Clinical Social Work in Child Welfare Settings
Alma J. Carten, MSW, Ph.D., Associate Professor, New York University Silver School of Social Work
Defining Clinical Social Work in Child Welfare Settings
With more states enacting legislation regulating the practice of social work, there has been an intensification of the ongoing “cause and function” debate within the profession, which currently centers on the definition of clinical social work. Some define clinical practice as psychotherapy undertaken in mental health settings or as private practice, for which appropriately-credentialed practitioners can bill and be reimbursed. Others, operating from the assumption that the integrative perspective is the foundation for all social work practice, view clinical practice as one form of direct services that is carried out in many practice settings with the practitioner drawing upon a repertoire of roles and practice interventions.
This discussion adopts the latter view and uses “direct” and “clinical” social work practice interchangeably. It also suggests a conceptualization of child welfare services that moves beyond the current narrow definition of a highly-specialized system that emphasizes child protective services to one that acknowledges multiple entry points into care systems that provide a comprehensive array of services of varying intensity and duration. Such a perspective would more adequately capture the range of practice settings in which social workers are delivering quality clinical services to children, youth and families.
Extensiveness of Need
Approximately 50-80% of children served by the child welfare system have moderate to serious emotional disturbances, and mental health services for them are far from adequate. Infants and toddlers comprise the largest percentage of children entering into the foster care system. They are being separated from their homes at critical periods of development when the quality of the attachments with caretakers will influence their social, cognitive and mental development at subsequent developmental stages, as well as impact their ability to successfully carry out adult roles in later life.
Children living in substitute care arrangements often blame themselves for the disruption of their families, as they are simultaneously trying to cope with the effects of the victimization and traumatic experiences that led to the placement. Adolescents often approach independent living with untreated or diagnosed mental health and behavioral problems that will be obstacles as they endeavor to establish themselves as autonomous adults. New immigrant children, who have witnessed or directly suffered various forms of trauma and victimization in their native countries, are a growing segment of the child welfare caseload in need of clinical services.
Separation and loss, attachment and bonding, trust, and continuity of familial relationships are dominating psychosocial themes of child welfare practice. Impacted children present with internalized symptoms such as withdrawal, sadness and depression, hyper-vigilance, over-compliance, phobias, sleeping and eating disorders, and anticipatory anxiety. Externalized symptoms may be expressed as overly aggressive and sexualized behaviors, fire setting, bullying or cruelty to animals, younger children and siblings. It is also known that many children emerge unscathed from living under intolerable conditions. New research on resiliency, protective and risk factors, and the ability of the brain to create new pathways that compensate for the effects of trauma on emotions and behavior indicates that timely and effective clinical interventions can mitigate some of the potentially long-term effects of trauma and victimization on the future development of children.
Putting a Face on the Statistics
Were we to paint a picture, we would see social workers providing clinical services to families in a variety of practice settings: a latency-age child receiving play therapy in a hospital sex abuse unit; a non-custodial father receiving anger management services in a men’s group in a domestic violence program as a condition for visitation with his children; an unescorted minor who has taken to smoking and drinking to cope with feelings of loneliness and isolation being evaluated by the school-based health team; a grandmother coping with chronic problems of aging while parenting two preschool-aged grandchildren and endeavoring to support her adult daughter who is diagnosed as bipolar; an immigrant family experiencing intergenerational conflicts with their gang-involved adolescent son; a single homeless mother endeavoring to maintain sobriety as a condition for being reunited with her children; teenage expectant parents who envisioned raising their child together, but now question their commitment to remaining in the relationship; and a gay adolescent from out of state who is receiving services in a shelter for homeless runaway youth.
All of these case examples suggest rich opportunities for the development of clinically-focused interventions that assist children, youth and parents in managing the psychological ramifications of their presenting problems.
Comprehensive Psychosocial Assessments
Social work’s integrative perspective emphasizes the inter-play between people and their environments, and endeavors to understand the needs of children and families in their totality, as well as the role of larger social systems in contributing to family stressors. A first priority of a comprehensive biopsychosocial assessment is to determine the level of safety of the child. The assessment takes into account attributes of the child, caretakers and the environment that increase or mitigate risk.
Social work emphasizes a developmental approach and draws upon a range of practice, behavioral, environmental, psychodynamic, and cross-cultural theories for conducting broad-based assessment for understanding the cause and contributing factors to presenting problems and for planning treatment interventions. Causal attribution will influence the choice of intervention. Because the causes of the problems experienced by children and families are complex and multifaceted, direct services workers will likely draw on a range of practice interventions and modify treatment goals in response to the changing needs of children, even while the central concern may be with improving mental health outcomes. Interventions may include individual, family or group treatment.
Transference and Countertransference
Practitioners providing services to troubled families must effectively manage complex transference and countertransference that emerge in the therapeutic relationship as they endeavor to establish trusting relationships with children and with adults who themselves often have a history of abuse or were reared in chaotic family environments. Adult perpetrators and child victims can induce strong countertransference feelings that must be effectively managed, along with cross-cultural dynamics and subjective reactions to clients with whom the clinician may not share a similar cultural background. Clinicians must also recognize the need for self-care to avoid the vicarious trauma and compassion fatigue that is not uncommon for direct services practitioners who are secondary witnesses to trauma, or who are listening to client narratives of hurt and suffering on a fairly consistent basis.
The Policy Context for Practice
It is critical for direct services workers to be knowledgeable about the impact of policy on clinical practice, and understand the political, economic and social context within which child welfare and mental health policy developed in the United States. The Supplement to the Surgeon General’s Report on Mental Health examines mental health policy and offers a comprehensive analysis of factors that slowed the development of a sound theoretical knowledge base for informing clinical practice with minorities, and specifically identifies children in foster care as a high-need and underserved population.
Similarly, child welfare reform legislation of the last two decades has endeavored to reverse the effects of policies that carried forth a residualist conceptualization for understanding the causes and cures of poverty that supported practices of rescuing children and punishing undeserving parents. The continuing effects of these flawed policies are a contributing factor to problems confronting the system today and to the disproportionate representation of poor children of color in the foster care system.
Social Work Contributions
Social work has a central role to play in the development and delivery of child and family focused clinical services. As major suppliers of practitioners for the child welfare and mental health workforce, schools of social work can ensure curricula development and renewal that prepare graduates for effective direct practice with children and families in a range of practice settings that is undertaken from a social justice perspective. Schools should also encourage scholarship that contributes to knowledge building supporting new conceptual approaches that target interpersonal and institutional causes to enhance best practice with children who are overwhelming poor children of color.
Finally and importantly, the profession must examine more closely the impact of the New York State Social Work Licensure Law on diminishing access to quality mental health services to children provided by caring, skilled and competent clinicians.