by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field
Welcome to the fold
New social work grads, congratulations and welcome to the fold. We need you more than ever.
When you sense that the world has turned upside down, that is because it has. I have been in this field for more than 15 years, and I have never seen levels of mental health suffering and acuity as extreme as they are right now. I have never seen bureaucracy less functional or threats against marginalized communities as unabashed or aggressive as they are. Cost of living is increasing while salaries are stagnating, and forgiveness around debt is elusive at best. Licensing boards are stringently gatekeeping as new grads are trying desperately to hand over their credit card numbers to take an exam that might lead to a paycheck. It’s not pretty out here.
But guess what!
You are the change we need to see in the world—the solution, the wisdom. I know that it will be you that saves us from the deteriorating conditions we are living in. No pressure, though…really. I mean that. We are all here for you as supervisors, mentors, and guides. And we are going to get through this together.
Let me tell you what I know at this exact moment, as a social worker who loves this work and loves this world and is really worried about everything. I know this might hurt a little, but I think it might help, too. At least I hope it will.
The Mental Health System
First, the mental health system is broken. It is almost impossible to find a psychiatrist who takes insurance without a waiting list of two to four months. And by insurance, I mean private insurance. Finding psychiatry that takes Medicaid…well, I am not totally sure that is possible. Psychiatrists who do take Medicaid have caseloads of well over 100 or more clients. Social workers who support those psychiatrists have caseloads of almost 60 to 80 clients and are having to double book so no dollars are lost for no-shows. We are constantly being asked to defend our work, to become more manualized in our treatments, to document more objectives than any one person could ever fit into a clinical hour.
There are few acute inpatient options that offer more than five days of care to an actively suicidal client and even fewer long-term inpatient options that can dig deeply into trauma symptoms like dissociation and perpetual hypervigilance. One insurance might cover a stay, another won’t. One insurance might think that bulimia is real and doesn’t need to be quantitatively substantiated, and the next will only cover an eating disorder based on a decreasing BMI. Nothing truly makes sense. Mental health parity laws are not enacted, and while we are paying huge portions of our paychecks to secure our health, many providers are turning away from insurance because it simply costs too much to work with and reimburses too little.
But here’s the good news, and I know it’s not great news.
The simple act of sitting and talking to someone in a room, with curiosity and tenderness, is a radical and healing act. Amidst all of this noise and chaos, you will have the honor of listening to the story of someone’s life, of asking questions about their scars (both inner and outer), and helping them secure future attachments after they have faced a lifetime of ruptures. It will be hard to find that time, to defend it to the insurance companies, to keep the manualized binders out of the room. But once you do, once you find some authentic quiet and peace and can sit across from another person (while both of your phones are put away), you have initiated the healing process. You are holding eye contact, refusing pathologization, honoring history, recognizing the gravity of trauma, and letting your clients know to take their time.
This is the real work. This is what you have been training for. This is what you know how to do. And the act of doing it is the work that will save us from our growing alienation from one another.
Managerial Class
We have thought, reductively, about socioeconomic classes as divided into basically three categories: upper, middle, and lower. While these are broad stroked characterizations of our current socioeconomic structure, the fact is that things are more nuanced than that. You, as MSW graduates, are about to enter what is considered to be the lower-middle class (earning $46,000 to $75,000), which is currently (in May 2019) 26% of this country. You might also be entering the working class, about 30% of this country, earning between $19,000 and $45,000 per year.
The majority of your work will be in direct service to the socioeconomic class below you, the lower class or working poor, 13% of the U.S., (earning $9,000 to $18,000 per year) and the underclass (14%, earning under $9,000 per year). And work will be designed to financially benefit the upper class, the class above you: the upper class (3% of the population), which is divided into upper-upper class (1% of the U.S. population, earning hundreds of millions to billions per year) and the lower-upper class (2%, earning millions per year). These are the CEOs of hospitals, insurance companies, pharmaceutical companies, corporate lawyers, and Wall Street investors who are investing in those insurance companies and pharmaceutical companies.
And the fact is that you are going to feel exactly as sandwiched as you are. You are going to feel poor as you sit all day long with clients who have so much less than you. But this won’t stop the student loan companies from calling you, and it won’t make your co-pays any less or your rent cheaper. It might give you perspective, but it won’t make things more comfortable. You are going to see, if you pay close enough attention, that this economic system was set up to keep the poor poor and the rich rich, and you are going to be in the managerial class that keeps this status quo intact.
But this is the thing.
You are also going to know the truth about the world and be able to discern fact from fiction while you validate that your clients feel like they keep trying to get out of this while they fall deeper and deeper into it. You aren’t going to gaslight your clients into thinking any of this is simple or a matter of willpower or good education. You are going to sit in the truth with them, and for the first time in many of their lives, they will be believed.
You are going to help clients surrender the shame that is making them feel so horrible about themselves but elucidating the ways in which they are suffering and discriminated against. Through your willingness to collapse the false binary between micro and macro work, you are going to join your clients in their perception of reality while every system around them has told them that they are the problem.
In 1990, Clifford Yorke wrote that “guilt brings material into an analysis while shame keeps it out.” Clients feel incredibly guilty for the ways in which they have messed up and will talk about that quite a bit, but the deep shame they feel for their own poverty and the way racial or cultural trauma has hurt them is harder to bring into the room. They feel ashamed, because they don’t understand that this is not all their fault. This is a system that they are a part of, just like you are a part of it. And just as you wonder if you will ever pay off your student loans but don’t tell anyone the total that is due, your clients don’t think they will ever get off food stamps while they keep agreeing to treatment plans that suggest that they can find it in themselves to break free.
Your work is going to be to free yourselves of economic shame, to empower your clients to do the same, and to both turn toward those who are benefitting off your positionality and question (endlessly question) how we can keep going this way. You and your clients are going to embrace reality together, while reality is assaulted all around you, and through that act you will offer liberation that your clients will not find elsewhere.
Radical Equality
You have sat in supervision in your field placements, or in classrooms with 30-page syllabi, or in the financial aid office at your university. You have become accustomed to feeling disempowered. Let this license, this degree, and all of your studying begin to turn that around. This is your CAP and your GOWN and your DEGREE. You have invested a lot and you deserve to reap the economic, psychological, and spiritual benefit of that fact. And to me, that benefit is best experienced when we start to truly articulate what it is that makes us healers. For me, healing is being real, healing is being sad, healing is being angry, and healing is being authentic in the presence of another person.
In 2018, psychologist David Mark coined the term “radical equality.” He argued that the clinical or social work relationship is a site where we can begin to dismantle toxic hierarchies that have long defined both our lives and the lives of our clients. Mark suggests that the clinical relationship has the potential to render both the social worker and the client as equally vulnerable and responsible to each other, offering repair to patterns of dehumanization that so many of our clients have become accustomed to.
As we enter even stormier political waters with each passing day, waters that are flooded with corrupt power and ideas about supremacy, we owe it to our clients to be vulnerable and real with each other. We owe it to our clients to tell them who we are, to not dangle our power in front of them, to not hide behind fictions about the need to not self-disclose or to remain neutral. The more real we are in the clinical setting, the more we create possibility for authenticity outside of the clinical relationship. This authenticity is viral in nature and ultimately remediates what feels so broken. I don’t know exactly how. I wish I could explain it better. I just know that the act of two people sitting in truth together serves as a protective factor against forces that have been designed to pit us against each other.
I know I am sharing some grim facts. I also know that social workers are the light.
I just hired some new grads at my agency, and I could have talked to them—each of them—all day long. You guys are on the cutting edge of identity politics, unlearning racism, radical thought, and the dismantling that we all need to see to rebuild some justice in this world.
Additional Reading
https://courses.lumenlearning.com/boundless-sociology/chapter/the-class-structure-in-the-u-s/
Dr. Danna Bodenheimer, LCSW, is the founder of Walnut Psychotherapy Center, and the executive director of the Walnut Wellness Fund. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field (The New Social Worker Press).