By Kaitlin Louie
About Gina Pascual, MSW: Ginal Pascual is an Integrated Behavioral Health Clinician at La Clinica, Inc., where she works with clients ages 12 to 25, providing short term therapeutic services, referrals, crisis interventions, and support. Prior to working at La Clinica, Inc., Ms. Pascual completed two internships through her MSW program–one at the University of California, San Francisco (UCSF) in the Pediatric and Adolescent Outpatient Department, and one with San Francisco Unified School District. During her MSW Program, she also worked as a Graduate Student Researcher at the UC Berkeley Center for Social Services Research, where she co-authored a scholarly journal article about subsidized employment programs to be published in Families in Society.
Ms. Pascual completed her Bachelor of Arts in Psychology from the University of California, Davis, and earned her MSW from UC Berkeley in the Children and Family Concentration in 2013. She has also earned her PPSC credential. During her MSW, she was also awarded the FLAS (Foreign Language and Area Studies) Fellowship in 2013, which included a stipend for advanced foreign language studies in the county or institution of her choice.
[OnlineMSWPrograms.com] Could you please describe your current role as an Integrated Behavioral Health Clinician at La Clinica Inc.?
[Gina Pascual, MSW] As an Integrated Behavioral Health Clinician (IBHC), I work with patients between the ages of 12-25 and their families or external supports. The most common issues that arise are moderate anxiety and depression. Considering this is a medical clinic, patients who are unaware of anxiety or depression symptoms are often concerned that their symptoms as signs of decaying health. Secondary issues that are frequent are family conflicts, relationship issues, domestic violence, developmental delays, learning and behavior problems in school, and drug use (marijuana, heroin, methamphetamine, alcohol). Least common issues are OCD, psychotic symptoms and active homicidality and suicidality. A big part of my job is completing state required assessments for pregnant patients as part of the Comprehensive Perinatal Services Program, which requires the Social Worker to administer assessments every trimester and one postpartum assessment.
My position is structured so that I spend four hours (½ day) in the medical provider office, located on the first floor of our very small building. During this time, three medical providers see 13 patients each. I will review the patients on the schedule and based on personal knowledge, the chief medical complaint listed on the computer, and automatic referrals (for new patients, patient transfers and postpartum medical visits), I will attempt to make contact with these patients by asking medical assistants or medical providers. Medical providers will also refer patients they have just seen with an identified need and I will usually spend an average of 15 minutes with patients seen in the medical clinic; these referrals are known as “Warm Hand Offs (WHO).” If these patients meet our criteria, such as moderate stressors or moderate mental illness, I will attempt to engage them in counseling myself. If the patient presents with severe symptomatology, I will make external referrals. There are two IBHCs in my clinic; we have opposite schedules, so one of us is always conducting counseling or in the medical provider’s office.
If a patient decides to engage in therapeutic services, the front desk will schedule the patient with myself in approximately two weeks (the average waiting time). I spend the second half of my day upstairs in my office, conducting counseling sessions that range from 30-45 minutes. I use a variety of therapies, but mostly CBT, supportive counseling, mindfulness, psychoeducation and relaxation techniques, as well as safety planning and crisis management. Technically, our service is based on a “brief treatment” (4-12 sessions) model; ideally patients will have improved within this allotted amount of time. Fortunately, due to the flexibility of my specific clinic, patients can continue to come after the 12 sessions if they are still symptomatic or need support. Many patients disengage or improve before 12 sessions. Due to our population, many patients come one time, while others (estimating 20-30%) engage in treatment for more than one session.
In this setting I am almost 100% confined to my physical office, as we are technically not allowed to attend external meetings with patients off-site.
[OnlineMSWPrograms.com] Could you also elaborate on your role as a pediatric social work intern at UCSF Mount Zion Pediatric Clinic?
[Gina Pascual, MSW] Working as a social work intern at UCSF Mount Zion Pediatric and Young Women’s OB-GYN clinic was a great experience. While at UCSF, I conducted primary and follow-up clinical assessments with pregnant adolescents and pediatric patients, provided short-term counseling and intervention with families experiencing domestic violence, drug addiction and psychiatric emergencies, and collaborated with my medical team to ensure patient safety, assistance and optimal care. I also accompanied patients to housing, judicial, educational and medical meetings to advocate and support their well-being and that of their family in community contexts.
Most issues in primary care at UCSF consisted of families who had children with behavioral issues, postpartum depression symptoms, some suicidality, custody issues, and/or a need for academic advocacy coaching (for parents) or legal, financial and counseling resources. Patients in the Young Women’s OB-GYN clinic were seen a minimum of 4 times, three times prenatal and one time post-partum. Treatment with these patients consisted of assessment, motivational interviewing related to substance abuse and returning to high school, as well as supportive counseling related to partner relationship problems and family issues. In both of these settings trauma was rarely discussed or treated.
Advocating and assisting patients in this setting consisted of mostly letter writing and phone calls to advocate for resources or to gather more information. It was very rare for us to visit a patient or attend external meetings, although it did happen on several occasions over the course of the year.
[OnlineMSWPrograms.com] Since you have worked at both a hospital and a community health clinic, could you please elaborate on the differences in these two types of medical environments? Were your responsibilities and the team on which you worked different in any way? How are social work services structured at a hospital, versus a community health clinic?
[Gina Pascual, MSW] Technically, Mt. Zion is an out-patient primary care facility, and not in-patient (i.e. hospital social work). So my previous and current roles are very similar. The main difference between UCSF and La Clinica is that La Clinica places great value on reaching patients’ mental health needs at the same site where medical treatment is provided–hence the term: integrated behavioral health. In typical outpatient primary care there are no mental health treatment options on-site. Social workers in most outpatient primary care offices have to refer patients to outside counseling referrals. Typically, patients have very low rates of accessing referrals or resources outside of an agency. To provide better services, La Clinica provides free mental health treatment in the medical setting when patients meet eligibility (i.e. moderate symptom). This is an excellent feature for patient care. Social workers are able to consult with medical providers, and vice versa. Social workers can also help patients advocate for better medical care and help coordinate medical services so that patients can receive physical and emotional support in the same place.
[OnlineMSWPrograms.com] What have been some of your most rewarding experiences during your career in pediatric and medical social work?
[Gina Pascual, MSW] Working as a medical social worker/clinician is very gratifying. Almost daily I meet a patient in the medical clinic who is suffering from severe stress or mental illness, that would most likely go unnoticed or untreated. Being able to screen, identify and possibly treat patients in need is a very gratifying and validating feeling. Many times patients do not engage on the first meeting, but at least they are aware of their symptoms and are aware of treatment options.
I enjoy the medical setting, but I also have a passion for analytical work that is hard to get in medical social work, where the structure demands social workers to do mostly all clinical work. I am gaining invaluable clinical experience due to the wide variety of patient populations and needs that the medical setting affords. Ultimately, I would like to do part-time clinical work, and part-time research, in a medical setting. I have some research experience from a Graduate Student Research position I held at the Center for Social Services Research at UC Berkeley, where I conducted qualitative and quantitative research about subsidized employment in Alameda County. Ideally, I would like to be a part of research that examines the efficacy of clinical social work in an agency. I am very interested in quality improvement and program evaluation. Ideally, I would love the opportunity to get a second masters in public health, but at this time it is not a feasible choice.
My work in child abuse prevention is very different from what I am currently doing. My work in child abuse prevention did lead me to medical social work because I wanted to see what other types of social work looked like. I am very glad I choose my second year internship in the medical field because it broadened my idea of social work, and I found a setting that fit my needs and my preference for a varied work day.
I also feel especially drawn to young adults (typically classified as ages 12-25). I speak to many young people who feel misunderstood by adults, their families and peers. In this setting, I am able to recognize the individual and provide support, empathy and skills to patients whose voice is sometimes not heard. This age is sometimes challenging, due to developmental aspects of adolescence. Adolescents sometimes lack awareness of their bodies, thoughts and personal power, and can engage in varying degrees of risk behavior. But overall, adolescents inspire me due to their insight, resilience, and need for support.
[OnlineMSWPrograms.com] On the other hand, what have been some of the most challenging aspects of your job in pediatric and medical social work? How would you recommend MSW students who wish to work in this field prepare for these challenges?
[Gina Pascual, MSW] Some of the most challenging parts of medical social work is seeing new symptoms that you have not worked with or being faced with patients engaged in very risky behavior or severe mental illness causing risk to their well-being. This is challenging because as a clinician you need to do a thorough assessment and possibly 51/50 a patient. This is especially challenging to me, because I am sometimes very sensitive to patients being angry with me. It is also very challenging because you are aware a patient can leave and possibly be in grave danger or be at risk for suicide. Another challenging part, not particular to this role, is countertransference. It is difficult working with patients and witnessing the problems they face.
On occasion, medical providers engage in behavior that can feel hostile, disrespectful or not client-centered, which can present another challenge. This is not always the case, and these issues are dealt with by seeking support in other places and maintaining a client-centered perspective or discussing it with the medical providers. I have faced some challenges balancing how to create boundaries with medical providers who want all of their patients to benefit from social services and needing to protect my time and workload. This has been done through subtle communication where I ask the medical provider questions before taking a referral to try and elicit them to think about what may necessitate a referral to social work. This role is also solitary in the sense I am not around other behavioral health clinicians and often feel a little isolated from other staff members who work amongst similar professional peers. I sometimes miss working among other social workers and value what that kind of team atmosphere offers.
I would recommend that interested MSW students shadow medical social workers and not hesitate to consult with colleagues and supervisors, which is extremely invaluable and necessary for new providers when dealing with all issues. La Clinica has a strong emphasis on consulting with your clinical supervisor, more than I witnessed at UCSF. Clinicians at UCSF would sometimes consult with other clinicians on their service, but at La Clinica I often consult with my clinical supervisor over phone up to five times a day, in addition to weekly individual supervision. Due to the population at La Clinica, there is much more risk, mental illness and need. I have found consulting in crisis to be the most important part of this job.
[OnlineMSWPrograms.com] For social work students who are interested in working in pediatric or medical social work, what advice do you have for them in terms of preparing for this field?
[Gina Pascual, MSW] I would recommend interested MSW students take in-depth assessment courses and courses focused on brief intervention, specifically Motivational Interviewing. The importance of thorough and artful assessments cannot be understated. I would also encourage patients to have a basic understanding of what depression, anxiety, substance abuse and psychotic symptoms look like, as well as how to conduct a thorough suicidality or homicidality safety plan.
Students who are confident and can communicate with medical providers and medical assistants clearly and succinctly will have a much easier time. Medical settings tend to be very fast paced with colleagues who are very busy and have very little time for convoluted messages. I would encourage students to shadow multiple medical social workers in different services. Also, in my experience medical social workers who are very proactive in the medical setting (i.e. seek patients, offer to help with mental health referrals or phone calls or assessments) can help increase trust and perceived value to medical providers. A previous medical social worker supervisor told me that medical social workers need to publicly announce their victories to gain provider confidence. It is something I have learned to do in a way that praises the patient’s behavior and what I have facilitated. I also learned to be very proactive. Having a good relationship with auxiliary staff (reception, medical assistants, facilities) can go a long way and help in patient care, especially when needing to acquire other resources or information.
If students are unable to get professional experience, both UCSF and La Clinica have wonderful volunteer programs that provide a lot of patient contact and professional exposure. Both of these places also provide training to volunteers as well as access to events and opportunities normally only available to internal staff. I also believe that working for agencies like UCSF and La Clinica early in your career is very helpful in sending positive signalling value to future potential employers. I was specifically told that my experience at UCSF during graduate school procured my current job for me (in addition to speaking Spanish). I specifically chose my internship at UCSF for this exact reason, since under normal circumstances, a new graduate would have a very little chance to get a job at UCSF due to the prestige and independent nature of the job.
Thank you Ms. Pascual for your time and insights into medical social work.