Clinical Social Work is defined as a specialized area of social work practice that involves diagnosing, treating, and preventing mental illness, and also helping individuals address psychological, emotional, behavioral, and/or social challenges that affect their quality of life. Such challenges include trauma, family conflict, physical illness, and difficult life situations such as unemployment or substance addiction. Clinical social workers typically use a combination of individual therapy, group therapy, and/or various case management responsibilities to support their clients; clinical social workers’ precise responsibilities depend on their work environment and the populations they serve.
Clinical social workers work in a wide variety of settings, including but not limited to hospital departments (ranging from pediatric acute care to oncology, cardiac, ER, and geriatrics), community health centers, child welfare agencies, employee assistance programs, schools, primary health care clinics, substance abuse and addictions clinics, eating disorder treatment programs, correctional facilities, and hospice and palliative care settings. Licensed Clinical Social Workers (LCSWs) also have the option of entering private practice.
Fast Facts: Clinical Social Work
Clinical social work is a field that focuses specifically on assessing, diagnosing, preventing, and treating mental illness. Practitioners of clinical social work are uniquely trained to combine individual psychotherapeutic methods with a broader understanding of the many contexts in which people live and develop mental health issues (ex. social, biological, familial, political, financial, etc.).
Clinical social workers work in many different settings, including medical, academic, military, and correctional institutions. Clinical social work is state-regulated, and practitioners must complete certain state-determined academic, professional, and examination requirements in order to obtain and maintain their license.
Overview of Careers in Clinical Social Work
Clinical social workers work in environments in which people need support in managing and navigating challenging life situations. Types of clinical social workers include but are not limited to:
- Child and Family Social Workers work with children, adults, families, and couples to help them address mental, emotional, social, and behavioral challenges.
- Child Welfare Social Workers provide support to children and families who require foster care and adoption services, or who are involved in the dependency court system.
- Criminal Justice Social Workers provide mental and emotional support, psychotherapy, and case management services to individuals involved in the criminal justice system.
- Geriatric Social Workers provide resource navigation services, emotional support/therapy, and care coordination services to elderly individuals and their families.
- Hospice, Palliative Care, and Home Care Social Workers work to provide palliative care to elderly patients and to people suffering from life threatening or severely debilitating illnesses and conditions.
- International Social Workers provide counseling and therapy, case management services, and resource connections to immigrants and refugees.
- Medical and Healthcare Social Workers work in hospitals, medical centers, and community health clinics to provide patients with counseling and therapy services, care coordination, health care resource navigation.
- Pediatric Social Workers provide emotional support and short-term psychotherapy, care coordination services, and resource referrals to pediatric patients and their families.
- Psychiatric Social Workers treat individuals who are suffering from serious mental illnesses and dual diagnoses by providing care coordination, psychotherapy, crisis interventions, and discharge services.
- Military Social Workers help military service members and veterans manage the psychological and emotional hardships that result from their professional experiences (ex. post-traumatic stress disorder, familial/marital conflicts, anxiety, substance abuse).
- School Social Workers provide emotional support and guidance to students on a regular and as needed basis, and also design interventions and educational programming to address school-wide social/emotional/psychological issues that might impact student performance or well-being.
- Substance Abuse Social Workers work in clinical settings such as residential treatment centers, hospitals, VA health centers, and community clinics to assist individuals struggling with chemical dependency and the emotional and physical factors that contribute to their addictions.
Techniques Used by Clinical Social Workers
Clinical social workers use a variety of methods to evaluate, treat, and case manage clients’ struggles. Several of these core methods include:
- Psychosocial Assessments: A holistic evaluation of an individual’s mental and emotional health in the context of his/her social, financial, familial, and cultural circumstances.
- Risk Assessments: Draws upon data from the psychosocial assessment to determine the chances that an individual will experience an adverse outcome.
- Diagnosis: The use of information from the psychosocial and risk assessments to make a diagnosis of a client’s condition.
- Cognitive Behavioral Therapy (CBT): A form of psychotherapy that teaches individuals to understand the interplay between their thoughts, feelings, behaviors, and core beliefs.
- Dialectical Behavioral Therapy (DBT): A combination of CBT methods and mindfulness principles.
- Problem Solving Therapy: A form of psychotherapy that involves reframing patients’ perspectives on their problems, and to guide them towards healthy problem resolution.
- Psychodynamic Psychotherapy: A type of psychotherapy that helps patients identify the unconscious thoughts that underlie their behaviors.
- Supportive Psychotherapy: Providing clients with emotional support and affirmation.
- Harm Reduction Techniques: Therapeutic methods that focus on reducing the negative consequences of problematic behaviors (ex. drug use, eating disorders) rather than condemning or attempting to eradicate these behaviors; such methods generally emphasize safety and an acceptance of the stubborn nature of problematic behaviors.
- Motivational Interviewing: A goal-oriented therapeutic method that aims to identify and address clients’ readiness to make positive changes.
- Mindfulness Based Stress Reduction: The use of mindfulness-based practices to reduce physical, mental, and emotional stress.
- Experiential Therapy: The use of concrete tasks or experiences (instead of talk-based therapy) to reveal the underlying beliefs, thoughts, and emotions that govern their behaviors.
- Theory of Change: A model that establishes the typical stages of therapeutic change, which can help mental health practitioners contextualize a client’s progress and determine the appropriateness of certain therapeutic methods at certain stages within the client’s treatment plan.
- Case Management Services: A combination of the practices of clinical assessment, diagnosis, and psychotherapy, along with other responsibilities such as advocacy, care coordination, and resource navigation.
The Ten Core Competencies of Clinical Social Work
In 2009, clinical social work professionals and educators across the nation convened to develop Advanced Social Work Practice in Clinical Social Work, a document that set standards for the depth, breadth, and ethics of clinical social work practice. This publication was an adaptation of the Council on Social Work Education’s 2008 Ten Core Competencies, which apply to all areas of social work. According to Advanced Social Work Practice in Clinical Social Work, clinical social workers should:
- Identify as a professional social worker and conduct themselves accordingly: Clinical social workers should align themselves with the core mission and values of the profession and continually seek to self-evaluate and improve in order to better serve clients.
- Apply social work ethical principles to guide professional practice: Clinical social workers should adhere to the Code of Ethics outlined by the National Association of Social Workers and combine these Ethics with their own moral judgments to navigate difficult professional situations.
- Apply critical thinking to inform and communicate professional judgments: Clinical social workers should employ analytical and critical thinking skills when assessing, evaluating, and addressing clients’ challenges and tackling larger social issues in collaboration with others.
- Engage diversity and difference in practice: Clinical social workers should have a sound understanding of how social, cultural, racial, and other forms of diversity affect individuals’ experiences, perspectives, and relationships.
- Advance human rights and social and economic justice: Clinical social workers should strive to expand their reach beyond individual and group therapeutic settings, and seek to advocate for the improvement of larger social issues that impact individuals’ well-being.
- Engage in research-informed practice and practice-informed research: Clinical social workers should stay well-informed about the latest research regarding evidence-based practices and incorporate these insights into their practice, while also taking the opportunity to contribute to the social work research field through identification of larger social issues that merit investigation.
- Apply knowledge of human behavior and the social environment: Clinical social workers should have a sound understanding of human development, psychology, and behavior across the lifespan, and use this knowledge to inform their work with clients of all ages and social situations.
- Engage in policy practice to advance social and economic well-being and to deliver effective social work services: Clinical social workers should learn about the policies and economic situations that directly impact their clients and other vulnerable populations, and advocate for policies and social measures that seek to improve the lives of individuals, groups, and larger communities.
- Respond to contexts that shape practice: Clinical social workers should remain aware of changes in the social, political, economic, and professional climates, understand how these changes affect how they should evaluate and address clients’ concerns, and adapt their practice accordingly.
- Engage, assess, intervene, and evaluate with individuals, families, groups, organizations, and communities: Clinical social workers should employ a combination of empathetic client engagement, sound clinical assessment techniques, evidence-based intervention methods, and rigorous evaluation of the effectiveness of certain interventions in order to serve their clients and advance social well-being.
Challenges Clinical Social Workers Face
Clinical social work is a challenging field due to the complex and sometimes urgent nature of the problems clinical social workers help their clients manage. Potential difficulties that clinical social workers may face on the job include emotional strain from exposure to client trauma and hardship, and stress from the intense emotional, intellectual, and physical demands of daily responsibilities. Clinical social workers should try and manage these challenges through appropriate self-care and setting healthy boundaries.
The Importance of Understanding Addiction in Clinical Social Work
Substance abuse and other types of harmful addictions can play a large role in the mental, emotional, and behavioral challenges that many individuals face. Addiction is a complex issue in that it can both originate from and cause or exacerbate mental illness and emotional dysregulation. Familial, cultural, and socioeconomic factors can also play into an individual’s susceptibility to destructive addictions; at the same time, these addictions can have a devastating impact on a person’s family, professional life, and social environment. Due to the prevalence and profound impact of substance abuse and other addictions in our society, clinical social workers who understand addiction, how it develops, and how to address it may be better equipped to support clients across a wide range of social backgrounds and situations. Additionally, by learning more about addiction and how to effectively treat it, clinical social workers may find that they are better equipped to help clients who do not have a severe addiction, but who are nevertheless attached to unhealthy thought patterns or behaviors.
Why People Become LCSWs
Despite the challenges of their field, clinical social workers often find their work to be rewarding on multiple levels due to the daily opportunity to make a direct positive impact on people’s lives, and the ability to connect with many people on a deeply meaningful level. Some social workers also find the rigorous nature of the work to be intellectually stimulating and energizing. Other rewards of clinical social work can vary depending on the specific role.
Clinical social work is characterized by a holistic, person-in-environment approach, meaning that clinical social workers not only assess and help to address their clients’ mental and emotional challenges, but also work to understand how clients’ challenges interact with their family, financial, and social lives. Clinical social workers then use this understanding to help people function better in these familial, social, and socioeconomic contexts.
Clinical social work is regulated at the state level. In general, clinical social workers are required to hold a master’s degree in social work from a program that has been accredited by the Council on Social Work Education (CSWE). In addition, to become licensed as a clinical social worker in their state of residence, individuals must complete state-specific requirements that include, but may not be limited to:
- A certain number of hours of post-graduate work experience in a supervised clinical environment (often amounting to at least two years or 3,000 hours of professional work).
- Passing licensing examinations as outlined by their state’s board of social work licensure. Social work licensure examinations are typically administered by the Association of Social Work Boards (ASWB).
- Completing specific coursework as required by their state.
Note: Social work licensing requirements vary by state, so students should check with their state’s board of social work licensure to receive the most up-to-date requirements.
Overview of Careers in Clinical Social Work
Clinical social workers work in many different settings, and are often some of the first professionals to help people manage and address difficult life situations. While their core mission is typically to identify people’s emotional and mental health challenges, and to help them address these difficulties, they can complete many different types of tasks on top of assessment, diagnosis, and therapy, depending on their work environment.
Types of clinical social workers include (but are not limited to):
Child and Family Social Workers
Child and family social workers work with children, adults, couples, and families to help them identify and manage psychological, emotional, and behavioral challenges. Places where child and family social workers can work include family counseling centers, residential treatment facilities, and community and university-based wellness centers. Child and family social workers can also enter private practice if they are licensed and have accrued sufficient experience.
Child Welfare Social Workers
While they fall under the category of child and family social workers, child welfare social workers work specifically in foster care and adoption services, working to protect children from abuse and neglect. Child welfare social workers typically work at child welfare agencies, on teams comprised of “emergency response” social workers who visit families at the first notification of child abuse or neglect; “back-end” social workers who work with children and their families involved in family reunification, family maintenance, and/or long-term foster care; and agency supervisors who allocate resources, triage situations, and provide guidance to the team. Damoun Bozorgzadarbab, ASW, a clinical social worker who worked for Los Angeles County Child Protective Services for three years, summarized the core mission of child welfare social workers in her interview with OnlineMSWPrograms.com. “The roles and responsibilities of child welfare social workers is first to keep children safe, then to assure their well-being and do both of those things while making sure they have a chance at permanent families,” she said.
Criminal Justice Social Workers
Criminal justice social workers (also known as forensic social workers or corrections social workers) typically work at correctional facilities, jail psychiatric services facilities, and courtrooms, to provide incarcerated individuals and people on probation with case management services, individual and group therapy services, and advocacy within the court system. Samantha Roberts, LCSW, who works as a Clinical Case Manager at UCSF’s Department of Psychiatry: Citywide Forensics Team, described her work with individuals who are recently released from jail in an interview with OnlineMSWPrograms.com. “Our clients face the challenges of trying to survive with the fewest resources possible. For instance, when a client gets out of jail, they have nothing; no place to live, no money, no food. We do the best we can to support and stabilize them during this difficult time,” she said, “[W]e do everything from getting the clients enrolled in Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), applying for housing, setting them up with a payee service if that is indicated, managing how they receive their medication, getting them assessed for in home health aides, communicating with family members, helping them learn appropriate ADLs (activities of daily living) and hygiene, helping them buy clothes, etc.”
Criminal justice social workers can also work with individuals who are victims of crimes, such as domestic violence victims, to provide counseling and support, and to help them with navigating the justice system. Leandra Peloquin, PPSC, who worked for over a decade at the YWCA Rape Crisis Center in San Jose, California, explained her responsibility as a legal advocate for victims of rape. “As legal advocates, [my colleagues and I] would notify survivors of their rights, as frequently victims of sexual violence are not informed of their rights throughout the process. We were able to update survivors about the status of their case, as well as explain the criminal justice system process,” she told OnlineMSWPrograms.com, “There are many steps to a criminal case, and the process can be confusing, daunting and scary. Our center had strong relationships with law enforcement agencies and the District Attorney’s office.”
Geriatric Social Workers
Geriatric social workers (also known as gerontological social workers) provide counseling, resource referrals, and care coordination to elderly individuals. They also provide support and guidance to the families of their patients in order to help optimize patient care. Geriatric social workers often work in geriatric/gerontological departments in hospitals, hospice and palliative care centers, and home care settings.
Hospice, Palliative Care, Home Care Social Workers
Hospice and palliative care social workers specialize in end-of-life counseling and care for patients suffering from severe, life-threatening, and debilitating diseases and conditions. Hospice and palliative care social workers also interact closely with the families of their patients to address mental and emotional health challenges brought on by grief and stress. Hospice social workers work for hospices, home care organizations, and palliative care organizations.
International Social Workers
International social workers provide case management services, resource referrals, and counseling and therapy to immigrants and refugees in need of guidance and support during their transition to a new country. International social workers can work for government departments, such as state departments of health and social services, as well as international non-profits and community organizations that serve immigrant and refugee populations.
Medical and Healthcare Social Workers
Medical social workers work at hospitals (often specializing in particular units, such as intensive care/ER, oncology, cardiology, etc.) as well as at medical centers and community health clinics. They are often the connection between patients and the medical care staff, serving as advocates for patients and their families. “Social workers in the medical setting are the bridges that connect the families to the people and resources that can get their needs met. They are the cheerleaders that encourage the family to cross the bridge, [and] the little birdies that help those on the other side of the bridge understand why the family is coming to see them,” Andrea S. Kido, LCSW, a clinical social worker at Marin Community Clinics who also worked for several years as a pediatric social worker, noted in an interview with OnlineMSWPrograms.com. Medical social workers also conduct psychosocial assessments for incoming patients, counsel patients and their families about health conditions, help patients navigate their health care rights and services/benefits such as Medicaid, and coordinate patient discharges. “Social workers truly provide order, direction, and consistency in an environment of so much uncertainty and chaos,” Ms. Kido explained.
Pediatric Social Workers
Pediatric social workers are a type of medical social worker that works specifically with pediatric patients and their families. Pediatric social workers interact closely with patients’ families to help them understand their child’s illness and how best to manage it. Pediatric social workers also provide short-term psychotherapy to parents, referrals to community resources, and advocacy when necessary. They operate as part of a larger team of medical and mental health professionals, and are often the people who communicate patient needs and feelings to the rest of the team.
“Essentially, [pediatric] social workers act as the primary support to the families of sick children (and, when appropriate, the patients themselves) regarding anything that is non-medical in nature,” Ms. Kido told OnlineMSWPrograms.com, adding that, when pediatric patients suffer from severe complications or rapid responses (i.e. medical situations that require immediate and acute care), “Families would need social workers to provide support, guidance, and information while the medical team was focused on the child and unable to attend to the family.”
Psychiatric Social Workers
Psychiatric social workers work with individuals suffering from severe mental illnesses (SMI) and dual diagnoses (ex. mental illness coupled with severe substance abuse), and are often employed by hospitals in departments that serve SMI and high-risk patients, as well as crisis service units at local departments of public health. They can also work in jails and correctional facilities in their behavioral health or psychiatric services departments. Within hospital settings, psychiatric social workers can work in psychiatry departments, chemical dependency support programs, in forensic units (serving severely mentally ill patients involved in the criminal justice system). Within crisis service units, psychiatric social workers provide intake assessments, case management services, and resource referrals to SMI individuals. Psychiatric social workers collaborate with medical professionals and mental health experts to provide patient intake, care coordination, and discharge services, and may also provide short-term or long-term counseling/therapy, depending on the work setting.
Charles Berman, ASW, who works as a Psychiatric Social Worker at the University of California, San Francisco’s (UCSF) Citywide Case Management Program on the Forensic Team, described the complex nature of his work in an interview with OnlineMSWPrograms.com. “Many of my clients have schizophrenia, schizoaffective disorders, or Bipolar with Psychotic features, so using psycho-education to promote med compliance is important,” he noted, “Nearly all clients are dually-diagnosed so I use harm reduction for substance abuse. All of my clients face trauma, some extremely complex, and so I try to use exposure therapy for specific experiences or refer to our seeking safety group for globalized trauma. A few clients have Borderline Personality Disorder and so I teach Dialectical Behavior Therapy skills and refer to our Dialectical Behavioral Therapy (DBT) day-treatment program.”
Military Social Workers
Military social workers work with active and former military service members to help them identify, manage, and overcome mental, emotional, and social challenges that result from their experiences in the military. Embedded military social workers provide counseling and therapy to active military men and women with the aim of helping them address the mental and emotional barriers that affect their ability to function at their job. Embedded military social workers often work as part of a larger team of medical and mental health professionals that serve a particular battalion. Military social workers also help veterans who are struggling with the mental and emotional repercussions of their past work; these military social workers are often employed by the Department of Veteran’s Affairs and/or its affiliated organizations, such as the Veterans Health Administration.
School Social Workers
School social workers work at schools to provide counseling and support to students on a regular and as needed basis. They also design and implement interventions when necessary–for example, in the case of bullying incidents, school violence, or other serious issue that occurs on campus. School social workers collaborate with school administrators, teachers, school counselors, and parents to identify, prevent, and address issues that pose barriers to student learning and well-being, such as family conflicts, parental neglect, truancy, substance abuse, bullying, and community violence.
Substance Abuse Social Workers
Substance abuse social workers work specifically with populations struggling with chemical dependency and/or other addiction behaviors. Substance abuse social workers work with individuals to assess, diagnose, and help them treat/manage their addictions and the underlying causes of these dependencies (ex. anxiety disorders, emotional trauma, family or social hardships, etc.) through therapy, resource referrals, and care coordination where applicable. They typically work at specialized medical clinics, hospitals (within certain departments or programs that address chemical dependency), residential treatment/rehabilitation centers, VA health centers, and community health centers.
Clinical Social Work: A Broad and Varied Professional Field
Students interested in becoming social workers should note that clinical social work in and of itself is not a career, but rather a broad field that encompasses many different types of roles and work environments (as the list above illustrates). In addition, the problems that clinical social workers help their clients tackle are often quite complex and multifaceted; therefore, some careers may actually fall into more than one of the roles described above. For example, a criminal justice social worker who works with inmates in a correctional facility may also effectively work as a psychiatric social worker, due to the nature of the mental and emotional challenges their clients face (ex. dual diagnoses, severe mental illnesses coupled with substance abuse, etc.). Some clinical social work roles are more interdisciplinary than others, and in general, the more complex and/or severe the problems a practitioner’s clients face, the more likely it is that this practitioner will have to engage in multiples areas of clinical social work to be effective at his or her job.
Techniques Used by Clinical Social Workers
Clinical social work is a unique field in that it effectively merges clinical psychology and psychotherapy with an understanding of the macro-level social forces and contexts that shape human behavior and emotions. As such, clinical social workers serve as client advocates and connections to community resources, while also implementing a variety of assessment techniques and therapeutic modalities in their practice. These modalities include but are not limited to risk assessments, psychosocial assessments, traditional counseling, cognitive behavioral therapy, dialectical behavior therapy, motivational interviewing, creative arts therapy, and experiential therapy. Below are descriptions of several of the core methods that clinical social workers use when working with clients in various settings. These methods are divided into four categories: Assessment/Evaluation, Diagnosis, Psychotherapy and Evidence Based Practices, and Case Management.
Whether they are working in private practice, in a hospital setting, or within a jail intake department, clinical social workers must conduct assessments of their clients’ mental, emotional, and physical well-being both at the beginning of their work with a particular client, and at key points within clients’ treatment. Two essential types of assessments that social workers use are:
A psychosocial assessment is a written report that presents and synthesizes essential information about a client across many categories, with the aim of producing a treatment plan that addresses the client’s problems across multiple domains. As the name suggests, psychosocial assessments bring together information about clients’ psychological and physical health, as well as their social circumstances, to provide an understanding of their overall well-being and needs. They are generally completed at the beginning of a client’s treatment, and at intervals throughout his/her treatment plan.
Typically, the psychosocial assessment describes the reason for the referral, summarizes the client’s strengths as well as hurdles to treatment, gives a diagnosis, and describes a treatment plan. It is usually detailed enough to provide readers with a picture of a client’s daily life, relationships, employment, medical history, substance abuse history, psychiatric history, psychological state, legal status, mental status, resources, and support systems.
Risk assessments gauge the chances that a client will experience an adverse outcome. Such assessments are an essential part of providing mental health care, because they determine what level of treatment is needed. If a patient is at high risk of harming himself or other people, he may need hospitalization, whereas if he is a low risk, he can receive outpatient treatment. Learning to assess risk requires an understanding of predictive and protective factors associated with adverse outcomes, and the ability to elicit them in an interview. For example, a depressed mood, hallucinations, substance abuse, or access to firearms are risk factors for suicide, while access to care, and cultural beliefs that discourage suicide are protective factors that reduce risk. Notably, assessment of risk requires aspects of the psychosocial assessment, as well as diagnosis of mental disorders.
Diagnosis of Mental Disorders
In order to choose an effective treatment, social workers must understand and accurately describe the nature of a client’s mental illness. Without the correct diagnosis, mental health care providers may risk using therapies that will not help the client. Clinical social workers will make a diagnosis of a client’s condition based off of the information they have gathered in their psychosocial and/or risk assessment. Making the correct diagnosis requires an understanding of diagnostic criteria for the various kinds of mental illnesses, as well as an understanding of how to observe the presence of these criteria in clients based on an interview. Most commonly, providers in the US utilize the diagnostic criteria established in the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association (APA).
Psychotherapy and Evidence-Based Practices
Psychotherapy is a broad term to describe non-pharmacologic treatment geared towards improving mental wellness, whether it stems from a diagnosable mental illness such as major depressive disorder (MDD), emotional suffering, and anxiety, or other life stressors. It typically involves talking with a therapist, either individually or in groups. There are hundreds of different kinds of psychotherapies, which vary from highly structured to open-ended, and from a focus on behavior to a focus on emotions and unconscious processes. Examples of common psychotherapies include psychodynamic psychotherapy, Cognitive Behavioral Therapy (CBT), Dialectical Behavior therapy (DBT), problem solving therapy, motivational Interviewing, experiential therapy, family therapy and supportive therapy.
Many forms of therapy have been used for decades because providers claim that they are effective, but have not actually been tested using rigorous scientific methods. On the other hand, evidence-based interventions such as cognitive behavioral therapy have been shown effective in controlled clinical trials, where clients have a specific mental illness, and providers follow a highly specific treatment manual when providing therapy. A specific treatment for a specific illness is considered evidence-based when it has been shown to be effective in a scientifically rigorous study. Some forms of treatment have a lot of evidence, while others have limited amounts.
Cognitive Behavioral Therapy (CBT)
CBT is a form of psychotherapy that teaches clients to examine and ultimately understand the relationship between their thoughts, feelings, and behaviors, and the core beliefs that underlie maladaptive patterns of thought. By examining situations in terms of the thoughts, feelings and behaviors involved, clients learn to modify maladaptive thought patterns that lead to a wide range of emotional, psychological, and/or behavioral problems, such as anxiety, depression, and psychosis. CBT exercises often include recording one’s thoughts, feelings, and behaviors on paper, subsequently connecting them to core values and beliefs, and then investigating the validity of these beliefs. There are many versions of CBT, but they are all based on the core principle of understanding and modifying the relationship between thoughts, feelings and actions. Many therapies, such as Dialectical Behavior Therapy and problem solving therapy, also make use of CBT principles.
Dialectical Behavior Therapy (DBT)
DBT is a form of psychotherapy that incorporates elements of CBT with mindfulness principles and a consideration of how one interacts with friends, family, and society. According to theLinehan Institute, DBT was developed by Dr. Marsha M. Linehan, and was initially geared towards the treatment of patients with borderline personality disorder (BPD), who tend to have reduced emotion regulation and impulse control, and struggle with chronic suicidality and self injury. DBT was the first psychotherapy to show clear benefits in treating BPD, but is now used to treat many forms of mental illness. True DBT involves treatment by an individual therapist and a group therapist, and includes phone coaching, and collaboration and consultation between all providers on the treatment team.
Problem Solving Therapy
Problem solving therapy is a form of cognitive behavioral therapy that focuses on empowering patients to restructure their views on the meaning of problems, and how to solve them in a healthy manner. In order to do these things, patients first learn to cope with stress, and become aware of negatively biased thought patterns, leading to increased resilience.
Psychodynamic psychotherapy is a type of psychotherapy that attempts to help patients describe aspects of the unconscious. The unconscious refers to aspects of the psyche which govern conscious patterns of thought and behavior and are based on past experiences, but of which a patient is not aware. By identifying elements of the unconscious, patients develop a better sense of themselves and the ways that they relate to others, alleviating many types of suffering, including poor self-esteem, unhappiness, and anxiety. In psychodynamic therapy, the ways that the patient relates to the therapist function as an important tool for understanding the unconscious.
Supportive psychotherapy is a form of psychotherapy in which the therapist takes an emotionally supportive role. Goals include maintaining the client’s self-esteem, reinforcing healthy and adaptive behaviors, and aiding in problem solving. Unlike psychodynamic therapy or CBT, supportive psychotherapy does not focus on the deeper motivations underlying behaviors or conflicts, nor does it investigate the role of past experiences.
Harm Reduction Techniques
Harm reduction techniques are founded on the philosophical stance that reducing the negative consequences of harmful behaviors is a more feasible, attainable and effective goal than trying to eradicate harmful behaviors entirely. Common examples of harm reduction approaches include needle exchange programs, opioid maintenance therapy, or designated driver campaigns. In her work with adolescents struggling with substance abuse, Samantha Roberts, LCSW implemented the Adolescent Community Reinforcement Approach (ACRA), which consisted of 17 procedures aimed at supporting youth in addressing their addictions. “ACRA was considered a harm reduction approach and was coupled with incentives to motivate the clients to cut down and eventually stop their drug use. We were also provided with cell phones and were encouraged to text with our clients since this was the main way they communicated. It was an engagement tool that ended up being invaluable to our team,” Ms. Roberts explained to OnlineMSWPrograms.com.
Motivational interviewing is a goal-oriented therapeutic approach focused on identifying and cultivating an individual’s motivation to change behaviors. Factors addressed include a client’s readiness to change, what is required to make changes, and any ambivalence they may have about change. Motivational interviewing was an innovative development in therapy techniques because of its emphasis on the client’s intrinsic motivation to change, and not the ability of the therapist to convince the client to change.
Mindfulness Based Stress Reduction
Mindfulness is defined differently by different cultures and thinkers, but generally describes a state of non-judgmental awareness and acceptance of present experience. According to theUniversity of Massachusetts Medical School, mindfulness based stress reduction (MBSR) is a specific mindfulness based program originally developed by Dr. Jon Kabat-Zinn to treat chronic pain. The original MBSR program included weekly group meetings, and focused on several types of meditation exercises. Mindfulness based approaches are now used to address many forms of mental illness, including anxiety and depression. For example, dialectical behavior therapy (DBT) makes significant use of mindfulness principles.
Experiential therapy engages clients in concrete tasks or experiences (rather than talk-based therapy) under the guidance of a therapist. These therapeutic tasks/experiences aim to reveal the underlying thoughts, emotions, and beliefs that clients have and which are not easily accessible through talk therapy alone. Examples of experiential therapy include equine assisted psychotherapy (i.e. having clients interact with horses in an arena to utilize and evaluate their problem solving and stress management skills), psychodrama (role playing with other individuals in a group therapy setting in order to help clients express their emotions and examine how they interact with others), music therapy (using music to connect with one’s thoughts and feelings), and expressive arts therapy (using art as a medium to express feelings).
Experiential therapy can be helpful for clients in scenarios in which talk-based therapies such as motivational interviewing and supportive psychotherapy are seeing limited results. For example, Donna Maglio, LCSW, a military social worker who also runs her own private practice, uses Equine Assisted Psychotherapy (EAP) with many of her clients. “EAP can be a great alternative approach to traditional office sessions, or can also be used to enhance office sessions,” she explained to OnlineMSWPrograms.com, “Since EAP is an experiential modality, clients have reported that one session in the arena can be equivalent to about three sessions in an office. By engaging clients both physically and emotionally, the effect can be much more profound and apparent.”
Theory of change
Theory of Change is a model for the stages of therapeutic change that can help practitioners contextualize their clients’ progress and determine the appropriateness of certain therapeutic modalities. The treatment of mental illness, including the use of all the modalities explained above, among others, depends upon a theoretical framework for understanding change and how it happens. According to the American Psychological Association, one classic and widely used model for therapeutic change originated with the work of psychology professors and alcoholism researchers Carlo C. DiClemente and James O. Prochaska, who conceptualized change as having defined stages. During precontemplation, a client does not intend to change, and may not even be aware of reasons to change. During the contemplation stage, clients are considering making a change, but remain ambivalent. When clients feel ready to change, and begin to make actual plans to change, they have reached the preparation stage of change. Once one actually makes a change, he reaches the action stage of change, which is followed by amaintenance stage. Considering how change happens in the individual, and how to support this change is important in cases of addiction, but is more generally important to many forms of mental illness.
Case management brings together the practices of assessment, diagnosis, and therapy, along with other tasks such as coordination of care, advocacy, and resource connection. Case management also encompasses record-keeping and reporting, which are necessary in evaluating a client’s progress towards his or her goals. For example, a child welfare social worker is required to keep records and submit documentation to the dependency court regarding a parent’s ability to care for his or her child, and the progress this parent makes towards this goal. Similarly, medical social workers and geriatric social workers must keep consistent records of their clients’ physical and mental health over time to ensure adequate and effective medical and mental health care. According to the National Association of Social Work, case management is typically a core responsibility of clinical social workers who must help their clients navigate complex social systems or manage challenging or ongoing physical, mental, and/or social challenges. Examples of settings that often require clinical social workers to practice case management include but are not limited to:
- Geriatric care settings
- Mental health and substance abuse clinics
- Child welfare agencies
- Correctional facilities
- Hospice and palliative care settings
- Employee assistance programs
- Health and medical care settings
- Housing services
- Immigrant and refugee services
- Military and veteran support programs
The Ten Core Competencies of Clinical Social Work
Clinical social work roles and techniques such as the ones described in the previous two sections are expected to abide by the standards set forth in the 2009 publication Advanced Social Work Practice in Clinical Social Work. This document was the product of a convention of clinical social workers who met in response to the Council on Social Work Education’s development of 10 Core Competencies, which were established in 2008 as part of the CSWE’s Education Policy and Accreditation Standards (EPAS) to ensure that social work programs across all areas (from micro to macro social work) sufficiently prepare their students for the workforce. According to Advanced Social Work Practice in Clinical Social Work, clinical social workers across all fields of practice should:
- Identify as professional social workers and conduct themselves accordingly: Clinical social workers should possess and demonstrate an awareness of the history and core mission of their profession, and to continually engage in professional development through self-awareness, self-correction, and lifelong learning.
- Apply social work ethical principles to guide professional practice: Clinical social workers are expected to apply the National Association of Social Workers’ Code of Ethicsand, where applicable, the International Federation of Social Workers/International Association of Schools of Social Work Ethics in Social Work, Statement of Principles (IFSW, 2004) to their daily professional practice. Clinical social workers are expected to combine the aforementioned standards with their own understanding of ethical principles when addressing morally ambiguous situations on the job.
- Apply critical thinking to inform and communicate professional judgments: Clinical social workers consistently combine research-informed methods with wisdom derived from clinical practice in order to effectively assess, understand, diagnose, and address clients’ challenges. Clinical social workers also use critical thinking skills to help clients identify and use their internal strengths and external resources to tackle difficult social, emotional, behavioral, and psychological issues.
- Engage diversity and difference in practice: Clinical social workers have an in-depth understanding of how diversity impacts people’s experiences, perspectives, and interactions with others. They acknowledge that differences in age, race, gender, class, culture, political views, sexual orientation, and other characteristics can lead to marginalization, alienation, oppression, and/or harmful power dynamics within society that can negatively impact people on an individual and community level. Clinical social workers also understand how demographic differences and the marginalization that can result from them affect how clients present and discuss their challenges during therapeutic sessions.
- Advance human rights and social and economic justice: In addition to addressing client challenges at the individual level, clinical social workers should be invested in examining, understanding, and working to address social oppression on a national and international level. Clinical social workers serve as scholars of and advocates for human rights, social and economic justice, and accessibility to social support.
- Engage in research-informed practice and practice-informed research: Clinical social workers understand the interplay between social work research and clinical practice, in that they utilize evidence-based interventions and use recent and relevant research to inform their work with clients. Additionally, clinical social workers may engage in research by contacting research institutions and communities about problems they have encountered in the field.
- Apply knowledge of human behavior and the social environment: Clinical social workers have a sound and functional knowledge of human development, psychology, and behavior across the lifespan, and use this knowledge to effectively address clients’ challenges in the context of their biological, intellectual, behavioral, and social development.
- Engage in policy practice to advance social and economic well-being and to deliver effective social work services: Clinical social workers are active scholars of state and national policy as it relates to the well-being of vulnerable populations and society as a whole. They also serve as advocates for policies that support and improve the lives of people in need.
- Respond to contexts that shape practice: Clinical social workers are flexible and adapt their clinical practice to the changing social, organizational, and professional contexts in which they work. They remain aware of evolving social, political, organizational, and economic climates, and also work to not only respond to these changes, but also lead positive developments in these areas as part of a larger group of human service professionals.
- Engage, assess, intervene, and evaluate with individuals, families, groups, organizations, and communities: Clinical social workers should have the knowledge and skills to assess, identify, analyze, and address clients’ challenges through a combination of empathetic and culturally sensitive engagement with individuals, families, and groups; rigorous and multi-faceted bio-psycho-social-spiritual assessment methods; evidence-based interventions that aim to help clients address, manage, and/or prevent issues that negatively impact their well-being; and evaluate the effectiveness of clinical assessments and interventions, with the intention to always improve one’s practice through continued research and professional development.
(Note: The CSWE released a 2015 update to the Core Competencies, condensing them into nine Competencies that place more emphasis on Engagement, Assessment, Intervention, and Evaluation. However, an official statement on the application of these new Core Competencies to the clinical social work profession has not yet been developed.)
By combining the core competencies above with some or all of the clinical social work techniques described previously in various contexts, clinical social workers across a wide variety of specializations can help individuals, families, groups, and communities to tackle stubborn problems that affect their well-being and happiness. As Advanced Social Work Practice in Clinical Social Work noted, “Clinical social work requires the professional use of self to restore, maintain, and enhance the biological, psychological, social, and spiritual functioning of individuals, families, and groups. The practice of clinical social work requires the application of advanced clinical knowledge and clinical skills in multidimensional assessment, diagnosis, and treatment of psychosocial dysfunction, disability, or impairment including emotional, mental, and behavioral disorders, conditions, and addictions. […] Advanced practitioners in clinical social work are knowledgeable about ethical issues, legal parameters, and shifting societal mores that affect the therapeutic relationship.”
As this description illustrates, clinical social work requires that practitioners constantly balance their clients’ concerns and situations with a broad yet in-depth understanding of how social, political, ethical, economic, and cultural forces operate across society and impact individuals, families, groups, and communities.
Challenges Clinical Social Workers Face
The field of clinical social work is fast-paced, challenging, and complex, and can be very stressful due to the often serious nature of clients’ struggles and the depth of responsibility that social workers feel for their clients’ well-being. While the types and degrees of stress on the job vary across different clinical social work fields and settings, almost all clinical social workers face the challenge of trying to motivate clients to minimize harmful behaviors and implement constructive changes in their lives; during this process, clinical social workers may encounter clients’ resistance to changes, and must find ways to work with clients’ goals, preferences, circumstances, and present beliefs in order to make progress.
While clinical social work in general involves helping clients identify, manage, and overcome trauma or hardship in their lives at various levels, certain fields of clinical social work, such as child welfare social work, international social work (working with refugees and/or immigrants), hospice/palliative care social workers, pediatric social work, and forensic social work expose clinical social workers to particularly high levels of trauma or tragedy that can impact their own emotional well-being. In an interview with OnlineMSWPrograms.com, Jessica Beitch, LCSW and Pediatric Social Worker at UCSF’s Benioff Children’s Hospital, noted, “Death is challenging, but that is not the most challenging for me personally. Encountering instances of neglect, severe mental illness, or the infliction of harm (physical or emotional)–those are the things that are most challenging for me to deal with, and the hardest for me to recover from.” When social workers feel distressed or otherwise affected by their clients’ trials, it is important for them to engage in regular self-care practices, and to potentially participate in individual or group therapy of their own to help them sort through and manage the emotions they feel during and after their daily work.
In addition to trauma exposure while on the job, clinical social workers can also struggle with the intense demands that this field places on their time, as well as their physical, mental, and emotional reserves. Whether they are in private practice, working at a hospital with pediatric patients, or supporting the elderly in a palliative care setting, clinical social workers typically manage heavy case loads and must find ways to provide individualized care to their clients/patients in an efficient manner. Furthermore, as clinical social work is inherently interdisciplinary, and requires its practitioners to balance so many moving pieces (from crisis interventions, intake assessments, and individual/group therapy, to care coordination and community resource referrals), social workers may sometimes feel overwhelmed.
Many social workers report feeling the urge to stay long hours at their job, as they feel no job is ever “finished” and that there is always so much that needs to be done to help a given client and/or his or her family. “I feel the most challenging aspect of this work was the inherent inability to meet the needs of every family. Given the number of patients to which we were assigned, the complexity of their lives and illnesses, the scarcity of resources both within and outside the hospital system, and the expectations of the medical teams, there was simply no way to achieve everything I set out to,” Andrea Kido told OnlineMSWPrograms.com in recalling her experiences at Lucile Packard Children’s Hospital, “The most difficult part, and for what I would advise MSW students to prepare, was the acceptance that there is only so much you can do. You will not change someone’s life completely. […] You have to be satisfied with knowing that you made an overwhelmed mother feel like she has someone she can call and won’t be judged; that you gave a father enough financial help to be able to eat tonight, even if he won’t have enough for breakfast tomorrow; that your smile made a child feel safe instead of scared. The small moments that, in reality, do mean so much to families must mean as much to you.”
Due to the physically, mentally, and emotionally demanding nature of clinical social work, many social workers encourage fellow practitioners to establish boundaries and implement self-care practices to help prevent burn-out. Jana Morgan, LCSW, a clinical social worker in private practice who has also supervised numerous MSW students, explained how she tries to consistently remind her students about the importance of self-care. “I see self-care as integral to professional survival. I try to teach by example in this area, while reminding my students that self-care is not an easy task, and requires conscious effort and time,” she explained, “I remember in my own training how run down many of my female mentors were. […] Even as I write this, years after my training experiences, I recall some of my mentors and have a sense of concern. I see that, at that time, I was in an environment where very few people spoke to this phenomenon. With the interns in my charge, I create openings to discuss such matters.”
Aside from proper self-care and setting of healthy boundaries, finding both mentors and peers who have experience in one’s field of work and can provide both sympathy and support is important. Being able to seek advice from and commiserate with people who are truly familiar with one’s challenges can help social workers stay resilient in the face of daily challenges at one’s work.
The Importance of Understanding Addiction in Clinical Social Work
Addiction, whether it is to illicit substances or unhealthy practices and patterns, is central to many mental, emotional, and behavioral problems that people struggle with. “Addiction is such a large part of our society that it permeates and reflects into almost all human behaviors and endeavors,” Jana Morgan, LCSW told OnlineMSWPrograms.com, “It is so recognized that even county social services have been merged so that mental health and substance recovery services are now one department, having one director. […] In private practice, I always assess and monitor for co-occurring substance abuse and chemical dependency.”
In describing her work with youth and incarcerated individuals struggling with substance abuse, Samantha Roberts, LCSW explained how harmful addictions can both originate from and cause or exacerbate psychological and emotional issues. “From my experience, there is an inherent connection between mental illness and substance abuse, and the longer I’ve worked in the field, the more difficult it is to determine which came first and how to treat both in the best possible way,” she told OnlineMSWPrograms.com, “Most clients I have worked with have a co-occurring disorder (substance use, as well as a mood/psychotic disorder), but depending when you begin to work with them, it is difficult to see which one has impacted the other. Many people with mental health issues turn to substance use to self-medicate and cope with their illness. There is also the chance that people with a pre-disposition to mental illness may be more inclined to use substances as a way of coping, and therefore create the perfect environment for a mental illness to grow.”
In a similar way, substance abuse and/or addictive behaviors can be both a symptom and a source of familial, social, and financial problems. “We see the main causes of substance abuse to be dysfunctional systems dynamics and life stressors that lead to negative coping mechanisms,” noted Tech Tran, ACSW, Lead Case Manager and Social Work Program Supervisor at the Rainbow Community Center (RCC), in an interview with OnlineMSWPrograms.com. Mr. Tran also explained how chemical dependency dramatically impacts, not only an individual’s well-being, but also his/her environment. “Substance abuse/addiction affects individuals and their families in the short term by causing strain on the individuals’ life as well as the families’ life,” he told OnlineMSWPrograms.com, “Substance abuse typically occurs alongside other mental/social/physical/psychological challenges–these co-occurring /dual disorders have an impact on our internal and external systems as everything is interconnected.”
As the experiences of the social workers noted above illustrate, substance abuse and addiction are very prevalent issues that require clinical social workers to have a deep understanding of how emotional, psychological, social/socioeconomic, and cultural problems develop and manifest themselves as behavioral and relational issues at the individual, familial, and community levels. This person-in-environment understanding isn’t just applicable to chemical dependency. Many, if not most, behavioral problems follow the same pattern as addictions do, in that they involve an attachment to actions that lead to emotional reward or relief–for instance, the expression of anger as a way to cope with difficult life circumstances, or an addiction to food, or exercise as a way to escape uncomfortable emotions. The treatment of these harmful behavioral patterns also follows the same essential structure and progression as the treatment of substance abuse does–that is, identifying the internal and external causes of the addiction (psychological issues such as anxiety, social and familial context, etc.), and using a person-in-environment approach to address both the causes and the effects of the harmful behaviors. As a result, understanding how addictions originate and develop, what the symptoms of addiction are, and what therapeutic modalities are important in treating these addictions can be a crucial aspect of clinical social workers’ training. The best therapeutic modalities and case management strategies for a given client vary according to that client’s circumstances and emotional and mental disposition; knowledge of a wide range of clinical techniques can therefore be very helpful for clinical social workers, as it enables them to customize their treatment plan for each of their clients.
In describing his work with youth struggling with substance abuse, Tech Tran, ACSW told OnlineMSWPrograms.com, “I utilize two main Evidenced-Based Practices–the first is Motivational Interviewing, an approach aimed at increasing change and overcoming ambivalence to change, and the second is the Seeking Safety model, an innovative treatment modality that focuses on PTSD and substance abuse. By using this therapeutic strategy, I aim at the underlying or root causes that drive the youth I work with to turn to alcohol and other drugs.” Mr. Tran also explained the importance of treating clients within the context of their environment, and recruiting support from within clients’ family and friend networks. “Working with families is essential in helping students overcome their addictions; we look at the student as a person in their environment,” he explained, “We work with families to promote a safe environment for healing and recovery from addiction through a research informed practice, and this research shows us that the most influential system in a young person’s life is their immediate family, then their nurturing support systems consisting of their friends and other people whom they trust and perceive to gain or give love towards.”
During her time working with adolescents and young adults who suffered from chemical dependency at The Odyssey House, Samantha Roberts, LCSW also used therapeutic and case management techniques that aimed to address clients’ substance abuse with the support of their families. “The main method used to deal with these clients’ addiction issues was the Adolescent Community Reinforcement Approach (ACRA) and Assertive Continuing Care (ACC). These are evidence based methods proven to work with adolescents and TAY (transitional age youth) […] ACRA involves using one or more of 17 specific procedures that aim to address the social, mental, emotional, behavioral, and environmental factors that contribute to substance abuse among youth. These procedures include ways to work with youth and their caretakers (both separately and together) to improve communication, problem solving, and stress management.”
Social work students and clinical social workers who are interested in learning about addiction and developing therapeutic skills that are useful in treating addictions should take the initiative to learn about these issues, not only during their undergraduate and graduate programs, but also through continuing education and post-graduate trainings. Tech Tran, ACSW, who is pursuing an Associate in Science program at Diablo Valley College for Addiction Counseling, told OnlineMSWPrograms.com that he found this additional post-MSW training to be instrumental in his work with clients with substance abuse issues. “This additional training has been profoundly helpful in my work as an addictions counselor,” he said, “As a counselor with training focused on the recovery model coupled with the social justice perspective, I am more equipped to intervene with counseling techniques aimed at reducing substance use especially in serving clients with dual disorders. […] I highly recommend that students who wish to work with individuals struggling with substance abuse complete continuing education in this area because […] these classes can provide the opportunity to learn from professors that are invested in providing accurate and up-to-date information regarding this population.”
Why People Become LCSWs
Despite the aforementioned challenges, clinical social work can also be incredibly rewarding, and indeed, the difficult aspects of this profession can, in some cases, be the very reason why this field of work is deeply gratifying for some. For example, the strong emotions of distress, frustration, and vulnerability that clients often feel are sometimes matched by their gratitude towards clinical social workers for helping them through some of the most difficult experiences of their lives (ex. hospitalization, the death of a family member, incarceration, chemical dependency, eating disorders, etc.). Jessica Beitch, LCSW, told OnlineMSWPrograms that, despite the challenges of her field of work, she finds the connections she makes with her patients and their families to be very fulfilling. “The most rewarding aspects of my experience as a clinical social worker are the relationships I form with patients and families, who are the strongest people I have ever met, and the lessons they teach me about the true meaningful moments of life,” she explained, “I get to witness and honor their journey, and lift them up when they are weary–or at least hold the emotion for a moment while they take a breath. It is powerful work.”
Additionally, some social workers report that the fast pace and multi-faceted nature of their work is intellectually stimulating and prompts them to constantly grow both personally and professionally. Jana Morgan, LCSW, described how the unique, collaborative relationship between herself and her clients in her private practice is both incredibly gratifying and educational. “The work is so collaborative and becomes increasingly meaningful as my clients and I get at what brings them to treatment,” she explained, “Together we begin the challenge of self-discovery, acceptance, tolerating the heat and re-directing energy into self healing out of self loathing.”
Rewards of clinical social work as a profession can also be field-specific. For example, individuals who find working with youth particularly gratifying might enjoy school social work, while social workers with several years of experience under their belt and who would like to be more creative with the therapeutic services they provide may find private practice to be a rewarding challenge. In her interview with OnlineMSWPrograms.com, Donna Maglio described the benefits of running her own private practice. “[Having] my own practice gives me the flexibility to set my own hours and fees, offer modalities such as EAP that might not otherwise be feasible, and be selective about which client populations I feel I am best suited to serve,” she said, “It also gives me the opportunity to expand beyond the direct client sessions, by presenting workshops, giving presentations, writing articles, and guest lecturing in graduate classes.”
Regardless of their specific field, and in the face of the difficulties of their profession, many social workers obtain satisfaction from knowing that they are directly impacting people’s lives for the better, both at the individual and the societal level. Whether it is keeping a family together, protecting a child from abuse or neglect, holding the hand of a daughter who has lost her parent, providing support and guidance to inmates, or helping military service members overcome trauma, the daily responsibilities and accomplishments of clinical social workers are powerful, far-reaching, and incredibly necessary.
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