Defining Clinical Social Work in Health Care
James Donnelly, DSW, LCSW, Private Practitioner; Board Member, Metropolitan Chapter of the Society for Social Work Leaders in Health Care and the International Conference for the Advanced Professional Practice of Clinical Social Work
A number of contextual issues underscore the importance of our current discussion regarding what is “clinical” in social work. The struggles around licensing, for example, highlight the problematic consequences of identifying a profession with a specific kind of practice. In health care, social work and the other professions labor within an increasingly finance-dominated environment. In such settings, the professions are defined and rewarded by their tasks instead of their meaning in the provision of healing.
Additionally, there is the reality that social workers in the health care arena practice in an interdisciplinary environment where all professions are clinical. The attribution of “clinical” is generic across disciplines and does little to distinguish the unique contribution of each. In the NASW definition of clinical social work, highlighted is the generic process of assessment, diagnosis and treatment common to all. Referring to social work as focusing on “psychosocial functioning” may be accurate, but it is abstract and the term “psychosocial” is no longer the exclusive domain of social work.
The term clinical does not define the professions. It is the professions that define the particular meaning of clinical in reference to their unique contributions addressing the maladies of the human condition. Understanding this, for example, points out that for social work, defining counseling as “clinical” and concrete services as “not clinical” makes no sense, and does us a disservice. It wounds our capacity to understand ourselves or define social work to others.
Articulating the Meaning of “Clinical” Within a Unified Frame of Social Work Practice
What is required is a unified frame of social work practice that redefines references to “clinical” in social work terms, regardless of methods. Making a referral to a home care agency is no less clinical than making an incision with a scalpel. Both actions are clinical in reference to a much wider frame for each profession’s specific approach to clients’ needs and care.
The task is not to “prove” what we do is clinical but, rather, to clearly articulate what the term clinical means in the context of social work practice.
The following is a frame (Donnelly, 1992, 2009a, 2009b) developed over 30 years of practice to help foster a unique social work understanding of clinical in health care. It has implications for explaining social work interventions to clients, fellow professions, as well as those who influence the contexts within which we work.
Responding to a Crisis of Worth and Meaning with Clinical Skills
The unique genius of social work and its contribution to health care or any other field of practice, is this comprehension along with the theories, training and interventions derived from it: that every concrete thing, event, and experience always has contextual meaning.
Context is simply another word for defining the web of mutually-defined expectations we hold for each other in our relationships. Everything we feel, think and do is within that web of expectations constituting our relationships with ourselves, our bodies, our intimates and our communities. Anything—person, event, thought or feeling—that disrupts the balance of this web of mutually-defined expectations can create a crisis of worth and meaning for any within it.
It is to that crisis of worth and meaning that social work responds with clinical understanding and skills. But social work uniquely responds in a manner that includes all the circumstances of such challenging events. Every aspect of a disruptive event must be addressed within the frames of meaning for all involved. “Clinical” in social work is defined by anything we think or do to address this challenge to persons and their communities. It includes education and training in highly-skilled approaches and interventions needed to engage clients in the often painful and difficult process of renegotiating mutually-defined expectations upon which all their relationships depend.
In healthcare, it is the disruptions of illness—chronic or acute—that present this challenge. Dilemmas and feelings must be faced and addressed regarding specific decisions, unavoidable choices and tasks. These are decisions and choices that literally force our clients to engage in a process of renegotiating expectations with the providers of care as well as their network of vital relationships.
It is in the context of facing this challenge to worth and meaning that social work builds its knowledge base, makes assessments and interventions regarding our clients’ and their communities’ needs, capacities and resources.
Standing With Our Clients in the Vortex of a Crisis
Our profession has two fundamentals which support and contain this frame. first is the critical importance of relationships, and relationship as the fundamental medium of intervention. Second is the imperative to “be where the client is.” That imperative is our commitment to stand with our clients in the vortex that a crisis in one’s worth and meaning engenders. It is a commitment to engage with them in the struggles both they and their communities present in facing this challenge.
Everything we do—and our discussions and explanations to ourselves and others about what we do—must be articulated with clarity and passion. Without this clarity we will be unable to effectively convey to our clients and our multiple audiences the unique social work contribution to understanding the meaning of “clinical.”
“The genius of social work has been its use of the concrete and circumstantial in the dynamics of context, to help people find their way to redefine themselves and their reality after their lives have been disrupted by events beyond their control” (Donnelly, 1992.)
Donnelly, J. (1992). A frame for defining social work in a hospital setting. Social Work in Health Care, 18(1), 107-119.
Donnelly, J. (2009a). Soundings: Exploration of social work in a changing health care environment. New York: South Garden Press.
Donnelly, J. (2009b). Ramifications: A social work exploration of therapeutic space. New York: South Garden Press.