Clinical Social Work Practice: Toward an Inclusive Viewpoint
Lorraine Tempel, Ph.D., LCSW, Senior Consultant, National Resource Center for Permanency & Family Connections
Expanding What is Understood as Clinical Practice
The word “clinical” in association with social work practice is a complicated notion to define and agree upon. As many authors have described, it is historically associated with a medical model that presupposes psychopathology and the need for psychotherapeutic treatment (Goldstein, 1996.) Furthermore, clinical social work has been described as privileging some roles and settings (such as may be found in psychiatric, mental health facilities and private practice venues) over a host of others. Carrying this even further, it has been equated with social work abandoning its mission of commitment to social justice (Specht & Courtney, 1994.)
In my opinion, these broad-brush defining statements about clinical social work stand far from being universal truths. In reality, clinical social workers are employed in a wide expanse of practice settings and require knowledge of multiple human behavior and practice theories as well as methods in order to differentially assess and intervene with the culturally complex persons and environments they encounter. Moreover, there are strong connections between clinical practice and the organizing principles of social justice in what social workers do with their clients on a daily basis. Many of these connections have not been articulated sufficiently, and it is time that we work together better to do this. Perhaps, through thinking more about these linkages, we can help define a more inclusive lens for understanding the depth and breadth of clinical social work practice.
Finding the Common Ground Between Clinical Practice and Advocacy for Social Justice
Discussions about the relationship between clinical work and social justice have appeared intermittently in the social work literature for a number of years (Swenson, 1998.) Historically considered to be controversial, the most prominent debates have tended to focus on what is frequently viewed as a dichotomy between the micro-level work of clinical, or what has been historically referred to as “casework” (on one side of the fence), and macro-practice activities, such as community organizing (on the other side.) Generally speaking, clinical practitioners have been viewed as working on the individual, family and small group level while community organizing has been more closely associated with targeting larger groups and social/environmental change—a realm more apparently connected to social activism.
In reality, there is a mandate for clinical practitioners not only to embrace but also to act upon activities associated with advocacy and social action in collaboration with their clients. Furthermore, in contemporary agency settings, it is not uncommon for the micro and macro levels to explicitly intersect within the same practitioner’s scope of practice in the context of the overall mission of the social agency. In settings more traditionally associated with clinical work, the beginnings often manifest as the client seeking help for a particular problem constellation that requires a biopsychosocial assessment to understand how the current situation came about and to determine how to intervene. While the assessment will most certainly involve dyadic work with the client, it often becomes quite clear in the exploration that the interventive target of change is not all about altering the client’s internal life and behavior. In fact, the causal factors inherent in many client situations have implications for case advocacy and for organizing actions with a collective of clients facing similar issues (i.e. movement from “case to cause.”) However, these actions do not eradicate the need to understand and address the intra-psychic processes operating within the individual and other family members in order to effect change. In other words, one social work method does not trump the other. There is not only room for both, it is imperative that we become clearer on how they work together.
Social Justice as a Critical Element in Building the Therapeutic Alliance
So, where do we find a common ground? Perhaps one answer to this lies in understanding how we absorb and apply the knowledge gained about clients in clinical practice as a means toward promoting social justice as an organizing principle in our work. There are multiple ways in which this can be done and articulation of this has begun to proliferate (e.g. see Aldarondo, 2007 for an excellent collection of articles on advancing social justice through clinical work.) My own interests lie in understanding the relational interactions that work in the service of (and against) the transmission of social justice during the process of forming a helping alliance.
Also referred to as the working or therapeutic alliance, the alliance is the collaborative bond that develops between client and worker through which they can mutually explore the tasks and goals for which the client is seeking help (Bordin, 1979.) The alliance is not unique to the psychotherapeutic relationship, although the primary focus of reference and research on it has occurred in the therapeutic context. However, recent developments are expanding this. For example, a major symposium held at the Society for Social Work and Research Annual Conference (whose title included the phrase, “Off the Couch and Out of the Clinic”) focused on the mandate to study the barriers to engagement in developing durable helping alliances with urban families of color through greater scrutiny of the complex systems they deal with daily (SSWR, 2009.)
Strengthening the Empathic Bond Between Worker and Client
It may seem quite obvious, but it is often not emphasized enough in the written word, that understanding the impact of poverty on the psyche requires that the clinician have an intimate window into what the other experiences. I believe we do not talk enough about how this window is obtained and how it deeply affects the development of empathy—a crucial ingredient in the helping relationship.
How the practitioner develops this empathic connection rarely occurs by exclusively sitting in the agency office with many of the clients we see. Mutuality in the relationship and the possibilities for engagement in meaning-making with the client are enhanced by an immersion into what it means to that person to live in this world. When we sit with our clients, what does it mean to really know them and for them to know us—particularly for the many who have experienced a myriad of oppressions? And, how do we go about understanding how to enhance service effectiveness use and outcomes for the individuals and families we see?
There is a central role that client/worker partnerships in case advocacy can play in this arena. As an intrinsic feature of the social work profession, advocacy is an integral part of clinical social work across several fields of practice—and its impact on intensifying the intersubjective field in the developing helping alliance may be profound. For example, I have written about the worker’s engagement in case advocacy with mothers in the child welfare system as providing opportunities for worker experience and communication of empathy with their clients as they engage in community-based appointments with them (e.g. to social services, hospitals, schools, child welfare services.) By being in these situations with their clients, workers could not only feel some of what their clients might experience, but through spontaneous self disclosures, their clients could see their authentic reactions to some of the frustrations inherent in these joint ventures. The experience of being in these scenarios together then led to more meaningful co-constructions in the therapeutic work when the client and worker returned to the clinician’s office (Tempel, 2009.)
Provision of “Concrete Services” as Opportunity for Valuable Change Work
Interestingly, in spite of the potential usefulness of case advocacy in developing durable and meaningful alliances, this method is often undervalued rather than justly recognized as an important therapeutic intervention. Instead, it tends to be relegated under the headings of jargon-based phrases such as ‘‘concrete services’’ or ‘‘case management.’’ The closest it gets to being included in a clinical/theoretical framework is through the heading of ‘‘ego supportive’’ intervention, which is not to be minimized. However, this descriptor is often used as a catch-all phrase that connotes limited change potential among many social workers most closely identified with doing clinical work. In my opinion, this is an incorrect and somewhat insulting representation of what is really happening. It is also fairly obvious to see how these micro-based therapeutic interventions can collectively have implications for larger scale social activism when clinicians see repeating themes in their work with individual clients.
I have emphasized here an aspect of clinical work that for me is very powerful—the development of meaningful relationships. In particular, I suggested how therapeutic work and case advocacy may intertwine in informing and supporting interventions that promote more socially just attitudes and actions in those relationships. Freire (1992) extensively described how crucial it is to hear and to be moved into action by the stories of those who are oppressed. I would also emphasize that we consider the multiple ways in which oppression can be felt and perpetuated within intimate relationships. Clinical social workers are trained and positioned to really hear, share and act upon those stories from the myriad of settings in which they work. May we look forward to more united dialogue in sharing those stories as we move ahead on their implications for our work.
Aldarondo, E. (2007). Advancing social justice through clinical practice. Mahwah, N.J.: Lawrence Erlbaum
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy Theory, Research, Practice, 16, 252-260.
Freire, P. (1992). Pedagogy of hope. New York: Continuum.
Goldstein, E.G. (1996). What is clinical social work? Looking back to move ahead. Clinical Social Work Journal, 24, 89-104.
SSWR (2009). Symposium: Off the couch and out of the clinic: Innovations in research on the therapeutic relationship in community-based settings. Annual Conference, January 15, 2009, New Orleans, LA.
Specht, H. & Courtney, M.E. (1994). Unfaithful angels: How social work has abandoned its mission. New York: Free Press.
Swenson, C.R. (1998). Clinical social work’s contribution to a social justice perspective. Social Work, 43, 527-538.
Tempel, L.R. (2009). The intersubjective action of case advocacy and engagement in a working alliance. Smith College Studies in Social Work, 79, 125-138.