Eye on Ethics

The Boundaries of Alternative Therapies in Clinical Social Work
By Frederic G. Reamer, PhD
June 29, 2012

Recently, I served as an expert witness in a complex licensing board case in which a clinical social worker’s former client alleged that the practitioner harmed her when he used an unorthodox and controversial treatment protocol, aura therapy, to treat her depression and anxiety symptoms. According to adherents, aura therapy is a type of healing that detects and treats disease by reading and manipulating a person's aura, an energy field surrounding the body that exhibits signs of physical disease before the body itself shows signs of disease. A popular form of aura therapy uses therapeutic touch.

The complainant alleged that the social worker “brainwashed” her into believing that this treatment strategy was empirically validated and widely used in the social work profession. Eventually, the client became dissatisfied with the social worker’s services, terminated treatment, and sought help from a more traditional clinical social worker. The second social worker was distressed when she learned of her colleague’s use of aura therapy to treat the client and suggested to the client that she may want to consider filing a licensing board complaint.

During the licensing board hearing, the accused social worker stated that he believes in the healing powers of aura therapy and acknowledged using these techniques in his work with the complainant. The social worker confirmed that his graduate social work curriculum had not included this clinical approach and that he received his postgraduate training in aura therapy from an online institute that awarded him a diploma. The licensing board ruled that the social worker had violated the state’s regulatory standards due to his failure to obtain the client’s written or verbal informed consent and failure to practice within the scope of his social work license.

Distinguishing Between Innovation and Unethical Practice
It would be a mistake to conclude from this case that clinical social workers should avoid all nontraditional treatment protocols and interventions. Creative and fruitful innovation in a profession requires its practitioners to push the boundaries of traditional practice in a constructive effort to create, implement, and evaluate new yet effective ways of helping people who struggle in life. After all, treatment approaches that are widely accepted today, such as eye movement desensitization and reprocessing therapy (EMDR), dialectical behavior therapy (DBT), hypnosis, and music therapy, were once considered unorthodox and, by some, controversial.

The enduring challenge in social work is to locate and walk what can be a fine line between necessary innovation that has therapeutic benefits and harmful, possibly exploitative, treatment of vulnerable clients. How should social workers assess the acceptability of interventions as diverse as aura therapy, EMDR, DBT, bioharmonics, color therapy, emotional freedom therapy, hypnosis, kinergetics, reflexology, music therapy, rebirthing therapy, and thought field therapy?

The Imperative of Client Protection
Not surprisingly, there often is no clear line separating ethical and unethical treatment. While some treatment approaches are patently unethical—for example, clinicians’ use of sexual relationships with clients as a form of healing—other approaches lie in a gray zone filled with competing points of view where reasonable minds differ and outcome research data are contradictory or inconclusive.

Social workers take seriously their duty to protect clients and “do no harm.” Social workers who consider using nontraditional, unorthodox interventions must ensure that these approaches do not pose serious risk of client injury. Practitioners have an ethical duty to examine the theoretical basis and empirical evidence supporting any intervention they plan to include in their clinical repertoire. During this process, social workers should ask themselves several key questions: To what extent is there evidence to suggest that this clinical approach is effective? Am I using this clinical approach because of my own personal interest in this protocol as opposed to being guided by my client’s needs and interests? How would a panel of my peers view my use of this clinical protocol?

Informed consent: Social workers are morally obligated to ensure that clients truly understand the nature of the interventions that practitioners use and their potential benefits and risks, especially when clear standards do not exist for particular clinical protocols. Although regulatory bodies and organizations have different interpretations and applications of informed consent standards, there is considerable agreement about what constitutes truly valid and informed consent by clients in light of prevailing legislation and case law. In general, for consent to be considered valid, six standards must be met:

• there has been absolutely no coercion and undue influence involved in the client’s decision;

• clients are mentally capable of providing consent;

• clients have consented to specific procedures or actions;

• the consent forms and procedures conform with ethical and legal protocols;

• clients have explicitly been given the right to refuse or withdraw consent without penalty;

• and clients’ decisions are based on adequate information.

Social workers must be familiar with ways to prevent the use of coercion to obtain client consent; ways to assess clients’ competence to give consent; information that must appear on consent forms (e.g., a statement of purpose, risks and potential benefits, clients’ right to withdraw or refuse to give consent, an expiration date); the need to have a conversation with clients about the content of the consent form; the need for interpreters when clients do not read or understand the primary language in the practice setting; exceptions to informed consent (e.g., genuine emergencies); and errors and ethical problems sometimes associated with using consent forms (such as having clients sign blank forms for the social worker to complete later or using jargon in the consent form).

Practitioner competence and integrity: In contrast to earlier generations of social workers, today’s practitioners are ethically obligated to examine empirical evidence concerning the effectiveness of clinical interventions and stay abreast of relevant evidence-based professional literature. Social workers who contemplate using nontraditional, unorthodox interventions should conduct a thorough review of reputable literature and consult with seasoned colleagues. They should pay particular attention to several standards in the NASW Code of Ethics, including the following:

• 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 (standard 1.04[a]).

• 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 (standard 1.04[b]).

• 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 (standard 1.04[c]).

• Social workers should base practice on recognized knowledge, including empirically based knowledge, relevant to social work and social work ethics (standard 4.01[c]).

Social work’s remarkable strength as a profession is in large part the result of impressive and creative advances in its models and methods of interventions. Clinical innovations should be viewed somewhat tentatively, with a commitment to critical thinking as an adequate body of sound outcome research evolves over time. Indeed, today’s clinical novelty may become tomorrow’s standard of practice. Social workers should continue their open-minded pursuit of new ways of helping, recognizing that these efforts must fall within the profession’s venerable moral tradition.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics.