- Okay, I just want to introduce Marsha Kline Pruett,
who is a professor at the school for social work.
Many of you know her.
Shhh.
Thanks.
And she can't speak very loudly tonight
so I just wanted to try and quiet things down
before she introduced our speaker, Jim Drisko,
so here she is.
- Thanks Josh.
See here I have laryngitis and I was trying
to get you all to be quiet and you couldn't hear me.
So I'm glad Josh came to help.
It's nice to see you all so excited to be back
and to see each other and we're glad
you're that excited because we have
an exciting program and hopefully
you'll bring some of that excitement
to your questions later, then you can
socialize afterwards.
Because we have a wonderful program tonight
and it's my distinct pleasure to introduce
my colleague, James Drisko, who will
be talking about what is clinical social work
in the 21st century?
Jim Drisko holds an MSW from Smith College
School for Social Work and a PhD
from the Boston College Graduate School
of Social Work.
He's done clinical practice in community
mental health centers and in public school settings,
as well as in private practice.
His areas of professional interest currently
include clinical practice with children and families,
reactive attachment disorders, and the treatment
of such disorders, psychotherapy evaluation.
He's written on clinical practice theory,
on psychotherapy process and outcome research.
Clearly he has wide-ranging interests having
to do with clinical social work
and he has been the author of The Evidence-Based
Practice in Clinical Social Work with Melissa Grady,
and author of many journal articles, book chapters,
he's written extensively on qualitative research methods,
he is currently a member of CSWE's Commission
on Accreditation for US Schools of Social Work,
and he was elected to the National Academies
of Practice for Social Work in 2008.
More recently he was named an Inaugural Fellow
of the Society for Social Work and Research.
He has given so much to our community
and we're looking forward to hearing
what he has to say about social work
in the upcoming years.
Jim.
(applause)
- Thank you Marsha for that kind introduction.
Can you all hear me?
Not quite sure in the back, okay.
I'm soft-spoken so do give me a wave
or something if it's difficult to hear.
I was asked to do this lecture by Dean Carolyn Jacobs
several months ago while Carolyn was our Dean.
As you know, she's moved on now to a well-earned sabbatical.
This is one of the things that we're asked
to do as Smith faculty, to give back
after we have sabbatical time,
and the idea is to inform the community
a bit about what we've done while we were on sabbatical.
And, for me, three events during my sabbatical
were really telling and very important.
The first one was that I was invited to participate
in September of 2013 at the first White House briefing
on social work education and it was an honor
to go to this event.
There were about 150 social work educators
from around the United States invited.
The members of the Obama Administration
who did presentations at this White House briefing
focused a lot on social work's role
within the Affordable Care Act.
But it was interesting to me that their focus was
on the role of social workers as patient navigators
and as case managers, not as providers
of more skilled assessment and treatment services,
and this I found profoundly disturbing.
Once again, it seemed like social work would have
to fight for an equal role with psychiatry and psychology.
A dilemma that we've been through in the past
and have been very successful in working on,
but here it is arising again as medical homes
become the focus for contemporary delivery
of public services.
The next event was participating
in a National Association of Social Workers
and Counsel on Social Work Education think tank
on the advance practice doctorate, or DSW degree.
This was held in October of 2013.
About 150 social work educators from the United States
and also Canada participated and they voiced a lot
of support for the need for advanced education
in clinical social work.
There was no question that training
beyond the Master's Degree was needed
to develop real expertise for clinical social work.
But in the discussion, research issues quickly
began to take priority over practice needs,
which appear to be due to a truly limited understanding
of what clinical social work practice takes
to do effectively and a priority on research evidence,
rather than the rest of what it takes
to do practice effectively.
And it became clear to me that the compentencies
for doing clinical social work practice weren't widely
understood and perhaps were being a little less
honored and respected than they had been
in recent years.
And it seemed to me that a more comprehensive
understanding of the competencies required
to do clinical social work well were needed.
And, as if that wasn't enough, a little bit later
Dr. Joan Berzoff, in the back, and I were asked
to do a keynote for the doctoral group,
the group for advancement of doctoral education
in social work.
And we basically did a paper that promoted
the need of the social work profession to train
advanced practitioners to meet the needs
of BSW, MSW, and PhD programs to train folks
who could do practice and could
also do practice research that really mattered.
And it was interesting that I think, Joan, our response
was mixed and there was certainly some active
disagreement with our position.
Several folks said that the role of the PhD in social work
should be on research and solely on research,
and clinical practice was actively off the radar
of many of the people in the room
who are directors of doctoral programs.
Now since both Joan and I had served
as co-directors of Smith's doctoral program,
we thought that a combined emphasis
on research and on clinical practice was
entirely possible and really justified
and really useful.
And it was also ironic to me that many
of the programs represented at the GADE meeting
were the same programs that were actively
going for an advance practice degree
called the DSW, but they didn't understand
the importance of clinical education at a PhD level,
as if somehow practice and research and scholarship
weren't going to be connected among the people
who'd become the future teachers, conceptualizers,
and researchers in social work.
So this got me thinking about two things.
What are the competencies for social work practice?
And it also got me thinking about the need
for much greater advocacy on our part
to support clinical social work practice
and excellence in clinical social work education.
The mission statement of the Smith College
School for Social Work is to educate for excellence
in clinical social work practice, and it's something
I believe strongly in, I'm a graduate of Smith
as well as a faculty member, and this has been
something that's really been sustaining for me
and something that I think we need to come back
to thinking about our role not only as students
and educators and practitioners, but also
as advocates for the needs of the profession at large.
So this led me to think about what is clinical social work
in the 21st century?
First thing that puzzled me is I often hear
that clinical social work is somehow not a key part
of the social work profession, but indeed,
we may be one of the larger parts.
Clinical social work draws on social work's person
and environment perspective, always looking
at the internal and the external dilemmas of clients,
and that's our key and unique professional way
of understanding people and situations.
And it's certainly part of clinical social work.
Clinical social work also draws on the six core values
of social work that are defined in the NASW Code of Ethics.
First, clinical social work seeks to serve those in need.
Service is our first value and especially we seek
to serve vulnerable, oppressed, and diverse populations.
And I hear too often that clinical social workers
hide in private practice and pay no attention
to vulnerable, diverse, and oppressed populations,
and frankly from my talk even with people
who are doing private practice, because of the diversity
in our population now and because of the challenges
of doing private practice, it's basically impossible
to avoid service to vulnerable, oppressed,
and diverse populations.
It's simply not true that clinical social workers
go out of their way to avoid these groups.
And all of this brings me to the next knock
on clinical social work, which has to do
with our role in promoting social justice.
Well Jerome Wakefield, a terrific social work scholar
at NYU, and Carol Swenson from Simmons College
School for Social Work, have written papers looking
at theories of social justice largely out of Rawls' theory
of distributed justice, and they claim that helping
people individually fully realizing their capacities
is socially just because it helps people realize
all they can be, and in turn, it helps society be better.
To me, that works as one definition of social justice.
And as I go further into this talk, we'll come back
to whether or not clinical social workers have
an obligation to do advocacy, and I'm going
to argue that we do and I think many of us
do roles that relate to advocacy in addition
to direct service.
So to say that clinical social work doesn't support
the social justice value of social work just seems
to me entirely unfounded.
The next value is to support the dignity
and worth of individuals and to enhance
the capacity of people to address their own needs.
And I would argue again that clinical social work
does this head-on, that there's very little way
to say that the work we do to help people get out
of the dilemmas that limit them, isn't a way
of building their worth and to do so requires us
to work in a way that supports their dignity
and that empowers them.
The next value, which to me has been the one
that social workers in writing about the values
of social work are most likely to leave out
of the list is the emphasis on the importance
of relationship, and this one strikes me
as the oddest omission of them all.
In clinical social work we have no choice
but to develop relationships with clients
and collaterals and community supports,
but it's also true in community organization
and advocacy and in policy.
You can't do any work with human beings
without developing relationships,
but for clinical social work this is really key
to what we do.
And then finally, the last two values relate
to our capacities and characteristics
as clinical social workers.
Clinical social workers have to show personal integrity
in their work and that doesn't differ whether it's
with individual clients, families, couples, groups,
organizations or communities, and I want to add also
with our colleagues.
And then finally, the last value is to be competent.
And again, I think that's critical.
We really need to know what we're doing
and not to practice outside of our areas of expertise.
And as if the value aspects weren't enough,
there are other components to doing clinical social work.
Clinical social work draws on numerous theories
of human development, of interpersonal interactions,
and also theories of intervention.
To make sense of these, we have to apply critical thinking,
and critical thinking in clinical social work has both
internal aspects about our use of self
and our self reflection and our mindfulness,
and it also has external conceptual and empirical aspects.
And finally, we do draw on research knowledge,
though I think probably social workers generally could
do a better job of that one.
All of this is to say that clinical social work fits easily
within the social work profession and when we get
into looking at the relative merits and limitations
of any form of social work practice, we have nothing
to be ashamed of.
Now my goal is to take a look at clinical social work
from different perspectives and multiple levels of scale.
So let me start by looking at the environment
in which we live and work right now and take
a macro-perspective on clinical social work.
The director of NIMH, Tom Insel,
reminds us that US mental healthcare costs
are about 6% of total healthcare costs
and that over 32,000,000 people paid for services
nearly $58,000,000,000 in cost.
That's a big chunk of our economy.
I should also point out that those 36,000,000 people
are about 12% of the US population.
Mental health expenditures are the third costliest
medical condition as of 2006, only behind
heart conditions and trauma, and are tied
with cancer.
Serious mental illness, according to Insel,
costs 193.2 billion in lost earnings in the year 2007.
These are tremendously large numbers
that show the impact and the importance of our work.
And this, of course, is from a large scale
policy perspective.
If we stand back even further the World Health
Organization estimates that by 2020, six years
from now, mental health disorders will surpass
all physical diseases as the cause of disability worldwide,
so that mental health disorders will become
a growing part of our mental healthcare
and healthcare expenditures.
Mental health is a major and growing economic influence.
Just looking at the public sector, $37,000,000,000 a year
are spent to serve nearly 7,000,000 people.
Notice how small a percentage of the 36,000,000 total
are publicly funded?
Isn't that surprising?
You'd think that there ought to be a larger percentage.
And the public services address 7,000,000
people in all of the 50 states.
But while we hear things about the role of mental health
and prevention in solving shootings like we have had
in California and in Connecticut, state mental health
facilities were cut $4.6 billion for federal funding,
about 12%, over the last four years.
So it's one thing to talk the talk about how important
we are, and it's another to walk the walk
and put the money where their mouths are.
And in fact, what's happening is we're being cut
while we're being asked to do more.
Now, that's not unusual in these political
and economic times, but it's a serious reality
that effects who we can serve and how well we can do it.
Now if there was real reason to be concerned
that mental health services weren't effective,
there might be more reason to consider these cuts.
But there's great evidence that mental health treatments
are generally effective and this was supported
by the US Surgeon General in 1999, and by many studies,
many of which authored by Michael Lambert,
a psychologist from Brigham Young in 2004 and 2013.
Beyond being generally effective, it turns out
that mental health treatments provide a return
on their initial investment, so to speak.
Economic analysis show for a dollar spent
in diagnosis of depression, $7.00 is returned
to the economy.
In public schools substance abuse prevention,
$1.00 spent returned $21.00,
and in several studies
of particular states between $4 to $7.00
return was found on public adult substance abuse
treatment services.
So what we do is not only effective,
but it's also cost effective, which may matter a lot
in today's politics.
And it's important that we, as clinical social workers,
understand this, that what we do has support,
it appears to be cost effective and at the same time
we're being cut in funding.
How do you put that together?
It just doesn't make sense.
And then we find, according to Insel,
3/4 of mental illnesses emerge before age 24,
but fewer than one in five youths receive treatment.
According to Reuters, of 45,000,000 americans
with mental illnesses each year, only 38% get treatment.
We could do a whole lot better, but it takes a commitment,
and it takes funding, and it takes good education
to create a workforce that can provide good services.
So mental health issues are a major part of
our total US healthcare costs, they are important
in terms of lost productivity, and social workers
turn out to be the largest providers of mental health
services in the US.
I assume that most of you know this,
we provide more services than all the other
mental health professions combined.
Ironically, in academe, there's been tremendous effort
on raising the research profile of social work
and bringing in external money for social work programs,
which in turn does provide scholarship dollars
for students, but there hasn't been a consistent,
well-organized professional effort to build
and support clinical social work services.
In fact, the old federation of societies
of clinical social work essentially fell apart.
And when I recently went on to its website,
it was an ad for paid substance abuse services.
Some of this stuff is just appalling.
But don't worry,
I'll turn the corner, things will look a little better.
So what do social workers do?
Another piece of the macro perspective.
According to NASW and the Bureau of Labor Statistics,
social workers work in three main areas,
children, family, and schools about 290,000 social workers,
medical and public health 139,000, mental health
and substance abuse 137,000, and in all other areas
a little over 73,000.
So out of 640,000 social workers
in the US 89% are practitioners.
Social work is largely a practice profession.
According to Laura Groshong, who looked
at the 404,000 state licensed social workers
in the United States, 96% do direct practice.
It would be very difficult to make an argument
that social work education doesn't have to train
for excellence in practice, and it would be very hard
to ignore the needs of clinical social workers
and other social work practitioners doing this work.
And I want to point out to you, because in some respects
I think these numbers, or at least the three divisions,
are a little misleading.
You can work in child, family, and school settings
and do clinical social work.
I worked for years in public school settings
and called myself a clinical social worker
and the theories and positions that I drew on
were from clinical social work.
I didn't think of myself as a school social worker
because I had training to do something a little more
and I think out of my education here at Smith
and also at Boston College, my vision of what
I was doing was bigger than just working in schools,
and for me that was profoundly helpful
and really motivating.
So where are we in the political and economic context?
Policy efforts are trying to reduce healthcare costs,
this is important, we're all paying for them.
But in meso practice, agencies are reimbursed
less than it costs to deliver a unit of service.
Forgive a "unit of service" because we provide
so many different services it's hard to give you
a specific example.
But I did some work recently for Mount Tom Mental Health
and in talking to administrators there,
in effect they were telling me they were costing $51.00
to provide a unit of service.
But their typical reimbursement was $47.00.
You can't run a business when you can't even break even.
And what happens because of this is that social workers
and other practitioners get nickel and dimed
by their agencies, and it's not out of thoughtlessness,
it's not out of lack of concern.
These folks running these agencies have no other choice.
They have to do this to keep the doors open.
So what do we get?
Piecework payments rather than salaries,
reduced pay rates, reduced benefits,
productivity demands that are high,
and in turn very large case loads.
That may not help us provide the best kind
of services that we can provide.
And in turn, supervision for staff
and for students is less frequent,
more administrative in nature,
and it seems to be focused on documenting
risk reduction, not on the development
of clinicians and on understanding
their cases.
So training opportunities for staff
and for students are being reduced,
and may be limited.
And where they are provided, your supervisor's
doing this out of love of the profession
and personal and professional commitment.
They're not doing it out of status.
They don't gain much for doing it.
They do it out of their own passion
and their own willingness to give back
to the folks in a similar way to those
who trained them.
Student supervision is more and more
a labor of love and a real challenge,
and without support for supervisors
and research and scholarship on supervision
and field advisement, we may not
be doing the best we can to support our students.
At the same time as the recession and other issues
have led to cutback in costs, there's been the rise
of the evidence-based practice movement.
The idea here is to bring research
into a more useful connection with practice.
It's basically quite a good idea.
But it's been used administratively in a way
where research evidence of varying quality
and comprehensiveness, and even,
I would say reasonableness, is used
as a rationale for reducing healthcare costs.
Agencies may be only allowed to do certain lists
of treatments that are set up by states,
or by payors, that they claim have an evidence base,
and ironically, when you look carefully at these lists,
they may not be the same lists of efficacious practices
that are determined by professional
international organizations.
I find this one really appalling, but I understand
they're using this as a vehicle to limit practices
and in turn limit costs.
Whether or not that's helpful for clients
has yet to be determined.
I think one of the things that social workers need to do
is to bring our clinical vision into research
so that we ask questions that fully reflect
the needs of clients, we don't just look at a list
of a couple of symptoms, but we think about
functioning, commitment to family, ability
to serve community, and basically, overall well-being.
And many of these studies don't look
at these kinds of ideas.
So from my point of view, there's a serious low-visibility
crisis in the public's understanding
of clinical social work.
And, in turn, both the public and I think we
as professionals, are doing less to voice our needs
and to garner the kind of public support
we need to do a better job.
We need to do more work jointly as a clinical social work
organization to be advocates for better funding,
for cost effective and socially just programs,
and we need to make sure that the public
is educated about changing social needs
and the context of our services.
We need to support ourselves better as professionals.
Now let me shift over to the micro-perspective.
Clinical social work for those of you who are new to it,
emerged as a specialty in the 1970s replacing
social case work and psychiatric social work.
And one key issue was that in medical settings
social workers felt undervalued for their expertise
and skills, particularly in the assessment
and treatment of families and children.
In addition, they knew how to do placements
and referrals, but they had treatment
and assessment expertise that wasn't being
acknowledged or rewarded.
That was one of the motivators for moving
to a clinical social work approach
that separated us from a medical model
and from psychiatry.
And it's interesting to me that in the White House briefing
when I heard the Obama administrators talking
about social workers as case managers
who would basically be doing the bidding
of physicians who ran medical homes,
it felt like there we are again,
a kind of deja vu.
And we need to speak up for what we're trained to do.
And of course another issue for us is professional autonomy,
to be able to bring the theories and approaches
that we believe are effective into our work.
Now when you look at the definitions
of clinical social work given by the 50 states,
and they're all different, but they're all variations
on a theme.
We apply theory and clinical knowledge to assess,
diagnose, and prevent mental, emotional,
and behavioral disorders, conditions and addictions,
and you do this through a variety of therapies
of a non-medical nature.
It's actually a very broad and encompassing definition,
but given this kind of definition of what we can do,
there's no plausible reason, other than
the need for medication, why we should be second
to physicians or to psychologists.
We're legal authorized to do exactly the same work
of a non-medical nature.
Okay?
Now, because we're basically set up to work
with mental disorders and behavioral disorders,
I want to take a moment to think about
what's mental health and also what's behavioral health.
When I came into this profession, I did it
because I wanted to work in mental health,
and I did it because of a vision very much like
this one from the World Health Organization,
mental health represents a state of well being
in which every individual realizes his or her
own profession, or excuse me, potential,
can cope with the normal stresses of life,
including giving public presentations,
can work productively and fruitfully
and is able to make a contribution
to her or his community.
It's a really aspirational definition.
It's not just bringing people back from some disorder
to where they were originally,
it's moving them forward to give more to themselves
to realize their abilities, to support their families,
and to be parts of their communities.
That was something that motivated me
to get up in the morning and do this work.
And it's also interesting that WHO, and the US
is a signatory to these agreements,
says that health is the state of mental,
physical, and social well being, and not merely
the absence of disease and infirmity.
Okay, so their aspiration is to be bigger
than just being good enough healthy,
and I think this fits well with what social work values
propel us to do.
Behavioral health, which has come in the last 10, 15 years,
is a philosophy that stresses individual responsibility
to apply behavioral science knowledge
to maintain health and prevent illness
through a variety of self-initiated individual
or shared activities.
It's almost like do-it-yourself.
And this is a definition from this group,
from the Behavioral Health Group,
I'm not making it up.
So it focuses on preventing illness
and on health maintenance.
Those are important pieces of mental health
and of what clinical social work should do.
The idea was that somehow mental health
had become so stigmatizing we needed a new label.
But the problem is the label only looks at behavior,
it puts the responsibility on the individual,
and I would argue, basically prioritizes behavioral
and cognitive theories of health and of treatment
in a way that privilege them for no rational basis.
It's a much narrower bring people back to baseline approach.
I would prefer that we stay with a larger aspirational
model of clinical social work as providing a basis
for mental health and promoting well being
and helping people being contributors to their communities.
So what's clinical social work?
In a recent definition, we see that clinical social work
seeks to restore and enhance the bio psychosocial
functioning of individuals, couples, families
through prevention, assessment and treatment.
Prevention, as in behavioral health, is emphasized
but so is assessment and treatment.
And it's important to bear in mind
that treatment covers many roles
and service activities, we're not just talking
about psychotherapy here, although
that is certainly one legitimate social work role.
And in thinking about what it takes
to do clinical social work well,
Etta Goldstein said that, professional
ethics and values have to mastered,
bio psychosocial developmental theories,
theories of psychopathology, of psychodynamics,
of interpersonal relationships, of environmental
determinants, and clinical methods.
That's enough to take three summers right there.
Simpson and other people also added to that
attention to prevention and to resiliency,
and I think those are good additions.
And I'd add to that racial and cultural sensitivity,
attention to societal oppressions, though
I'm not clear whether or not that's part
of environmental determinants, and it
may well be that Etta Goldstein had already put
them in there.
But I think, too, we need to know some basic
neurobiology, we need to appraise strengths,
we need to understand evidence-based practice,
and to be able to do basic evaluation research
on our practices.
And then critical thinking has to be applied to it all.
We ask a lot of clinical social workers and in turn,
we have to do a lot in clinical social work education.
Etta Goldstein, a clinical social worker and professor
at New York University, who unfortunately passed away
a couple of years ago, wrote in 2007 that educating
students for clinical practice is more and more daunting,
and social work education for clinical practice is
in considerable disarray, if not in a state of crisis.
There's little agreement among practitioners
and academic faculty about what students need to know
and more knowledge to be mastered, greater questioning
of what seemed to be valuable in the past,
and increasing necessity to help students
critically evaluate both traditional and emerging theories.
So Goldstein, seven years ago was saying that
she thought we needed to be paying more attention
to what are we doing in social work education
and what kind of supports do we need to provide
to clinical social workers?
She went on to say that schools of social work
are not providing students with in depth clinical knowledge
and critical thinking skills, and that our
academic and professional organizations aren't
providing needed leadership.
There continues to be a low key crisis
in clinical social work and many unanswered questions
about the optimal education of clinical social workers.
And I'm going to argue that I think this crisis
has deepened in the recession and the lack
of funding has only made it more pronounced
and it's also been exacerbated by the decline
of clinical social work societies and organizations.
There are now three, where there used to be one.
And unfortunately each of these organizations
seems to represent a different set of states,
rather than being a truly national collaborative
operation and in turn it makes it harder
for us as clinical social workers to join in a truly
national effort to support our work
and work on behalf of our clients.
But I do want to say there is a diamond
in this story, and it's the Smith College
School for Social Work.
Don't worry, a little further in
I'm going to come back to being humble
about the state of the Smith College
School of Social Work.
But we've always been a source
of advocacy for social work education,
and that's been true from 1918 on.
Smith is the home of the Diagnostic School
and there's been a consistent focus
on the mission on excellence on clinical
social work education.
We offer in depth clinical and theoretical knowledge
and not only do we teach practice, but we
also emphasize advocacy, policy, and research,
and we actually do all of those things in depth,
which is one of the great opportunities
provided by our three summer block program.
In training folks in practice in the field
we have twice the minimum required standards
for internships, a lot of support for students
for different forms of faculty advisement,
and we provide more elective opportunities
at least at the Master's level than any other
school I know of, and by comparison
you should know that as a commissioner
on the Accreditation Commission it seems
like one elective is the average in most
traditional social work programs.
And at Smith most of your third summer
in the Master's program is electives.
All of this said, I think Smith needs to be
yet more active as individual faculty
and as a community in support
of clinical social work education.
So having taken a look at the background,
let's take a little look at what we need to do.
I've tried to define seven competencies
for clinical social work.
They have different parts.
But the first is, we need to know theory,
and this is something that we do differently as Smith
than is true for most other schools of social work.
In most other schools of social work, a human behavior
course might be a two-part life span development course,
and here at Smith we have many individual courses
on family theory, theories of development,
in second summer child development,
and it's equally true at doctoral level,
different forms of theory are used
to guide our practice.
And the idea is to make sure that you're trained
to have a background with multiple approaches,
not just wedded to one theoretical perspective.
Smith is often seen as the psychodynamics school,
and I think there's a lot of truth to that.
We teach psychodynamic theory in depth,
but in the first year of Master's practice
we're also teaching family theory and family practice.
And we all so have courses on group theory
and group practice.
When you stop and think what we actually do
just by surveying our curriculum, psychodynamic
theory is one of several theories that are taught here
in depth and also in breadth.
Clinical social workers need to know multiple theories
to choose those tools that guide you best
in different practice situations.
So we need multiple theory education with attention
to relationship and conscience use of self,
but theory has to come back to practice
and practice theory is a part of our theoretical base.
And this also needs to be tied to professional values,
critical thinking, and the ability
to communicate effectively.
It can be very important to doing healing
to help people understand the rationale
for the services that we provide.
Part two, competency two.
Clinical social workers have to be able to engage
with a wide variety of clientele.
We have to have strong and flexible engagement
skills that can be applied in clinics, in outreach
with mandated clients, with resistant clients
and with actively hostile clients, and yes
you will see them all if you haven't already.
Despite that, we need to show respect
and active appreciation for the dignity
and worth, the potential and the strength
of each client in our practice efforts
and also in administrative and policy work.
All relationships take time and a key part
of what makes them work is rupture and repair.
So part of engagement may be to make mistakes
that are almost inevitable, but to recover from them
with some grace, and to work collaboratively
with your client in a theoretically informed way
to enhance the relationship.
Carolyn du Bois says, and this is probably a quote
from Yale Child Guidance somewhere,
that everything you say and do as a clinical social worker
has to be done on behalf of the client.
And I think that's really true and it limits,
but in focuses what we can do.
When we're working with clients on their behalf
everything we do needs to be thoughtful,
theory guided, and on behalf of the client.
And of course, we have to start where the client is,
and that may be a hostile, or resistant,
or impatient client.
This piece of wisdom which I don't know if we can
cite a source for, it's traditional, still fits,
still works, and still is vital to doing good practice.
Clients are going to inevitably vary in motivation
and in readiness to use services.
We get people who are window shoppers.
We get people who are distrustful and can't make
use of our services, and it's important
that we can distinguish where they are
so we can tune in to what they need
and start where they're at.
Clients can also be extremely vulnerable
and anxious, which comes across in many kinds
of responses, but the surface is not all there is,
that there's both manifest and latent content.
And, again, integrity in our work is always important.
Third part, attention to race, culture, gender,
class, sexual orientation, age, and other forms
of human diversity have to be considered
as an intersectionality of multiple factors.
That our sensitivity to oppression must be active
and continuous, it's a piece of our anti-racism
commitment, but it goes further from race
to other forms of social diversity.
And we need to bear in mind that our clients
aren't us, even if they look like us and they share
some of our demographics.
The mere fact that we share social identities
doesn't mean that what they think and how
they view these things are the same as any of us do.
And, we need to acknowledge our openness
to differences because to do so may be a spark
to open up relationship.
Competency four, clinical social workers need
to have wide-ranging assessment skills,
including the appraisal of the whole person
and situation.
I don't know how you do this in 45 minutes,
and I was talking to another faculty member,
a colleague today, and she was saying
that one of the things that she got called on
was not checking off all the boxes on an assessment.
And as we talked about that, they weren't about
suicidal ideation or risk of self harm.
They were about whether or not you knew
the developmental history, let's say, of a client.
I don't know how you do that in 45 minutes,
find out everything you need to know,
start where they're at and get it all in one session.
We've set public policies up that don't allow us
to live up to our aspiration to get to know
people in situations.
I just argue it's simply not possible.
One of the things that goes is understanding
the client's view of the problem.
I work with children and families and I'm stunned
by reading the write up where the teacher says,
or the parent says here's the kid's problem,
but nobody tells us what the kid's view
of the problem is, and the kid's the identified patient.
The identified client.
Why wouldn't we ask the person who's the focus
of our service for their view of what's going on?
It just seems to lack dignity and respect
and it basically doesn't inform us adequately
about what our client's needs are.
We always have to keep attention to strengths
and ultimately to formulate the client's dilemma
in plain language.
This is really, really hard and what we're hearing
from our placement sites, and it's true of other
social work programs, at least in New England,
is that skills in assessment and skills in formulation
among students, and also among new clinicians,
has really declined.
That folks have become so symptom focused
that they don't seem to be able to crystallize
the dilemma of a client in plain language,
which is really important for showing them
you understand what's going on and
for guiding our interventions.
The detail matters in very important ways.
So our assessment skills have to be wide-ranging.
And then we have to actively engage the client
in treatment planning, which is also part
of evidence-based practice, in order to build
their investment in the work.
Then I want to add on something that's a little hard
to articulate, but I think that going beyond
what the client tells us, to interrogate
what we wonder about, what's unstated
but implicit is actually part of our job as clinicians.
To encourage them to aspire to more.
To ask them to think about problems
from other people's perspective.
To wonder about how things might look
and again, to do this in very focused,
symptom-oriented treatments is very difficult
and it may be disallowed by lists of evidence-
supported treatments.
But it's necessary for us to help clients aim
to be more and to live up to a full definition
of mental health.
We have to create room for change
and to continuously apply our assessment skills
because assessment is not a one-shot deal.
Another thing we have to attend to is our ability
to develop and act and discuss and to change
therapeutic relationships across varied settings.
What you do in crisis intervention or in stabilization,
or in outreach may be different than what you do
in a longer term therapy situation.
We have to find ways to repackage what we're doing
to fit to the needs of particular clinical settings.
We need of course to listen, to be empathic,
to tolerate and make use of ambiguity,
painful affect, silence, and enactments.
And this I think is something that unless
we think dynamically and about interpersonal
interaction we will simply fail to see,
and many of our advisers and supervisors
note that in discussions with colleagues
folks don't see how enactments are useful
clinical communications.
And to lose that source of information
when we deal with anxious clients who may not
be able to state their needs really limits
what we can bring to the clinical situation.
We need to be authentic and sometimes vulnerable,
and at the same time, we need to be clearly bounded
and to selectively withhold our own reactions and ideas
on behalf of better hearing the client.
All of this takes self awareness and ability
to articulate our understandings of
interpersonal interactions.
It's necessary to do that with clients
and it's also necessary to do that
to bring in supervision the kinds of questions
you may have as a clinician.
And this is true whether it's consultation
for a senior clinician or supervision for a student.
All of this is based on understanding different
theories well enough to have them be guides
for you in practice situations.
We need to stay open to diversity of many kinds
and to show our cultural sensitivity.
And then, finally we need to show awareness
of the overt and internalized effects
of social oppressions.
All of that is to say that when we see internalized
homophobia or racism, we need to have ways
to maintaining the dignity and respect that we show
for our clients to call into question some
of their own views about themselves
and about other people.
Looking at the time, let me move on.
Part six, we need to evaluate our practices.
We need to understand the basics
of case-based practice evaluation
in order to demonstrate accountability, and also
to build knowledge for other social workers to use.
This has become a huge effort and it's an area
where clinical practice is being researched
by people who don't understand the work
and impose a more limited perspective on it,
and unless we bring to practice evaluation the theories
and views and perspectives and knowledge
that we've developed, it's going to be done
in ways that further limit us.
So another demand on clinical social workers is
to think about evaluating your practice
and sharing your knowledge.
One of the great things here at Smith is
to have a thesis or dissertation obligates you
to do some of that and gives you the opportunity
to do it, and it's also part of Master's case summaries.
Part seven, I actually think that clinical social workers
need to be advocates.
And I was thinking about this and it's not clear
that policy planners need to be able to do
clinical practice,
but it's going to be a requirement on us
as clinicians that we can do advocacy.
We need to advocate for our clients
at the organizational level, at the system level,
but I'm going to argue that we also need
to advocate for ourselves as clinical social workers
because one of the things that's happening now
is we don't have a unified voice.
And unless we develop one other people will speak
for us, or they will ignore us, neither of which
is to our advantage.
So we need to advocate from case to cause
for the profession to join together and to do advocacy,
and to promote the kinds of theories and thinking
and practices and the kinds of supports for good practice
that we think fully realizes our idea
of clinical social work.
So those are the competencies
and it turns out that there is an evidence base
to support these, and I'm basically going
to blow through this and I'm going to set up
my colleague, Liz Keenan, who's going to do
next Monday's lecture.
Some of the evidence base supporting these ideas
that clinical concepts and theories and a focus
on relationship is key to change comes out
of the common factors model.
And let me just highlight a couple of simple
aspects of it.
In the latest work, about 30% of what researchers find
can be explained change in therapy is due
to client factors, and if you're a clinician this makes
perfect sense.
If your client goes home and their partner says
it's stupid that you're doing that therapy stuff,
they are less likely to be invested in it.
On the other hand, if they go home and the partner says
it's brave of you to take this on,
they may be more invested.
So the client's world inevitably shapes as much
as anything what happens in therapy,
and we don't have a whole lot of purchase on that
and we don't have a whole lot of power
to alter or support it, unless we're doing work
in systems like schools or inpatient or residential units.
12% of the variation in outcome is due
to the therapeutic relationship.
It's the biggest single interactive factor
that's been identified in outcome research.
8% has to do with specific therapies and this
would be the choice of psychodynamic
or cognitive-behavioral, or MBSR, mindfulness-based
stress reduction, or family systems theory.
7% has to do with our own characteristics as clinicians.
This is when we ought to really pay attention to,
there are pieces of what we do that we may not
be flexible enough to alter in ways that are actually
helpful to our clients.
And another 3% relate to other factors.
Now this research is based on interdisciplinary
psychotherapy research, but there's been
recent research by social workers that show
that variation in case management is similar,
that 11% of outcomes in case management
are based on the quality of the client
and worker alliance and some other work
that I heard last year at SWER suggests
that that's equally true for other social work services.
So what we do may be more based on what
we bring as clinicians and our ability to develop
alliances with clients then with choice of specific
therapeutic techniques.
And there's another model which looks at the nature
of the therapeutic relationship and this group
with Louis Castonguay, Lloyd Butler,
and also Marsha Linehan have looked at
what pieces of therapy lead to
good outcomes.
Most of it is the kind of stuff you look at as a clinician
and you say, well yes of course.
So client expectations play a lot in outcomes.
Well yeah, we all know that and in fact,
that's what the common factors material shows.
Clients with higher levels of impairments
or who have personality disorders
or interpersonal problems early in life
are likely to have poorer outcomes.
Right, there's no rocket science in that one.
What these folks have worked out empirical support
by using quantitative research methods
to come to these conclusions.
Which these days is very helpful in terms of the kinds
of evidence that are most honored.
There are more of these, but I'm going to just
pass through them if you'd like the full Powerpoint
I'm happy to share it with you.
Another thing that amazes me is there's very little
research on supervision, but some that's done,
and I'm pitching this as an idea for theses
and for dissertations, I think it's a great one.
Laura Berenson, one of our students,
is working on a dissertation related to field advising,
and I wish there was more research being done
in this area because it's really important
and we don't know much.
But in a great study by Knight, who's a researcher
out at University of Maryland, what does she find?
Frequent, regular supervision of good duration,
plus unscheduled access aided student learning.
(chuckling)
All right, it's duh, right?
We all understand this, but on the other hand,
if we don't support supervisors and supervisors
are doing this in addition to all of their work,
they're not going to be able to provide
this kind of support.
What else helps?
Reviewing cases, doing process recording,
and having process recordings carefully read
by supervisors were seen as really useful
for improving student self-awareness
and integrating theory in practice.
And then the biggie.
Clear roles, openness to affect and taboo subjects.
You wonder what that is,
but I think we can all guess, right?
Support for feelings and encouragement
of autonomy and self-criticism all enhanced
student learning.
Now we should know more about how
this stuff works and which is relatively
more important than other pieces.
But there is evidence to support
that attention to theory and use of self
is critical to good social work education.
So what's clinical social work in the 21st century?
It's a perspective.
It's a way of understanding and serving other people
based on our knowledge, values, and skills.
The clients that we serve can be informally
or formally defined.
Sometimes in working in school systems
I began to think that the client was just
the person standing in front of me,
and I know I would insult many
of the really fine teachers that I worked with
by thinking of them as clients.
But it became clear to me that some of what
I could do would be to take a therapeutic tact,
not to treat them any less as professional colleagues,
but to use my professional knowledge and skill
to help them get through a situation,
or to better understand one of the kids
that was posing difficulty for them.
So I think we need to be wide ranging
in how we apply what we know.
And in a lot of settings like schools
and especially inpatient units, residential facilities
where parallel process is often enacted and reenacted
to apply our clinical skills to look at our colleagues
and even ourselves is really important.
Thorough assessment is a vital part
of clinical social work and is increasingly,
I think, being eroded and limited.
Interventions should always be based on a plan.
Okay, and notice that I'm not trying to say
what kind of a plan, because I think we can be informed
about a lot of theories and a lot of purposes,
but it's interesting that I speak to supervisors
who tell me they don't think that students have a plan.
Now part of the job is that, we as educators
and they as supervisors, should help the students
develop those plans, but what we do should
be based on our theory and there should
be a plan for what you're doing.
Clinical social work is also a portable perspective.
It doesn't have to be applied only in an office
in a 50-minute hour, it's applicable to a lot
of different roles and client situations.
So we can take the heart of what clinical social work is,
the competencies that I've kind of mapped out
for you and apply them in a variety of settings
to restore and enhance the functioning of individuals,
couples, groups, families, through prevention
diagnosis, treatment and advocacy.
And I'm going to argue that linking brokering,
advocacy, and mediating are all important parts
of clinical social work.
One of the things that I've come to think about
is almost everything in social work
has a place in clinical social work.
And I'm not sure that works the other way around,
because I don't think policy people have to do
some of the things we do in clinical practice.
But I think that in clinical social work we have to be
Jacks and Jills of all trade.
We have to be able to do all of these things
when they're necessary and helpful.
Right now, I think we really need to work
to be advocates for our profession,
and in turn for the needs of our clients.
Carolyn du Bois took a look at this
and she said, Jim, you have to be careful
that this thing doesn't come across
just as a downer.
It's important that we recognize
there are the bright spots.
One of the things here at Smith is that
MSW interns at Smith, I'm just looking
at MSWs because it's easier to count,
provide annually more than 150,000 hours
of service to clients.
It's a tremendous amount of service.
It's a wonderful thing and it fits with
our primary social work value on service.
We provide needed supports for people
with mental illnesses, medical conditions,
trauma and depression histories,
and adjustment challenges.
In schools, in hospitals, in all kinds of different
settings, in jails, in prisons, in client's homes
and even on the street if needed.
The program and Smith students really help people
realize their potential, cope with the stresses of life,
to work productively and fruitfully, and make meaningful
contributions to their families and their communities.
That's the WHO definition of mental health,
and I think we should be aspiring to
and I am pleased to work in an institution
that still seeks that.
You also should know that the school
was rated number one in social work programs
in a national survey of social work students,
and this is across all different schools
of social work in the United States.
So that other people appreciate that what we offer here
at Smith is special and is somewhat different.
And also, in a similar poll by
the same Columbia researchers,
we rank number one in a survey
of graduate social work practitioners.
People do understand what Smith offers
and it is honored.
We're number 16 now in the US News
and World News and Reports ranking
of schools.
But of the nine university schools of social work
we're the only one in the top 30.
All the rest of them are big universities
with a much larger research focus.
And our graduates provide services,
supervision, and administrative leadership
nationally and internationally.
And a lot of our PhD graduates serve
as faculty members in programs also
nationally and internationally.
And our faculty do all kinds of clinical
and policy practice, as well as research
and service of many kinds.
So I don't want to lose sight of what we do,
but notice that some of what we do in teaching
and in research, in service and in scholarship
goes beyond what most people think
of the traditional roles of clinical social work per se.
As next steps, let me ask you to really thing about
what you can do to support clinical social work.
I think we need to better organize
and to advocate for services and on behalf
of social work titles, and for definitions
of the services we can provide,
for better payment and for expanding
the public's awareness and understanding
of the work we do to support diverse populations.
I think it's an important and special thing
and we should stand up more for what we do.
So I ask you to think about being more active
and being more involved.
Part of that is to keep learning, do the best you can,
if you are a student, then continuing learning,
to apply critical and creative thinking,
build relationships, build your competence,
build knowledge, and according to my colleague,
Joan Berzoff, keep it complicated, because it is.
This is unbelievably complicated stuff
we're asking you to do.
Now, in closing let me say one thing about Smith.
If you look at our ads, Smith is the leader
in clinical social work.
I look at that and I have to tell you
with my Mainer background, as a New England
Anglo guy, it's so lacking in humility
that sometimes it makes me cringe,
this is just not what you do.
You don't self-promote in that kind of way,
but lo and behold, Smith is the leader
in clinical social work and we do need to honor
what we do.
And when I think what's provided here
and how different and how increasingly special
what we do has become, we should take credit
in being the leaders in clinical social work.
That said, I think we do need to do a whole lot more.
We need to be the source of a national movement
in support of excellence in clinical social work
to live up to our mission fully, and to make sure
that it doesn't just rest here at Smith,
but that it goes national and international.
I want to give a quick shout out to Yvette Colon,
my colleague and friend who's here as part-time faculty
and has served in many roles on our Alumni Committee,
and also as faculty and is a faculty member
at another distinguished school of social work.
Yvette is one of the leaders of one of the three
clinical social work organizations,
and I want to point her out because if you want
to become more involved that may be one avenue to do it.
And together, maybe we can see, over the summer,
if we can make sure in the bulletin and in other
announcements to our alumni and beyond
this immediate community, we make people aware
of what organizations are available, and help you
find a way to be part of this activity.
So Yvette, would you mind just standing up
so they can see who you are?
- I (mumbles) as president of the board
for the Center for Clinical Social Work
one of the (mumbles) we have done in the past year
is to create an entire online student center
and provide student memberships,
so hopefully you'll be able to hear more about that.
Thank you.
- So I thank you for bearing with me.
I was thinking about this and you know, Carolyn
says make sure you're not a downer,
I was thinking this may be very heady
and intellectual and it is,
and part of that is because I'm in this role
as a commissioner on the
CSWE Accreditation Commission and one
of the things we're doing now is to figure out
what are the competencies that will be required
at BSW and MSW level social work education
for the next eight years.
So I've been immersed in this stuff
and I thank you for bearing with me and helping
me think it through and I'm now really interested
to see if you have thoughts or questions
or different points of view to expand the conversation.
So, thank you.
(applause)
Any comments?
Devina.
(No microphone being used, unable to hear)
So I don't know if you all heard the question,
but it's basically, why haven't you emphasized
DBT and other
contemporary approaches to therapy.
And basically, one of the things I've tried to do here
is not to look at any individual kind of therapy.
Part of that is because as we look at the research,
the outcome shows that the impact of therapy
is about 8% of the overall cause of change
and that that's less than what's caused
by the alliance or the factors based on the client.
So I haven't tried to call out, you know,
family systems theory or EMDR, or DBT.
That said, Devina, I agree with you and I think
part of what we have to do is to educate
students in the theories behind these approaches,
and also to note that in some of them like DBT,
there is actually a range of theories
and that there's no one theory that guides
the intervention, there are actually several
different components, each of which is based
on a somewhat different take.
So in no way do I mean to devalue attention
to those theories and to those practices.
I think, in fact, they are increasingly part
of what we're providing here,
but it was not my intention tonight
to really identify any specific theory,
other than to speak to what I think is a slightly
off target understanding of Smith
that we're so psychodynamic that we're nothing else.
And in my view, that hasn't been true for decades.
I was hired by Ann Hartman and at that point,
looking at what was offered, there was equal
attention to individual theories, family theories
and groups.
So, you know, the idea was to provide people
multiple exposures and multiple opportunities
because there's no just one single way
to do anything.
I think I'm answering your question, but I don't know
if I'm doing it fully.
So there was no intention to devalue any contemporary,
empirically supported treatment,
though one of the things I think we do have to do
is to be critical thinkers about them and I run
a doctoral course for third summer students
where we look at the empirical support
for some of these treatments,
and in fact it's a whole lot thinner than you might think.
And one of the big problems, especially with
something like DBT, is that almost all the research
is done by Linehan, and what happens is
when people research their own treatments,
it tends to look better than when other people
research it, which is know as attribution by us.
And don't misunderstand me, I'm not saying
that DBT is not helpful to lots of people.
I think that it can be, but I also think that we need
to be both aware of these theories
and critical about them.
Barbara.
- [Voiceover] You make a very compelling case
for a national clinical social work voice.
I sort of wonder how you see that in regard
to say NASW and the idea that some people
consider themselves social workers
but might not have identified as clinical social workers
and, I'm just looking forward, I just wonder
how you see that?
I mean should all social workers be ...
do you that there's another group
of social workers that are not clinical or ...
how would that work on a national level?
- That's a great question.
So you know as everybody who does social work
practice a clinical social worker?
Well I don't think a lot imagine themselves that way,
and I think part of that is that many social work programs
In the United States at the Master's level train
advanced generalists.
When you ask those people what they're trained
to do it's like everything.
- [Voiceover] What community organization (mumbles).
- Oh, I have no quarrel with we should have groups,
in fact, the COSA for community organizers
is very active group and there are active groups
for policy planners.
The interesting thing to me is that
there's no single group for clinical social work,
there are several.
And what's the alternative, I mean
to be a direct practitioner?
I'm not sure that people aspire to be
you know, social work direct practitioners.
Now some of this has to do with how
we imagine ourselves and how we label ourselves,
and I'm not sure there's an easy answer to that.
You know when we look at the numbers
of what people do, children, families and schools
has more than mental health for medical settings
in terms of practitioners.
School social workers have small scale organizations,
but they don't do national advocacy.
There might be some way to tuck these groups together,
but I'm going to argue that I think the first thing
we ought to do is to get our house in order,
and I think we do know enough about
clinical social work to support it and affirm it.
And we ought to do a better job of that
and we need to work with our friends in advocacy
to take it on and do a better job.
I've been a board member for Mass NASW,
I'm a member, I'm committed to it.
I've been part of the Massachusetts board's
group to do strategic planning for the next three years.
We surveyed the membership in Massachusetts,
what came back from the survey?
We need title protection.
Many of you are not from Massachusetts,
but recently we had a couple of highly publicized
deaths of kids in the care of the Department
of Child and Family Services.
The solution was to fire the director,
as if that was going to change services.
You know, may be it was an appropriate step,
I'm not questioning that, but I'm not sure
it's the solution.
The interesting thing is the social workers
through Protective Services in Massachusetts
are called social workers.
So the public doesn't understand the distinction
between what clinical social workers do
that requires a different value set
and basis in training.
So what does the survey say
from Massachusetts social workers?
Protect our title, make sure that people
better know what we do, that maybe
the people who work for Child and Family Services
ought to be Protective workers or something else
that doesn't call on the same thing as people
with licensure in the state, and I don't think
this is a unique idea.
I think this is probably true in a lot of different states.
The other thing they asked for was to
be more effective in supports for better
working conditions and rates of payment.
Now those are entirely reasonable things.
But how do you organize that without thinking
about what kinds of services are we providing?
And one of the challenges for NASW,
and I think there are tremendous people
working for NASW and in support of it,
is how do you focus these efforts to make them
effective in specific areas?
I'm going to argue we haven't been effective in ACA.
That in Obamacare the role of social workers
is not good, this is not going to help us.
I'm not saying I'm not in favor of what it offers,
I think it offers wonderful opportunities.
But one of the things I heard at a strategic planning
meeting was by an social worker who is a policy
planner and economist, and lo and behold, it turns out
that in the ACA, the payment rates for administrators
are a totally separate money line
than for direct practitioners.
And if you look at the payment rates,
looking at the New York Times, they did a survey.
There was a small mental health center in New Jersey.
The director was paid $22,000.
You'd think that'd be appalling,
but the person made $20,000,000
in side income.
Okay, in non-direct payments.
That stuff is actually allowed
under ACA and the whole rules
and regulations for administrators
is a separate funding source from practitioners.
It makes no sense that we have folks
being paid 200 times, 400 times what line workers are.
So I think we need to be much more active.
I'm not sure I'm answering your question,
but it's a great one and it would be wonderful
if we could work not only as clinical social workers
but to be more effective as social workers as a whole.
And what I hear from NASW national,
and Jeane Anastas, who was faculty here,
is our current president of NASW
and just ending her term.
And Jeane said basically one of the big problems is
we don't have enough funding support
from our members to do the kinds of lobbying
they want to do.
So some of it is we have to provide better support
for people to have the voice in our own support.
And that's a dilemma because we're not rich,
we don't have deep pockets.
So how do you do that?
But maybe numerous voices is a solution
where money, per se, can't be.
Anybody else?
You sir.
Go back.
- [Voiceover] I guess I sort of want to stay
with the discussion of what is a clinical social worker
because it seems to be sort of central
and you know the clearest ...
I guess I'm sitting here wondering,
I'm a little confused what a clinical
social worker is still.
And wondering if that is not part
of the problem here in many ways.
How do you advocate for something
if it is unclear what the thing is,
your advocating (mumbles),
and I get really uncomfortable
listening to
conversations that happen here, let's say,
or in other places that seriously tries
to distinguish, we'll say well that's just,
that's just case management.
Yeah, it's the sense that there's
a kind of elitism that says if you're
doing that then it's not real social work,
and I mean as a historian
I go back to looking at case work,
the beginnings of case work
and case management and going into
people's homes and working in the homes
and trying to help people find jobs,
and enough food, and doing clinical work
in those settings is what social work was.
So it seems to me that perhaps we should
spend some time trying to reconfigure
or reimagine what the borders of
clinical social work really is and
we might have a better time arguing
for ourselves if we had a better
definition brought, or some more clarity,
something.
- Are you all hearing this?
I have no quarrel with what you're saying
at all.
I actually think one of the things about
being a clinical social worker is
a perspective and a portable one,
but it also requires having a background
in multiple theories and approaches
and particular ways of using yourself
that allow you to do more in situations
that people without that background
may be able to do.
It's not necessary in all cases,
but in some situations it's really, really
important, and it does may a difference.
So I in no way mean to devalue, you know,
social work that doesn't have a more
specialized focus.
In fact, I think what we're looking at
is both, and, and, and, and.
And clinical social workers just do
more stuff than some other social workers do.
That's a crumby definition, right?
- [Voiceover] Yeah, because I mean what
the context of that more stuff is exactly
this is what ...
- Well let me go back to looking at
how state law has formulated what
clinical social work is, it's basically
in terms of mental, emotional,
and behavioral disorders and their
assessment, prevention, and treatment.
So in some respects, it really is
a specific skill set.
But to do that work and to be,
to not be cognizant of your client
doesn't get three square meals,
or Carolyn du Bois presented a case
at orientation where a young boy
kicked his teacher.
And part of the story basically goes
that later they find out this kid has dental
problems and abscesses all through
his mouth and the teacher says something
to the effect of when I reached out
to him I might have appeared to be
going towards his face.
The kid may have kicked her because
he was trying to keep her from hurting him.
Now the teacher didn't know this
and it took like months of understanding
the kid's broader needs to make sense
of this whole situation.
But nobody had done it before
and I think some of what we do
does come back down to this isn't
a mental illness or a disorder,
this was a physical problem
that had interpersonal consequences.
I don't know how much skill that takes,
but I think there are a lot of situations
with clients where you do need
an extensive theory background
and terrific use of self, and I fear
that a lot of social work programs
don't aim for excellence in that,
and it's really tough to pull off.
Each of us will have areas of strength
and limitation.
We're not all good at everything,
even with advanced training.
But you're asking a great question.
I'm looking at the time and maybe
we can take one more?
(No microphone being used, unable to hear)
- You know, and that's a really, really tough area.
The issue is, you know, what constitutes
a quality review for clinical social work practice?
And increasingly insurance companies
and providers are asking us to
be accountable and interestingly,
kind of like a lot of research,
much of this reduces to symptom profiles.
And one of the dilemmas I think that clinicians face
is that it seems to suck the life out of what
the work is actually about,
and when I think about clients that I've
worked with, it's progress when a particular
woman who I've seen several times
and sits tight and anxious, takes her purse
off her lap and puts it down on the floor
for the first time.
I mean, how can I justify that for
an insurance company?
But it's a step in a direction toward
something larger.
And I think many of the small victories
that we find as clinical social workers
are totally unrecognized in quality review,
and then you get into bigger issues
of what should we pay for and what
kind of success do we require?
Let me just say one other thing here,
research on the efficacy of psychotherapy,
the magnitude of what's gained
by being in therapy, basically shows
that often therapy has
probably twice the gain of many
medical procedures.
So when you look at actual outcome
numbers, what we do is more efficacious
than all kinds of medical procedures
and medications.
Which I think is something most people
are not even aware of, but when
you look at what quality's about,
and then there are disorders that
are mind boggling.
I think the stats from the New York Times
were in the United States we pay
$420,000,000,000 annually for back pain treatment,
most of which produces no useful result.
$420,000,000,000.
So when you're looking at quality review
I think there's several issues.
What constitutes quality?
How fine grain is it?
How big a sweep does it take?
And again, I think clinical social work
organizations have to help providers
understand what are the parameters
of our success and what are
we aspiring to do,
but it's a really tough nut to crack,
so I appreciate the profound difficulty.
Nick.
- [Voiceover] I just want to acknowledge
you gave a more upbeat piece to it.
We've needed (mumbles) for about two years.
I want to say that the social work students
that we get, and when I think about
what I learned I don't think that (mumbles)
what I learned is wrong.
I think the theory (mumbles), I think
the critical thinking skills is what
differentiates the social work from (mumbles)
and I've always felt it's been
far better than the other schools.
Smith is good, but there's other good
schools too.
(laughing)
- Absolutely.
- [Voiceover] But I want to say I think
the social workers have the best
critical thinking skills and I really
like the term that says keep it complicated.
I know that sounds weird, but people
come in thinking they're going
to summarize the person in a sentence
and it just isn't likely.
- I have to point out that Nick Flescher and I
were students here together at Smith
in the Master's program and
Nick and his wife Peggy have both
served as supervisors for a lot
of our students.
I hope I haven't maligned administrators
tonight, because actually I think
that to be a social service administrator now
is very, very difficult and I go back
to that little vignette of we don't
get paid enough to cover the cost
of services.
How do you deal with that?
- [Voiceover] Well I think that people
(mumbles) I said many of you will
be going into administration
because (laughing drowns out words)
care act there's going to be a lot
of money coming towards the kind
of work that we do, but it's going
to be coming at Bachelor's level,
there's going to be supervisors
and coordinators and planners (mumbles)
and I think (mumbles).
- And indeed nationally,
(two people talking over each other)
- [Voiceover] There is a new appreciation
that integrating (mumbles) behavioral health
(mumbles) integrate behavioral health
with medical care and that's going to be
you know, the kind of direction things are going,
and so that social workers are putting (mumbles).
- I hope it plays out in that way,
I do want to point out that I don't think
that all of the reasons that folks come
to us are medical conditions,
and you know, philosophically we all
have different positions on, you know,
the role of medication.
Maybe it all is medical at some level.
But I'm not sure we have the technology,
the expertise to go their quite yet.
I think Nick is also making another point.
Roger Miller who is now professor emeritus here
and some of you may know, one of Roger's
favorite lines was, you know all theories
are wrong.
And it's true, all theories are wrong
that's why they're theories, but their
purpose is to guide our thinking.
It's not that they're always right,
and as Nick is saying, we do have
to be critical thinkers about their
application, but we also need to
have ways to imagine other people
and to open things up and to think further.
But thank you for that ray of sunshine,
hopefully we can, through Obamacare,
find ways to better integrate services.
Thank you all very much.
(applause)