4. The written report must
include the name and contact information for the person making the report.
Disclosure of Reporter Identity: 31-33-18-2. The identity of the reporter is
protected whenever the report is made available to the subject of the report.
Iowa
Professionals Required to Report: 232.69; 728.14. Health practitioners, Social
workers, school employees, certified para-educators, coaches, or instructors
employed by community colleges, employees or operators of health care facilities,
childcare centers, Head Start programs, family development and self-sufficiency
grant programs, substance abuse programs or facilities, juvenile detention or
juvenile shelter care facilities, foster care facilities, or mental health centers,
employees of Department of Human services institutions, peace officers,
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counselors, or mental health professionals, commercial film and photographic print
processors.
Reporting by Other Person: 232.69. Any other person who believes that a child has
been abused may report.
Standards for Making a Report: 232.69; 728.14. When, in the scope of professional
practice or their employment responsibilities, they reasonably believe that a child
has been abused. A commercial film and photographic print processor who has
knowledge of or observes a film, photograph, videotape, negative, or slide that
depicts a minor engaged in a prohibited sexual act or in the simulation of a
prohibited sexual act.
Privileged Communications: 232.74. The husband-wife or health practitionerpatient privilege does not apply to evidence regarding abuse to a child.
Inclusion of Reporter’s Name in Report: 232.70. The report shall contain the name
and address of the person making the report.
Disclosure of Reporter Identity: 232.71B. The department shall not reveal the
identity of the reporter to the subject of the report.
Kansas
Professionals Required to Report: 38-1522. Physicians, dentists, optometrists,
nurses, chief administrative officers of medical care facilities, or emergency
medical services personnel, teachers, school administrators, or other school
employees, licensed childcare providers, Psychologists, clinical psychotherapists,
marriage and family therapists, social workers, clinical marriage and family
therapists, professional counselors, or alcohol and drug abuse counselors,
firefighters, mediators, law enforcement officers, or juvenile intake and assessment
workers.
Reporting by Other Persons: 38-1522. Any other person who has reason to suspect
that a child has been injured as a result of maltreatment may report.
Standards for Making a Report: 38-1522. When they have reason to suspect that a
child has been injured as a result of maltreatment, When they know of the death of
a child.
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Privileged Communications: Not addressed in statutes reviewed.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 38-1507. Authorized disclosures of information
shall not identify a reporter of a child in need of care.
Kentucky
Professionals Required to Report: 620.030. Physicians, osteopathic physicians,
nurses, coroners, medical examiners, residents, interns, chiropractors, dentists,
optometrists, emergency medical technicians, paramedics, or health professionals,
teachers, school personnel, or child-caring personnel, social workers or mental
health professionals, peace officers.
Reporting by Other Persons: 620.030. Any person who knows or has reasonable
cause to believe that a child is dependent, neglected, or abused shall immediately
report.
Standards for Making a Report: 620.030. When they know or have reasonable
cause to believe that a child is dependent, neglected, or abused.
Privileged Communications: 620.050. Neither the husband-wife nor any
professional-client/patient privilege, except the attorney-client and clergy-penitent
privilege, shall be a ground for refusing to report.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 620.050. The identity of the reporter shall not be
disclosed except: To law enforcement officials, the agency investigating the report,
or to a multidisciplinary team, under court order, after a court has found reason to
believe the reporter knowingly made a false report.
Louisiana
Professionals Required to Report: Children’s Code art. 603. Physicians, surgeons,
physical therapists, dentists, residents, interns, hospital staff members, podiatrists,
chiropractors, licensed nurses, nursing aides, dental hygienists, emergency medical
technicians, paramedics, optometrists, coroners, or medical examiners,
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psychiatrists, psychologists, marriage or family counselors, or social workers,
members of the clergy, including priest, rabbis, deacons or ministers, Christian
science practitioners, or other similar functionary of a religious organization,
teachers, childcare providers, school principals, teacher’s aides, school staff
members, foster home parents, or group home or other childcare institutional staff
members, personnel of residential home facilities, daycare providers, or any
individuals who provide such services to children, police officers, law enforcement
officials, or probation officers, commercial film or photographic print processors,
mediators.
Reporting by Other Persons: Children’s Code art. 609. Any other person who has
cause to believe that a child’s health is endangered as a result of abuse or neglect
may report.
Standards for Making a Report: Children’s Code art. 609; 610. When they have
cause to believe that a child’s health is endangered as a result of abuse or neglect,
commercial film or photographic print processors when they have knowledge of or
observe any film, photograph, videotape, negative, or slide depicting a child that
constitutes child pornography.
Privileged Communications: Children’s Code art. 603. Only the clergy-penitent
privilege is permitted. No claim to privilege by other professionals is permitted.
Inclusion of Reporter’s Name in Report: Children’s Code art. 610. The report must
include the name and address of the reporter.
Disclosure of Reporter Identity: Rev. Stat. 46:56. The identity of the reporter shall
not be released unless a court finds that the reporter knowingly made a false report.
Maine
Professionals Required to Report: Tit. 22, 4011-A. Allopathic and osteopathic
physicians, emergency medical services persons, medical examiners, podiatrists,
physicians’ assistants, dentists, dental hygienists and assistants, chiropractors,
nurses, home health aides, medical or social service workers, teachers, guidance
counselors, school officials, children’s summer camp administrators or counselors,
or childcare personnel, social workers, psychologists, or mental health
professionals, Court Appointed Special Advocates, guardians ad litem,
homemakers, law enforcement officials, fire inspectors, municipal code
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enforcement officials, or chairs of licensing boards that have jurisdiction over
mandated reporters, commercial film and photographic print processors, clergy
members acquiring the information as a result of clerical professional work except
for information received during confidential communications, humane agents
employed by the Department of Agriculture, Food and Rural Resources.
Reporting by Other Persons: Tit. 22, 4011-A. Any other person who knows or has
reasonable cause to suspect that a child has been or is likely to be abused or
neglected may report.
Standards for Making a Report: Tit. 22, 4011-A. When the person knows or has
reasonable cause to suspect that a child is or is likely to be abused or neglected.
Privileged Communications: Tit. 22, 4011-A. A member of the clergy may claim
privilege when information is received during a confidential communication.
The husband-wife and physician and psychotherapist-patient privileges cannot be
invoked as a reason not to report.
Inclusion of Reporter‘s Name in Report: Tit. 22, 4012. The report shall include the
name, occupation, and contact information for the person making the report.
Disclosure of Reporter Identity: Tit. 22, 4008. The identity of the reporter is
protected in any release of information to the subject of the report.
Maryland
Professionals Required to Report: Fam. Law 5-704. Health practitioners, educators
or human service workers, police officers.
Reporting by Other Persons: Fam. Law 5-705. Any other person who has reason to
believe that a child has been subjected to abuse or neglect must report.
Standards for Making a Report: Fam. Law 5-704; 5-705. When, acting in a
professional capacity, the person has reason to believe that a child has been
subjected to abuse or neglect.
Privileged Communications: Fam. Law 5-705. Only the attorney-client and clergypenitent privileges are permitted.
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Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: Not addressed in statutes reviewed.
Massachusetts
Professionals Required to Report: Ch. 119, 51A. Physicians, hospital personnel,
medical examiners, emergency medical technicians, dentists, nurses, chiropractors,
optometrists, or psychiatrists, teachers, educational administrators, daycare workers
or persons paid to care for or work with children in facilities that provide daycare
or residential services, family daycare systems and childcare food programs, or
school attendance officers psychologists, social workers, licensed allied mental
health and human services professionals, drug and alcoholism counselors, clinical
social workers, or guidance or family counselors, probation officers, clerk or
magistrates of district courts, parole officers, foster parents, firefighters or police
officers, priests, rabbis, clergy members, ministers, leaders of any church or
religious body, accredited Christian science practitioners, persons performing
official duties on behalf of a church or religious body, leader of any church or
religious body, or persons employed by a church or religious body to supervise,
educate, coach, train, or counsel a child on a regular basis.
Reporting by Other Persons: Ch. 119, 51A. Any other person who has reasonable
cause to believe that a child is suffering from abuse or neglect may report.
Standards for Making a Report: Ch. 119, 51A. When, in his or her professional
capacity, the person has reasonable cause to believe that a child is suffering injury
from abuse or neglect that inflicts harm or a substantial risk of harm.
Privileged Communications: Ch. 119, 51A. A clergy member shall report all cases
of abuse, but need not report information gained in a confession or
other confidential communication. Any other privilege relating to confidential
communications shall not prohibit the filing of a report.
Inclusion of Reporter’s Name in Report: Ch. 119, 51A. Reports shall include the
name of the reporter.
Disclosure of Reporter Identity: Not addressed in statutes reviewed
Michigan
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Professionals Required to Report: Physicians, physician assistants, dentists, dental
hygienists, medical examiners, nurses, persons licensed to provide emergency
medical care, or audiologists, school administrators, counselors, or teachers,
regulated childcare providers, psychologists, marriage and family therapists,
licensed professional counselors, social workers, or social work technicians, law
enforcement officers, members of the clergy, department employees, including
eligibility specialists, family independence managers, family independence
specialists, social services specialists, social work specialists, social work specialist
managers, or welfare services specialists.
Reporting by Other Persons: 722.624. Any other person, including a child, who
has reasonable cause to suspect child abuse or neglect, may report.
Standards for Making a Report: 722.623. When they have reasonable cause to
suspect child abuse or neglect.
Privileged Communications: 722.631. Only the attorney-client or clergy-penitent
privilege can be grounds for not reporting.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 722.627. The identity of the reporter is protected
in any release of information to the subject of the report.
Minnesota
Professionals Required to Report: 626.556, Subd. 3. A professional or
professional’s delegate who is engaged in the practice of the healing arts, hospital
administration, psychiatric treatment, childcare, education, psychological
treatment, social services, or law enforcement, members of the clergy.
Reporting by Other Persons: 626.556, Subd. 3. Any other person may voluntarily
report if the person knows, has reason to believe, or suspects that a child is being
neglected or subjected to sexual or physical abuse.
Standards for Making a Report: 626.556, Subd. 3 When they know or have reason
to believe that a child is being neglected or sexually or physically abused.
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Privileged Communications: 626.556, Subd. 3 & 8. A member of the clergy is not
required by this subdivision to report information that is otherwise privileged under
595.02, subdivision 1, paragraph (c). No evidence relating to the neglect or abuse
of a child or to any prior incidents of neglect or abuse involving any of the same
persons accused of neglect or abuse shall be excluded in any proceeding on the
grounds of privilege set forth in section 595.02, subdivision 1, paragraph (a)
[husband-wife], (d) [medical practitioner patient], or (g) [mental health
professional-client].
Inclusion of Reporter’s Name in Report: 626.556, Subd. 7. The report must include
the name and address of the reporter.
Disclosure of Reporter Identity: 626.556, Subd. 11. The name of the reporter shall
be kept confidential while the report is under investigation. After the investigation
is complete, the subject of the report may compel disclosure of the name only upon
the reporter’s consent or a finding by the court that the report was false and made
in bad faith.
Mississippi
Professionals Required to Report: 43-21-353. Physicians, dentists, interns,
residents, or nurses, public or private school employees or childcare givers,
psychologists, social workers, or child protection specialists, attorneys, ministers,
or law enforcement officers.
Reporting by Other Persons: 43-21-353. All other persons who have reasonable
cause to suspect that a child is abused or. neglected must report.
Standards for Making a Report: 43-21-353. When they have reasonable cause to
suspect that a child is abused or neglected.
Privileged Communications: Not addressed in statutes reviewed.
Inclusion of Reporter’s Name in Report: 43-21-353. The department’s report shall
include the name and address of the reporter, if known, and whether he or she is a
material witness to the abuse.
Disclosure of Reporter Identity: 43-21-353. The identity of the reporting party shall
not be disclosed to anyone other than law enforcement officers or prosecutors
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without an order from the appropriate youth court.
Missouri
Professionals Required to Report: 210.115; 568.110; 352.400. Physicians, medical
examiners, coroners, dentists, chiropractors, optometrists, podiatrists, residents,
interns, nurses, hospital and clinic personnel, or other health practitioners, daycare
center workers or other childcare workers, teachers, principals, or other school
officials, psychologists, mental health professionals, social workers, ministers,
which includes clergyperson, priest, rabbi, Christian science practitioner, or other
person serving in a similar capacity for any religious organization, juvenile
officers, probation, parole officers, or peace officers, law enforcement officials, or
jail or detention center personnel, other persons with responsibility for the care of
children, commercial film and photographic print processors, computer providers,
installers, or repair persons, or Internet service providers.
Reporting by Other Persons: 210.115. Any other person who has reasonable cause
to suspect that a child has been subjected to abuse may report.
Standards for Making a Report: 210.115; 568.110.When they have reasonable
cause to suspect that a child has been subjected to abuse or neglect, when they
observe a child being subjected to conditions or circumstances that would
reasonably result in abuse or neglect, commercial film and photographic print
processors when they have knowledge of or observe any film, photograph,
videotape, negative, slide, or computer-generated image or picture depicting a child
engaged in an act of sexual conduct.
Privileged Communications: 210.140. Only the attorney-client or clergy-penitent
privilege may be grounds for failure to report.
Inclusion of Reporter’s Name in Report: 210.130. The report must include the
name, address, occupation, and contact information for the person making the
report.
Disclosure of Reporter Identity: 210.150. The names or other identifying
information of reporters shall not be furnished to any child, parent, guardian, or
alleged perpetrator named in the report.
Montana
327
Professionals Required to Report: 41-3-201. Physicians, residents, interns,
members of hospital staffs, nurses, osteopaths, chiropractors, podiatrists, medical
examiners, coroners, dentists, optometrists, or any other health professionals,
school teachers, other school officials, employees who work during regular school
hours, operators or employees of any registered or licensed day-care or substitute
care facility, or any other operators or employees of child care facilities, mental
health professionals or social workers, Christian science practitioners or religious
healers, foster care, residential, or institutional workers, members of clergy,
guardians ad litem or court appointed advocates authorized to investigate a report,
peace officers or other law enforcement officials.
Reporting by Other Persons: 41-3-201. Any other person who knows or has
reasonable cause to suspect that a child is abused or neglected may report.
Standards for Making a Report: 41-3-201. When they know or have reasonable
cause to suspect, as a result of information they receive in their professional or
official capacity, that a child is abused or neglected.
Privileged Communications: 41-3-201. A person listed as a mandated reporter may
not refuse to make a report as required in this section on the grounds of a
physician-patient or similar privilege. A member of the clergy or priest is not
required to make a report under this section if the communication is required to be
confidential by canon law, church doctrine, or established church practice.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 41-3-201. The identity of the reporter shall not be
disclosed in any release of information to the subject of the report.
Nebraska
Professionals Required to Report: 28-711. Physicians, medical institutions, nurses,
school employees, social workers.
Reporting by Other Persons: 28-711. All other persons who have reasonable cause
to believe that a child has been subjected to abuse or neglect must report.
Standards for Making a Report: 28-711. When they have reasonable cause to
believe that a child has been subjected to abuse or neglect. When they observe a
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child being subjected to conditions or circumstances that reasonably would result in
abuse or neglect.
Privileged Communications: 28-714. The physician-patient, counselor-client, and
husband-wife privileges shall not be grounds for failing to report.
Inclusion of Reporter’s Name in Report: 28-711. The initial oral report shall
include the reporter’s name and address.
Disclosure of Reporter Identity: 28-719. The name and address of the reporter shall
not be included in any release of information.
Nevada
Professionals Required to Report: 432B.220. Physicians, dentists, dental
hygienists, chiropractors, optometrists, podiatrists, medical examiners, residents,
interns, nurses, or physician assistants, emergency medical technicians, other
persons providing medical services, or hospital personnel, coroners, school
administrators, teachers, counselors, or librarians, any persons who maintain or are
employed by facilities or establishments that provide care for children, children’s
camps, or other facilities, institutions, or agencies furnishing care to children,
psychiatrists, psychologists, marriage and family therapists, alcohol or drug abuse
counselors, athletic trainers, or social workers, clergymen, practitioners of
Christian science, or religious healers, unless they have acquired the knowledge of
the abuse or neglect from the offenders during confessions, persons licensed to
conduct foster homes, officers or employees of law enforcement agencies or adult
or juvenile probation officers, attorneys, unless they have acquired the knowledge
of the abuse or neglect from clients who are, or may be, accused of the abuse or
neglect, any person who is employed by or serves as a volunteer for an approved
youth shelter, any adult person who is employed by an entity that provides
organized activities for children, any person who maintains, is employed by, or
serves as a volunteer for an agency or service that advises persons regarding abuse
or neglect of a child and refers them to services.
Reporting by Other Persons: 432B.220. Any other person may report.
Standards for Making a Report: 432B.220. When, in their professional capacity,
they know or have reason to believe that a child is abused or neglected, when they
have reasonable cause to believe that a child has died as a result of abuse or
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neglect.
Privileged Communications: 432B.220; 432B.250. The clergy-penitent privilege
applies when the knowledge is gained during religious confession. The attorneyclient privilege applies when the knowledge is acquired from a client who is or
may be accused of abuse. Any other person who is required to report may not
invoke privilege for failure to make a report.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 432B.290. The identity of the reporter is kept
confidential.
New Hampshire
Professionals Required to Report: 169-C:29. Physicians, surgeons, county medical
examiners, psychiatrists, residents, interns, dentists, osteopaths, optometrists,
chiropractors, nurses, hospital personnel, or Christian science practitioners,
teachers, school officials, nurses, or counselors, daycare workers or any other child
or foster care workers, social workers, psychologists or therapists, priests,
ministers, or rabbis, law enforcement officials.
Reporting by Other Persons: 169-C:29. All other persons who have reason to
suspect that a child has been abused or neglected must report.
Standards for Making a Report: 169-C:29. When they have reason to suspect that a
child has been abused or neglected.
Privileged Communications: 169-C:32. Only the attorney-client privilege is
permitted.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: Not addressed in statutes reviewed.
New Jersey
Professionals Required to Report: None specified in statute.
Reporting by Other Persons: 9:6-8.10. Any person having reasonable cause to
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believe that a child has been subjected to child abuse or acts of child abuse shall
report.
Standards for Making a Report: 9:6-8.10. When they have reasonable cause to
believe that a child has been subjected to abuse.
Privileged Communications: Not addressed in statutes reviewed.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 9:6-8.10a. The identity of the reporter shall not be
made public. Any information that could endanger any person shall not be released.
New Mexico
Professionals Required to Report: 32A-4-3. Physicians, residents, or interns, law
enforcement officers or judges, nurses, teachers or school officials, social workers,
members of the clergy.
Reporting by Other Persons: 32A-4-3. Every person who knows or has a
reasonable suspicion that a child is an abused or a neglected child shall report the
matter immediately.
Standards for Making a Report: 32A-4-3. When they know or have a reasonable
suspicion that a child is abused or neglected.
Privileged Communications: 32A-4-3; 32A-4-5. A clergy member need not report
any information that is privileged. The report or its contents or any other facts
related thereto or to the condition of the child who is the subject of the report shall
not be excluded on the ground that the matter is or may be the subject of a
physician patient privilege or similar privilege or rule against disclosure.
Inclusion of Reporter’s Name in Report: Not specifically required in statute
Disclosure of Reporter Identity: 32A-4-33. Any release of information to a parent,
guardian, or legal custodian shall not include identifying information about the
reporter.
New York
331
Professionals Required to Report: Soc. Serv. Law 413. Physicians, physician
assistants, surgeons, medical examiners, coroners, dentists, dental hygienists,
osteopaths, optometrists, chiropractors, podiatrists, residents, interns, nurses,
hospital personnel, emergency medical technicians, or Christian science
practitioners, school officials, social workers, social services workers, daycare
center workers, providers of family or group family daycare, employees or
volunteers in a residential care facility, or any other childcare or foster care worker,
psychologists, therapists, mental health professionals, substance abuse counselors,
or alcoholism counselors, police officers, district attorneys or assistant district
attorneys, investigators employed in the office of a district attorney, or other law
enforcement officials.
Reporting by Other Persons: Soc. Serv. Law 414. Any other person who has
reasonable cause to suspect that a child is abused or maltreated may report.
Standards for Making a Report: Soc. Serv. Law 413. When they have reasonable
cause to suspect that a child coming before them in their professional or official
capacity is an abused or maltreated child. Where the parent, guardian, custodian, or
other person legally responsible for the child comes before the reporter and states
from personal knowledge facts, conditions, or circumstances that, if correct, would
render the child an abused or maltreated child.
Privileged Communications: Not addressed in statutes reviewed.
Inclusion of Reporter’s Name in Report: Soc. Serv. Law 415. The report shall
include the name and contact information for the reporter.
Disclosure of Reporter Identity: Soc. Serv. Law 422-a. Any disclosure of
information shall not identify the source of the report.
North Carolina
Professionals Required to Report: 7B-301. Any institution
Reporting by Other Persons: 7B-301. All persons who have cause to suspect that
any juvenile is abused, neglected, or dependent, or has died as the result of
maltreatment, shall report.
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Standards for Making a Report: 7B-301. When they have cause to suspect that any
juvenile is abused, neglected, or dependent, or has died as the result of
maltreatment.
Privileged Communications: 7B-310. No privilege shall be grounds for failing to
report. Only the attorney-client privilege shall be grounds for excluding evidence
of abuse in any judicial proceeding.
Inclusion of Reporter’s Name in Report: 7B-301. The report must include the
name, address, and telephone number of the reporter.
Disclosure of Reporter Identity: 7B-302. The department shall hold the identity of
the reporter in strictest confidence.
North Dakota
Professionals Required to Report: 50-25.1-03. Physicians, nurses, dentists,
optometrists, medical examiners or coroners, or any other medical or mental health
professionals or religious practitioners of the healing arts, school teachers,
administrators, or school counselors, addiction counselors or social workers,
daycare center or any other childcare workers, police or law enforcement officers,
members of the clergy.
Reporting by Other Persons: 50-25.1-03. Any other person who has reasonable
cause to suspect that a child is abused or neglected may report.
Standards for Making a Report: 50-25.1-03. When they have knowledge of or
reasonable cause to suspect that a child is abused or neglected if the knowledge or
suspicion is derived from information received by that person in that person’s
official or professional capacity.
Privileged Communications: 50-25.1-03; 50-25.1-10. A member of the clergy is
not required to report such circumstances if the knowledge or suspicion is derived
from information received in the capacity of spiritual adviser. Any privilege of
communication between husband and wife or between any professional person and
the person’s patient or client, except between attorney and client, cannot be used as
grounds for failing to report.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
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Disclosure of Reporter Identity: 50-25.1-11. The identity of the reporter is
protected.
Ohio
Professionals Required to Report: 2151.421. Physicians, residents, interns,
podiatrists, dentists, nurses, other health care professionals, speech pathologists,
audiologists, coroners, licensed school psychologists; administrators or employees
of child daycare centers, residential camps, or child day camps; school teachers,
employees, or authorities licensed psychologists, marriage and family therapists,
social workers, professional counselors, or agents of county humane societies,
persons rendering spiritual treatment through prayer in accordance with the tenets
of a well recognized religion, CEU Superintendent, board member, or employee of
a county board of mental retardation; investigative agent contracted with by a
county board of mental retardation; or employee of the department of mental
retardation and developmental disabilities Attorneys.
Reporting by Other Persons: 2151.421. Any other person who suspects that a child
has suffered or faces a threat of suffering from abuse or neglect may report.
Standards for Making a Report: 2151.421. When a mandated person is acting in an
official or professional capacity and knows or suspects that a child has suffered or
faces a threat of suffering any physical or mental wound, injury, disability, or
condition of a nature that reasonably indicates abuse or neglect of the child.
Privileged Communications: 2151.421. The attorney-client or physician-patient
privilege is waived if the client or patient is a child who is suffering or faces the
threat of suffering any physical or mental injury. The physician-patient privilege
shall not be a ground for excluding evidence regarding a child’s injuries, abuse, or
neglect, or the cause of the injuries, abuse, or neglect in any judicial proceeding
resulting from a report.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 2151.421. The name of the person who made the
report shall not be released.
Oklahoma
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Professionals Required to Report: Tit. 10, 7103-7104; Tit. 21, § 1021.4.
Physicians, surgeons, residents, interns, dentists, osteopaths, nurses, or other health
care professionals, teachers, commercial film and photographic print processors.
Reporting by Other Persons: Tit. 10, 7103. Any person who has reason to believe
that a child is a victim of abuse or neglect must report.
Standards for Making a Report: Tit. 10, 7103-7104; Tit. 21, 1021.4. When they
have reason to believe that a child is a victim of abuse or neglect, when a health
care professional treats the victim of what appears to be criminally injurious
conduct, including, but not limited to, child physical or sexual abuse, when a health
care professional attends the birth of a child who tests positive for alcohol or a
controlled dangerous substance, when any commercial film and photographic print
processor has knowledge of or observes any film, photograph, video tape, negative,
or slide, depicting a child engaged in an act of sexual conduct.
Privileged Communications: Tit. 10, 7103. No privilege shall relieve any person
from the requirement to report.
Inclusion of Reporter’s Name in Report: Tit. 10, 7108. Reports may be made
anonymously.
Disclosure of Reporter Identity: Tit. 10, 7109. The department shall not release the
identity of the person who made the initial report unless a court orders the release
of information for good cause shown.
Oregon
Professionals Required to Report: 419B.005. Physicians, interns, residents,
optometrists, dentists, emergency medical technicians, naturopathic physicians, or
nurses, employees of the Department of Human Resources, State Commission on
Children and Families, Childcare Division of the Employment Department, the
Oregon Youth Authority, a county health department, a community mental health
and developmental disabilities program, a county juvenile department, a licensed
child-caring agency, or an alcohol and drug treatment program, school employees,
childcare providers, psychologists, members of clergy, social workers, foster care
providers, counselors, or marriage and family therapists, peace officers, attorneys,
firefighters, or court appointed special advocates, members of the legislative
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assembly.
Reporting by Other Persons: 419B.015: Any person may voluntarily make a report.
Standards for Making a Report: 419B.010. When any public or private official has
reasonable cause to believe that any child with whom the official comes in contact
has suffered abuse.
Privileged Communications: 419B.010. A psychiatrist, psychologist, member of
the clergy, or attorney shall not be required to report if such communication is
privileged under law. An attorney is not required to make a report of information
communicated to the attorney in the course of representing a client, if disclosure of
the information would be detrimental to the client.
Inclusion of Reporter’s Name in Report: Not specifically required in statute
Disclosure of Reporter Identity: 419B.035. The name, address, and other
identifying information about the person who made the report may not be
disclosed.
Pennsylvania
Professionals Required to Report: Ch. 23, 6311. Physicians, osteopaths, medical
examiners, coroners, funeral directors, dentists, optometrists, chiropractors, nurses,
hospital personnel, or Christian science practitioners, members of the clergy,
school administrators, teachers, or school nurses, social services workers, daycare
center workers, or any other childcare or foster care workers, or mental health
professionals, peace officers or law enforcement officials.
Reporting by Other Persons: Ch. 23, 6312. Any person who has reason to suspect
that a child is abused may report.
Standards for Making a Report: Ch. 23, 6311. When, in the course of their
employment, occupation, or practice of their profession, they have reasonable
cause to suspect, on the basis of their medical, professional, or other training and
experience, that a child coming before them is an abused child.
Privileged Communications: Ch. 23, 6311. Except for confidential communications
made to an ordained member of the clergy that are protected under 42 Pa.C.S. 5943
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(relating to confidential communications to clergymen), the privileged
communication between any professional person required to report and the patient
or client of that person shall not apply to situations involving child abuse and shall
not constitute grounds for failure to report.
Inclusion of Reporter’s Name in Report: Ch. 23, 6313. Mandated reporters must
make a written report that includes their name and contact information.
Disclosure of Reporter Identity: Ch. 23, 6340. The release of the identity of the
mandated reporter is prohibited unless the secretary finds that the release will not
be detrimental to the safety of the reporter.
Rhode Island
Professionals Required to Report: 40-11-6. Any physician or duly certified
registered nurse practitioner.
Reporting by Other Persons: 40-11-3(a). Any person who has reasonable cause to
know or suspect that a child has been abused or neglected must report.
Standards for Making a Report: 40-11-3(a); 40-11-6. When they have reasonable
cause to know or suspect that a child has been abused or neglected. When any
physician or nurse practitioner has cause to suspect that a child brought to them for
treatment is an abused or neglected child or when they determine that a child under
the age of 12 years is suffering from any sexually transmitted disease.
Privileged Communications: 40-11-11. The privileged quality of communication
between husband and wife and any professional person and his or her patient or
client, except that between attorney and client, shall not constitute grounds for
failure to report.
Inclusion of Reporter‘s Name in Report: Not specifically required in statute
Disclosure of Reporter Identity: Not addressed in statutes reviewed
South Carolina
Professionals Required to Report: 20-7-510. Physicians, nurses, dentists,
optometrists, medical examiners, or coroners, any other medical, emergency
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medical services, or allied health professionals, school teachers or counselors,
principals, or assistant principals, childcare workers in any childcare centers or
foster care facilities, mental health professionals, social or public assistance
workers, or substance abuse treatment staff, members of the clergy including
Christian science practitioners or religious healers, police or law enforcement
officers, judges, funeral home directors or employees, persons responsible for
processing films or computer technicians.
Reporting by Other Persons: 20-7-510. Any other person who has reason to believe
that a child’s physical or mental health or welfare has been or may be adversely
affected by abuse and neglect may report.
Standards for Making a Report: 20-7-510. When in their professional capacity they
have received information which gives them reason to believe that a child has been
or may be abused or neglected.
Privileged Communications: 20-7-550. The privileged quality of communication
between husband and wife and any professional person and his patient or client,
except that between attorney and client or clergy member, including Christian
Science Practitioner or religious healer, and penitent, does not constitute grounds
for failure to report.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 20-7-510. The identity of the person making a
report pursuant to this section must be kept confidential by the agency or
department receiving the report and must not be disclosed.
South Dakota
Professionals Required to Report: 26-8A-3. Physicians, dentists, osteopaths,
chiropractors, optometrists, nurses, coroners, teachers, school counselors or
officials, child welfare providers, mental health professionals or counselors,
psychologists, social workers, chemical dependency counselors, employees or
volunteers of domestic abuse shelters, or religious healing practitioners, parole or
court services officers or law enforcement officers, any safety-sensitive position, as
defined in 23-3-64
Reporting by Other Persons: 26-8A-3. Any person who knows or has reasonable
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cause to suspect that a child has been abused or neglected may report.
Standards for Making a Report: 26-8A-3. When they have reasonable cause to
suspect that a child has been abused or neglected.
Privileged Communications: 26-8A-15. The following privileges may not be
claimed as a reason for not reporting: Physician-patient, husband-wife, school
counselor-student, social worker-client.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 26-8A-11.1. The name of the reporter is not
disclosed unless: The report is determined to be unsubstantiated within 30 days, the
subject of the report requests disclosure of the reporter’s identity. A hearing is held
to determine whether the report was made with malice and without reasonable
foundation and that release of the name will not endanger the life or safety of the
reporter.
Tennessee
Professionals Required to Report: 37-1-403; 37-1-605. Physicians, osteopaths,
medical examiners, chiropractors, nurses, hospital personnel, or other health or
mental health professionals, school teachers, other school officials or personnel,
daycare center workers, or other professional childcare, foster care, residential, or
institutional workers, social workers, practitioners who rely solely on spiritual
means for healing, judges or law enforcement officers, neighbors, relatives, or
friends.
Reporting by Other Persons: 37-1-403; 37-1-605. Any person who has knowledge
that a child has been harmed by abuse or neglect must report.
Standards for Making a Report: 37-1-403; 37-1-605. When they have knowledge
that a child has been harmed by abuse or neglect, when they are called upon to
render aid to any child who is suffering from an injury that reasonably appears to
have been caused by abuse, when they know or have reasonable cause to suspect
that a child has been sexually abused.
Privileged Communications: 37-1-411. The following privileges may not be
claimed: Husband-wife, Psychiatrist-patient or psychologist-patient
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
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Disclosure of Reporter Identity: 37-1-409. The name of the reporter shall not be
released, except as may be ordered by the court.
Texas
Professionals Required to Report: Fam. Code 261.101. A professional, for
purposes of the reporting laws, is an individual who is licensed or certified by the
state or who is an employee of a facility licensed, certified, or operated by the state
and who, in the normal course of official duties or duties for which a license or
certification is required, has direct contact with children, teachers or daycare
employees, nurses, doctors, or employees of a clinic or health care facility that
provides reproductive services, juvenile probation officers or juvenile detention or
correctional officers.
Reporting by Other Persons: Fam. Code 261.101. A person who has cause to
believe that a child has been adversely affected by abuse or neglect shall
immediately make a report.
Standards for Making a Report: Fam. Code 261.101. When they have cause to
believe that a child has been adversely affected by abuse or neglect.
Privileged Communications: Fam. Code 261.101: No privilege may be claimed to
exempt a person from the duty to report.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: Fam. Code 261.201. The identity of the reporter is
confidential and may not be disclosed to the subject of the report.
Utah
Professionals Required to Report: 62A-4a-403. Any person licensed under the
Medical Practice Act or the Nurse Practice Act.
Reporting by Other Persons: 62A-4a-403. Any person who has reason to believe
that a child has been subjected to abuse or neglect must report.
Standards for Making a Report: 62A-4a-403. When they have reason to believe
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that a child has been subjected to abuse or neglect, when they observe a child being
subjected to conditions or circumstances that would reasonably result in sexual
abuse, physical abuse, or neglect.
Privileged Communications: 62A-4a-403. The requirement to report does not apply
to a clergyman or priest, without the consent of the person making the confession,
with regard to any confession made to him in his professional character in the
course of discipline enjoined by the church to which he belongs.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 62A-4a-412. The name and contact information of
the reporter shall be deleted prior to any release of records to the subject of the
report.
Vermont
Professionals Required to Report: Tit. 33, 4913. Physicians, surgeons, osteopaths,
chiropractors, physician’s assistants, hospital administrators, nurses, medical
examiners, dentists, psychologists, or other health care providers, school
superintendents, school teachers, school librarians, daycare workers, school
principals, school guidance counselors, mental health professionals, or social
workers, probation officers, police officers, camp owners, camp administrators or
counselors, members of the clergy.
Reporting by Other Persons: Tit. 33, 4913. Any other person who has reasonable
cause to believe that a child has been abused or neglected may report.
Standards for Making a Report: Tit. 33, 4913. When they have reasonable cause to
believe that a child has been abused or neglected.
Privileged Communications: Tit. 33, 4913. A member of the clergy is not required
to report if the knowledge comes from a communication that is required to be kept
confidential by religious doctrine.
Inclusion of Reporter’s Name in Report: Tit. 33, 4914. Reports shall contain the
name and address of the reporter.
Disclosure of Reporter Identity. Tit. 33, 4913. The name of the person making the
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report shall be confidential unless: The person making the report requests
disclosure. A court determines that the report was not made in good faith.
Virginia
Professionals Required to Report: 63.2-1509. Persons licensed to practice medicine
or any of the healing arts, hospital residents or interns, nurses, or duly accredited
Christian Science practitioners, teachers or other persons employed in public or
private schools, kindergartens, or nursery schools; persons providing childcare fulltime or part-time for pay on a regularly planned basis, social workers, mental
health professionals, or any person responsible for the care, custody, and control of
children, probation officers, law enforcement officers, mediators, or courtappointed special advocates.
Reporting by Other Persons: 63.2-1510. Any person who suspects that a child is
abused or neglected may report.
Standards for Making a Report: 63.2-1509. When, in their professional or official
capacity, they have reason to suspect that a child is abused or neglected.
Privileged Communications: 63.2-1519. The physician-patient or husband-wife
privilege is not permitted.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: Not addressed in statutes reviewed.
Washington
Professionals Required to Report: 26.44.030. Practitioners, county coroners or
medical examiners, pharmacists, or nurses, professional school personnel or
childcare providers Social service counselors or psychologists, employees of the
State Department of Social and Health Services, juvenile probation officers, law
enforcement officers, personnel of the Department of Corrections, or placement
and liaison specialists, responsible living skills program staff, HOPE center staff,
State family and children’s ombudsman, or any volunteer in the ombudsman’s
office, any adult with whom a child resides.
Reporting by Other Persons: 26.44.030. Any person who has reasonable cause to
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believe that a child has suffered abuse or neglect may report.
Standards for Making a Report: 26.44.030. When they have reasonable cause to
believe that a child has suffered abuse or neglect.
Privileged Communications: 26.44.060. Making a report shall not be considered a
violation of any of the following privileges: clergy-penitent, physician or
optometrist-patient, psychologist-client.
Inclusion of Reporter’s Name in Report: 26.44.030. The department shall make
reasonable efforts to learn the name, address, and telephone number of the reporter.
Disclosure of Reporter Identity: 26.44.030. The department shall provide
assurances of appropriate confidentiality of information in the report.
West Virginia
Professionals Required to Report: 49-6A-2. Medical, dental, or mental health
professionals; emergency medical services personnel, school teachers or other
school personnel; childcare workers or foster care workers, Christian science
practitioners or religious healers, social service workers, peace officers or law
enforcement officials, circuit court judges, family law masters, employees of the
division of juvenile services, or magistrates, members of the clergy.
Reporting by Other Persons: 49-6A-2. Any person who has reasonable cause to
suspect that a child is abused or neglected may report.
Standards for Making a Report: 49-6A-2. When they have reasonable cause to
suspect that a child is abused or neglected. When they observe the child being
subjected to conditions that are likely to result in abuse or neglect. When they
believe that a child has suffered serious physical abuse or sexual abuse or sexual
assault. Privileged Communications: 49-6A-7. The privileged quality of
communications between husband and wife and between any professional person
and his patient or his client, except that between attorney and client, cannot be
invoked in situations involving suspected or known child abuse or neglect.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: Not addressed in statutes reviewed.
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Wisconsin
Professionals Required to Report: 48.981. Physicians, coroners, medical
examiners, nurses, dentists, chiropractors, optometrists, acupuncturists, other
medical or mental health professionals, physical therapists, dietitians, occupational
therapists, speech language pathologists, audiologists, or emergency medical
technicians, school teachers, administrators or counselors, childcare workers in
daycare centers, group homes, or residential care centers, or daycare providers,
alcohol or other drug abuse counselors, marriage and family therapists, or
professional counselors, social workers, public assistance workers, first responders,
police or law enforcement officers, mediators, or court appointed special advocates,
members of the clergy or a religious order, including brothers, ministers, monks,
nuns, priests, rabbis, or sisters.
Reporting by Other Persons: 48.981. Any person, including an attorney, who has
reason to suspect that a child has been abused or neglected or who has reason to
believe that a child has been threatened with abuse or neglect and that abuse or
neglect of the child will occur may report.
Standards for Making a Report: 48.981. When, in the course of their professional
duties, they have reasonable cause to suspect that a child has been abused or
neglected. When, in the course of their professional duties, they have reason to
believe that a child has been threatened with abuse or neglect or that abuse or
neglect will occur.
Privileged Communications: 48.981. A member of the clergy is not required to
report child abuse information that he or she receives solely through confidential
communications made to him or her privately or in a confessional setting.
Inclusion of Reporter’s Name in Report: Not specifically required in statute.
Disclosure of Reporter Identity: 48.981. The identity of the reporter shall not be
disclosed to the subject of the report.
Wyoming
Professionals Required to Report: None specified in statute.
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Reporting by Other Persons: 14-3-205. All persons must report.
Standards for Making a Report: 14-3-205. When they know or have reasonable
cause to believe or suspect that a child has been abused or neglected. When they
observe any child being subjected to conditions or circumstances that would
reasonably result in abuse or neglect.
Privileged Communications: 14-3-210. Only the clergy-penitent and attorney-client
privileges are permitted.
Inclusion of Reporter’s Name in Report: 14-3-206. The reporter is not specifically
required to provide his or her name in the written report. If photographs or x-rays
of the child are taken, the person taking them must be identified.
Disclosure of Reporter Identity: Not addressed in statutes reviewed.
Typical Minimum Reporting Requirements
Typically, minimum requirements for what must be reported include:
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A description of how the reporter learned of the injuries or neglect and of
any actions taken to assist
Information on previous injuries, assaults, neglect or financial abuses
The date, time, nature, and extent of the abuse or neglect* The date of the
report
The perpetrator's name, address, and relationship to the (possible) victim
The reporter's name, agency, position, address, telephone number, and
signature
Abuse or neglect suspected at an institution or facility
Mandated reporters are required to file a report whenever there is reasonable cause
to suspect or believe any resident of a care facility has been abused or neglected by
a staff member of a public or private institution or facility that provides care.
Whenever the results of an investigation leads to the conclusion that there is
reasonable cause to believe that that there has been abuse or neglect perpetrated by
staff, then the institution, school or facility must provide records concerning the
investigation to the appropriate investigating agency and/or to the agency that
licensed the facility. An institution may suspend employee(s) during an
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investigation, or, at the conclusion of an investigation, may impose penalties in
addition to any separate penalties resulting from civil litigation or criminal
prosecution. Employers may not discharge, discriminate or retaliate against an
employee for making a good faith report or for testifying at an abuse or neglect
proceeding (Mandated Reporter video and online training resource - 'Recognizing
and Reporting Child Abuse and Child Sexual Abuse').
Anonymity and immunity
Mandated reporters are usually required to identify themselves by name when
making a report, but may request anonymity to protect their privacy. A mandated
reporter who knowingly makes a false report will ordinarily have their identity
disclosed to the appropriate law enforcement agency, and their identity may be
disclosed to the alleged perpetrator of the reported abuse or neglect. A mandated
reporter may be subject to penalties, though immunity from civil or criminal
liability is granted to reporters who report in good faith. Immunity is also granted
to reporters who, in good faith, have not reported. However, failure to report
suspected abuse or neglect could result in fines or other sanctions, such as
participation in a training program. Failure to act may result in even stiffer
penalties, such as civil litigation or criminal prosecution with the prospect of
potential imprisonment (Mandated Reporter video and online training resource 'Recognizing and Reporting Child Abuse and Child Sexual Abuse').
Conflicts
Conflicts between a mandated reporter's duties and privileged communication
statutes are common. It has been argued that the category of "mandatory reporters"
should be expanded to members of the clergy; however in some more traditional
denominations the conflict this creates with the "confessional" makes this
unworkable. When such conflicts arise, professionals often choose not to report;
e.g., in a large number of cases involving clergy, numerous alleged child sexual
assaults have gone unreported (Mandated Reporter video and online training
resource - 'Recognizing and Reporting Child Abuse and Child Sexual Abuse').
Informing family members and guardians
Mandated reporters typically are not obligated to inform parents, siblings or
offspring that a report has been made. In many circumstances, however, it may be
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necessary and/or beneficial to do so. When a report is made at a care giving
facility, the person in charge of a hospital, school or other institution is generally
required to notify family members, or other caregiver(s) responsible for the
(possible) victim, that a report has been made. Healthcare professionals or
members of the clergy, however, often must to talk with family members or
guardians to offer support and guidance, or to assess the cause of an injury. In cases
of serious physical abuse or sexual abuse, it may be unwise to advise caregivers
before a case is reported, as it may put a victim at greater risk and/or interfere with
a criminal investigation (Mandated Reporter video and online training resource 'Recognizing and Reporting Child Abuse and Child Sexual Abuse').
Investigation of reports
Law enforcement or public health agencies are responsible for immediately
evaluating and classifying all reports of suspected abuse, neglect, or imminent risk.
When reports contain sufficient information to warrant an investigation, authorities
must make efforts within a reasonable time frame to begin an effective
investigation, often within hours, particularly when there is an imminent risk of
physical harm or another emergency; investigations must also be completed within
a reasonable or specified time frame. The investigation also must also include a
determination of whether the report was warranted or unfounded (Mandated
Reporter video and online training resource - 'Recognizing and Reporting Child
Abuse and Child Sexual Abuse').
Agencies must coordinate activities to minimize impacts upon the (possible)
victim. Consent to interview(s) of the (possible) victim often must be obtained
from caregivers, family members or guardians, unless there is reason to believe
such person is the alleged perpetrator. In cases where serious abuse or neglect is
substantiated, local law enforcement, prosecutors or other public offices must be
notified, and a copy of the investigation report must be sent (Mandated Reporter
video and online training resource - 'Recognizing and Reporting Child Abuse and
Child Sexual Abuse').
Professionals responsible for mandated reporting
In many US states, mandatory reporting requirements apply to all people in the
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state. In other states, mandated reporting requirements generally apply to staff
members of a public or private institution or caregiving facility, as well as to a
variety of public safety employees and medical professionals, or a public or private
school responsible for the safety and well being of vulnerable persons. These
generally include, but are not limited to the following:
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Adult protective service employees
Child advocates
Child protective service employees
Chiropractors
Clergy
Commercial Film and Photographic Print Processors
Dentists and dental hygienists
Emergency medical service providers
Marital and family therapists
Medical examiners
Mental health professionals
Nurses
Ombudsmen
Optometrists
Parole officers
Pharmacists
Physical therapists
Physician assistants
Physicians
Podiatrists
Police officers
Probation officers
Psychologists
Public health service providers responsible for the licensing or monitoring of
child day care centers, long term care and nursing facilities, group day care
homes, family day care homes, and youth camps
Professional counselors
Resident medical interns
School teachers, coaches, guidance counselors, paraprofessionals, and
principals
Sexual assault and battered women’s counselors
Social workers
Substance abuse rehabilitation counselors
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Training is typically offered wherever mandated reporting laws are enforced,
entailing matters such as recognition of abuse and neglect, what must be reported,
how to report it, anonymity, immunity and penalties (Mandated Reporter video and
online training resource - 'Recognizing and Reporting Child Abuse and Child
Sexual Abuse').
14. References
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California Welfare and Institutions Code, Section 5008 (m) emergency defined
California Welfare and Institutions Code, Section 5256: Certification Review
Hearing defined
California Welfare and Institutions Code, Section 5332: Capacity Hearing defined,
involuntary medication
California Welfare and Institutions Code, Section 5325-5325.2: Patients' Rights
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hospitals in California are governed by CCR Title 22
California Health & Safety Code, on seclusion and restraint
CAMFT Ethical Standards
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About the Course Presenter:
Course Presenter Nicole Hiltibran, MA, LMFT, is a graduate from Pepperdine University,
where she earned her Masters Degree in Clinical Psychology with an emphasis in Marriage and
Family Counseling, and is a Licensed Psychotherapist. Nicole has 25 years of experience serving
adults, children, couples and families both in the public sector and private practice. Nicole has
written state licensing exams for the California State Board of Behavioral Sciences for 10 years
as well as offering continuing education courses to licensed mental health and social work
professionals including LMFT’s, LCSW’s, LPCCs, RN’s, and PhD’s.
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