Real World Clinical Blog: The Anxious Social Work Mind (Part 1)

by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way

If there is anything that I have come to learn about how clinical social workers feel, it is that we are an anxious bunch. The anxiety that I hear about when teaching and supervising is largely thematic, although I know it often feels more amorphous than precise and meaningful. I also know that the anxiety can feel out of control and unstoppable. Sometimes supervision helps; sometimes it makes it worse. I also know that anxiety viciously interacts with us in a way that leaves us drained, depleting us of many of our internal resources.

There is a relationship between anxiety and depression, deeply cyclical in nature, that harms our development as clinical social workers and healers. This is something that, to thrive in the field, we need to start to make sense of.

So, why so anxious? I have a few theories.

One of the main reasons that I hear that social workers feel anxious is because of a sense of being an imposter. Some call it imposter syndrome, but I would rather refer to it as a false sense of professional self. The idea of a false sense of self can be linked to both object relations theory and self psychology. It is based on the notion that we have somehow suppressed our true selves in the service of maintaining our attachment to a caregiver who could not deal with the whole of who we were or who we are. An anxious mother can’t stand to hear the cries of the child; the child becomes endearingly sweet to win back the affection of the mother and to soothe/coax the mother back into the attachment.

This is actually very relevant. On some level, I think that a parallel of this occurs in many agencies. Your supervisors, bosses, and insurance companies are seeking out a very specific kind of social worker. This is a social worker who can perform a manualized treatment, accomplish specific treatment goals within a session limit, write progress notes that suggest how these treatment goals were addressed, and increase client functionality in a measurable way. So, you find ways of trying to do this. You write “progress” notes about it. On session 11, you do the psychoeducation as prescribed. Or you don’t. Either way, what your client is needing and what your agency is asking for is typically misaligned. In it, you are trying incredibly hard to stay with both polarized needs. For the most part, you feel torn. Sometimes you tell your supervisor the truth, but it isn’t easy, because you feel self conscious and actually worried about getting in trouble. You become the kid trying to stay connected to the mother.

Meanwhile, you are sitting with a client who has no interest in talking about their trauma. But they could spend the next 10 sessions complaining about a complicated dynamic at work or with their boyfriend or girlfriend. The whole time, you are worrying if you are doing what you are supposed to be doing by listening to your client and by “meeting them where they are” (which you learned in school). You know that you aren’t adhering to the treatment goals. You aren’t seeing any measurable symptom reduction, and you certainly aren’t using the manual. You make up something in your note about how you used reflective listening to lessen the presence of intrusive thoughts, and you hope that fits.

How can you not have a false sense of professional self? The fact is that to be doing our work well, at this point in time, we are often triangulated between agency/financial/insurance company/evidence-based practice demands and the bumpy human spirit and need of our clients. There is a constant tension. You are right in the middle. This does not make you a fraud, but it does leave you a pawn in a game that you must figure out how to master without undoing your authentic professional self. When we start to feel like the problem is us, the anxiety expands. When we recognize that we are part of a complex system, very similar to the complex system that our clients are in, the anxiety lessens. We can use our nuanced understanding of our circumstances to better understand our clients. Rather than to undo our ability to work, our anxiety lessens.

Another dimension of our anxiety is our fear of feeling the whole of the affectual experience of being with clients. It has been hypothesized that there are basically four core emotional states from which all of our emotions originate. These are anger, sadness, joy and fear. I guess you could think about the movie Inside Out to get a sense of what it might look like inside our minds and souls. There is some thinking that suggests that our anxiety is our effort to avoid feeling, to avoid truly inhabiting our affect states. Instead of feeling sad, we feel anxious. Instead of feeling angry, we feel anxious. This list goes on. The reason why we opt for anxiety is that something internally tells us it is safer. This sounds crazy, of course, because anxiety is so unbearable. But anxiety also keeps us on the periphery of issues and feelings that scare us - that panic us.

When we hear the stories of our clients' lives, it is almost impossible to not feel overwhelmed. I had a supervisee present a case of a child who was raped between the ages of one and six before being placed in foster care, which provided no relief because of the physical abuse that was experienced. Of course, we are pulled to flee the gravity of that. How could we really feel that? There is a fear that we have, that if we let it all in, it might annihilate us. This fear operates both consciously and unconsciously. When it operates unconsciously, the feelings that we avoid often become anxiety. When we avoid it consciously, the feelings that we avoid often become shame and guilt. Either way, letting the feelings in is the way forward. Perhaps there is no room for this truth in how our days speedily move along with the constant pressure to perform, always being pressed to do more with less. That said, creating space for our internal experiences, for the pain brought to us by our clients' lives, will relieve our anxiety.

And when you are feeling anxious, I know that there is nothing more that you want than relief.

Our clinical anxiety is often driven, too, by a fear of and a desire for theory. When we think about theory, we are often comforted, because it helps us understand our clients and our work. The anxiety comes because it is often hard to literally integrate theoretical thoughts into our clinical interactions. When we are not integrating theory into our clinical interactions, we start to worry that we aren’t “doing anything.” We worry that we don’t know enough - that we haven’t read enough or learned enough in school.

I cannot even count how many times I have heard a student or supervisee say that they feel as if they aren’t doing anything. Part of the basis of this feeling is that when we start to really reflect on what we are doing, we can’t link it to our readings or to our teachings. It is hard to describe in supervision, too. A supervisor will make a suggestion, like “maybe you can give your client breathing exercises.” In the next session, that won’t happen, of course. This is because of the idiosyncrasy of human interaction. When we talk about theory integration, we don’t literally mean that you say something from an attachment perspective or from a CBT stance. The theory is supposed to give you a sense of the spirit of your work, the overall direction and possibility. You are not doing nothing by not thinking of theory every time you talk. In fact, you are doing something huge, and that is being with your actual client instead of a teacher, author, or supervisor. You have also likely internalized the theory in a way that almost feels nonverbal at this point.

The other piece of this is that we don’t actually do as much as we are directed to do. We worry that we aren’t doing much, because we aren’t doing much. Our work truly falls under the heading of “less is more.” Essentially, our work is to help clients to say more. This often requires moving out of the way. This leads us to feel that we aren’t doing anything. And that is exactly what we are supposed to be doing. It is hard to write nothing in a note. It is hard to explain it in supervision, and it doesn’t exactly fit a modality or theory.

We often just ask for our clients to tell us more. We ask them how they are feeling, then we ask them to tell us more again. What is that intervention? Can you name it? Probably not. Does that make you less than professional? Absolutely not. It makes your work hard to explain, nuanced, and very dynamic. Minute to minute, you don’t have a plan and you shouldn’t. That’s as hard as a job gets. Own this. Don’t let the energy suck of anxiety lead you to un-know the power of your own surrender to spontaneity and the acceptance of your clients’ varied processes.