Clinical I DB. Week 2

Clinical Social Work Journal Vol. 24, No. i, Spring 1996

C S W J F O R U M

WHAT I S C L I N I C A L S O C I A L WORK? L O O K I N G B A C K TO M O V E A H E A D

Eda G. Goldstein, DSW

ABSTRACT:. This paper traces the evolution of the concept of clinical social work and looks at where we are and where we are headed as clinical social work- ers. It reaffirms the view that clinical social workers intervene with clients pre- senting the full range of problems in a variety of facilities and in private practice and must draw on a broad knowledge base within a person-situation perspective and address the special needs of culturally diverse and oppressed populations. The paper also considers the move toward legal regulation, the role of private practice, the need for clinical doctoral education, the importance of new models for clinical research, and the significance of advocacy for a broad range of services to clients.

K E Y WORDS: clinical social work; direct practice.

W h i l e t h e t e r m "clinical social w o r k " e n t e r e d o u r p r o f e s s i o n a l lan- g u a g e i n t h e l a t e 1960s a n d e a r l y 1970s, its definition still e l u d e s con- s e n s u s . C o n c e i v e d in c o n t r o v e r s y a n d d e d i c a t e d to t h e "people-helping" r a t h e r t h a n "society-changing" pole o f social work's d u a l m i s s i o n (Gold- stein, 1980), i t connotes different t h i n g s to d i f f e r e n t people a n d con- t i n u e s to a r o u s e o f t e n p a s s i o n a t e d e b a t e , i f n o t o u t r i g h t a n t a g o n i s m ( S p e c h t & C o u r t n e y , 1994; Walz & Groze, 1991). M u c h t i m e h a s p a s s e d since clinical social work's infancy a n d o u r society a n d profession h a v e w i t n e s s e d s t a g g e r i n g changes. As w e a p p r o a c h t h e 2 1 s t c e n t u r y , i t s e e m s t i m e l y to r e v i e w w h e r e we h a v e b e e n , w h o a n d w h e r e w e are, a n d w h e r e w e a r e h e a d e d as clinical social w o r k e r s .

T H E B E G I N N I N G S O F C L I N I C A L S O C I A L W O R K

D u r i n g t h e K e n n e d y - J o h n s o n p r e s i d e n c i e s society t u r n e d its a t t e n - tion to e r a d i c a t i n g social p r o b l e m s t h r o u g h t h e m o u n t i n g of l a r g e - s c a l e

89 �9 1996 Human Sciences Press, Inc.

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federal p r o g r a m s . P r i o r to this period, casework, which relied heavily on F r e u d i a n t h e o r y a n d ego psychology for its knowledge base, d o m i n a t e d t h e social w o r k a r e n a a l t h o u g h family a n d group modalities also were utilized extensively. D u r i n g t h e 1960s, however, t h e social w o r k profes- sion i t s e l f t u r n e d its a t t e n t i o n away from individual, family, a n d group t r e a t m e n t to c o m m u n i t y organization, social p r o g r a m a n d policy design, and social action. This change h a d m a n y ramifications: service delivery c h a n g e d dramatically; caseworkers a n d others in direct practice lost sta- tus; m a n y schools of social work r e d u c e d t h e a m o u n t of c u r r i c u l u m space allocated to p e r s o n a l i t y t h e o r y a n d "microsystems" i n t e r v e n t i o n in favor of social science, organizational, a n d social change t h e o r i e s a n d "macrosystems" i n t e r v e n t i o n ; crisis a n d s h o r t - t e r m i n t e r v e n t i o n took hold; social w o r k u n d e r g r a d u a t e p r o g r a m s proliferated r e s u l t i n g in large n u m b e r s of B.S.W. t r a i n e d individuals e n t e r i n g t h e field; a n d so- cial w o r k doctoral p r o g r a m s increasingly e m p h a s i z e d a d m i n i s t r a t i o n , social policy a n d p l a n n i n g , a n d r e s e a r c h r a t h e r t h a n direct practice (Goldstein, 1995; S t r e a n , 1993).

T h e Civil Rights m o v e m e n t , feminism, a n d s o m e w h a t later, t h e gay liberation m o v e m e n t c o n t r i b u t e d to a n anti-labeling a n d a n t i - t r e a t m e n t a t m o s p h e r e . T h e r e was w i d e s p r e a d criticism of t h e medical model. Sup- p o r t e r s of i n d i v i d u a l t r e a t m e n t were accused of being a g e n t s of social control a n d were a t t a c k e d for '~blaming t h e victim" r a t h e r t h a n t h e ef- fects of oppression, poverty, a n d t r a u m a a n d for "pathologizing" t h e be- havior of w o m e n , gays a n d lesbians, a n d o t h e r culturally diverse per- sons r a t h e r t h a n r e s p e c t i n g t h e i r u n i q u e characteristics a n d s t r e n g t h s .

D i s c o u r a g i n g r e s e a r c h findings on casework's effectiveness also di- m i n i s h e d t h e d o m i n a n c e of direct practice (Mullen, D u m p s o n , & Associ- ates, 1972; Fischer, 1976). M a n y called for m o r e s y s t e m a t i c outcome s t u d i e s a n d different ways of a d d r e s s i n g t h e i n t e g r a t i o n of r e s e a r c h a n d practice. Some r e s e a r c h e r s even advocated d i s r e g a r d i n g t h e o r y as a guide t o practice a l t o g e t h e r in favor of i n t e r v e n t i o n s derived from empir- ical s t u d i e s (Bloom, 1983; Blythe & Briar, 1985; F i s c h e r & H u d s o n , 1983; Levy, 1983; Mullen, 1983; Reid, 1983).

N o t all of t h e s e d e v e l o p m e n t s were g r e e t e d enthusiastically. L a r g e n u m b e r s of social w o r k practitioners felt t h a t clients' p r o b l e m s w e r e be- ing viewed simplistically as a function of social a n d e n v i r o n m e n t a l fac- tors solely a n d t h a t t h e y were being deprived of n e e d e d individualized services; t h a t t h e poor were b e i n g viewed as if t h e y lacked p e r s o n a l psy- c h o d y n a m i c s a n d variable coping m e c h a n i s m s ; t h a t social w o r k s t u d e n t s were n o t b e i n g e q u i p p e d w i t h t h e full knowledge base a n d skills neces- s a r y to h e l p t h e i r clients, particularly t h o s e showing m o r e severe coping difficulties; t h a t practice s t a n d a r d s were eroding; t h a t social w o r k was b e c o m i n g deprofessionalized; a n d t h a t t r e a t m e n t models a n d i n t e r v e n - tions t h a t w e r e t h e easiest to operationalize a n d m e a s u r e b u t n o t neces-

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sarily t h e best w e r e being promulgated. Many felt abandoned by NASW, ignored by professional journals, and alienated from t h e profession gen- erally (Frank, 1980, p. 16).

In t h e late 1960s, social workers began to organize to reverse the tide. Dismayed about t h e i r place within the profession, m a n y w e r e also concerned about their acceptance by the larger community as qualified clinicians, along with psychologists and psychiatrists. They became ac- tive in efforts to promote direct practice, to establish h i g h e r s t a n d a r d s and professional credentials, and to achieve legal regulation for private practice. An early formal use of the t e r m clinical can be found in a 1968 California licensing s t a t u t e (Waldfogel & Rosenblatt, 1983, p. xxv).

In 1971, g r o u p s of practitioners in various geographic areas, partic- ularly New York a n d California initiallyl were i n s t r u m e n t a l in t h e for- mation of a new professional organization, t h e Federation of Societies for Clinical Social Work, t h a t had different aims from t h e broader-based National Association of Social Workers. The Clinical Social Work Jour- nal was initiated one y e a r later in 1972. A vocal n u m b e r of the Federa- tion's leadership saw themselves as psychotherapists a n d psychoana- lysts, some h a v i n g u n d e r t a k e n advanced t r a i n i n g in psychoanalytic institutes, and w e r e interested in the advancement a n d protection of private practice (personal communication with Helen Krackow, Presi- dent the New York State Chapter of the Society for Clinical Social Work- ers, New York, New York, April 19, 1995). The stated aim of t h e Federa- tion, however, was to establish standards for direct-service practitioners, to m e e t t h e needs of practitioners and consumers of direct practice, and thereby to correct for the perceived lack of attention to direct practice on the p a r t of t h e l a r g e r profession (Strean, 1993, p. 15).

WHAT'S IN A NAME?

As n u m e r o u s authors have pointed out, the word "clinical" itself was heavily l a d e n with meanings t h a t aroused mixed, if not negative sentiments. Its original m e a n i n g connoted t h e t r e a t m e n t of disease or "medical t r e a t m e n t at sickbed" (Waldfogel & Rosenblatt, 1983, p. xxvi). Many social workers both inside and outside of the Federation equated clinical social work with psychodynamically-oriented casework and psy- chotherapy aimed at promoting a person's internal resources, a n effort to promote private practice, and an attempt on t h e p a r t of a segment of t h e profession to achieve greater status by setting themselves a p a r t from the rest as t h e y viewed "psychiatric" social workers as doing previ- ously (Frank, 1980, pp. 14-15). Consequently, broader-based social work practitioners a n d academics raised questions about the appropriateness of both t h e t e r m and the concept, viewing it as too connected to the

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medical model, narrow in scope, elitist, and ill-suited to a profession whose mission it was to address the concerns of poor a n d oppressed pop- ulations.

In other helping professions, however, the t e r m "clinical" referred to "hands-on" care and aptly captured the spirit of direct practice defined more broadly. Moreover, it portrayed social work practitioners as shar- ing certain similarities with other m e n t a l h e a l t h clinicians, an advan- tage with respect to social workers' quest for acceptance of their compe- tence to provide therapeutic services. Moreover, it lent itself to a more contemporary conception of direct practice t h a t was not wedded to indi- vidual t r e a t m e n t b u t instead embraced a range of t r e a t m e n t modalities. Some saw t h e need for the term, however problematic, as b r o u g h t about by t h e emergence of new knowledge bases, the expansion of the unit of a t t e n t i o n to encompass individuals, families, a n d groups, r e n e w e d inter- est in work with t h e social environment, and t h e need to establish an empirical base for practice (Waldfogel & Rosenblatt, 1983, p. xxvii).

Thus, to m a n y in t h e profession, clinical social work t r a n s c e n d e d a narrow definition as a psychotherapeutic specialization a n d became more of a n umbrella t e r m - - a n o t h e r n a m e for social work t r e a t m e n t , direct practice, or "microsystems" intervention t h a t draws on a n expand- ing a n d diverse knowledge base, encompasses a broad range of tradi- tional a n d emerging practice models and roles, and spans both agency and private practice.

Despite w h a t appeared to m a n y practitioners as its lack of attention to t h e needs of clinical social workers, NASW surprisingly and some- w h a t controversially moved to recognize and establish s t a n d a r d s for clinical social work by issuing a Registry of Clinical Social Work in 1976. Embodying a broad conception of clinical social work, it defined clinical social workers as those who '%y education and e x p e r i e n c e . . , were qual- ified a t t h e autonomous practice level to provide direct, diagnostic, pre- ventive, and t r e a t m e n t services to individuals, families, a n d groups where functioning is t h r e a t e n e d or affected by social and psychological stress or i m p a i r m e n t (Registry of Clinical Social Workers, 1976, p. xi). Clinical social work services could be provided in private practice or in public, voluntary, or proprietary settings. Those MSW social workers who h a d completed two years of supervised experience or its equivalent in providing clinical social work services could apply for listing in t h e Register.

I n 1978, NASW formed a Task Force on Clinical Social Work, as a response to t h e pressing needs of practitioners, m a n y of whom were un- comfortable about t h e "split" in t h e professional organizations. Its report along with n u m e r o u s papers t h a t were presented at t h e National Invita- tional F o r u m on Clinical Social Work in June, 1979 (Ewalt, 1980) de- fined clinical social work broadly. Attempting to convey t h a t clinical so-

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cial w o r k h a d a central core t h a t was consistent w i t h t h e values a n d goals of t h e social work profession, it reaffirmed its p e r s o n - s i t u a t i o n per- spective, its concern w i t h t h e social as well as personal context, its bio- psychosocial a s s e s s m e n t lens, its inclusion of a r a n g e of a p p r o a c h e s e n c o m p a s s i n g w o r k w i t h i n d i v i d u a l s a n d e n v i r o n m e n t s , its b r o a d knowl- edge base, its u s e i n both p r i v a t e practice a n d a h o s t of agency settings, its a c k n o w l e d g e m e n t of p s y c h o t h e r a p y as a p a r t b u t n o t t h e whole of t h e i n t e r v e n t i o n process, a n d its reliance on i n t e r v e n t i o n s w i t h people di- rectly or t h e social s i t u a t i o n (Cohen, 1980, pp. 23-32). T h e Handbook of Clinical Social Work (Waldfogel & Rosenblatt, 1983) also embodied t h i s inclusive definition a n d its principles have been m a i n t a i n e d i n l a t e r more specific definitions.

I f t h e e q u a t i o n of clinical social work wi.'th psychodynamically ori- e n t e d p s y c h o t h e r a p y a n d private practice was viewed as too n a r r o w a n d elitist by m a n y m e m b e r s of t h e profession, t h e b r o a d e r use of t h e t e r m was criticized for being too all-inclusive. I t raised questions a b o u t w h e t h e r t h e r e are any b o u n d a r i e s to clinical social w o r k a n d w h e t h e r i t reflects a u n i q u e core of values, knowledge, a n d skill.

E F F O R T S AT A U N I F Y I N G CONCEPTION OF SOCIAL WORK PRACTICE

U n h a p p y w i t h t h e t r a d i t i o n a l polarization in t h e profession b e t w e e n direct practice a n d social change a n d a t t e m p t i n g to p u t forth a distinc- tive a n d u n i f y i n g conception of sociai work practice, a n u m b e r of a u t h o r s proposed t h a t general s y s t e m s t h e o r y become a n overarching f r a m e w o r k (Bartlett, 1970; Gordon, 1969, pp. 5-11). G e r m a i n (1979) a n d l a t e r Ger- m a i n & G i t t e r m a n (1980) developed t h e ecological perspective or life model t h a t is a broad, systemic conceptualization of practice. The propo- n e n t s of t h i s approach a t t e m p t e d to correct for w h a t t h e y perceived as clinical social work's c o n t i n u i n g reliance on psychodynamic t h e o r y a n d p s y c h o t h e r a p y a n d lip-service a t t e n t i o n to a p e r s o n - s i t u a t i o n perspec- tive. It e m p h a s i z e s p e r s o n - e n v i r o n m e n t a l t r a n s a c t i o n s a n d w o r k i n g a t t h e interface b e t w e e n people a n d e n v i r o n m e n t s . The life model e m p h a - sizes a s t r e n g t h s r a t h e r t h a n pathology orientation, focuses on h e l p i n g clients w i t h problems in living r a t h e r t h a n t h e i r disorders or illness, a n d is m o r e t r a n s a c t i o n a l a n d e n v i r o n m e n t a l l y oriented t h a n t h e r a p e u t i - cally o r i e n t e d i n its choice of i n t e r v e n t i o n s , including a n e m p h a s i s on organizational a n d social change. Thus, it encompasses both micro- a n d m a c r o s y s t e m s foci. While, in principle, ecosystems t h e o r y can include b o t h i n - d e p t h a n d i n - b r e a d t h knowledge of a n d i n t e r v e n t i o n s w i t h peo- ple a n d e n v i r o n m e n t s , its followers h a v e t e n d e d to m i n i m i z e t h e impor- t a n c e of m o r e dynamically o r i e n t e d individual, family, a n d group theo-

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ries a n d therapeutically oriented t r e a t m e n t . Thus, a variation or continuation of the longstanding controversy about w h e t h e r t h e social work profession should emphasize "people-helping" or "society-chang- ing" r e a s s e r t e d itself. This division can be described as clinical vs. eco- systems or clinical vs. traditional or "real" social work.

While initially it was more of a perspective t h a n an intervention model a n d m a n y of its principles were difficult to operationalize, t h e ecological perspective h a s developed extensively in its application and has achieved considerable popularity among broad-based practitioners and academics. A well-known social work theoretician proclaimed t h a t t h e "ecological systems perspective has evolved into a basic conceptual framework for our practice theories as well as for our behavior theories �9 . . a n d we now have a viable, highly useful, and basic paradigm for social work, as well as for clinical practice (Siporin, 1985, pp. 200-01). Despite this positive appraisal, the ecological framework still lacks ap- peal to certain segments of the direct practice community who argue t h a t it negates t h e importance of personality theory and more severe psychopathology and has contributed to t h e dilution of this content in social work educational programs, t h a t it does not equip workers with a n in-depth knowledge base of w h a t occurs within r a t h e r t h a n across a v a r i e t y of systems, a n d t h a t its focus on working at t h e interface be- tween people and environments does not encompass certain types of necessary intervention skills.

THE RESURGENCE OF DIRECT PRACTICE

Direct practice r e a s s e r t e d its importance during t h e 1970s and 1980s for n u m e r o u s reasons. General disillusionment in government was prevalent as a consequence of political assassinations, t h e struggle over a n d failure of the Vietnam War, a n d disappointment in t h e results of the G r e a t Society programs aimed a t wiping out poverty. The prevail- ing political philosophy became increasingly more conservative as t h e government did not believe its role was to bear responsibility to help those who were economically disadvantaged. Social work professionals were among those who felt powerless about creating and m a i n t a i n i n g responsive social programs and policies as services to the poor were cut back (Goldstein, 1995, p. 43).

Concurrently, t h e awareness of the pressing needs of clients for in- dividualized services led to renewed attention to microsystems interven- tion a n d g e n e r a t e d creative approaches in work with special popula- tions. More traditional theories were refined a n d extended a n d new frameworks a n d intervention models emerged. For example, m a n y psy- chodynamically oriented clinicians moved away from an exclusive re-

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liance on classical psychoanalytic psychology a n d e m b r a c e d t h e n e w e r d e v e l o p m e n t s in ego psychology, object relations theory, a n d self psy- chology w h i c h are more i n t e r p e r s o n a l a n d t r a n s a c t i o n a l in n a t u r e ; cou- ple a n d family theories exploded; t h e c o g n i t i v e / b e h a v i o r a l a p p r o a c h g a t h e r e d m o r e a d h e r e n t s ; crisis i n t e r v e n t i o n , task-centered, a n d o t h e r s h o r t - t e r m models became prevalent; m o r e affirmative a n d e m p o w e r i n g models for w o r k w i t h women, people of color, a n d gays a n d lesbians were p u t forth; empirically based practice models were advocated; practi- tioners b e g a n to e x p e r i m e n t with hypnosis, biofeedback, g e s t a l t tech- niques, a n d o t h e r n e w e r forms of i n t e r v e n t i o n . A p o p u l a r social work t e x t cites over t w e n t y different f r a m e w o r k s for practice a n d does not include some of those which have developed since (Turner, 1986). For example, some clinical social workers h a v e i n t e g r a t e d more s p i r i t u a l l y o r i e n t e d approaches into t h e i r work a n d n e w e r models such as t h e nar- r a t i v e a n d social constructionist approaches have emerged, b o t h of w h i c h t a k e a radically different stance t h a n do t r a d i t i o n a l psycho- d y n a m i c frameworks.

D u r i n g t h e h e i g h t of this e x p e r i m e n t a t i o n , one a u t h o r n o t e d t h a t to s o m e it s e e m e d as if clinical social work t h e o r y was in d i s a r r a y a n d t h a t t h e climate r e p r e s e n t e d "an effort to a c c u m u l a t e n e w techniques, piling t h e n e w u p o n t h e old, in a wild k i n d of eccleticism t h a t gives t h e appear- ance of t h o u g h t l e s s ignorance a n d inconsistent, illogical self-contradic- tions" (Siporin, 1979, p. 76). He goes on to say, however, t h a t this be- havior reflected a positive a n d constructive a t t e m p t a t acquiring n e w knowledge, techniques, a n d self-development as h e l p i n g persons (p. 76) a n d in a l a t e r paper, proclaimed t h e h e a l t h of clinical social work t h e o r y a n d practice, i n all its diversity, as good a n d of p r o v e n effectiveness a n d s a w a r a p p r o c h e m e n t growing between practice a n d research (Siporin, 1985, pp. 198-99).

CLINICAL SOCIAL WORK TODAY

Clinical social workers comprise t h e l a r g e s t proportion o f social w o r k e r s i n t h e country. A m o n g NASW m e m b e r s , 70 p e r c e n t of master's- level a n d 40 p e r c e n t of doctoral-level workers describe direct services as t h e i r p r i m a r y function. The proportion of s t u d e n t s who indicate direct practice or clinical practice as t h e i r p r i m a r y field of i n t e r e s t h a s in- creased. T h e r e are approximately 10,000 m e m b e r s of t h e National Fed- e r a t i o n of Societies of Clinical Work a n d a b o u t 20,000 clinical social w o r k e r s hold Diplomates e i t h e r t h r o u g h NASW or t h e A m e r i c a n Board of E x a m i n e r s (Swenson, 1995: 504). For t h e first time, clinical social w o r k h a d its own e n t r y in t h e 19th Edition of t h e Encyclopedia of Social Work (1995, pp. 502-12).

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Clinical social workers intervene with clients presenting t h e full range of problems in a variety of facilities and in private practice, for example, Vietnam veterans, persons with AIDS a n d their families, sur- vivors of physical a n d sexual abuse and other types of t r a u m a , those w i t h m e n t a l illness and less severe forms of emotional disorder, sub- stance abusers, victims and perpetrators of domestic violence, rape and other violent crimes, those with physical illness and disability, family problems, or normative life cycle and situational crises. Likewise, clini- cal social workers integrated, albeit slowly, theory a n d practices t h a t address t h e special needs of culturally diverse a n d oppressed popula- tions. Based on their work w i t h these populations, clinical social work- ers grasped t h e importance of utilizing individual, family, and group modalities a n d a full range of direct practice interventions and roles including case m a n a g e m e n t , educational and support groups, linkage to e n v i r o n m e n t a l resources, client-centered advocacy, and other types of e n v i r o n m e n t a l interventions.

The broadened theoretical t h r u s t of clinical social workers was evi- d e n t in a national study of experienced clinicians d r a w n from a 1982 Register of Clinical Social Workers. While the majority of respondents still identified ego psychology as guiding their approach, socio-cultural, cognitive/behavioral, a n d family systems theories h a d i m p o r t a n t second- ary influence. Further, "these clinical social workers did not adopt a uni- dimensionsal stance in choosing theories of h u m a n behavior upon which to ground t h e i r u n d e r s t a n d i n g of c l i e n t s . . , the average n u m b e r of theo- ries identified as having a significant role in one's theoretical perspec- tive was g r e a t e r t h a n two" (Mackey, Burek, and Charkoudian, 1987, p. 372). A more recent study of private practitioners d r a w n from t h e 1991 NASW Register of Clinical Social Workers found t h a t respondents said t h e y utilized 4.2 theoretical bases in their work. "Psychodynamic or psy- choanalytic theory was reported used by 83 percent of t h e respondents, systemic by 53 percent, a n d cognitive/behavioral by 62 percent" (Strom, 1994, p. 80-81). The results also indicated t h a t task-centered a n d cogni- tive/behavioral approaches were gaining ground.

The American Board of Examiners in Clinical Social Work, which issues t h e Board Certified Diplomate, recognized clinical social work's e n l a r g e d focus, defining it "as a form of social work grounded in t h e overall mission, values, ethics, a n d principles of t h e social work profes- sion" a n d consisting of "direct client intervention, client-centered clinical supervision, a n d client-centered consultation," where direct client inter- ventions "include b u t are not limited to, differential diagnosis, crisis in- tervention, brief and extended psychotherapy, case m a n a g e m e n t , a n d client-centered advocacy. ~ I t also views clinical social work as encom- passing "a wide r a n g e of client diversity associated w i t h race, culture, socioeconomic status, gender, sexual orientation, age, a n d physical chal- lenges (American Board of Examiners, 1995, pp. iv-v).

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THE GROWTH OF PRIVATE PRACTICE

If clinical social work encompasses a broad range of intervention models and roles, a diverse knowledge base, and both facility-based and private practice, why is there a lingering perception of clinical social workers as narrow, elitist, and sometimes misguided practitioners who have flocked to private practice, abandoned their commitment to the values of the profession, and disidentified with the social work profes- sion altogether? No doubt this perception is promulgated and fueled, in part, by a combination of legitimate philosophical differences about the social work profession's mission, deep-seated beliefs about the legitimate goals and locus of intervention, and sometimes outright distortions re- garding the motivations of clinical social workers, the objectives and scope of their practice, and the nature of the clientele that they serve (Specht & Courtney, 1993). Nevertheless, clinical social workers them- selves have contributed to this extreme view in various ways.

Concurrent with the resurgence of direct practice in the 1970s and 1980s and clinical social work's extension and application to a range of special problems and special populations, increasing numbers of social workers entered private practice. This resulted from a variety of factors: 1) a general climate which stressed the unbridled pursuit of financial gain; 2) the attack on people who were poor and on public services; 3) the increasing business ethos in agency settings, budgetary and service constraints, and regulatory and other paperwork demands that created administrative burdens on workers, lessened their autonomy, dimin- ished the time available to spend with clients, and lessened the quality and availability of services; 4) the absence of career ladders and finan- cial rewards for direct practice social workers in agencies; 5) the move toward privatization of services in which agencies and independent pro- viders competed for contracts to deliver services; 6) the demand for and ability to pay for services on the part of the middle class; and 7) a de- crease in the numbers of applicants to social work programs who were interested in working with the poor and who wanted to become thera- pists.

By the early 1990s, 63 percent of NASW members reported that they were in private practice although more than 30 percent indicated that they saw clients 10 or fewer hours a week (Swenson, 1995, p. 507). Some studies show that those in private practice generally are serving clients who come from the middle class (Brown, 1990; Strom, 1994). Fur- ther, private practitioners do seem to differ substantially from non-pri- vate practice practitioners in their value systems, m a i n activities, and identifications w i t h the social work profession (Brown, 1990; Perlman, 1994; Seiz & Schwab, 1992; Strom, 1994). Regrettably t h e r e are those who do seem to disassociate themselves from a n d abandon their identi- fication w i t h t h e profession (Perlman, 1994).

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D e s p i t e t h e increase in t h e percentage of social w o r k p r a c t i t i o n e r s in p r i v a t e practice, however, m o s t who are so e n g a g e d do so on a part- t i m e r a t h e r t h a n full-time basis a n d continue to be identified w i t h social w o r k as a profession. According to one study, social w o r k e r s e n t e r e d p r i v a t e practice a n average of 10 y e a r s after receiving t h e i r MSW~s a n d t h e m a j o r i t y w e r e employed i n a n o t h e r social w o r k position concurrently (Brown, 1990). F u r t h e r , t h o s e in private practice are n o t uniform. T h e r e are t h o s e i n d i v i d u a l s who engage in advocacy a n d o t h e r forms of social a n d political action. One s t u d y clearly i n d i c a t e d t h a t "combination work- e r s " m t h o s e who work in b o t h agency a n d p r i v a t e p r a c t i c e - - o c c u p y a m i d d l e position w i t h respect to t h e i r values. "Combination p r a c t i t i o n e r s v a l u e job security, h a v i n g peer support, h e l p i n g t h e poor a n d p r o m o t i n g social j u s t i c e t h r o u g h social c h a n g e significantly m o r e t h a n do p r i v a t e p r a c t i t i o n e r s only. This m a y explain in p a r t w h y t h e y r e m a i n employed in a n agency w h e r e t h e s e values can be met" (Seiz & Schwab, 1992, p. 332).

T h u s , t h e v a s t m a j o r i t y of clinical social w o r k e r s are employed in social agencies w h e r e clinical knowledge a n d skills, broadly defined, as well as advocacy a n d linkage to necessary resources are n e c e s s a r y to help clients. F u r t h e r , even w o r k i n g in p r i v a t e practice w i t h m i d d l e class clients exclusively does not, in itself, d e t e r m i n e t h e focus of interven- tion. Middle class clients are not i m m u n e from physical a n d m e n t a l ill- n e s s a n d disability, u n e m p l o y m e n t , s u b s t a n c e abuse, h a v i n g to place p a r e n t s i n n u r s i n g homes, a n d o t h e r problems t h a t n e c e s s i t a t e involve- m e n t s w i t h organizational s t r u c t u r e s a n d e n v i r o n m e n t a l resources.

While some h a v e s u g g e s t e d t h a t t h e values a n d i n t e r e s t s of social w o r k s t u d e n t s are i n c o n s i s t e n t w i t h t r a d i t i o n a l l y defined concepts of so- cial w o r k identify (Bogo, Raphael, & Roberts, 1993), a n a t i o n a l s t u d y of g r a d u a t e social w o r k s t u d e n t s shows t h a t t h e beliefs a b o u t " s t u d e n t s flight from t r a d i t i o n a l social work values into e n t r e p r e n e u r i a l , p r i v a t e practice o r i e n t a t i o n s h a v e been overestimated." I t p r e s e n t s evidence t h a t " s t u d e n t s , now as in t h e past, are p r e d o m i n a n t l y e n t e r i n g social w o r k to advance t h e i r professional skills a n d p o t e n t i a l a n d are highly c o m m i t t e d to t h e concept of i n v o l v e m e n t w i t h t h e d i s a d v a n t a g e d " (Abell & McDonnell, 1990, pp. 63-64).

LEGAL REGULATION

While t h e profession established practice s t a n d a r d s a n d a v a r i e t y of credentials, t h e F e d e r a l g o v e r n m e n t , p r i v a t e i n s u r a n c e companies, a n d t h e m a n a g e d care i n d u s t r y h a v e looked to legal r e g u l a t i o n increasingly as t h e s t a n d a r d by w h i c h providers are recognized as c o m p e t e n t a n d eligible for financial r e i m b u r s e m e n t . Certification offers title protection;

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licensing e s t a b l i s h e s who can do what; a n d v e n d o r s h i p allows one to qualify for t h i r d p a r t y p a y m e n t . The F e d e r a t i o n of Societies for Clinical Social Work, often in collaboration w i t h NASW a n d o t h e r groups led t h e fight for licensing a n d vendorship. While t h e forms of legal regulation, titles, a n d scopes o f practice differ from s t a t e to state, all s t a t e s a n d t h e District of C o l u m b i a h a d some form of licensing by 1993 (Biggerstaff, 1995, p. 1518).

U n f o r t u n a t e l y , n o t all of t h e licensing s t a t u t e s are equally protec- tive a n d p r a c t i t i o n e r s in some s t a t e s are n o t able to compete effectively in t h e m a n a g e d care arena. A majority of t h e states h a v e m u l t i - l e v e l licensing w i t h licensed clinical social work being t h e m o s t a d v a n c e d level w i t h special r e q u i r e m e n t s for supervised experience a n d o t h e r qualifying criteria. Some h a v e criticized t h i s move as c r e a t i n g a clinical social w o r k specialization t h a t is elitist a n d divides t h e profession while others a r g u e t h a t t h e educational a n d experience s t a n d a r d s for autono- m o u s a n d clinical social work practice should be even stronger. A fact t h a t often is overlooked is t h a t legal r e g u l a t i o n n o t only h a s e n a b l e d social work p r i v a t e practitioners to achieve m o r e recognition a n d p a r i t y w i t h o t h e r m e n t a l h e a l t h professionals, it also h a s b e n e f i t t e d c o n s u m e r s a n d social w o r k p r a c t i t i o n e r s in agencies across the board by establish- ing s t a n d a r d s a n d clearly defined titles a n d scopes of practice.

INCREASING SPECIALIZATION AND THE CLINICAL SOCIAL WORK IDENTITY

F r o m t h e 1970s to t h e present, questions about t h e scope a n d b o u n d a r i e s of clinical social work have continued. The a b u n d a n c e of in- t e r v e n t i o n models a n d varied i n t e r e s t s h a s led to a n exciting a r r a y of t r e a t m e n t models a n d techniques b u t also to incre~Ising specialization a n d professional f r a g m e n t a t i o n . T h e r e is considerable controversy a b o u t w h e t h e r c e r t a i n approaches are consistent w i t h social w o r k practice a n d about t h e knowledge a n d skills t h a t constitute its core. For example, i f t h e p e r s o n - s i t u a t i o n perspective is essential to guiding clinical social work a s s e s s m e n t a n d intervention, are psychoanalysis, hypnosis, bio- feedback, cognitive/behavior therapies, a n d certain schools o f couple, family, a n d group t h e r a p y , a legitimate p a r t of clinical social work, par- ticularly w h e n t h e y are utilized by practitioners who identify m o r e w i t h m e m b e r s of t h e i r p a r t i c u l a r specialty, regardless of t h e i r professional discipline, t h a n w i t h social workers generally?

The n a t u r e of t h e r a n g e of complex problems t h a t clients p r e s e n t requires no less t h a n t h a t we d r a w u p o n diverse conceptual f r a m e w o r k s a n d t r e a t m e n t strategies i n t h e process of our work w h e t h e r we practice in p r i v a t e or facility-based settings. No theory or i n t e r v e n t i o n m o d e l has

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proven itself to be useful in all or most circumstances. We cannot r e t u r n to a reliance on those psychodynamic or other theories t h a t conceptually isolate people from their interpersonal relationships or environment or psychotherapeutic models exclusively but we also cannot disregard cli- ents' difficulties in coping t h a t stem from i m p a i r m e n t s or deficits in their i n n e r capacities and their need for more supportive a n d intensive individual, family, and group t r e a t m e n t . A person-situation perspective r e m a i n s central to a clinical social worker's assessment lens. While some of t h e t r e a t m e n t models t h a t are being used m a y focus more on t h e person t h a n on t h e environment or t h e linkage between them, it is natu- ral t h a t different clients will require different approaches. Nevertheless, the choice of intervention should be based on our a s s e s s m e n t of w h a t the client needs r a t h e r t h a n our favorite t r e a t m e n t model. The view t h a t psychotherapy is aimed self-understanding or self-actualization r a t h e r t h a n or in addition to helping clients cope more effectively represents a gross m i s u n d e r s t a n d i n g of the t r e a t m e n t process (Specht & Courtney, 1984). In t h e wake of m a n a g e d care and the c u r r e n t widespread govern- m e n t a l a t t a c k on m e n t a l health, health, a n d other social services, it seems less i m p o r t a n t to argue about the boundaries and scope of clinical social work a n d more important to protect and foster clients' rights to a range of services based on their need and t h e role of clinical social work- ers in providing such services in both private and facility-based practice.

While essential to addressing the complex problems t h a t clients pre- sent, diversity a n d specialization do create a diffusion and confusion in our core identification as social workers and in how we portray our pro- fessional activities. There is not a simple solution to this. The impor- tance of m a i n t a i n i n g a strong and vital profession requires t h a t what- ever our individual pursuits, we r e m a i n i d e n t i f i e d as clinical social workers, as p a r t of a profession in which we t a k e pride, a n d t h a t we stay connected to its organizations. Clinical social workers m u s t take t h e lead in applying our vast knowledge base to addressing the problems of diverse, oppressed, and economically disadvantaged populations. De- spite t h e i r direct practice focus, clinical social workers m u s t strive to r e m a i n committed to the historical mission and values of t h e profession and to fight with others for responsive social policies and service deliv- ery to all groups in society but particularly those who are disem- powered. The "age of narcissism" m u s t be replaced by a n era of responsi- ble autonomy. The very legitimacy t h a t clinical social work has h a d over the past several decades demands no less, particularly as we face t h e constraints on practice t h a t stem from shrinking budgets, t h e widening gap b e t w e e n clients' needs and available resources, t h e increasing em- phasis on very brief t r e a t m e n t , the mechanical a n d indiscriminate appli- cation of m a n a g e d care, and efforts to dismantle social welfare programs and t h e service delivery structure as we have known it for over fifty years.

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EDUCATION AND ADVANCED TRAINING F O R CLINICAL SOCIAL WORK

A c o n t i n u i n g problem for clinical social w o r k is t h e i n a d e q u a t e edu- cational p r e p a r a t i o n t h a t practitioners receive in our schools of social work. A r e s u l t of guidelines e s t a b l i s h e d by t h e Council on Social Work Education, social w o r k curricula a t t h e MSW level h a v e t e n d e d to em- body a g e n e r a l i s t or m u l t i - m e t h o d model of practice t h a t addresses w o r k w i t h individuals, families, groups, organizations, a n d social change. While each p r o g r a m is able to select its own Advanced Concentration, t h e c u r r i c u l u m guidelines for MSW p r o g r a m s t e n d to be skewed i n t h e direction of m a c r o s y s t e m s c o n t e n t a t t h e expense of personality theory, family s y s t e m s theories, a n d groups theories a n d models. Likewise, un- til more recently, t h e r e was a d e a r t h of doctoral p r o g r a m s t h a t offered specializations i n direct practice or clinical social w o r k a n d t h e r e h a s been a n e g a t i v e s e n t i m e n t expressed a g a i n s t t h e idea of developing clin- ical social w o r k doctorates b o t h w i t h i n u n i v e r s i t y based schools of social w o r k a n d free-standing, n o n - u n i v e r s i t y based p r o g r a m s on t h e p a r t of certain i n d i v i d u a l s (Shore, 1991). I t is of i n t e r e s t t h a t a 1991 s t u d y com- p a r i n g u n i v e r s i t y based t r a d i t i o n a l a n d clinical or direct practice doc- toral p r o g r a m s , which n u m b e r e d 10 out of 48 such programs, f o u n d no differences in t h e i r s t r u c t u r e , r e q u i r e m e n t s , or s t a n d a r d s (Walsh, 1993).

Several problems have r e s u l t e d from t h i s s t a t e of affairs. First, MSW g r a d u a t e s lack t h e clinical knowledge a n d skill n e c e s s a r y for di- rect practice w h a t e v e r t h e setting, a n d both t h e availability a n d q u a l i t y o f agency social w o r k supervision a p p e a r s to h a v e declined substantially. F u r t h e r , u n l e s s s t a t e licensing laws establish clear guidelines for auton- omous practice, MSW social workers can e n t e r private practice u p o n g r a d u a t i o n a n d do n o t have to u n d e r t a k e supervision or any a d d i t i o n a l education a n d training. Second, post-MSW social workers who w a n t to e n h a n c e t h e i r knowledge a n d skills i n clinical social work t h r o u g h a formal course of s t u d y m u s t a t t e n d p r o g r a m s outside of schools of social w o r k for t h e m o s t part. This p r o m p t s t h e m to e n t e r t r a i n i n g i n s t i t u t e s i n various t h e r a p e u t i c modalities in which t h e y often are n o t t a u g h t or supervised by social workers nor i m b u e d w i t h social work's mission a n d values. Third, t h e faculty in schools of social work commonly lack expe- rienced practitioners. Professors who have a t t a i n e d doctorates i n a d m i n - istration, social policy, or r e s e a r c h oriented p r o g r a m s do n o t necessarily h a v e t h e educational b a c k g r o u n d or clinical experience, broadly defined, to be able to serve as experts i n t h e classroom while o t h e r professors who were once g r o u n d e d in practice m a y n o t have seen a client in years.

T h e r e is a n u r g e n t n e e d for social work educational p r o g r a m s to address t h e n e e d s of practitioners by allocating m o r e c u r r i c u l u m space to clinical content, to c r e a t i n g s u b s t a n t i v e specializations a t t h e MSW, DSW, a n d PHD levels for t h o s e who w i s h to be clinical social workers, to

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r e c r u i t i n g a n d s u p p o r t i n g experienced practitioners for faculty positions a n d h e l p i n g t h e m to achieve t e n u r e , a n d by involving qualified a n d re- spected p r a c t i t i o n e r s in t h e c u r r i c u l u m building a n d t e a c h i n g process.

T H E ROLE OF CLINICAL RESEARCH

Since t h e discouraging s t u d i e s on casework's effectiveness m e n - t i o n e d earlier, findings on t h e outcomes of i n t e r v e n t i o n h a v e yielded m o r e positive r e s u l t s (Rubin, 1985: 469-76; Thomlison, 1984: 51-56). Yet t h e p r o b l e m of operationally defining psychosocial variables a n d inter- v e n t i o n processes r e m a i n s . T h e r e have been m o r e studies of behavioral, cognitive, a n d t a s k - c e n t e r e d t h e r a p i e s , whose t e c h n i q u e s a n d outcomes are m o r e easily specified a n d m e a s u r e d , t h a n of more dynamically-ori- e n t e d or t r a n s a c t i o n a l i n t e r v e n t i o n models.

O u t c o m e e v a l u a t i o n is n o t t h e only type of r e s e a r c h m e t h o d o l o g y t h a t can be u s e d to s t u d y practice. While studies of t h e effectiveness of i n t e r v e n t i o n w i t h specific t a r g e t problems and populations a r e needed, q u a l i t a t i v e a n d o t h e r diverse r e s e a r c h strategies t h a t move b e y o n d t h e c u r r e n t preoccupation w i t h l a r g e e x p e r i m e n t a l or single case designs a r e equally necessary. Practice principles o u g h t to guide t h e choice of re- search s t r a t e g y r a t h e r t h a n r e s e a r c h methodology drive clinical work (Simon, 1994; Thyer, 1994). This issue is likely to become i n c r e a s i n g l y i m p o r t a n t as m a n a g e d care d e m a n d s t h e use of r e d u c t i o n i s t m e a s u r e - m e n t tools to e v a l u a t e p a t i e n t outcomes a n d to a u t h o r i z e t r e a t m e n t . While t h o s e involved in practice m u s t help to formulate, design, a n d i m p l e m e n t clinical r e s e a r c h e i t h e r by acquiring practice r e s e a r c h exper- tise t h e m s e l v e s or t h r o u g h collaboration w i t h r e s e a r c h e r s i n t e r e s t e d i n clinical studies, it is e s s e n t i a l t h a t researchers become m o r e practice friendly. "From this critical perspective, t h e real crisis in social w o r k r e s e a r c h is t h e a l i e n a t i o n of countless s t u d e n t s from experiencing re- search as useful or r e l e v a n t a n d t h e failure to articulate a n a p p r o a c h to i n q u i r y t h a t is rooted in t h e mission a n d values of t h e profession a n d t h e realities of practice" (Witkin, 1995, p. 426).

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E d a G. Goldstein, D S W N e w York University S h i r l e y M. E h r e n k r a n t z School o f Social Work 1 Washington Square N o r t h N e w York, N e w York 10003-6654