Nasw procedures for professional review

Unethical Social Work: Comparing Licensing and NASW Perspectives

Michael R. Daley and Michael O. Doughty

Previously published studies of ethics complaints have been based primarily on records of the National Association of Social Workers (NASW). However, with the extension of legal regulation for social work throughout the country, state regulatory bodies are assuming an increasingly important role in reviewing the • ethical behavior of social workers, many of whom are not members of NASW. Yet, there has been little study of ethical complaints against this much larger group of social workers. This article examines ethics complaints filed between 1995 and 2003 against licensed social workers in Texas in order to better understand how ethics review in the public regulatory sector compares with that of NASW. Findings indicate some similarities between the two types of complaints in the areas of poor practice and boundary violations and differences between the two in reports of honesty and conflict-of-interest violations.

Introduction

For many years social work has been a leader among the professions in developing a strong ethical base for practice. The profession's commitment to ethical practice is formalized in ways that include the development of a strong and detailed code of ethics (NASW, 1999), integration of ethics content in social work education (CSWE, 2003), the development of a commitment to ongoing professional education including ethics (ASWB, n.d.-b; NASW, 2002), and the requirement in state licensing laws for continuing ethics education. These measures are designed both to promote ethical practice and to discourage the unethical practice of social work.

Yet, despite the importance of ethical behavior to the profession, surprisingly little empirical research into unethical practice and the associated behaviors has been done. Three studies examining violations of the NASW Code of Ethics (McCann & Cutler, 1979; Berliner, 1989; Strom- Gottfried, 2000) have been published since the late 1970s. Taken together, these studies provide a historical perspective by investigating ethical violations of the NASW Code of Ethics that occurred in the forty-three-year span from 1955 to 1997 and offer a good description and analysis of

Aretê, Vol. 30(2), 35-50 © 2007 Universitv of South Carolina

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unethical social work behavior and code violations. However, the landscape of ethics has changed over time, and NASW is

no longer the only entity reviewing the ethical behavior of social workers. The growth of legal regulation of the profession has now reached all 50 states, the District of Golumbia, Puerto Rico, and the Virgin Islands (ASWB, n.d.-b). Each entity that provides legal regulation has some code of ethics or conduct that guides the practice of social work. These codes of conduct may incorporate or parallel the NASW Gode of Ethics, but their primary intent is protection of the public, as opposed to defining principles to guide practice (ASWB, n.d.-b; Strom-Gottfried, 2003).

The research on ethics complaints reported to state social work licensing boards is even less well developed than NASW-based studies of professional ethics reviews. Only one published study of ethics complaints filed with a state regulatory body was identified, and it appears to differ in complaint profile from NASW-based data (Kinderknecht, 1995). Furthermore, no comparison of NASW and public regulatory ethics complaints has been undertaken.

The regulation of unethical behavior by social work boards is an important avenue for investigation for three reasons. First, NASW membership currently represents only a fraction of social work practitioners in the United States. The Department of Labor estimated that in 2004 there were 562,000 social workers in the United States, while NASW reports a membership of 153,000, or 27.2% of the total (U.S. Dept. of Labor, 2004; NASW, 2006). The NASW membership may not be entirely representative of the profession in another way, as only about 5% of NASW members have a BSW as the highest degree (Gibelman & Schervish, 1993). Thus, ethics data drawn exclusively from NASW members may not give the entire picture of what is happening across the profession. Second, the process of ethical review of social workers may be changing. With the growth of legal regulation of the profession, state entities have increasingly assumed primary responsibility for the investigation of ethical complaints. Third, relatively little research on ethical violations as determined by the social work regulatory entities has been conducted. As a result of these factors, the published studies on ethical complaints in social work may represent only a partial picture of unethical practice for the whole profession.

If the profession is to follow through on its commitment to promote ethical practice, we should examine data on social workers who violate these standards, with the aim to address these violations more effectively and to protect the pubhc. This article reports on the results of a study of data collected from a state social work licensing board related to ethics

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complaints. Gomplaints filed with the Texas State Board of Social Worker Examiners (TSBSWE) from 1995 through 2003 are examined, compared with NASW studies of ethics complaints, and discussed in terms of the implications for addressing ethical social work practice.

Previous Research on NASW Ethics Complaint

In the most current and comprehensive examination of ethics complaints to date, Strom-Gottfried (2000) studied ethical complaints filed with NASW between 1986 and 1997. She reviewed 894 of the 901 complaints filed during that period. Her report documents that hearings were not held on 466 cases (52.1%) and that violations were found in 276 (62.3%) of the 428 cases that were heard.

Strom-Gottfried (2000) noted that in the 276 sustained cases, 785 different violations occurred under the 1979 NASW Gode of Ethics. For the purpose of analysis, she placed the violations in 10 categories: Violating Boundaries (32.4%), Poor Practice (20.4%), Competence (12.0%), Record Keeping (8.9%), Honesty (6.5%), Confidentiality (5.2%), Informed Consent (4.7%), Collégial Actions (4.2%), Reimbursement (2.9%), and Conflicts of Interest (2.8%). She also identified subcategories of these classifications that were used to provide detail and clarity in explaining her findings. With the exceptions of collégial violations and, to a lesser extent, record keeping, all of the categories identified by Strom-Gottfried (2000) relate to ethical violations that could negatively impact the social worker's professional relationships with and services provided to clients.

Berliner (1989) studied 292 ethics cases filed between 1979 and 1985, presumably, based on the 1979 NASW Gode of Ethics (NASW, 1979). He found that 58 (18.5%) were closed without a formal hearing, and allegations were sustained in 96 of 243 cases (41.5%). Of the 96 validated complaints, 19 violations of social worker responsibility to clients were found. These included 8 cases of sexual misconduct, 6 breaches of confidentiality, 3 cases of fee splitting, and 2 cases of soliciting another's clients.

Berliner (1989) also found evidence of a negative correlation between the number of complaints filed with NASW and the state regulation of social work practice. Gomplaints to NASW were more likely to come from states that did not regulate social work practice. This finding would tend to support the importance of examining complaint data from the state regulatory bodies. This finding may also be an early indicator of the current trend for many ethics complaints to go first to state regulatory bodies before being reviewed by NASW.

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McCann and Cutler (1979) reported on 154 ethics complaints filed with NASW between 1955 and 1977. Only 21 (13%) of these complaints dealt with the relationship between a client and a social worker, but the specific nature of these complaints was not identified. This low proportion of worker-client complaints may reflect the practice of NASW receiving agency personnel standards cases more frequently than is done currently. This study reported 10 violations of confidentiality and 8 sexual practices violations, which may be client related; however, both categories could include violations of other professional relationships. McCann and Cutler recognized that the official record of complaints they examined likely underestimated the actual number of violations due in part to the general nature of the Code of Ethics (NASW, 1969) at that time. The current code's ethical tenets and its public protection provisions are far more specific and detailed (NASW, 1999).

State Complaints

Unlike NASW, no comprehensive national data set exists on ethical complaints filed against state-regulated social workers. The Association of Social Work Boards (ASWB, n.d.-a) compiles and maintains a national Disciplinary Action Reporting System (DARS) that identifies social workers against whom action has been taken (ASWB, n.d.-a), but the information in this database does not appear to have been used in social work ethics research. Much of the specific information on violations of social work ethics regulated by the states must be obtained from the regulatory body that took the action.

Only one published study of social work complaints filed with a state regulatory body was identified. Kinderknecht (1995) examined 252 complaints filed against social workers with the State of Kansas Behavioral Sciences Regulatory Board from 1980 through 1994. Kinderknecht's study classified complaints in four categories, including conduct and comportment, client-related, colleague-related, and employer/social work profession. Though most of the complaints contained multiple allegations, she limited her analysis to the "presenting or focal complaint" (p. 271). She found that 54.8% of the complaints were client-related, 19% were conduct and comportment, 15.1% were employer/social work profession-related, and 11.1% were colleague-related.

Kinderknecht (1995) analyzed the client-related complaints in her study and found that 26.1% of the violations related to reporting false or misleading information about the client. This type of complaint parallels

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Strom-Gottfried's (2000) honesty category, which addressed fraudulent actions and intentional misrepresentation but contained only 6.29% of the complaints. Kinderknecht found that 23.2% of the complaints involved sexual advances or impropriety and that 17.4% were for breaches of confidentiality, while Strom-Gottfried's figures were 32.4% and 5.2%, respectively. The Kansas study also found that 13.8% of ethics complaints were for discrimination, 6.5% were for undue influence, 6.5% were for abandonment, 5.1% were for conflicts of interest, and 1.4% involved failure to terminate.

These variances between state regulatory data and that from NASW could indicate a number of things, including inconsistencies in the unethical practices between state-licensed social workers and NASW members,. regional differences in reporting, changes occurring in the five years that elapsed between the two studies, or differing research methodologies used by the two authors. Strom-Gottfried examined all the alleged violations in sustained cases. Kinderknecht (1995) looked only at the primary allegation in all complaints that went to a hearing, without regard to its final disposition.

The present study takes advantage of the previous research to explore these differences further. Using data from complaints filed with TSBSWE between 1995 and 2003, this study presents its findings utilizing violation categories developed by Strom-Gottfried (2000) to facilitate comparison of complaints against licensed social workers in Texas versus those filed against NASW members and to examine the similarities and differences.

Method

The authors analyzed complaint data on 594 cases filed with TSBSWE from 1995 through 2003. TSBSWE licensed approximately 23,000 social workers at multiple levels during this time period. Complaint data is maintained on the board's computer tracking system, which processes all applications, examinations, licensing actions, renewals, and complaints. The database includes information on the licensing law and rules that social workers were alleged to have violated.

TSBSWE uses a code of ethics that parallels, but is not identical to, the NASW Code of Ethics (1999) section that addresses worker-client relationships. TSBSWE also operates under a set of administrative regulations that define a code of conduct for social workers. In applying the Texas Code of Ethics and the Code of Conduct, the sole purpose is public protection. The most significant difference between Texas licensing

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regulations and the NASW Code of Ethics is that Texas does not attempt to regulate a social worker's professional responsibilities beyond those to the client. The Texas Code of Conduct includes 13 specific standards of practice that parallel, but are not identical to, the NASW Code of Ethics. Generally the standards of practice in the Texas Code appear to be based on ethical standards from the NASW Code. However, the wording of the Texas standards of practice is more succinct and without as much explanation as is found in the NASW Code. The Texas Code of Conduct has specific sections addressing confidentiality, prohibition of sexual contact with clients, dual relationships, conflicts of interest, professional boundaries, professional competence, honesty, accuracy of billing, and termination of services. It also establishes basic standards of practice such as basing services on assessment, evaluation or diagnosis, and continuing evaluation of client progress (TSBSWE, 2004). In many respects, the Texas Code of Conduct is similar to section 1 of the NASW Code of Ethics, which addresses social workers' ethical commitment to clients (NASW, 1999). However, the Texas Code does not contain specific elements that address commitment to clients, self-determination, informed consent, cultural competence, access to records, or derogatory language. The Texas Code also adds provisions from sections 2 and 4 of the NASW Code of Ethics, which prohibit discrimination, require honesty, promote continuing education, encourage the use of supervision, and address impairment. Violation of the Texas Code of Conduct may result in an ethical complaint to TSBSWE.

When a complaint is received, each alleged violation of ethics or code of conduct is recorded based on an evaluation of the best available information. Any alleged ethical breach may be covered by more than one section or subsection of the regulations. In most cases, more than one alleged violation of the code is recorded for each complaint received.

A decision was made to compare the Texas licensing coniplaint data with those of Strom-Gottfried (2000) because the latter was the most comprehensive study of NASW ethics violations and the closest to the reporting period. We used the 10 violation categories that Strom-Gottfried developed for her study to classify the Texas licensing data and to facilitate comparison. These categories were violating boundaries, poor practice, competence, record keeping, honesty, confidentiality, informed consent, collégial actions, reimbursement, and conflicts of interest. In general, matching Texas violations to appropriate categories (Strom-Gottfried, 2000) was straightforward. In some cases, matching data to categories required explication of the wording of the complaint. Complaints that could not be matched to specific subcategories were placed in a general nonspecific

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violation category. Using this approach, matches between the Texas regulations and nine

violation categories were found. No matches were found for the collegia) actions category, which is not client-related and therefore not covered under Texas regulations. The authors did identify two types of allegations that could not be matched directly with Strom-Gottfried's violation categories. These violations were legal requirements for licensure and nonspecific ethics violations. These violations were excluded from the analysis since the first was not covered by the NASW Code and the other was too vague.

In the analysis of data, tables were created and used to categorize each of the alleged violations cited in 594 complaints filed with TSBSWE from 1995 through 2003. The findings for each of the violation categories are presented and compared with the earlier research, noting, where appropriate, the differences between the NASW Code and the state regulations. Conclusions are drawn from the comparisons, and recommendations for future research are made.

Results: Reported Licensing Violations

Within the 594 complaints, there were 2,139 specific allegations of violations of Texas licensing law or the Gode of Gonduct, ranging from very specific charges such as practicing without a license or having sexual relations with a client to vague allegations such as unethical conduct or conduct that discredits the profession. Five hundred individuals were named in the complaints. The complaint rate was only 0.24% of the 23,000 licensed social workers per year over the nine-year period, a relatively low rate.

Of the 500 social workers, 428 had a single complaint, 56 had two complaints, 12 had three complaints, 3 had four complaints, and 1 had six complaints during the nine years covered by the study. Only the complaints alleged were analyzed, as information on dispositions was not in the database. Gomplaint data were reviewed, and complaints were categorized using Strom-Gottfried's (2000) classification in order to facilitate comparison with her research on NASW. The results of this study's analysis of ethical complaints lodged with the Texas State Board of Social Worker Examiners are reported in Table 1 alongside those of NASW (Strom- Gottfried, 2000).

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Table 1: Ethical Complaints by Citation Category

Citation Category

Poor practice Boundary violations Honesty Conflicts of interest Breach of confidentiality Competence Informed consent Record keeping Billing Total

n

310

291

198

158

131

107

65

65

64

1,389

Texas %

22.3 21.0 14.3 11.4 9.4

7.7

4.6

4.7

4.6

100.0

Rank 1 2

3 4 5 6 7 8 9

n

160 239

51 22

41

94 37 70 23

737

NASW %

21.7 32.4

6.9

3.0

5.6

12.8 5.0

9.5

3.1

100.0

Rank 2 1

5

9 6 3 7 4 8

Poor Practice

Practice, as used here, refers to the activities directly related to the provision of services to clients from initial assessment to termination. Standards of practice are based on a conception of what is reasonable or normal within the profession, and poor practice covers actions and omissions that do not conform to the concept of standard practice. Specific behaviors identified in this category included failure to use accepted treatment methods, misapplying self-determination, yelling at a client or using derogatory language, using inappropriate techniques, and failing to follow accepted processes for termination or transfer (Strom-Gottfried, 2000).

In this study, 22.3% of reports for ethics violations fell into the poor practice category. This proportion of poor practice is consistent with findings of Strom-Gottfried (2000), who found poor practice in 21.7% of the NASW cases examined. Poor practice complaints were examined further using subcategories developed by Strom-Gottfried (2000). Within this category, 53.9% of the Texas complaints were general, 31.6% were ior failure to use accepted practice skills, 11.3% were for prolonged care, and 3.2% were for failure to act regarding child abuse.

Boundary Violations

Business and social relationships with a client outside the treatment

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setting are potentially harmful to the client and to the professional relationship. Because outside contact with clients presents a potential risk to clients, social workers must discuss potential boundary issues with clients and develop a plan to "set clear, appropriate, and culturally sensitive boundaries" (NASW, 1999). The boundary violation category included behaviors such as inappropriate physical contact with clients, pursuit of a sexual relationship, social relationships, bartering, business partnerships, and other exploitive relationships.

In Texas reports, 21% of the complaints were classified as boundary violations. The violations in this category were split between dual relationships (62%) and sexual relations (38%). Specific dual relationship complaints were primarily linked to two types of violations, business relationships and supplying drugs or alcohol. The Texas sexual relations reports include contact with clients prior to, during, and after treatment.

Strom-Gottfried (2000) found the highest percentage of ethics violations within the boundary violations category (32.4%), with dual relationships at 30.3%, sexual relationships at 42.1%, and more general boundary violations at 27.6%. While boundary violations were a significant source of complaints in both studies, Strom-Gottfried found significantly higher percentages of boundary violations.

Honesty

Public perception of the integrity of the social work profession is critical to its members. Clients and the public must believe in the basic honesty of a social worker to enter into and maintain working relationships with the social worker. Any action by a social worker that raises questions about her or his honesty threatens that relationship and the public trust. This category included both intentional misrepresentations and fraud.

Our data indicated that the honesty category had the third-highest percentage of violations (14.3%), most of which (50.5%) were general. Intentional misrepresentations (48.5%) accounted for most of the remainder, with 1% being fraudulent actions. The honesty category was ranked lower (fifth) in Strom-Gottfried's study, with only 6.9% of the violations.

Conflicts of Interest

The NASW Code of Ethics (1999) states, "Social workers elevate service to others above self-interest." Thus, practice decisions based primarily on the interests of the social workers, rather than the clients, are unethical. This category included behaviors in which the needs of the social workers or the

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social workers' organizations came in conflict with the needs of the clients. Often these infractions involved allegations of conflicting relationships between social workers and members of the clients' families. In this study, 11.4% of the complaints were for conflicts of interest. This ranked fourth in frequency among the categories. Within this category 90.5% of the violations alleged conflict between the social worker and the client, and 9.5% alleged denial of care. The conflict of interest category ranked last in Strom- Gottfried's (2000) study with only 3% of the reported violations. Conflicts of interest frequently involve conflicts between the clients' needs and those of the employing organizations (Strom-Gottfried, 2000), as is the case with the Texas data.

Breaches of Confidentiality

Both legal and ethical tenets affirm the client's right to privileged communications. It is the social worker's responsibility to respect and protect that privilege. Allegations of confidentiality violations included revealing confidential information w îthout the client's consent, failure to obtain adequate consent for shared information, and issues related to duty to warn (Strom-Gottfried, 2000). The breach of confldentiality category ranked fifth in frequency at 9.4% in our study versus sixth in Strom-Gottfried's study with 5.6% of violations.

Competence

The criteria for licensure established by state agencies are designed to screen for competency through requirements such as academic degrees, examination scores, references, experience, and supervision in an effort to assure that licensees possess the minimum entry-level knowledge and skills necessary for safe practice. Here the provisions of the Texas Code of Conduct are similar to the provisions of the NASW Code of Ethics standard 1.04 (a). Allegations of competency violations included lack of competency due to impairment, inadequate professional preparation, and failure to use supervision appropriately. Competency violations were ranked sixth in percentage of complaints at 7.7% in this study, as opposed to Strom- Gottfried's (2000) study, in which it ranked third with 12.8% of the violations. Although the Texas standards of practice lack the specificity of the NASW Code, they are very close to the NASW ethical standards 1.04 (a), 1.04 (b), and 4.05 in the competency category. In the present study, competency violations could be classified as insufficient education or training at 65.6%, practitioner impairment at 13.1%, and substance abuse with 1.9% of the

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complaints. The remaining 19.4% of the complaints were too general to classify.

Informed Consent

Full knowfledge of the nature and potential consequences of proposed services is necessary for a client to give informed consent to care. Alleged behaviors related to informed consent weve failure to discuss fees or polices with the client, obtaining consent from an inappropriate source, and taking actions after the clients objected to them. Informed consent ranked seventh in our study with 4.6% of the complaints and is similar to Strom-Gottfried's (2000) findings, where 5% of the violations occurred in this category. Specifically, our data indicated that all informed consent complaints were for failure to discuss policies adequately with clients.

Record Keeping

Case records are intended to document what and how services are provided, and keeping accurate records is generally viewed as a means of protecting the social worker if ethical violations are reported. Reports of ethical violations in this category included keeping records that were incomplete or inaccurate, mishandling of records, or withholding records from clients (Strom Gottfried, 2000). The record keeping category, with 4.7% of the total citations, ranked eighth in frequency in our study. This compares to Strom-Gottfried's (2000) results, in which a higher percentage, or 9.5%, of the violations were classified as record keeping. Our data indicate that 40% of the reports of record keeping violations were for failure to make records or reports and that 43.1% were for withheld records. General allegations account for the remainder of complaints.

Billing/Reimbursement

The reimbursement or billing category of complaints contained reports of violations related to reimbursement for services such as fraud, billing for services that were not rendered, and charging in excess of agreed rates. In our study this allegation ranked as the ninth most frequent with 4.6% of the complaints. This compares to Strom-Gottfried's (2000) results with reimbursement identified in 3.1% of the violations.