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Promoting Mental Health through Clinical Social Work
The mission of clinical social work is to achieve mental, emotional and social well-being of individuals, families and groups. Using a great variety of therapeutic resources, it places the improvement of the relations between individuals and their environment in the center of its preoccupations. Clinical social workers professionally apply the social work theory and its methods to assess, to treat and prevent dysfunctions, disabilities and psycho-social disorders/problems of different people, couples, families and groups.
In the XIX-th edition of the Social Work Encyclopedia, C. Swenson (1995) shows that clinical social work is often contested by practitioners, although there is no other more adequate term that would better describe the social workers` activity of helping clients to adjust to their environment. The term clinical has its origins in the word kline, which means bed. Beside its medical significance and the pathological connotation of the term, underlined by those who are criticizing clinical social work, the clinician isn’t just the person who stays near the ill person’s bed, but also the professional involved in a close relationship with the person who needs assistance. The access to the private world of the patient, by getting out of offices and labs, brings to the clinician’s work a „non-stigmatizing, normalizing, perspective” (Swenson, 1995, 503). Clinical social workers respond to the needs of the assisted persons in a large variety of social services: family centers, shelters, residential homes for children and dependent persons, community centers and residential homes for elderly, schools, hospitals, mental health and social rehabilitation centers, either governmental or private.
The clinical social work approach means individualization, involvement and intervention. As Swenson (1995) underlines, clinicians are active helpers (not passive), based on observation (not on laboratory studies and experiments) in unique life situations (not statistically significant ones). A special characteristic that describes the clinical social worker’s activity consists in the partnership between the helper and the client who tries to cope with his/her problems.
The purpose of the present issue of Social Work Revue (Revista de Asistenţă Socială) is to demonstrate that, among other roles and tasks of social workers – from Romania, USA, Germany or elsewhere – there are roles and attributions aiming to enhance the adjustment/coping capacities of a variety of persons who aren’t able to manage all the social challenges by themselves. The articles published here, written by Romanian and foreign professionals, demonstrate the possibilities that social workers have – to promote the mental health of clients, their psychological comfort, the resilience and trust in their own resources, which are preconditions of social integration. The papers demonstrate the need and importance of proper training for social workers in order to be able to evaluate the persons` problems and improve their coping skills. Extracting the personality issues from the complex systemic equations of helping is not simplifying or making easier the activity of a social worker but rather reduces the practical ways of helping and the chances of enhancing clients` autonomy in front of the social work system.
Google search for clinical social work brings forefront terms like mental health, therapeutic services, mental and emotional disorders, domestic violence, disabilities, professional care for patients, supervision, evaluation instruments, evidence based intervention, clinical training, direct and indirect activities, social workers` code of ethics, personal resources and others. Articles gathered in this issue are dealing with these terms, giving them practical contents which reflect social work researches and interventions.
In order to make a synthetic presentation of the studies in this issue, we have grouped them into several categories. Some of them are mostly theoretical and present general problems like the possible interventions, as well as the pressures resulting from the social worker’s position and their consequences on the professionals. The German author, Johannes Herwig-Lempp, presents two articles where he argues – in a constructivist conception – the unique social value of the social work profession. In a world in which the individualism gains ground, social workers are maintaining their values: social justice, equal chances, non-discrimination, partnership with clients, empathy and social relation mediation. In one of his articles, Lempp analyzes the nature of social worker’s power, often forgotten by professionals, especially by women social workers. Power derives from the abilities developed in their systematic training, for instance their ability to establish links with helping networks, to mediate conflicts, to improve the quality of client’s life, both material and psychological. Besides presenting the advantages of the ecological perspective of person in environment, Herwig-Lempp calls for strengthening the profession from a feminist perspective: women, who are the majority of the social workers, can be proud of their contribution, as professionals, to the better use of social resources in favour of vulnerable persons, instead of feeling themselves vulnerable. The second article of the same author, as well as Mihaela Gotea’s article are looking at the systemic social work model and social networks as means of structuring the social workers’ actions for a better socio-emotional balance and a better linkage between the clients and the necessary resources. These three articles draw attention upon the complexity of the social work profession, which is compared by Herwig-Lempp to decathlon, the king of sports, in which the athlete doesn’t necessary achieve exceptional performances in a specific domain, but they are able to practice 10 disciplines. The metaphor refers to the great variety of social work abilities, based on different/divers scientific, methodological and practice grounds.
The forth theoretical article is the one of Judith McCoyd, which was included in this issue because it is approaching the problem of bio-psycho-social analysis of the attachment between mothers and children. The richness of the literature brought into discussion, analyzed from the perspective of the clinician working in direct relation with the pregnant women or loosing pregnancy create the conceptual framework for clinical interventions in order to prevent child abandonment.
As a follow-up of the children-parent relation theme, the article of Shari Munch and Judy Levick can be a source of inspiration for the development of the social workers` roles in paediatric hospitals. Here we can find the rationale and the thorough description of activities for brothers and sisters of the newborn babies organized in neonatology, and demonstrate the large variety of psycho-social aspects that social workers have to face. The article shows some pathways around the status of the social worker in such an institution, and discusses the need to collaborate in a multidisciplinary team, as well as capability to influence family cohesion through a clinical approach, through the direct interaction with children and their families.
We included in this issue of the revue a series of articles that reflect the status quo of the Romanian researches in key medical fields for social work. In this category we included the article of Elena Holeab (Mardare), who presents a research on psycho-social evaluation of 38 coronary patients. She demonstrated the need for a continuum of care for the coronary patients that can be achieved through the collaboration between the specialized services of the hospital and the medical and social services of the community (primary services).
To illustrate the issues that social work is supposed to tackle in oncology hospitals, Csaba Dégi presents the results of his research concerning the psycho-social effects of non-disclosing the cancer diagnosis to the oncology patients. The analysis highlights that patients who are not informed about their cancer diagnosis are significantly more depressed, they feel more hopeless and demonstrate lower levels of problem-focused coping compared to patients who are informed. From these conclusions balanced with arguments from the literature concerning the author discusses the role of the social worker in disclosing and discussing the diagnosis to cancer patients.
The article signed by Sorina Poledna, Mihai Iovu and Nicoleta Golea is based upon a research in a rural school and analyzes school violence as a form of early deviancy. Results of the survey applied to 267 school children showed – once more – that there is a significant correlation between experiencing family violence and committing school violence. From this data authors exemplify fields of action – in the area of psycho-social intervention – for social workers, who are the main actors expected to reduce the risks of school violence.
A topic of interest for many social workers involved in child protection is adoption. In a research project from which Ana Muntean presents here a fragment, the author raises the problem of the grief generated by the Romanian cultural practices related to the non-disclosure of adoption to the child. Among the needs highlighted here by the presentations of the results of interviews and questionnaires strongly came out the wish to protect the image of the adoptive parents in the eyes of children and of the community and also the wish to protect the child against community discrimination. From our perspective, the thorough analysis of parental reasoning is a very important issue for the social workers involved in a direct work with adoptive families and in the prevention of unexpected disclosures.
Another article based on case studies is the one presented by Ecaterina Porumb, who approaches the needs of young adults who left residential care. Their stages of identity development went through extremely difficult moments, lacking stable relations and differentiated treatment along their life in the special environment of the residential foster homes. Besides the emotional aspects that abound in the interview fragments presented here, that are for sure impressive for the reader interested in the problem of assisted childhood, the article reveals also the needs of the youngsters for continuation of assistance: without assisting them in processing their childhood traumas, analyzing social support, discussing aspects of today and future possible identities, their social integration can remain just a desiderate.
E. Goldstein (1999) finds that clinical social workers are involved in problem-solving process for very different clients, in a large variety of institutions. To be able to cope with this wide range of problems, the training of social workers cannot avoid the psychological aspects of adapting to the environment and those concerning the individual or group interventions that aim to behavioural changes. Two of the articles of this issue are concerned with social work training. Both articles start with the need that social work training should compound theoretical models and intervention strategies applicable to a wide range of situations and cases, and stress the importance of developing direct work skill-training opportunities that stimulate clients’ resilience. In her article, E. Albert-Lőrincz presents an innovative model with the essential elements consisting in theoretical and practical training to promote mental health. Teaching counselling methods to enhance the psychological well-being, trust, mental health and self consciousness for both clients and practitioners represents a sine qva non condition of proper university-level training in social work. Counselling is doable only if social workers can maintain their own mental health, which is possible through professional supervision that has to start from the very beginning of the social work practice, even during the training. The emphasis on supervision is often mentioned in the literature, some of the reasons being contained also in this article. Applying clinical methods in the client’s best interest, respecting their own values and that of the profession, impose often moral dilemmas that can be solved with and through supervision (Osman et al., 2002).
Betty Blythe, Kristin Heffernan and Barbara Walters, a group of authors from USA, analyze the requirements for social work training in the field of child protection. Based on a number of interviews applied to social workers and trainers, the authors explain the advantages of cross-training, a new concept for Romania. In cross-training, child protection social workers deepen knowledge in interdependent sectors such as domestic violence, alcohol and drug abuse and mental health. The researchers present this cross-training model, based on inter-institutional cooperation, as the key to professional success and as a guaranty of intervention efficiency. An important component of this training model is teaching about the periodic evaluation of the applicability and the efficiency of the learned competences.
Another group of papers gives clinical social work examples from the field of psychiatry, domain considered as classically belonging to clinical social work. In 1989, NASW defined clinical social work as treatment and prevention of psycho-social dysfunctions, disabilities and mental health problems of the persons. To illustrate the concept of clinical social work, we included in the present issue research that tackles people with mental health problems. In the article The “Social Case” Illness, Psychiatry, and Deinstitutionalization in Post-socialist Romania, Friedman presents the results of a research based on 78 interviews with psychiatrists and persons hospitalized in psychiatry facilities in Romania. The study analyzes the perspectives of social integration of a special category of psychiatric clients, those lacking financial resources and family support: the so called social cases. The expression “social case” appeared before 1989, and unfortunately didn’t disappear after the UE integration. Because the lack of social mechanisms of reducing poverty effects and because of the weaknesses of the psychiatric network of services – here we include the lack or, perhaps, the scarcity of psychiatric community centres and of human resources: social workers and therapists – societal integration of social cases has low chances of success. Using quantitative and qualitative data and also theoretical models and comparisons with American psychiatric reform, the author explains the mechanisms through which a category of persons with recovery and integration potential is maintained through the years into psychiatric hospitals, even though the medical symptoms are improved.
A second article in the field of psychiatry completes the picture of, and criticizes the psychiatric system nowadays. It reflects the professional expectations for the future from the point of view of the psychiatric patients participation to the labour market. Based on field literature and on a research conducted by the author, Imola Antal argues that the difficulties for patients to obtain a job are the most debilitating effects of their illness, which can be only surpassed with systematic support and periodic assistance.
According to the U.S. professional standards (Weismiller et al., 2005), the clinical social worker is the professional directly involved in establishing a diagnosis and elaboration of the intervention plan for a client with psychiatric and behavioral problems, chronic illness or disabilities, traumas, adjusting difficulties of any kind. In the article Counselling suicidal human behavior, D. H. Dumitraşcu reviews the diagnosis criteria of suicidal behavior and recommends an intervention plan for social workers based on active listening and the analysis of the social context. From the practitioner’s point of view, the article is interesting due to the detailed information about the symptoms of suicidal persons, including adolescents, and because of the highly emphasized idea of continuing the treatment of the suicidal person out of the hospital, in community services.
If the old writings on clinical social work with individuals insist on the paramount importance of acquiring direct work skills such as counselling and therapy, newer literature (eg. D. Grant, 2008) underlines the importance of complementing these – by all means necessary – competences with those of indirect social work, such as the awareness of the range of rights and benefits available to clients, as well as the procedures that can be used in order to ensure higher life quality. To illustrate the need of combining the direct and indirect methods of work we recommend the article Combination of direct and indirect activities in case management, written by Adina Rebeleanu and Paula Cristina Nicoară. Here you can see an action plan that combines mother counselling, based on cognitive behavioral therapy, with assisting her to obtain the benefits she is entitled too, and with fund-raising to help the family get the necessary resources for applying the best possible treatment. The case-manager social worker sets in motion an entire service network, foundations, and volunteers to create a strong social and support network that made possible the treatment of the sick child.
ASWB (2003) completes the list of indirect social work activities that can be used to support direct activities with elements like advocacy for the client at macro-social/decisional level and program evaluation looking for evidence through research. An example of indirect practice linked to direct social work, that aims to increase the practitioner’s capacity to intervene on behalf of the vulnerable clients, is presented by K. Wehrman. The author demonstrates how an American professional social workers organization succeeded through advocacy to enhance the resources and the organisational framework for direct services. Clinical social workers are on the front-line working with clients, so they have the opportunity to gather information about clients’ needs and how well programs are responding to address them. That is why clinical social workers have to be well organised and involved in advocacy actions and social policy demands that will bring better services to cover clients` needs. Social worker representation can demonstrate that strengthening mental health can improve clients’ financial problems, and reduce their dependency on care and social support. The paper highlights a wide range of indirect activities of practitioners that contributes to a more efficient direct activity with individual clients, families and groups.
According to the concepts illustrated in this issue, clinicians are those who have to apply all the techniques and procedures of behavioral change for clients. Starting from the large variety of interventions that seem to be efficient, the professionals have the role to choose the proper means/methods of intervention for each case. This option expresses the clinical expertise of the practitioner and it has to be based on their knowledge about therapeutic methods and about clients’ characteristics. To illustrate those therapeutic aspects, a group of articles present case studies and case interventions. Claudia Osvath analyzes the need for and the possibilities of intervention in favour of children with neuro-psychomotor impairment. The author identifies the stress factors that are pressing upon the family and recommends ways of direct and indirect intervention, at individual or group level, for children and their families. Monica Ghiţiu and Ioana Bumb investigate the social work intervention in a case of a young mother 16 years old, with the purpose to enhance the bonding with her baby in a residential facility for mother and child. The analysis starts by presenting the value of HOME Inventory, a standardized instrument that assesses the child’s life environment from a developmental and safety needs perspective. Information gathered after evaluation of the mother’s ability to address her child’s needs, her capacity to accept the child and her own situation, her planning skills and involvement capabilities, as well as her social interactions are essential reference points in the counselling process of the mother, in order for her to develop a social and family support network. Giving details of the case work, the article offers an intervention model for preventing abandonment and strengthening the attachment relation.
Shlonsky and Gibbs (2004) emphasizes the importance of change in operating of social work, putting more accent on evidence based interventions and less on mainly subjective interventions. From this perspective, evidence based intervention represents a systematic process that selects the most valid interventions, taking into account the client preferences and their own clinical expertise. In addition, there are other two relevant studies that illustrate the value of clinical social work in the context of its scientific progress: the one written by Dana Paula Brăescu and the one signed by Gaviţa, David and Dobrean. Brăescu illustrates the conscious, explicit and judicious use of data gathered through assessment; literature based theoretical conceptions; and in-built evaluation of results. Based on her intervention in a child protection case, in which – in her capacity of social worker – she evaluated the risk of a child sexual abuse and the mother’s capacity to protect the child, Brăescu reflects on her sources of information that can guide her choices for actions that stimulates the mother’s capacity to protect her own child and allow her to care for him.
Designed in the same paradigm of evidence based interventions, the article of Gaviţa, David and Dobrean presents an example of group work realised with a cognitive-behavior therapy program. Starting with the evaluation of the needs of the foster parents who care for children with disruptive behaviour, the authors carried out a parenting-skills training program and thoroughly assessed its results. Using standardised questionnaires to asses the level of parental skills before and after the intervention and a rigorous evaluation-research design with target and control group, the authors demonstrated the efficiency of the applied program. Based on the validity of the intervention, the publication of this study hopefully will encourage specialists to replicate the intervention program with other groups of parents with difficult children.
Among the methods used in clinical social work, counselling has an important place. For Barker (2003), social work counselling means guiding the individuals, families, couples, groups and communities so as they could sort out their alternatives, formulate goals and gather the information needed for their choices. Psychotherapy can also be part of the repertoire of the clinical social worker if his/her psychotherapeutic relation with the client involves a contract of improving or solving the psychological symptoms that blocks or hardens their social adaptation. Among the therapeutic approaches frequently used in social work services we can mention family therapy, psycho-social therapy, cognitive-behavioural therapy, and different forms of group therapy. The requirements towards the methods and techniques used in clinical social work are similar to those used in medicine, meaning that one can only consider those methods applicable to clients for which there are enough evidence about their positive therapeutic effect.
In conclusion, the 2nd 2010 issue of the Journal of Social Work aims to present to Romanian social workers specific aspects of clinical social work activities that are taking place today in and outside Romania. In the articles of this issue we gathered research on the needs, the risk factors and the resources of beneficiaries served in social services. We also collected here research papers that present systematic activities to improve mental health and enhance the adaptive capacities of assisted persons. We hope we succeeded to illustrate in these pages the usefulness of a large range of behaviour modification, therapeutic and counselling methods and techniques applicable by trained social workers. We also presented programs that can take place in social, medical or educational services to prevent the risks of adapting difficulties. We hopefully proved that there are options to combine direct and indirect methods for the benefit of the assisted people. By revealing a variety of mental health needs through research, we suggested possible directions for clinical social work interventions. The wealth of articles sent to the editors demonstrates the presence of clinical social work in Romania and allows for the projection of some of its future development directions.
Bibliografie
ASWB (Asociaţia consiliilor de licenţiere în asistenţa socială) (2003) www.aswb.org/SWLE/2003practiceanalysis.asp
Barker, R. (2003) The Social Work Dictionary, 5th ed, NASW Press
Goldstein, E. (1996) What is clinical social work? Looking back to move ahead. Clinical Social Work Journal, 24, 1, March, 89-99.
Grant, D. (2008) Clinical Social Work. In Encyclopedia of Social Work. Terry Mizrahi and Larry E. Davis. Copyright © 2008 by National Association of Social Workers and Oxford University Press, Inc.. Encyclopedia of Social Work: (e-reference edition). Oxford University Press. Rutgers University Libraries. 2 August 2008 http://www.oxford-naswsocialwork.com.proxy.libraries.rutgers.edu/entry? entry=t203.e63
NASW (2005) Standards for Clinical Social Work in Social Work Practice. http://www.socialworkers.org/practice/standards/naswclinicalswstandards.pdf
Osman, S., Dungee-Anderson, D., Holzhalb, C., Martin, J. A. & Timberlake, E. (2002) Professional Development and Practice Competencies in Clinical Social Work. A Position Statement of the American Board of Examiners in Clinical Social Work, http://www.cswcenter.com/images/Competen.PDF
Shlonsky, A. & Gibbs, L. (2004) Will the Real Evidence-Based Practice Please Stand Up? Teaching the Process of Evidence-Based Practice to the Helping Professions. In: Brief Treatment and Crisis Intervention, 4, 137-153.
Swenson, C. (1995) Clinical Social Work, In: Encyclopedia of Social Work, 19th edition, eds. Richard L. Edwards & June Gary Hopps, Washington, D.C.: NASW Press, 1, 502-513.
Weismiller, T., Whitaker, T., Bateman, N., Coleman, M. (2005). Standards of Clinical Social Work, NASW. http://www.socialworkers.org/practice/standards/NASWClinicalSWStandards.pdf
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