Clinical Social Work Journal (2019) 47:332–342

https://doi.org/10.1007/s10615-018-0693-2

ORIGINAL PAPER

Clinical Social Work Scope of Practice Related to Diagnosis

Avani Shah1 · Kim Granda Anderson1 · Xiao Li2 · James T. Meadows1 · Tara B. Breitsprecher3

Published online: 9 November 2018

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
This paper discusses a relatively undocumented movement by clinical social workers to gain mental health diagnostic
privileges as part of their scope of practice across the United States. The primary purpose of this paper is to identify which
states permit social workers to diagnose. Reviewers located the state regulatory codes on social work scope of practice to
determine if diagnosis of mental disorders was permitted and contacted corresponding state boards and NASW chapters to
understand diagnostic privileges and grassroots movements in this area. We found that only three states do not authorize social
workers to diagnose mental disorders: Alabama, Pennsylvania, and Indiana. The secondary purpose is to determine what
percentage of graduate social work programs require a mental health assessment course to understand how graduate students
are being prepared to diagnose. A minimum of two reviewers evaluated social work curricula for Masters-level programs
(N = 226) accredited by the Council on Social Work Education. A majority of programs offered or required coursework on
the assessment of mental disorders. We also discuss the state training requirements as they apply to diagnosis. As clinical
social workers begin to practice in new areas, it is worthwhile examining efforts in addressing policies to expand social
work scope of practice. This paper provides examples of successful and unsuccessful efforts to expand scope of practice on
diagnosis to inform future efforts to impact policy change as applied to professional practice. A coordinated effort to align
academic requirements with clinical social work scope of practice and professional practice guidelines can better prepare
the clinical social work workforce.

Keywords Diagnosis · Clinical social work · Policy · Mental disorders · Training

Introduction area of practice (Gibelman 1995; NASW 2003). It is esti-

mated that social workers make up 28–60% of the mental
The profession of clinical social work has emphasized the health workforce, and as a result are the first to diagnose and
diagnosis of mental disorders as an area of practice in the treat individuals with mental health needs (Ellis et al. 2009;
National Association of Social Work Standards for the Proctor 2004).
Practice of Clinical Social Work (NASW, 1989, pp. 1–2): Over the past two decades, there has been a movement by
“Clinical social work services consist of assessment; diag- clinical social workers (CSWs) in the United States to ensure
nosis; treatment, including psychotherapy and counseling; that the social work scope of practice includes the diagnosis
client-centered advocacy; consultation; and evaluation.” and assessment of mental disorders in state-level regulations.
More importantly, over half of social workers surveyed by Seemingly at odds with these actions, social work academic
NASW indicate mental health as their primary or secondary communities have expressed mixed feelings about training
students in diagnosing patients (Tosone 2016). According to
a survey by Frazer et al. (2009) a majority of participating
* Avani Shah social workers used the Diagnostic and Statistical Manual
shah009@sw.ua.edu
(DSM; APA 2000) frequently for purposes of assessing or
1
School of Social Work, University of Alabama, Tuscaloosa, billing clients. However, if diagnosing were not required for
USA reimbursements, half of the surveyed social workers would
2
Department of Social Work, East China University not use the DSM. Similarly, interviews of practicing social
of Science and Technology, Shanghai, China workers revealed that unless required, most would not give
3
National Association of Social Workers, Chapter, PA, a diagnosis despite acknowledging the value of the DSM in
Mechanicsburg, USA

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Clinical Social Work Journal (2019) 47:332–342 333

validating the client’s experience, informing medication or In 2003, LaCasse and Gomory evaluated mental health
other treatment choices, communicating with others, serving assessment course syllabi in 79 out of 153 CSWE-accredited
as a starting point for treatment, and providing psychoeduca- MSW programs. Of 43 of these programs, they found that
tion (Probst 2013). over half required coursework and nearly a third offered an
One qualitative study (Hitchens and Becker 2014) elective. Later work (Newman et al. 2007) evaluated the
reflected a similarly mixed attitude regarding practicing availability of DSM coursework in 104 out of 174 CSWE-
social workers’ opinions on the DSM (APA 2013). On one accredited MSW programs. While 74% of the programs
side, social workers reported the value of the DSM in aid- offered coursework on the DSM, only 48% of the MSW
ing clinical practice, communicating with other profession- programs required students to take it (Newman et al. 2007,
als, establishing credibility, and helping clients comprehend p. 302). Even more telling is that in 1985, 33% of the sur-
their symptoms. On the other side, social workers reported veyed schools offered a course on the DSM with 66% of
concerns regarding the DSM’s diagnostic validity and reli- students enrolled, a trend that increased to 75% of students in
ability; cultural, political and social system biases; negative 2006 (p. 302). Examining a probability sample of 62 MSW
future impacts to clients (e.g. disability insurance, employ- programs, Ponniah et al. (2011, p. 454) learned that most
ment); and stigmatization of mental disorders. Further, they of these programs offered didactic training in DSM content
report challenges with service-payer organizations such as: while 61.8% required it. They also examined the clinical
(1) requiring diagnoses in family therapy where there is not supervision received by students. More than 70% of the
an identified patient, (2) insufficient reimbursements for schools offered clinical supervision on DSM content, while
assessments, (3) lack of payment for the V-codes, and (4) only a quarter of them required it.
reimbursement for only certain diagnoses. A recent survey of social work educators from various
Previous surveys of social work programs have voiced social work programs revealed that a majority of graduate
many of these advantages and limitations (Raffoul and students in both required and elective courses were taught to
Holmes 1986; Newman et al. 2007). Newman et al. (2007, formulate a DSM diagnosis (Lyter and Lyter 2016). Most of
p. 303) also found that 88% of those surveyed at various those who participated in the survey were teaching in states
programs believed that labeling was a disadvantage to the where diagnosis was legally permitted. Yet it is unclear from
client and not consistent with social work practices. In addi- the study which states these included or how many social
tion, qualitative interviews of social workers in the field have work programs were represented. Since 2011, the number of
also captured that they are uncomfortable labeling clients MSW programs has burgeoned. It is unknown if the trend to
(McLendon 2014). Even acknowledging that the DSM does offer mental health assessment content in clinically-focused
not incorporate the person-in-environment or strengths per- graduate programs has followed at the same rate. Despite
spectives, most social work educators who were surveyed reservations of academic communities and previously sur-
by Lyter and Lyter (2016) reported that the DSM was an veyed social workers, over the past two decades, there has
essential tool for social work practice in mental health. Prior been a movement by clinical social workers to ensure that
surveys of social work educators in 1985 and 2006 (New- the social work scope of practice includes the diagnosis and
man et al. 2007) indicate, likewise, that a majority believe assessment of mental disorders in state-level regulations.
that DSM (APA 1987, 2000) content should be taught to Not unique to social work, this movement also includes
students. Moreover, most of the recently surveyed educa- other mental health practitioners. In 2002, Hartley et al.
tors believed that students could be taught to use the DSM conducted an analysis of state code language permitting
critically, understanding its strengths and limitations (Lyter diagnosis in the scope of practice for 40 states. Of those 40
and Lyter 2016). states, 30 states permitted social workers, 37 states permit-
Despite social work’s significant contribution to men- ted psychologists, 24 states permitted marriage and family
tal health care in the United States, the Council on Social therapists, and 23 states permitted professional counselors
Work Education (CSWE) has not required coursework on the to diagnose (Hartley et al. 2002). At that time, Alabama,
assessment and diagnosis of mental disorders as part of the Arkansas, Georgia, Idaho, Illinois, Montana, Nebraska,
clinical social work curricula. In contrast, the Association North Dakota, Pennsylvania, South Carolina, and Washing-
of Social Work Board’s (ASWB) licensing exam places a ton did not permit social workers to diagnose based on the
heavy emphasis on mental health content considering that language or lack of language in the codes (Hartley et al.
approximately a quarter of the exam at the Masters-level 2002). Social workers and psychologists could directly bill
evaluates the assessment, diagnosis, and treatment of mental Medicare for mental health services unlike marriage and
disorders (ASWB 2011, p. 11). Given this discrepancy, it is family therapists and professional counselors. Scope of prac-
imperative to know what percentage of Masters-level social tice laws affect who insurers and Medicare are willing to
work (MSW) programs offer training on the DSM or mental reimburse for services. By 2008, marriage and family thera-
health assessment. pists were permitted to independently diagnose in 24 states

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and psychologists were permitted to diagnose in all states their interpretation, we called the state regulatory boards.
(Tran 2008). A reviewer associated with the NASW Pennsylvania Chap-
More concerning, states are still determining what CSWs ter (T.B.) independently conducted an examination of state
can and cannot do. Though state social work policies may codes and provided confirmation of what we found. Subse-
be guided by social workers on each state board, the NASW quently, we contacted the NASW chapters in states where
chapter and social work boards are dependent on legislators social workers could not diagnose for additional confirma-
to pass legislation authorizing what functions they perform. tion. After reviewing codes and regulations for all 50 states,
Determination of what training is needed to diagnose may we contacted 14 state boards to clarify ambiguities in the
vary based on the experiences of social workers on each social work scope of practice as well as five NASW chapters.
state social work board causing a lack of uniformity. Instead,
a consensus could be reached by state social work boards,
Identifying Required Coursework for Mental Health
academic communities, and professional organizations on
Diagnosis
training guidelines for diagnosis. As a result of policies in
states where social workers are not permitted to diagnose,
A total of four researchers collected data. At least two
other allied professions may be more employable and social
independent reviewers examined CSWE-accredited MSW
workers may not be able to bill for services resulting in a
websites for mental health assessment courses from Octo-
negative economic impact on the profession, decreased
ber of 2012 to May of 2015. If there were disagreements
employment opportunities, and an inability to address the
between these two reviewers on whether a course was
needs of vulnerable populations with mental health con-
required or there was difficulty locating information, a third
cerns (D.A. Ellis Murray, personal communication, June
reviewer examined the MSW website for curricular infor-
15, 2016).
mation. Using the CSWE website, researchers examined
We identified states permitting social workers to diagnose
every CSWE-accredited Masters-level social work program
through a literature review and by contacting social work
in the United States. For the search strategy, researchers
professional organizations. This information was surpris-
accessed school websites via a link from CSWE. When
ingly difficult to obtain because NASW, Council on Social
links were inoperable, a web search identifying the school
Work Education (CSWE), and Association of Social Work
was conducted. Researchers examined the curriculum for
Boards (ASWB) had no such list for all states. Therefore, our
each school to determine whether coursework in mental
primary research goal became to identify which states per-
health assessment/ psychopathology /DSM /diagnosis was:
mitted social workers to diagnose, explore training require-
(a) required for all students (even if it was within a larger
ments, and recognize examples of social work advocacy
course), (b) required only for particular concentrations or
efforts in this area to better understand how to impact policy
specialized areas of study, (c) offered only as an elective, or
change for the profession of social work. As a secondary
(d) not available at all. We examined the course titles and
goal, we wished to examine if graduate level social work
course descriptions for the terms “diagnosis” or “DSM” as
programs were requiring or offering courses on the diagnosis
well as additional possible search terms (e.g. assessment,
of mental disorders given the trend of more states granting
evaluation, mental health, mental illness, psychiatric disor-
this privilege across time.
der, psychological disorder, behavioral disorder, cognitive
disorder, emotional disorder, mental disorder, differential
diagnosis, psychopathology, and developmental disabil-
Methods
ity). If a website’s information was inconclusive, another
reviewer contacted program staff to clarify information.
Review of State Codes

Two independent reviewers examined state codes for any

language referring to diagnosis specifically pertaining to Results
the definition of social worker, scope of practice, and/or
training requirements. We examined the state codes for the Aim 1: What States Permit Clinical Social Workers
terms “diagnosis” or “DSM” as well as additional possible to Diagnose?
terms (e.g. assessment, evaluation, mental health, mental
illness, psychiatric disorder, psychological disorder, behav- Our review of the state codes indicates that, at the time of
ioral disorder, cognitive disorder, emotional disorder, men- this writing, three states specifically do not include language
tal disorder, differential diagnosis, psychopathology, and in the code permitting social workers to independently diag-
developmental disability). In cases where the language was nose mental disorders: Alabama, Indiana, and Pennsylvania.
ambiguous, missing, or where two researchers disagreed in All other states and Washington D.C. have language in the

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Clinical Social Work Journal (2019) 47:332–342 335

code permitting licensed Masters-level CSWs to provide nor offered such a course as an elective; (2) 20.8% offered
mental health diagnoses provided certain professional expe- only an elective but did not require students to take such a
rience and training requirements based on the state codes course, (3) 18.6% required courses as part of a clinical con-
are met. Refer to Table 1 to view the requirements by state. centration, and (4) 41.2% required mental health assessment
coursework as part of the core curriculum. See Fig. 1. This
Aim 2: What Percent of Programs Require or Offer suggests that a majority of the programs (80.5%) had oppor-
Coursework on Mental Health Assessment? tunities for training students in mental health assessment. A
slightly greater proportion of programs in states that permit-
We reviewed a total of 226 graduate social work program ted social workers to diagnose (78.7%) offered opportunities
websites for course descriptions. In cases when there was a for diagnostic training through electives or required course-
disagreement between two reviewers, a third independent work compared to programs in states (63.7%) in which social
reviewer examined the course descriptions. This process workers were not permitted to diagnose. Table 2 displays the
occurred in 43.8% of the cases. When there was a discrep- percent of programs that had opportunities for diagnostic
ancy, the course description was unclear, or the information training based on whether the state permitted social workers
could not be found, we contacted program staff (n = 54) for to diagnose or not.
additional information or specifications to help improve
consensus.
Only 6.6% of all graduate social work programs, a total
of 15 out of 226, were in states that did not permit social Discussion
workers to diagnose. There were variations in how indi-
vidual programs prepared students for diagnostic assess- This research aimed to document which states authorize
ment. One program did not offer an elective but required an CSWs to diagnose and how graduate social work programs
abnormal psychology course prior to admission. Two other are preparing students in assessing and diagnosing mental
programs neither required a course, nor offered an elective, disorders. Through our evaluation of social work curricula
but noted the availability of a psychopathology course in a and state codes on social work scope of practice, we found
different department. Still other programs embedded diag- that a majority of programs offer courses in the assessment
nostic assessments into existing courses: Human Behav- and diagnosis of mental disorders and that most states permit
ior and Social Environment (n = 4), Psychopharmacology social workers to engage in the assessment and diagnosis of
(n = 1), Mental Health Intervention (n = 1), Integrative Prac- mental disorders if certain training and professional require-
tice (n = 1), Direct Practice (n = 2), and across courses in the ments have been met. Our research has a number of limi-
foundation year (n = 7). Some programs require diagnostic tations. First, the research team only had access to syllabi
assessment coursework for only certain concentrations or and curricular information posted on the program websites.
tracks: direct practice (n = 5), mental health (n = 8), clini- Thus, it is possible that the information may not be the most
cal (n = 17), health (n = 3), aging (n = 3), casework (n = 1), recent or updated. Next, it is possible that our team engaged
interpersonal (n = 1), micro practice (n = 1), families and in coding errors and missed programs that offered diagnostic
groups (n = 2), and a combination of these noted clinical training though we attempted to reduce that possibility with
tracks (n = 8). Students in the macro concentration (commu- reliability checks and contacting programs when there was
nity development, program evaluation, planning, or manage- a disagreement between coders. In almost half the cases, we
ment) or who were in a solely macro-focused program were contacted staff from the social work programs for further
not required to take a diagnostic assessment course. clarifications and are dependent on the accuracy of the infor-
We were interested in understanding what percentage of mation provided by program staff. Because we chose to only
graduate social work programs were requiring students to examine information from program websites, we may have
complete a diagnostic assessment course. Most of the pro- missed information about social work programs teaching
grams (N = 226) required a diagnostic assessment course, mental health assessment and diagnosis in other ways such
59.8% versus 40.2% who did not. Our results are consistent as through field education or re-occurring required semi-
with the probability sample of programs evaluated by Pon- nars or within other courses. It is possible that social work
niah et al. in 2011 in which 61.8% of the programs required programs may be preparing students in diagnostic training
a diagnostic assessment course. We were also interested in with other approaches that we failed to capture using our
understanding if programs were offering opportunities for methodology. We refer individuals to Lyter and Lyter (2016)
diagnostic training through electives or if requirements were and Ponniah et al. (2011) for a more comprehensive under-
imposed for those in clinical concentrations. After examin- standing of other training approaches being utilized by social
ing these programs more closely (N = 226), we found that work programs. Future research should develop a consensus
(1) 19.5% neither required a diagnostic assessment course on what students, early career CSWs, and graduate social

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Table 1  State policies related to diagnosis and training

State Number of post-grad h/years Required Additional requirements/information
courses

Alabamaa 2 yrs. in 36 mos No Diagnosis not allowed, but diagnostic opinion is permitted
Alaska 3000 h No No
Arizona 3200 h No At least 1600 h of direct client contact involving the use
of psychotherapy, no more than 400 h of which are in
psychoeducation
Arkansas 4000 h No No
California 3200 h Yes At least 750 h must be in psychotherapy and at least 2000 h
must be in combined diagnosis, assessment, treatment,
counseling, and psychotherapy
Required courses vary depending on when MSW was
commenced
Colorado 3360 h over not less than 24 mos No At least 1680 of the hours must be spent in a role that
includes testing, diagnosis, assessment, treatment, or
counseling
Connecticut 3000 h No No
D.C., District of Columbia 3000 h Yes Required courses include a minimum of 12 units clinical
coursework, at least six from an MSW program
Delaware 3200 h No Must document at least 1600 h under professional supervi-
sion acceptable to the Board
Florida At least 100 wks. practice under LCSW supervision Yes At least 1500 h providing face-to-face psychotherapy
Degree programs should include at least 24 semester hours
of clinically focused human behavior and social work
practice methods courses; at least one course should be in
psychopathology
Must spend 50% of time in direct clinical practice (psycho-
therapy or counseling)
Georgia 3000 h No 120 supervision hours, at least 60 of them with an LCSW
who is in good standing and has the requisite experience.
(36 mos.)
Hawaii 3000 h No Hours completed between 2 and 5 yrs
No more than 900 h of client centered advocacy, consulta-
tion, evaluation
At least 100 h face to face supervision
2000 h of assessment, clinical diagnosis, and psycho-
therapy
Idaho 3000 h No 1750 h direct client contact involving treatment
1250 h of assessment, diagnosis, and other clinical social
work
Illinois 3000 h No If candidate has doctoral degree only 2000 supervised
hours needed
Indianaa 3000 h Yes Does not permit diagnosis
2 yrs. paid experience, including evaluation and assessment
1500 h per yr
CSWE accredited program Foreign program requires 24
semester hours (or 37 quarter hours) theory and research
of HBSE and practice methods, 21 semester hours (or
31 quarter hours) in clinically oriented services with
not more than 6 semester hours (9 quarter hours) of
independent study
Iowa 4000 h No At least one component of supervision must include provi-
sion of diagnostic practice and include provision of treat-
ment including but not limited to evaluation of symptoms
and behaviors, effects of the environment, psychosocial
therapy with individuals, couples, families or groups,
establishment of treatment goals and differential treat-
ment planning
Work must include diagnosis and treatment and must
utilize the DSM

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Clinical Social Work Journal (2019) 47:332–342 337

Table 1  (continued)
State Number of post-grad h/years Required Additional requirements/information
courses

Kansas 4000 h Yes Specialist requires 15 credit hours supporting diagnosis

or treatment of mental health disorders through study of
psychopathology, DSM, diagnostic assessment, interdis-
ciplinary referral and collaboration, treatment approaches
and professional ethics
MSW must receive 350 h of diagnostic supervision using
DSM during internship/ If no practicum then, must have
700 DSM post-graduate supervision hours
2 yrs. FT in area of specialty, 1500 direct client contact
conducting psychotherapy and assessments and not less
than 150 h of clinical supervision
Must consult with an MD or client waives requirement
Kentucky 2–3 yrs. work experience No Supervision 2 h per week (200 h of supervision)
Louisiana 5760 h No 96 h face to face supervision required (3840 under supervi-
sion)
Maine 6400 h if non-clinical, 3200 h if clinical setting No Must consult with an MD or client waives requirement
Maryland 2 yrs. or 3000 h No 144 h face to face supervision in assessment formulation of
diagnostic impression, treatment of mental disorders and
other conditions and the provision of psychotherapy
1500 h face to face client contact
Massachusetts 3500 h No 3500 h must be in a clinical setting
Michigan 4000 h No To diagnose, must have an MSW with clinical focus
Minnesota 4000–8000 h Yes 1800 h must be “direct client contact”
24 credit hours of clinical social work classes, including
diagnosis and biopsychosocial assessment; treatment
planning; intervention methods; evaluation methods;
social work values and ethics; and culturally specific
assessment and intervention
Must have adequate training before using a diagnostic
instrument
Must inform a client of the purpose before administering
the instrument and make the results available to the client
Mississippi 2–3 yrs No 2–3 yrs. of supervision must be clinical
Missouri 3000 h No Work must be clinically-focused; Licensed Advanced
MSW cannot diagnose only CSW can
Montana 3000 h No 3000 h must be in “psychotherapy;” 1500 h must be “direct
client contact”
Nebraska 3000 h No 3000 h must be in “mental health practice;” partly in a
mental health service facility; 1500 h must be “direct
client contact” clients with major mental illness
Nevada 3000 h No 3000 h must be “clinical”
New Hampshire 3000 h No 3000 h must be “clinical”
New Jersey 2 yrs. FT Yes 2 yrs. must be in “clinical” social work
Must complete “minimum course requirements established
by the board to ensure adequate training in methods of
clinical social work practice”
Must complete 12 credits of courses on diagnosis and
assessment of mental disorders and human behavior and
social environment
New Mexico 3600 h; 5 yrs Yes Must take course in “New Mexico cultures”
New York 3 yrs Yes 3 yrs. must include “supervised experience in diagnosis,
psychotherapy and assessment-based treatment planning
acceptable to the Department”
12 h of MSW courses must be in “clinical coursework”
North Carolina 2 yrs No 2 yrs. must be in “clinical experience”
North Dakota 3000 h No 3000 h must be clinical
Ohio 3000 h No No
Oklahoma 4000 h No 3000 h must be in “direct client care”
Oregon 3500 h No 2000 h must be “direct contact with clients”

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Table 1  (continued)
State Number of post-grad h/years Required Additional requirements/information
courses

Pennsylvaniaa 3000 h No Diagnosis not permitted

At least 1/2 of the experience in one or more of the follow-
ing areas: Assessment, Psychotherapy, Other psycho-
social-therapeutic interventions, Consultation, Family
therapy, Group therapy
Rhode Island 3000 h No 1500 h must be “direct service to clients”
South Carolina 3000 h Yes Must complete “a board-approved academic program that
includes at least 45 contact hours of psychopathology and
45 h of psychodiagnostics”
South Dakota 2 yrs. FT No No
Tennessee 3000 h No 3000 h must be “clinical contact hours”
Texas 3000 h No No
Utah 4000 h Yes 1000 h must be “mental health therapy”
Have completed a case work, group work, or family treat-
ment course sequence with a clinical practicum
A minimum of two hours of training in suicide prevention
via a course
Vermont 3000 h No No
Virginia 3000 h Yes 1380 h must be “face-to-face client contact”
Must complete a 3 semester hr. course on assessment of
mental disorders and psychopathology
Additional coursework stipulated
Washington 4000 h No 1000 h must be “direct client contact;” applicants must
have 4 h of HIV/AIDS training; must complete 36 h of
CE
West Virginia 2 yrs. FT or 3000 h PT Yes Must complete a graduate course in either psychopathology
or abnormal psychology
Wisconsin 3000 h Yes 1000 h must be “face-to-face client contact”
Degree must have concentration in clinical social work
with a clinical concentration
Must take a psychopathology course and two other clini-
cal courses and submit the syllabi as part of licensure
application
Wyoming 3000 h No 1200 h must be “direct client contact hours”

H hours, yrs. years, mos. months, PT part time, FT full time, MD medical doctor/physician, CE continuing education
a
Diagnosis not permitted in this state

work programs believe are the best practices in diagnostic accurately. Below, we point out the challenges we experi-
training. enced in extracting information based on differences in the
There are also limitations to our evaluation of the state codes.
codes. Again, we are limited by the state codes available on Our research team observed wide variations in definitions
the state websites. Though our results were confirmed by an of CSW, social work scope of practice, training require-
independent evaluation by an NASW chapter staff member, ments, course work stipulations, completed hours of super-
both of our investigations were limited by the availability of vision, current employment specifications, and licensure
the most current and updated state codes. If there had been test requirements to conduct mental health assessment and
recent updates to the codes or a delay in posting the cor- diagnosis within various state codes. To make matters more
rect codes on the websites, then we may have miscoded the untenable, wording of state regulations can be ambiguous.
information. The scope of practice regarding diagnosing can Ambiguity about wording and the above noted challenges
also be modified through legal cases, or case law, that take have also been found in codes for allied professionals (Tran
place within each state. These revisions, as a result of case 2008). Searching for information about scope of practice
law may not be reflective in the most current state codes. within the codes can also be challenging. In some cases,
The research team did not include attorneys and therefore there are no definitions for social work or clinical social
legal language in the codes may not have been interpreted work.

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Clinical Social Work Journal (2019) 47:332–342 339

Fig. 1  This figure shows the Opportunities for Diagnostic Training in Accredited MSW Programs (n=226)
percent of programs that (1) do
not require a course and have
no elective (2) offer an elective
only (3) require a course only
for certain clinical concentra- 19.48%
tions or (4) require the course No course or elective
for all students in the program
41.16% Elective only

Required for clinical

20.78% concentration
Required for all

18.58%

Table 2  Diagnostic coursework offered or required in MSW pro- has attempted a consultation with a physician during the psy-
grams based on social work scope of practice on diagnosis by state chosocial evaluation or the client waives this option. States
Diagnosis permitted in Diagnosis not also vary in the requirements imposed on social workers who
state n = 211, % permitted in state wish to diagnose. Our research found that each state var-
n = 15, % ies in the amount of postgraduate clinical supervision hours
Diagnostic course 21.3 33.3 needed to diagnose and in the level of licensure needed.
not offered or Additionally, some states require masters-level social work-
required ers to have courses on diagnosing mental disorders. Vari-
Diagnostic course 78.7 66.7 ations in state requirements for advanced clinical practice
offered or have also been documented by Donaldson et al. (2014).
required
Florida requires social workers who diagnose to spend at
least 50% of their time in direct clinical practice (psycho-
therapy or counseling).
In other cases, the information stating permission to Other states, such as Massachusetts, Kansas, and New
diagnose is listed under other elements of practice. Take Jersey, may require a specified number of hours of super-
the Idaho code, for example, where diagnosis is included vised experience and/or subsequent attainment of licensure
under the definition of psychotherapy and subsequently at that level of training (e.g. Licensed Independent Social
stipulates what level of trained social workers can conduct Worker). The Minnesota code specifically stipulates that
psychotherapy. Similarly, California recently added language social workers should have adequate training before using
to its state code due to prior vagueness in the language. It a diagnostic instrument and provides practice guidelines.
now reads “and the use, application, and integration of the At advanced practice levels, South Carolina requires addi-
coursework and experience required by Sect. 4996.2 and tional coursework in psychopathology (Donaldson et al.
4996.23….Section 499.6 a) 1. A minimum of 2000 hours in 2014, p. 57). Similarly, Kansas, Florida, Minnesota, New
clinical psychosocial diagnosis, assessment, and treatment, Jersey, Virginia, and West Virginia require coursework
including psychotherapy or counseling” (Cal. Leg. Code. in the assessment of mental disorders for CSWs. Kansas
2017). Despite this change to the language, it was still dif- even specifies that MSW students should receive diagnostic
ficult to recognize that social workers were able to diagnose. supervision during internship.
California’s state board was composed of allied professionals To promote greater consistency and clarity among state
without much information on one specific professional code. regulations, the ASWB has developed the Model Social
As such, we obtained the information that social workers Work Practice Act (ASWB n.d.). This was developed using
could diagnose from the NASW local chapter employee who input from state boards, social work professional organiza-
was able to direct us to the code and inform us about the tions, the CSWE, and a number of other social work con-
chapters’ efforts to change the wording. stituencies to serve as an example for states planning to alter
Some states require CSWs to diagnose with physician their regulatory codes. According to the Model Social Work
consultation. Maine and Kansas permit diagnosis if the CSW Practice Act, clinical social work “requires the application

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340 Clinical Social Work Journal (2019) 47:332–342

of specialized clinical knowledge and advanced clinical efforts to address policy in the state of Alabama to add diag-
skills in the areas of assessment, diagnosis and treatment nosis to scope of practice: one in which the academic setting
of mental, emotional, and behavioral disorders, conditions was engaged and another in which it was not. The Marriage
and addictions” (ASWB n.d., p. 6). Based on Sect. 106 of and Family Therapists (representing a much smaller group of
this act, Practice of Clinical Social Work, “Clinical social practitioners than social workers) partnered with academic
workers are qualified to diagnose using the Diagnostic and communities to require coursework on the diagnosis of men-
Statistical Manual of Mental Disorders (DSM), the Inter- tal disorders. Earlier versions of the state code included a
national Classification of Diseases (ICD), and other diag- requirement for coursework on mental health disorders and
nostic classification systems in assessment, diagnosis, psy- continuing education credits on diagnosis beginning in 2013.
chotherapy, and other activities” (ASWB n.d., p. 6). These In 2018, after further advocacy efforts and academic part-
two statements within the Model Social Work Practice Act nership, a bill passed the House and Senate and the Gover-
suggest that there was a consensus by social work organi- nor recently signed a law permitting Marriage and Family
zations, accrediting bodies, and state boards that diagnosis Therapists to diagnose (S.B. 166, AL, 2018). In contrast,
was the domain of social workers and that social workers without an academic partnership, CSWs’ ability to diag-
would be qualified to diagnose using common diagnostic nose mental disorders has not been approved over multiple
classification systems. Although the act specifies that social attempts of advocacy and efforts to educate legislators about
workers are qualified in the assessment and diagnosis of the importance of expanding social work scope of practice
mental disorders, it nowhere indicates what type of training (S.B. 82, AL, 2018). In Alabama, Senate Bill 82 (2016) has
or coursework would qualify CSWs to provide such services. been signed into law and permits social workers to assess
Ponniah et al. (2011) point out that other fields accorded mental disorders and provide opinions independently to cli-
diagnostic privileges have accrediting bodies that require ents. This incremental gain towards the ability to diagnose
graduate training on the assessment and diagnosis of occurred after 30 years of lobbying and several failed legis-
mental disorders and recommend that social work should lative efforts (D.A. Ellis-Murray, personal communication,
change accreditation criteria to improve clinical prac- June 15, 2016). As a result, Alabama social work graduate
tice. Expanding the scope of practice to include diag- schools have held discussions about standardizing diagnostic
nosis necessitates that students specializing in clinical training requirements.
concentrations receive graduate education that includes Other CSWs have organized to ensure that the social work
coursework on mental health assessment and diagnosis. scope of practice includes diagnosis and assessment of men-
Receiving this education not only supports competence in tal disorders in state-level regulations. The NASW Penn-
assessment and diagnosis, but also prepares social work sylvania chapter is one of the most recent groups to have
students for subsequent licensure. We further encourage advocated for the passage of legislation to clarify the scope
the coordination of academic and curricular bodies to of practice in Pennsylvania to include diagnosis of mental
stipulate specific competencies for clinical social work- disorders (NASW-PA 2015). According to the NASW Penn-
ers working in mental health. In our litigious society, it is sylvania chapter (NASW-PA, n.d.), there were at least 35
paramount that social workers are academically prepared states, plus Washington D.C., which allowed social workers
to engage in all areas of practice that licensure confers in to assess and diagnose mental illnesses when they began
individual states. Harkness (2011) discusses the danger their advocacy. To formally recognize diagnosis as a part of
for malpractice suits involving social workers who incor- social work scope of practice, Pennsylvania House Bill 1415
rectly diagnose. This is particularly important as CSWs (2016) passed the House of Representatives and has passed
throughout the United States advocate legislatively to the Senate as Senate Bill 530 (2018). It is currently awaiting
maintain and expand their scope of practice to include approval by the House.
the assessment and diagnosis of mental health disorders In 2007, NASW Nebraska successfully partnered with
in state-level regulations. Though this paper focuses on Licensed Marriage and Family Therapists (LMFTs) and
advocacy efforts in social work to expand scope of practice counseling to pass a bill permitting social workers, LMFT
on diagnosis, information gained about this process may and counseling to diagnose as Licensed Independent Men-
inform future attempts to expand scope of practice in other tal Health Practitioners (LIMHP), which requires 3000 h of
ways (e.g. psychotherapy, telehealth services, health care experience working with individuals who have major mental
education and coaching). disorders. Nebraska permits a diagnosis under the super-
The effort to transform policies can involve a variety vision of a clinical psychologist, physician or a Licensed
of approaches that include organizing professional CSWs, Independent Mental Health Practitioner for graduate-level
educating legislators about social work training, interpro- social workers without a LIMHP. Through advocacy, edu-
fessional partnerships, and at the cornerstone-collaborating cation, and a lobbyist hired by LMFTs, social workers and
with academic settings. Take the case of two contrasting counselors known to a Senator who sponsored the bill, they

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Clinical Social Work Journal (2019) 47:332–342 341

were able to pass the bill on the first attempt (Terry Werner, American Psychiatric Association (APA). (2000). Diagnostic and
personal communication, May 15, 2018). statistical manual of mental disorders: DSM-IV-TR. Washington,
D.C: American Psychiatric Association.
American Psychiatric Association (APA). (2013). Diagnostic and sta-
tistical manual of mental disorders: DSM–5. Washington, DC:
Conclusion American Psychiatric Association.
Association of Social Work Boards. (2011). Content outlines and KSAs
social work licensing examinations. Retrieved 2, 2014 from https​
In conclusion, CSW’s movement to gain diagnostic privi- ://www.aswb.org/wp-conten​ t/upload​ s/2014/02/Master​ sKSAs​ .pdf.
leges at the legislative level and the authorization to diag- Association of Social Work Boards. (n.d.). Model social work practice
nose by many insurance companies, even in the absence of act. Retrieved April 4, 2017 from https:​ //www.aswb.org/wp-conte​
legal authority in some states, indicate that CSWs may be nt/uploa​ds/2013/10/Model​_law.pdf.
Cal. Leg. Code. ch. 14, § 4996–4997.1. Social Workers. 2017.
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practice across the United States. Lack of uniformity in state (2014). Contemporary social work licensure: Implications for
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level estimates of mental health professional supply in the United
health assessment and diagnosis may result in social work- States. Psychiatric Services, 60(10), 1315–1322.
ers being less prepared to diagnose than similarly-trained Frazer, P., Westhuis, D., Daley, J. G., & Phillips, I. (2009). How
professionals. As we found in our research, not all programs clinical social workers are using the DSM-IV: A national study.
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nostic assessment, which is concerning if students plan Gibelman, M. (1995). What social workers do. Washington, DC:
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lar concerns, CSWs have little guidance on what training Harkness, D. (2011). The diagnosis of mental disorders in clini-
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Even with state code differences that may not be feasibly 5-010-0263-8.
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fessional Counselors Act, 2016. Assemb. Reg. Sess. 2015–2016.
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social work education: Then and now. Journal of Social Work Tran, A. (2008). A comparative analysis: MFT scope of practice across
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Probst, B. (2013). “Walking the tightrope”: Clinical social workers’ Avani Shah is assistant professor of social work at the University of
use of diagnostic and environmental perspectives. Clinical Social Alabama. Her research focuses on increasing the number of mental
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Proctor, E. (2004). Research to inform mental health practice: Social older adults and to improve access to specialized behavioral health
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Raffoul, P., & Holmes, K. (1986). Dsm-iii content in social work
curricula: Results of a national survey. Journal Of Social Kim Granda Anderson is a doctoral student with 20 years of clinical
Work Education, 22(1), 24–31. https​://doi.org/10.1080/10437​ experience as a licensed clinical social worker. Her research area is on
797.1986.10671​726. military families.
S. B. 82. Assem. Reg. Sess. 2016. (AL, 2016).
S. B. 530. Social Workers, Marriage and Family Therapists and Pro- Xiao Li is a Lecturer in the Department of Social Work. Her research
fessional Counselors Act, 2017. Assemb. Reg. Sess. 2017. (PA, areas are social professional development, social work education, and
2016). medical social work practice in China.
Socialworklicensure.org. (2018). Social work licensure requirements.
Retrieved June 5, 2018 from https:​ //socia​lwork​licen​sure.org/artic​ James T. Meadows is a doctoral student whose research focuses on
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the DSM-5. Social Work in Mental Health, 14(2), 103–111. https​ Tara B. Breitsprecher has worked with the NASW Pennsylvania Chap-
://doi.org/10.1080/15332​985.2015.10835​13. ter on legislative advocacy efforts.

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