Clinical Social Work in a Mental Health Clinic
James G. Chavez, LCSW-R, Supervisor, Manhattan Mental Health Clinic, The Puerto Rican Family Institute, Inc. Extending Beyond the 45-Minute Psychotherapy Session
The standard mental health clinic is responsible to provide comprehensive psychiatric care to the recipients it services. The scope of what comprises psychiatric care can fluctuate on a daily basis in response to recipient needs. In an outpatient mental health setting, “clinical” social work is most commonly understood as psychotherapy treatment where the client presents the symptoms that negatively impact his or her functioning. The clinician’s role is to help the client best determine the appropriate response to minimize the symptoms’ negative impact. The process that eventually leads to this outcome consists of an experience where the client is assessed, validated, supported and occasionally challenged. This is straightforward “clinical” social work. However, in many circumstances the common understanding of clinical social work can undermine and limit the potential benefit it can have on a client’s treatment and well-being. Clinical social work in the mental health arena can extend far beyond the confines of a psychotherapy session, and even outside the walls of the clinic. It is most effective when supported and reinforced by both the clinician and client in everyday experiences of the client’s life outside of a psychotherapy session.
Clinical social work is best achieved by an initial open dialogue between the client and social worker that accurately reflects the client’s strengths, needs, symptoms and desire to recover from mental illness. In a mental health clinic, the initial steps toward helping the client achieve management of their symptoms and their desired level of recovery is begun during an intake during which the foundation of treatment is established and stepping stones toward recovery are identified.
Interacting with Clients in the Community
The clinical staff is instructed by the supervisor of the mental health clinic that their primary role with clients is to provide psychotherapy and facilitate self-sufficiency in the community. It is inherently important that the staff understand that this does not restrict their work to a forty-five minute psychotherapy session. With the abundance of resources available to the mental health community in New York City, it is quite common for a clinician to withdraw from the client’s treatment once the psychotherapy session has ended. With workers handling intensive and supportive case managers, home-based crisis intervention workers, Medicaid Home and Community Based Service (HCBS) waivers, placement prevention, as well as those providing the rest of the gamut of services within the mental health system, clinical social workers can often decide that it is not their role to interact with clients in the community. During some circumstances, this belief can be a contradiction to the actual goal of treatment to support clients in their efforts to resume self-sufficiency in their communities.
Clinical Interventions to Support Day-to-Day Functioning
Even with such an array of services available to the client, if a clinician is able to extend him or herself in situations when the clinical work requires implementation outside of session, then treatment can be more effective in preventing over-utilization of emergency room visits and psychiatric hospitalization. Recently, one of my clients who struggles with psychotic symptoms was scheduled to meet with a hospital physician to be informed of the extent of injuries one of her sons sustained during an assault on both her children. I made several efforts to have one of several case workers supporting the family accompany the client to this meeting, however, none were available. As a result, I arranged to be available myself via telephone during the meeting in the event that the client fell into a crisis. During the meeting the client began to decompensate in response to the severity of the information she received. I was contacted by the physician’s assistant to speak with the client as she became increasingly distressed. While on the phone I was able to review exercises that the client had learned in the psychotherapy session, repeating the steps she had learned to help calm herself. The client was able to regain her composure and complete the consultation with the physician.
A few days later, she was informed of the initial findings of injuries inflicted on her other son. Using the exercises from the previous call, she was able to complete the consultation. However, after leaving the hospital the client called my office because her psychotic symptoms were becoming difficult to manage. Again on the phone, I was able to assess for her safety and reinforce the responses to her psychotic symptoms that have been effective throughout treatment in maintaining her stability.
Concrete Services and Clinical Judgment
Both of the experiences demonstrate that the clinical social worker’s role can extend beyond the constraints of the mental health clinic. It can be a reinforcement of the interventions in psychotherapy sessions to help the client maintain stability and remain a functioning member of their community. They also illustrate how the application of clinical judgment can make a critical difference in activities that are commonly seen as “concrete” services or case management.
Although it is good practice to support clients in accessing the multitude of services available in their communities, it is critical that social workers extend their clinical work when necessary to strengthen the work done in psychotherapy. Lastly, it is also important for the profession to recognize that effective clinical work can take place outside a psychotherapy session.