Real World Clinical Blog: Keeping the Clinical in Social Work

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

     It is not uncommon for social workers to feel excluded from conversations on clinical work. There is a misperception that a privileged few are practicing clinically, while the majority of social workers are in non-clinical settings, doing non-clinical work. These misperceptions are rooted in a fantasy of the inflexibility and non-transferable nature of what makes social work clinical. The fact is that clinical social work happens everywhere. It is only dependent on a mindset, not an actual physical setting.

     There are six key ways in which any social work becomes clinical. These are not anything inaccessible or particularly difficult to construct. Instead, they are simply ways of thinking that shift all of our work into a transformative and therapeutic psychological space.

1. Manifest vs. Latent Content

     Conversations are made therapeutic or clinical by the social worker’s dual attention to both the manifest and latent content. While the age old proverb goes, Sometimes a cigar is just a cigar, clinical social work requires us to wonder about what else a cigar might actually be. This does not mean that we think classically about cigars and simply interpret them as phallic symbols. Instead, we wonder why someone would smoke a cigar and what might be getting in the way of stopping. We wonder about underlying patterns of self destruction or the significance of the smoking ritual itself. To render social work clinical, we listen for more, and think about what is behind the scenes of what is said. The stage itself is considered to be the manifest content, and everything that goes on behind the scenes is considered to be the latent content - the more unsayable and unknowable material. Bringing this material into consciousness is a clinical act.

2. Transference vs. Countertransference

     In any clinical encounter, there ought to be a willingness to consider the role of transference and countertransference. Transference means the experience of past relationships that a client has had and the impact those connections are having on the treatment. Countertransference signifies all of the associations and past experiences that the social worker has had that come to the surface as a result of each idiosyncratic clinical interaction. The reason why transference and countertransference are of prime importance is that they help us to better under what is happening in any relationship. For example, if an afterschool program is available to students through Big Brothers/Big Sisters and one kid simply won’t attend the meetings, it makes sense to wonder if transference is playing a role. Perhaps that kid has been disappointed by an interaction with Big Brothers/Big Sisters before. Perhaps that kid has lost a sibling and even the name of the organization is triggering.

     In terms of countertransference, we need to be aware of our own past and the role it plays in our work, in order for our work to truly be considered clinical. There are some clients we become inexplicably attached to and others that we simply dislike or would like to avoid. This is typically the byproduct of some sort of countertransferential response. Certain clients elicit different responses in us. This phenomenon is almost always associated with the often unconscious ways we are bringing our past relationships and stories to the table.

3. Symbolic Symptomology

     Although we have to take symptoms seriously and largely at face value, we also need to consider the deeper meaning of symptoms. We see clients who are actively symptomatic all the time. We might have a client who is actively having auditory hallucinations or engaged in compulsive rituals.  We need to think about how to reduce the symptoms and how to understand them. In clinical work, we are in the relentless business of meaning making. This meaning making ought to accompany our efforts to alleviate the symptoms.

     Why does someone engage in compulsive rituals? Often it is to create a sense of internal equilibrium and safety. If we are advocating for symptom reduction, via medication for example, we can think about ways of enhancing internal and external feelings of safety. Thinking about symptom meaning and symptom reduction is a dualistic way of thinking. It is also a clinical technique. The more levels that we think on, the more clinical our work becomes, regardless of our setting or intervention.

4. The Past Makes Itself Known in the Present

     Yes, an awareness of one’s past can take the shape of studying transference. It can also simply happen through a studied attention to what parts of an interaction are about the here and now and what parts feel like psychological residue. For example, if a client is repeatedly late for meetings or never fills out the paperwork for additional services properly, we need to wonder if this is resistance about something in the moment or a way to work out unresolved struggles from the past. Noting that every interaction is laced with historical remnants strengthens our capacity to help clients toward the future. It is our willingness to see behaviors as multi-significant, and aiding our clients to do the same, that can liberate them from the shackles of imprisoning past struggles. Sometimes the mere utterance of the distinction between past and present can induce change and create transformation liberation.

5. Attachment Style

     Although I am not of the mind that attachment style is performed or experienced unilaterally, I do think that attention to attachment tendencies renders our work more clinical. People generally tend to attach in three separate ways: securely, anxiously, and avoidantly. Their attachment style is relevant if they are on an oncology floor in a hospital, or if they are in a community mental health setting. It is a lens through which to understand someone and the way they are interfacing with the world. Attachment theory suggests that we are all biologically driven by attachment. But our past attachment experiences influence how we interact in the present and have diluted, many times, this biological drive. Many of our clients have created internal defensive structures to regulate their disappointment and fear around attachment. This often results in confounding behaviors, across settings, that are better managed by being better identified and understood.

6. The Whole Person

     Finally, our work is made clinical when we refuse to divide a person up according to their diagnosis, past behaviors, current behaviors, socioeconomic realities, racial identity, job status, sexuality, and so forth. This is the hallmark of our profession -- it separates us from other similar fields, and it renders almost everything we do as clinical. This is because recognizing the whole person actually heals the whole person. Accustomed to systems that isolate parts of the self and interact with only these selected parts, a person can become re-integrated by our willingness to mirror the magnitude of their individual complexity.

     Social work is clinical social work. And clinical work, done well, is infused with social work values that create several restorative possibilities. The clinical social work values should be used in diverse settings that don’t readily identify themselves as clinical, but are in fact profoundly and exactly that.

Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She provides more of her clinical perspective and tips for developing clinicians in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.