NASW Standards for Clinical Social Work in Social Work Practice

Introduction

Clinical social workers represent one of the largest groups of mental and behavioral health practitioners in the United States and its territories. Clinical social workers are often the first to diagnose disorders and treat people with various mental, emotional, and behavioral health conditions. Clinical social workers are essential to a variety of client-centered settings, including but not limited to community mental health centers, hospitals and hospices, substance use treatment and recovery programs, courts and other criminal justice settings, schools, primary healthcare centers, child welfare agencies, businesses, aging and rehabilitation services, employee assistance programs, nonprofit organizations, religious institutions, private practice, and the uniformed services.

Clinical social work focuses primarily on the mental, emotional, and behavioral well-being of individuals, couples, families, groups, organizations, and communities. It centers on a holistic and systematic approach to psychotherapy and the client’s relationship to their environment. Clinical social work views the client’s relationship with their environment as essential to treatment and care planning—from assessment and diagnosis to treatment and follow-up.

Clinical social work is a regulated professional practice. Clinical social workers must meet and maintain the minimum requirements of practice while adhering to local tribal/state jurisdictions and federal regulations.

Clinical social work is broadly based and addresses the needs of individuals, families, couples, groups, communities, and psychosocial systems affected by life changes and challenges in various areas of functioning, including mental, behavioral, and physical health conditions. Clinical social workers seek to provide essential services in the environments, communities, and psychosocial systems that affect the lives of the people they serve.

Clinical social workers are committed to the delivery of competent services to individuals, families, couples, and groups. Therefore, they shall recognize the client’s role in his or her treatment planning and the client’s right to have a knowledgeable, skilled practitioner who is guided by sound ethical practice. These Standards for Clinical Social Work Practice set forth by the National Association of Social Workers (NASW) are intended to guide clinical social workers in all clinical settings. Specifically, the goals of the standards are to: n maintain or improve the quality of services provided by clinical social workers n establish professional expectations to assist social workers in monitoring and evaluating their clinical practice provide a framework for clinical social workers to assess responsible, professional behavior inform consumers, government regulatory bodies, and others about the professional standards for clinical social work practice.

The scope of clinical social work extends across many practice settings and populations. It is anticipated that these standards will reinforce and support current clinical practice in all settings, while affirming the value of clinical social work services as a discrete practice area.

Goals of the Standards

Clinical social workers are committed to the delivery of culturally competent services to individuals, families, couples, groups, communities, and social systems. Therefore, in practicing cultural humility, clinical social workers should recognize the client’s role in treatment/care planning and the client’s right to have a knowledgeable, skilled, caring, responsive, and compassionate practitioner who is guided by ethical, evidence-based research; comprehensive clinical assessment; client-centered treatment; and holistic practice.

These standards for clinical social work practice set forth by NASW are intended to guide clinical social workers in all areas of specialization and clinical settings. Specifically, the goals of the standards are to

• maintain and improve the quality of services provided by clinical social workers.
• establish professional expectations and guidelines to assist social workers in monitoring and evaluating their clinical practice.
• provide a framework for clinical social workers to assess and perform responsible and ethically sound professional behavior.
• inform consumers, government regulatory bodies, and others about the professional standards for clinical social work practice.
• encourage engagement in lifelong learning to continually improve and update social work theory, knowledge, methods, and skills to remain relevant, effective, and responsive to clients’ needs in a rapidly changing society.

The scope of clinical social work extends across many geographic regions, practice settings, and populations. It is anticipated that these standards will inform, reinforce, enhance, and support current and future evidence-based research and client-centered clinical practice in all settings, while affirming the value of clinical social work services as a discrete and efficacious practice area.

Standards for Clinical Social Work in Social Work Practice

Standard 1. Ethics and Values

Clinical social workers shall adhere to the values and ethics of the social work profession, utilizing the NASW (2021) Code of Ethics as a guide to ethical decision making.

Interpretation

The social work mission is rooted in six core values: service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence (NASW, 2021). All social workers have a responsibility to embrace these values as a service to clients, the profession, self, colleagues, and society.

In delivering clinical social work services, the social worker’s primary responsibility is to their client. It is also important to note the clinical social worker may see clients who are mandated for treatment and need to meet the demands of the institution that mandates the treatment with ethical responsibilities to the client. An example of this would be a clinical social worker who is contracted to provide services for a criminal justice agency.

Clinical social workers shall acknowledge the right of clients to receive competent services and demonstrate a commitment to act on professional judgment, knowledge, and trainings, which are informed by the current NASW Code of Ethics.

Clinical social workers shall be prepared for the challenges that encompass the assessment and treatment of people with various emotional, behavioral, and/or psychiatric conditions. This includes maintaining a commitment to the client while simultaneously demonstrating responsibility to the practice setting, society, policies, and regulations governing the clinical social worker’s practice. In the event that conflicts arise among competing interests, social workers are directed to the Code of Ethics as one of the reference points for decision making. Services should only be provided in a setting where the boundaries of the professional relationship can be maintained. Clinical social workers should adhere to the Code of Ethics with regard to limits on private and/or dual relationships with clients and determine when referral is appropriate in accordance with Standard 3.

Standard 2. Specialized Practice Skills and Interventions

Clinical social workers shall demonstrate the knowledge, skill, and ability to effectively intervene with the population and client configuration to whom they are providing clinical social work services.

Interpretation

Drawing on knowledge of evidence-based practices and community standards of care, clinical social workers shall be familiar with psychosocial, environmental, cultural, and health factors that influence the mental, emotional, and behavioral functioning of the client configuration with whom they are working.

Additionally, clinical social workers shall have the ability to

• establish and maintain a relationship of mutual respect, acceptance, and trust.
• gather and interpret social, personal, environmental, and health information.
• evaluate and treat problems in their scope of practice.
• establish achievable treatment goals with the client.
• facilitate cognitive, affective, and behavioral changes consistent with treatment goals.
• evaluate the effectiveness of treatment services provided to the client.
• identify appropriate resources and use assessment instruments, as needed.
• advocate for client services.
• collaborate and work effectively with social workers and other professionals, when appropriate.

When additional knowledge and skills are required to address clients’ needs, the clinical social worker shall seek when appropriate training, supervision, or consultation, or refer the client to a professional with the appropriate expertise. Clinical social workers shall limit the scope of their practice to clients whom they have the knowledge, skill, and resources to serve.

Standard 3. Referrals

Clinical social workers shall be knowledgeable about community services and make appropriate referrals, as needed.

Interpretation

To ensure that clients receive optimal psychosocial services, it may be beneficial to collaborate or coordinate services with appropriate community programs to strengthen or improve the continuity of care. Clinical social workers shall be knowledgeable about available community resources. When appropriate, clinical social workers shall advocate on behalf of the client for appropriate services. The clinical social worker shall maintain collaborative contacts with social workers or other related professionals and make appropriate referrals, as needed. They should not share information about the client without the client’s informed consent or as otherwise indicated in Standard 5. Clinical social workers must be familiar with emergency services where the client is located.

Standard 4. Accessibility to Clients

Clinical social workers shall be accessible to their clients.

Interpretation

Social workers have an ethical responsibility to help people in need and address social issues (NASW, 2021). Given the many challenges people face with accessing healthcare services, it is crucial for clinical social workers to provide psychotherapy during scheduled sessions and have an emergency plan in place for situations when they are unavailable. In addition, clinical social workers shall also develop a plan for clients in the event of vacations, pandemics, natural disasters, inclement weather, holidays, illnesses, and at other times when the office may be closed. Arrangements or plans and procedures for emergencies, virtual clinics, or telehealth coverage shall be made in partnership with competent mental health professionals or reputable institutions.

Levesque et al. (2013) identified five dimensions of accessibility that are applicable to healthcare settings: approachability, acceptability, availability and accommodation, affordability, and appropriateness. The first step in accessing the healthcare system is the identification of needs. Seeking services, reaching services, obtaining services, and having that need fulfilled are also central to the process (Levesque et al., 2013). The healthcare setting shall therefore be accessible and have helping/assistive devices as appropriate.

The accessibility standards issued under the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and Section 1557 of the Patient Protection and Affordable Care Act of 2010 all prohibit discrimination based on disability. These statutes together require healthcare providers to make reasonable modifications in policies and practices and provide auxiliary aids and services when necessary to facilitate effective communication. All office policies should be discussed with the client prior to providing services.

The office setting shall be physically accessible and provide a safe environment. When providing services virtually, clinical social workers shall ensure that clients have guidance on what to expect, as well as the capability and resources to access the telehealth platform. In accordance with the ADA (1990), any office limitations should be discussed prior to scheduling appointments.

Standard 5. Privacy and Confidentiality

Clinical social workers shall maintain adequate safeguards for the private nature of the treatment relationship.

Interpretation

Confidentiality is a basic principle of social work intervention and is a cornerstone of creating safe therapeutic relationships because it ensures the client that what is shared with the social worker will remain confidential. Information related to or obtained from the client by the clinical social worker is viewed as private and confidential. Clinical social workers are often mandated reporters and shall be familiar and comply with mandates governing privacy and confidentiality, such as the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) rules and state laws. The NASW (2021) Code of Ethics standard 1.07 also requires social workers to respect clients’ right to privacy and to protect the confidentiality of all information obtained while providing professional services.

Clinical social workers should explain the ethical and/or legal limitations of confidentiality at the beginning of and throughout treatment, so the client has a clear understanding of what confidentiality means. There may be other exceptions to confidentiality as required by law or professional ethics, such as mandates to report when the client is a danger to self or others and for reporting child or elder abuse and neglect. The client may choose to give informed consent for the clinical social worker to release or discuss the information with another party to facilitate support, treatment, and collaboration of care. Clinical social workers should discuss potential situations where information would be shared without the client’s permission.

Professional judgment in the use of confidential information shall be based on best practice, as well as legal and ethical considerations.

Standard 6. Supervision and Consultation

Clinical social workers shall maintain access to professional supervision and/or consultation.

Interpretation

Clinical social workers receive guidance through supervision and/or consultation. The purpose of supervision is to provide education, accountability, and direction to supervisees. Supervisors are responsible for the work of their supervisees, whereas consultants are not responsible for the work of their consultees. The consulting relationship is not hierarchical. Clinical social workers may provide consultation to colleagues who are seeking recommendations on specific issues. Both supervisors and consultants provide guidance to those who seek supervision or consultation.

Clinical social workers should ensure that professional social work supervision is available to them in a clinical setting. If a supervisor is not available or accessible, case consultation may be obtained from qualified professionals of other related disciplines. Clinical social workers may continue to use consultation on an as-needed, self-determined basis. In addition, clinical social workers shall adhere to statutes and regulations regarding supervision and consultation in their states of practice, as well as the Best Practice Standards in Social Work Supervision (NASW & Association of Social Work Boards [ASWB], 2013) relating to supervisor and supervisee responsibilities and accountability.

Clinical social workers may offer their expertise to individuals, groups, and organizations, as well as offer training and mentoring opportunities to novice social workers or those making the transition into clinical social work. Supervisors should abide by any state or jurisdiction standards for approved supervision.

Standard 7. Professional Environment and Procedures

Clinical social workers shall maintain professional work environments, policies, and procedures.

Interpretation

Agencies providing clinical social work services and clinical social workers in private practice shall develop and implement written policies that describe their office or work environment procedures, such as the client’s rights, including the right to privacy and confidentiality; limits to confidentiality; required notices and authorizations; procedures for release of information; fee agreements; procedures for payment; cancellation policy; termination procedures; technology, social media, and telehealth policies; coverage of services during emergency situations or when the clinical social worker is not available; and contact information for the appropriate licensing board. These policies shall be made available to and reviewed with each client prior to beginning services. Clinical social workers shall maintain appropriate professional liability insurance and have a current working knowledge of risk management issues.

Additionally, the work environment shall be properly maintained to ensure a reasonable degree of comfort, privacy, and security for the social worker and clients. In-person settings shall meet all local tribal/ state jurisdictions and federal as well as local requirements regarding posting notices and professional licenses. If services are provided via telehealth, clinical social workers must meet any licensure requirements of the jurisdiction where they are licensed and the jurisdiction where the client is physically located. Clinical social workers shall also verify the rules and regulations of their professional liability insurance and thirdparty payers to confirm that telehealth services are covered.

Standard 8. Documentation

Documentation of services provided to, or on behalf of, the client shall be recorded in the client’s file or clinical record.

Interpretation

Clinical social workers must document services rendered to clients and keep the notes in a secure location, maintaining them as private and confidential records. Documentation, to meet their regulatory responsibilities under HIPAA, may include assessment and diagnosis, treatment plan goals, interventions, and other communications such as phone calls, emails, or relevant clinical conversation outside of the treatment milieu. Documentation shall be recorded after each encounter and be consistent with all applicable requirements around record retention (Hayes, 2024).

It should be noted that there is a difference between progress and psychotherapy notes. Progress notes document the client’s response to treatment and are required in the clinical record. These notes are subject to the HIPAA Privacy Rule and can include details such as the start and stop times of counseling sessions, medication prescriptions and monitoring, treatment modalities and their frequencies, and clinical test results. Additionally, they provide a summary of the patient’s diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date (Hayes, 2024).

Psychotherapy notes are 

notes recorded 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 patient’s medical record. Psychotherapy notes do not include any information about medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, or results of clinical tests; nor do they include summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. (U.S. Department of Health and Human Services [HHS], n.d., p. 2) 

If a clinical social worker would like to keep psychotherapy notes, they must be in a secure file separate from the clinical record (NASW, 2022). Clinical social workers should refer to laws regarding important exceptions to psychotherapy notes and HIPAA.

Standard 9. Independent Practice

Clinical social workers, when licensed to do so by state/jurisdiction laws, shall have the right to establish an independent practice.

Interpretation

Clinical social workers may establish an independent solo or group practice. When doing so, they shall ensure that all services, including diagnoses and treatment planning, meet professional standards. When clinical social workers employ staff, they, as employers, bear responsibility for the competency of all services provided, maintaining clinical and ethical standards.

To avoid conflicts of interest, clinical social workers who are both employed by agencies and have independent practices shall not refer agency clients to themselves without prior agreement with the agency and informed consent of the client. As part of informed consent, clinical social workers should provide clients with all available options, including but not limited to transferring the client to another treatment provider in or outside of the agency, referrals to other appropriate treatment providers, and/or terminating services and supporting the client in choosing the option most appropriate for them.

Clinical social workers in private practice may bill third-party payers or their clients for services rendered. Clients shall be provided with all invoices and receipts in a timely manner. When a client can no longer afford services—or a third-party payer or an agency terminates services— reasonable efforts should be made to identify alternatives with the client. For example, a referral, termination of services, a sliding scale, or pro bono services could be offered. If services continue, consideration must be given to any applicable laws and regulations as well as insurance or managed care contracts that may limit the type of continuing care.

Standard 10. Cultural Competence

Clinical social workers shall demonstrate culturally congruent and inclusive service delivery in accordance with the NASW (2015) Standards and Indicators for Cultural Competence in Social Work Practice . An increasingly growing diverse population seeking clinical supports requires that clinical social workers optimize and commit to diversity, equity, and inclusion to ensure individuals, families, groups, and communities are provided with opportunities to grow. Clinical social workers shall acknowledge clients as experts of their own lived experiences.

Interpretation

Culture is conceptualized as the shared values, norms, traditions, customs, arts, history, folklore, and institutions that influence a group of people; a learned internalized perspective that is central to that person’s identity implicitly and explicitly; and underlying expectations from the individual and the group.

Understanding culture requires

• a willingness to examine and grasp its many elements and to comprehend how they come together.
• increasing knowledge of the values, beliefs, customs, behaviors, traditions, institutions, arts, folklore, and lifestyles.
• enhancing cross-cultural knowledge, understanding, and application of differences through self-reflection in race, gender, religion, sexual orientation, ethnicity, nationality, socioeconomic status, language, disability, religion, history, traditions, beliefs, values, worldviews, lived experience, geographic regions, and family systems as they relate to clinical practice with individuals, families, groups, and communities.
• sensitivity to intersectional sociocultural trauma and a complex understanding of the institutional and societal context along with culturally congruent clinical responses for effective therapeutic outcomes.

Equity is the active process of identifying and eliminating the structural barriers related to race, class, disability, and gender. Equity requires understanding the root causes of disparities and identifying the barriers to inclusion, particularly as they apply to historically underrepresented groups in our society. Equity works to ensure justice, access, opportunity, and advancement for individuals in the policies, practices, procedures, processes, and distribution of resources by institutions, systems, and clinical services.

Clinical social workers shall foster inclusion and belonging through creating inviting environments based on policies and practices. They must also be self-aware of personal biases that may be interpreted as a barrier to treatment. Clinical social workers shall be knowledgeable about diverse groups and apply appropriate practice skills. Inclusion is the intentional act to include differences and create a therapeutic environment where any individual or group is welcomed, respected, supported, valued, and given the opportunity to fully participate. Inclusion fosters a sense of belonging through centering, valuing, and amplifying the voices and perspectives of all individuals and includes eliminating practices and behaviors that marginalize groups of people or individuals.

Antiracism means actively resisting and dismantling the existing system of racism to obtain racial equity. It involves acknowledgment of the existence of racism throughout history including in the social work profession. Clinical social workers must take a stand against racial hatred, bias, violence, systemic racism, and the oppression of specific groups on individual, interpersonal, institutional, and structural levels. In clinical practice, clinical social workers shall demonstrate cultural humility by applying critical reflection, self-awareness, and self-regulation to manage the influence of bias, power, privilege, and values in working with clients and constituencies.

Standard 11. Professional Development

Clinical social workers shall assume personal responsibility for and are obligated to engage in continuing professional development across the entirety of their career.

Interpretation

Competent, ethical, evidence-based, and effective practice is actuated through the clinical social worker’s continuing professional development efforts. Clinical social workers are obligated to routinely engage in approved continuing education opportunities. These professional development opportunities shall reinforce foundational knowledge, ethics, and skills for social work practice—and they shall provide comprehensive professional development related to emerging theories and interventions; enhancing cultural diversity, equity, and inclusion; endorsing compliance with existing and new standards of care in the social work profession; and confirming changes to policies and regulatory reforms. Clinical social workers must stay abreast of research in social work and their related areas of specialization to ensure that their practice aligns with evidence-based knowledge, skills, and interventions. Clinical social workers are additionally obligated to maintain currency with state (and other relevant authorities’) regulations around the definition and scope of clinical social work practice. Areas in which clinical social workers should maintain currency in their continuing education efforts include the following:

• Reporting requirements related to vulnerable populations
• HIPAA
• Part 2—Confidentiality of Substance Use Disorder Patient Records (42 C.F.R., 2017)
• Technology, telehealth, and electronic health records (EHRs)
• Risk management and liabilities
• Interprofessional and emerging science in specialized areas of practice
• Implicit personal biases, knowledge of social and health inequities across populations, and best practice standards in working with cultural differences and diverse clients
• Federal and state statutes and regulations regarding social work practice

Reliable and valid opportunities for professional development are available through NASW as well as other professional organizations, institutions, and agencies. Clinical social workers shall regularly engage with advancing the profession through attending, providing, and participating in professional conferences or continuing education trainings and contributing to social work education (e.g., as faculty), field education (e.g., as a field instructor), or professional or scholarly publications.

Standard 12. Technology

Clinical social workers shall have access to computer technology and the internet, as the need to communicate via email and to seek information on the internet for purposes of education, networking, and resources is essential for efficient and productive clinical practice. Clinical social workers who provide telehealth services shall be knowledgeable of all rules and regulations that govern the jurisdiction in which the social worker and client are located. Clinical social workers shall be transparent and technologically knowledgeable about using artificial intelligence (AI), as well as the use of applications, avatars, and metaverse in psychotherapy assessment and treatment.

Interpretation

The NASW, ASWB, CSWE, & CSWA Standards for Technology in Social Work Practice (NASW et al., 2017) has become the standard for how technology is used in social work practice. The major areas covered in the standards include provision of information to the public; designing and delivering services; gathering, managing, and delivering information; and social work education and supervision through videoconferencing. Use of technology to provide treatment also requires an informed consent form that outlines the limits of communication to include email, texting, and social media. A videoconferencing platform that is HIPAA compliant (i.e., provides a business associate agreement) should be used. Payment for services should include a platform that is encrypted and password protected. Clinical social workers also have an ethical responsibility to safeguard their client’s protected health information when storing their records using a HIPAA-compliant EHR.

Clinical social workers shall also be aware of the benefits and risks associated with using technology. When providing telehealth, clinical social workers shall educate clients on the benefits and risks while assessing appropriateness for services. It is imperative that clinical social workers have a clear understanding of the way matters of diversity, equity, and inclusion are impacted in the use of technology. Some clients are not skilled in the use of technology in ways that maintain confidentiality and do not have access to a computer or smartphone with video capacity. Alternative options such as in-person visits or provider referrals should be offered to clients when virtual services are not appropriate. Audio-only treatment is another option for clinical social workers. Finally, new ways of receiving treatment from clinical social workers through technology are in need of evaluation and should be approached with caution, with each client’s needs carefully considered.

Clinical social workers who use technology to provide services must be aware of the ethical guidelines, standards of care in their professional community, and any regulations that impact the use of technology-based services.

As AI continues to evolve, clinical social workers should exercise judgment in incorporating it into practice and should also stay informed on AI advancements and their practice implications. AI can negatively impact privacy, confidentiality, and the medical record. Ethical issues in using AI in the clinical social work setting also include client autonomy, transparency, and algorithmic bias (Reamer, 2023). The NASW (2021) Code of Ethics states that social workers should respect the dignity of the client, maintain confidentiality, and obtain informed consent. These ethical principles are also applicable when using AI-based interventions. While AI tools such as chatbots for mental health and predictive analytics in risk assessment may improve service delivery, careful oversight is needed to avoid unintended harm to clients and protect the quality of care. NASW, ASWB, CSWE, & CSWA Standards for Technology in Social Work Practice (NASW et al., 2017) also emphasizes that AI should not replace human judgment and clinical decision making. Clinical social workers should ensure that the AI tools employed are ethical and client focused and do not perpetuate systemic biases or limit access to equitable care.

Standard 12. Termination

Clinical social workers shall prepare clients for termination of services.

Interpretation

Clinical social workers shall consider termination of services as an ethical and necessary procedure with clients. Termination can occur for a variety of reasons. If a client has met all treatment goals and is no longer in need of services, the clinical social worker shall prepare them for termination. If a client’s treatment ends prior to attaining their treatment goals, the clinical social worker shall follow policies and best practices regarding engagement for follow-up. When appropriate, the clinical social worker shall refer the client to another qualified treatment provider.

If a clinical social worker leaves a role, agency, or private practice prior to achieving treatment goals, the clinical social worker shall provide both the agency (if treatment setting) and clients with reasonable notice, when possible. The clinical social worker should discuss issues surrounding termination in the therapeutic setting as appropriate and provide clients with information regarding the process (the transfer of the clients to another treatment provider in the agency or referrals to providers outside of the agency).

Glossary

ANTIRACISM. Actively resisting and dismantling the existing system of racism to obtain racial equity. Antiracism involves acknowledgment of the existence of racism throughout history, including in the social work profession.

CLIENT/PATIENT/CONSUMER. Social workers generally use the term “client” to refer to the individual, group, family, or community that seeks or is provided with professional services. The client is often seen as both the individual and the client system or those in the client’s environment. The term “patient” is more commonly used by social workers employed in healthcare settings. The term “consumer” is also used in settings that view the client as the consumer—that is, one capable of deciding what is best for them—and encourages self-advocacy and self-judgment in negotiating the social services and welfare system (Barker, 2014), and may also be used for insurance reimbursement purposes in health, mental health, and substance use settings.

CLINICAL SOCIAL WORK. The professional application of social work theory and methods to the treatment and prevention of psychosocial dysfunction, disability, or impairment, including the diagnosis and treatment of people with various mental, emotional, and behavioral health conditions and disorders (Barker, 2014).

EQUITY. This is an active process of identifying and eliminating structural barriers related to factors such as race, class, disability, and gender. It involves understanding the root causes of disparities and identifying obstacles to inclusion, especially for historically underrepresented groups in society. Equity aims to ensure justice, access, opportunity, and advancement for individuals in the policies, practices, procedures, processes, and distribution of resources by institutions, systems, and clinical services.

INCLUSION. This is the deliberate act of embracing diversity and creating a therapeutic environment where all individuals or groups are welcomed, respected, supported, valued, and given the opportunity to fully participate. Inclusion promotes a sense of belonging by centering, valuing, and amplifying the voices and perspectives of all individuals, and involves the elimination of practices and behaviors that marginalize certain groups or individuals.

PROGRESS NOTES. Notes are a required part of the clinical record that include details about the services rendered to clients. Information in progress notes may include counseling session start and stop times; response to treatment; medication prescription and monitoring; treatment modalities and frequencies; clinical test results; and a summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. Importantly, progress notes are subject to the HIPAA Privacy Rule, ensuring they meet certain standards for privacy and confidentiality (Hayes, 2024).

PSYCHOTHERAPY. A specialized, formal interaction between a social worker or other mental health professional and a client (either individual, couple, family, or group) in which a therapeutic relationship is established to help resolve symptoms of mental disorder, psychosocial stress, relationship problems, or difficulties in coping in the social environment. Types of psychotherapy include, but are not limited to, family therapy, group therapy, cognitive–behavioral therapy, psychosocial therapy, and psychodrama (Barker, 2014).

PSYCHOTHERAPY NOTES. Notes recorded by a healthcare 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 individual’s medical record. Psychotherapy notes exclude medication prescription and monitoring; start and stop times of counseling session; the modalities and frequencies of treatment; clinical test results; or any summary of the diagnosis, functional status, treatment plan, symptoms, prognosis, or progress to date (HHS, n.d.).

TELEHEALTH. The practice of delivering clinical healthcare services via technology-assisted media or other electronic means between a practitioner and a client who are located in two different locations. The term “telemental health” is another way of describing the same practice.

THERAPY. A systematic process designed to remedy, cure, or abate some disease, disability, or problem. This term is often used by social workers as a synonym for psychotherapy, psychosocial therapy, or group therapy (Barker, 2014).

References

Americans with Disabilities Act of 1990, P.L. 101-336, 104 Stat. 327 (July 26, 1990).

Barker, R. L. (2014). The social work dictionary (6th ed.). NASW Press.

Hayes, J. (2024, January). Psychotherapy notes. National Association of Social Workers, Legal Defense Fund. https://www.socialworkers.org/About/Legal-Defense-Fund/Legal-Issues/Social-Workers-and-Psychotherapy
-Notes

Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, 110 Stat. 1936 (August 31, 1996).

Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centered access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12, Article 18. https://doi.org/10.1186/1475-9276-12-18

National Association of Social Workers. (2015). Standards and indicators for cultural competence in social work practice. Author.

National Association of Social Workers. (2021). Code of ethics of the National Association of Social Workers. Author.

National Association of Social Workers. (2022). Clinical social workers in private practice: A reference manual. Author.

National Association of Social Workers & Association of Social Work Boards. (2013). Best practice standards in social work supervision. Author.

National Association of Social Workers, Association of Social Work Boards, Council on Social Work Education, & Clinical Social Work Association. (2017). NASW, ASWB, CSWE, & CSWA standards for technology in social work practice. National Association of Social Workers.
Part 2—Confidentiality of Substance Use Disorder Patient Records, 42 C.F.R., 82 FR 6115 (January 18, 2017). https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2

Patient Protection and Affordable Care Act of 2010, P.L. 111-148, 124 Stat. 119 (March 30, 2010).

Reamer, F. (2023). Artificial intelligence in social work: Emerging ethical issues. International Journal of Social Work Values and Ethics, 20, 52–71. https://doi.org/10.55521/10-020-205

Rehabilitation Act of 1973, P.L. 93-112, 87 Stat. 355 (September 26, 1973).

U.S. Department of Health and Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved September 10, 2024, from https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf