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Social Work Direct Practice The Clinical Relationship Chapter Six.

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1 Social Work Direct Practice The Clinical Relationship Chapter Six

2 Direct Practice and Indirect Practice The concept of “direct practice” is used in contrast to and in comparison with the concept of “indirect practice”. These terms reflect deeply held, often opposing, ideological convictions about the profession of social work and its mission. They also reflect ideological assumptions about the causality of personal problems and public issues.

3 Terminological Turmoil Within Direct Practice Ideological differences between direct and indirect practice influence definitions of the worker-client relationship in direct practice. Clinical social workers have been variously described as (1) direct practitioners,(2) case managers, (3) allocators of resources, (4) psychotherapists/counselors, and (5) traitors to the profession.

4 Differential Use of Self in Direct and Indirect Practice Given this ideological disarray, it is important to differentiate the practitioner’s use of self in direct and indirect practice. In direct practice, the use of self (worker-client relationship) is therapeutic. In policy, advocacy, community and management practice, the worker’s use of self (worker-others) is based on leadership. (See chapter seven).

5 Direct Practice: Two Functions Direct practice is differentiated by its two functions: (1) the face-to-face delivery of concrete services (case management) through a worker-client relationship based on belief bonding (2) the delivery of therapy through a worker-client relationship based on a theory-guided therapeutic alliance.

6 Core Values of the Helping Relationship According to Biestek (1957), a professional social work relationship in direct practice is purposeful and is characterized by the values of: (1) acceptance (2) a non-judgmental attitude (3) respect for client self-determination

7 The Helping Relationship Belief Bonding The helping relationship in direct clinical practice is based on belief bonding. The “bond” mirrors the facilitative conditions of an effective relationship- empathy, warmth, acceptance, and actual interest in the client. It is based on an emotional interaction between the help seeker and help giver.

8 The Professional Clinical Relationship The professional clinical relationship in direct practice reflects: (1) the function of the agency, (2) different stages of worker-client engagement (beginnings, middles, ends), (3) different levels of intensity (case management or therapy), and (4) different roles and functions for the worker and client. Not all worker-client interactions in direct practice are considered therapy, however, all worker-client interactions are intended to benefit the client and are therefore therapeutic.

9 Working Relationship A working relationship is defined as the observable ability of the worker and the client to worker together in a realistic, collaborative manner based on a mutually committed belief in the helping relationship. Worker and client bond in the belief that mutually agreed upon activities will bring about changes in the client’s circumstances that will both benefit the client and enhance the client’s self worth.

10 Characteristics of an Effective Helping Relationship Efficacy in the worker-client relationship is based on empathic understanding, non-possessive warmth, unconditional positive regard, congruence, genuineness and authenticity (Truax and Carhuff, 1967). According to Kadushin these characteristics are necessary conditions for effective interviewing. Not all helping interactions need the same level of of relationship intensity.

11 Relationship: A Dynamic for Change Many hold that relationship is, in and of itself, a dynamic for change. Relationship, not theory, matters (Effectiveness studies). Others hold that it is the theory that guides the clinician and the therapeutic intervention that accounts for change i.e. empirically supported treatment (efficacy studies). The role of relationship to clinical outcome success is controversial.

12 Therapy and the Therapeutic Alliance In therapy, relationship depends on the formation of a therapeutic alliance. Therapeutic alliance requires declarative knowledge of specific theories which, through their prescriptions, direct the enactment of a therapeutic process. See chapters 12 and 13. The worker’s use of self in therapeutic alliance is the art of healing.

13 Declarative Knowledge Generic descriptions of the social work relationship cannot tell a clinician how to enact a therapeutic process. Enactment competency relies on the linkage between congruent theories of human behavior (normal and abnormal) and the treatment process. How to do therapy (practice) is linked to content on how humans behave and change (theory).

14 Procedural and Tacit Knowing Procedural knowing consists of declarative knowledge (scientific knowing) Declarative knowledge consist of (1) Theories of cause-effect (if this, then that; explanation) that lead to…. (2)Theories of practice (prediction and intervention (practice theories) Tacit knowing refers to the mastery of procedural knowing in the art of relationship.

15 Does Therapy Work? The Science of Relationship The trend toward evidence-based practice, has renewed interest in therapy outcome and the therapeutic process. Outcome studies (does it work?) benefit clients when clinicians use best practices. Process studies (how it works) benefit educators by driving curriculum and optimizing training. Comparative studies (which therapy works best) legitimizes therapy choice, especially in a managed care environment.

16 The Science of Therapy Meta Analysis and Effect Sizes Early efforts to prove that psychotherapy worked concluded that there was no evidence that psychotherapy was more effective than no treatment at all (Eysenck, 1952). Currently, meta analytic approaches, (based on design rigor) are used to determine whether therapy works. As a research statistical technique, meta-analysis pools results from multiple studies and calculates an effect size across studies.

17 Meta Analysis –Continued Systematic Reviews Meta analyses may include efficacy studies only or both efficacy and effectiveness studies. Meta analyses requires skill in conducting a systematic review of the literature i.e. rigorous, well-conducted studies on a focal topic must be located. The researcher must document a study’s inclusion or exclusion in the analysis. An effect size across studies is create a larger standardized statistical measure of change.

18 Efficacy Studies Promote scientific and design rigor Participants are randomly assigned to different treatments and to control groups Treatment is standardized and clinicians are trained to deliver the intervention according to manual protocol. Standardized pre and post test measures are administered by blind raters.

19 Efficacy Studies-Continued Measures are specific to the defined treatment goals ( i.e. not generalized measures of overall improvement). Efficacy-based outcome studies are concerned with therapeutic process because replication requires standardization of process. When clinician interaction is controlled by study design (treatment protocol/manual), greater confidence can be placed in the conclusion that the outcome is attributable to a specific theory.

20 Effectiveness Studies In contrast, effectiveness studies allow for greater clinician spontaneity and flexibility (less standardization) in therapeutic process. Effectiveness studies allow a more expansive definition of change and outcome success. (generalized measures). Effectiveness studies are more aligned with the complexities encountered in real practice and are self-correcting

21 Does Therapy Work? The Empirical Evidence According to numerous meta-analytic studies, therapy does work better than no treatment. Therapy works for adults, adolescents, and children. Studies have focused on anxiety and depression. Meta analyses continue to provide evidence about what works, how it works, for whom, and at what cost.

22 Is One Therapy Better Than Another? Luborsky (1975;1997;2002) found that many treatments work- therefore “other things” or “common factors” must account for outcome differences. Other factors that influence outcome are: (1) chance, (2) expectancy, (3) placebo effect, (4) variability in clinician expertise, (5) client factors, (6) severity of the problem being treated. Few studies to date provide enduring evidence that one therapy is better than another (Drisko, 2004).

23 Other Factors that Influence Therapy Outcome Chance Individuals get better just by chance. Expectancy Individuals get better because they have sought help and expect that the helping process will lead to positive change. Placebo Individuals get better no matter what treatment is used as long as they perceive something is being done that may help.

24 Evidence for Empirically Supported Treatments Empirically supported treatments (manuals) are supported both by the American Psychological Association task force on the promotion and dissemination of psychological procedures and by the American Psychiatric Association. Research on the use of treatment manuals have repeatedly concluded that their use leads to more positive outcomes than does therapy without such manuals. The science behind EST’s serves as an antidote to ideological-based models and preferences.

25 Arguments Against Empirically Supported Treatments Arguments against EST’s cluster around practitioner variability as a dynamic, in and of itself, in the art of healing i.e.the master clinician versus the novice clinician. Clinicians fear that rigid protocols will underutilize therapist expertise and oversimplify the complexity with which clients present. Few EST protocols deal with V codes, personality disorders, co-morbidity, and differences in problem severity at the onset of treatment.

26 Clinical Social Work Statistics Federal statistics indicate that clinical social workers provide more mental health services (a large proportion of which is psychotherapy) than do professionals from other disciplines combined (Drisko, 2004).

27 Summary Clinical social workers do not reject social causality. They recognize that the day-to-day survival of individuals often cannot wait for social change to occur; therefore they deliver concrete services and assure client safety according to existing policies and programs. They recognize that sometimes more than a timely injection of resources is needed and they combine material resources with supportive counseling.

28 Summary-Continued They recognize that external events and interpersonal relationships can traumatize, therefore they offer individual, couple, family and group therapy through a theory-guided therapeutic alliance. Committed to open assessment, multi-causality, and evidence-based decision making, social work promotes best practices by allowing the practitioner flexibility and competency in theory and method choice.

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