Social Work Practice: Integrating Concepts, Processes, and Skills 9780231546553

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SOCIAL WORK PRACTICE

Social Work Practice, Second Edition INTEGRATING CONCEPTS, PRO CESSES, AND SK ILLS

Marion Bogo

columbia university press new york

columbia university press

Publishers Since 1893 New York Chichester, West Sussex cup.columbia.edu Copyright © 2018, 2006 Columbia University Press All rights reserved Library of Congress Cataloging-in-Publication Data Names: Bogo, Marion, author. Title: Social work practice : integrating concepts, processes, and skills / Marion Bogo. Description: Second edition. | New York : Columbia University Press, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2017053787 (print) | LCCN 2017057122 (e-book) | ISBN 9780231546553 (e-book) | ISBN 9780231186223 (hardcover : alk. paper) | ISBN 9780231186230 (pbk. : alk. paper) Subjects: LCSH: Social ser vice. | Interviewing in social ser vice. Classification: LCC HV40 (e-book) | LCC HV40 .B5465 2018 (print) | DDC 361.3/2—dc23 LC record available at https://lccn.loc.gov/2017053787

Columbia University Press books are printed on permanent and durable acid-free paper. Printed in the United States of America

d e d i c at e d t o l a u r e n av e r y and dy l a n c a r t e r a s yo u g r e w, s o d i d t h i s b o o k

contents

a c k n o w l e d g m e n t s  IX i n t r o d u c t i o n  XI pa r t o n e Conceptual Frameworks for Social Work Practice1 one



A View of Holistic Competence in Social Work3

two



Holistic Competence: Cognitive and Affective Processes28

three



Learning to Practice48

four



The Helping Relationship: Conceptual and Empirical Contributions80

five



Engage Diversity and Difference104

six



The Helping Relationship: From Theory to Practice126

seven



Contemporary Practice Issues159

pa r t t w o The Helping Process in Social Work Practice189 eight



Beginnings191

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nine



Toward Developing Shared Understanding: Assessment and Formulation217

ten



The Social Worker as Process Expert241

eleven



Change Processes Continued268

t w e lv e



Endings295

pa r t t h r e e Interviewing in Social Work Practice309 thirteen



Communication and Interviewing Skills311

r e f e r e n c e s  369 i n d e x  399

contents

acknowledgments

t h e i m p e t u s f o r t h e f i r s t e d i t i o n of this book came from the late John Michel, who was senior executive editor at Columbia University Press. His encouragement, humor, and warmth inspired me to attempt to produce a social work practice book that would integrate theory and practice in a manner that would be useful for students as well as practitioners. Since the first edition, many editors at the Press encouraged me to write a second edition, finally leading to discussions with Stephen Wesley about this endeavor. I thank him for his enthusiasm for this project—it spurred me on to write this second edition. I am grateful to the many clients I have worked with as a social worker— they stimulated the reflection and analysis that led to further conceptualizing practice theory. The material in this book draws from many studies on social work practice and I thank my coinvestigators such as A.K.T. Tsang for our work on cross-cultural practice, Cheryl Regehr for our work on competence, and Faye Mishna for our work on cyber communication. Many creative and hard-working doctoral students—many of whom are now colleagues—were instrumental in carrying out these research studies and contributing invaluable insights for practice. Much appreciation goes to Carmen Logie, Ellen Katz, Michael Woodford, Kenta Asakura, Lea Tufford, Barbara Lee, and Karen Sewell. I have valued and learned from feedback from my academic colleagues Andrea Litvack, Roxanne Power, and Toula Kourgiantakis. The first edition of this book has been used by many teaching teams and students over the years at the Factor-Inwentash Faculty of Social Work. I thank them all for their response to the material, as it has helped me expand on the first edition and develop the current edition.

introduction

s o c i a l w o r k p r a c t i c e is highly complex. Practitioners are challenged to integrate and apply a wide range of elements and to do so in collaboration with clients. Professional practice involves the synthesis of the knowledge and value base of the profession, helping processes and skills, in a way that is compatible with the social worker’s “personal self.” The aim of the first edition of this book was to provide generic theoretical knowledge and information about processes for direct social work practice that social workers could use to build their competence and guide their actions. An attempt was made to synthesize information about traditional and emerging conceptual approaches, practice models, and principles, relevant and supporting empirical work, and skills that are needed to implement and demonstrate effective work with clients. I was motivated to write a second edition of this book in light of the continuously expanding social work knowledge base and the notion of educating for competence, first articulated in the Educational Policy and Accreditation Standards (EPAS) of the Council on Social Work Education (CSWE) in 2008 (CSWE 2008). EPAS 2015 (CSWE 2015) further expanded the notion of competence to include holistic competence, stating, “the demonstration of competence is informed by knowledge, values, skills, and cognitive and affective processes that include the social worker’s critical thinking, affective reactions, and exercise of judgment in regard to unique practice situations” (6). This book integrates conceptualizations and findings from the research on competence undertaken with my team that is consistent with this perspective (Bogo et al. 2013; Bogo et al. 2017; Bogo et al. 2004; Bogo et al. 2006).

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The person-in-environment and bio-psychosocial perspectives remain dominant in direct practice that aims to integrate attention to diversity in work with clients. These organizing frameworks are used to gain understanding about the human condition, social functioning, and well-being. Increasing theoretical and empirical contributions from basic and social sciences now provide more depth and render these concepts more complex. Indeed, the number of practice models and principles continues to grow. Social work educational programs are committed to exposing students to the profession’s intellectual debates and to both traditional and innovative approaches. They aim to cover considerable ground, from societal to individual perspectives, and from philosophical positions to empirical findings. As a result, social work students are likely to find a program of study that is crammed with innumerable bodies of knowledge, perspectives, values, and practice approaches. Course reading lists grow and basic practice texts expand with the publication of each new edition as authors incorporate the newest concepts and debates into their work. As more specialized models are described and tested, students are also presented with an ever-expanding range of procedures and specific intervention techniques. Students clearly state that at the beginning of their studies, they want to learn about a core foundation of interrelated concepts, processes, principles, and skills for practice. Such a core is seen as a place to start, that is, a place that can serve as a foundation throughout one’s career—a foundation that provides a sense of being grounded as a professional and engenders confidence that one possesses a core of competencies that is available to use in practice. Such a core can be built on and adapted based on the mandate of the agency, the worker’s role, the specific model procedures, specialized information about populations and problems, and the needs of the particular client in the working relationship with the social worker. In both editions of this book, the aim was to address these challenges by presenting an integration of information about selected generic theoretical concepts and models, relevant empirically based helping and change processes, long-standing social work practice principles, and communication and interviewing skills. These dimensions can be used as an integrated foundation for generalist and specialist practice when working directly with clients, including in advanced clinical social work practice. This book is organized into three sections: “Conceptual Frameworks for Social Work Practice,” “The Helping Process in Social Work Practice,” and

introduction

xiii

“Interviewing in Social Work Practice.” Part 1, “Conceptual Frameworks for Social Work Practice,” provides a comprehensive discussion of holistic competence in relation to EPAS 2015 and identifies key themes in the contemporary knowledge base. It also addresses challenges for students learning about social work as they integrate information about values, theories, and models while developing their professional identity and use of self. Collaborative relationships with clients and working with diversity and difference are examined in the remaining chapters in this section. Part 2 is entitled “The Helping Process in Social Work Practice” and includes chapters on the actual stages, tasks, processes, and interventions used to assist clients in bringing about changes in their lives or to offer them support. Chapters in this section draw on the concepts and competencies discussed in part 1, and demonstrate how practitioners can bridge theory and practice through preparatory, beginning, assessment, middle, and ending stages. Processes for supporting clients and helping them to bring about change in their lives are discussed in depth. The final section of the book is entitled “Interviewing in Social Work Practice” and consists of one chapter. Chapter 13 provides a detailed discussion of the interviewing skills social workers use in practice. Skills are described and illustrated with examples. These interviewing behaviors constitute a skill set that the practitioner uses to ground and operationalize the concepts and processes discussed in the previous two sections of the book. Chapter 13 can be used on its own in social work courses on interviewing or in conjunction with the entire book in social work practice courses in undergraduate and graduate programs, and at generalist and specialized levels. The book’s material can be used in clinical programs and adapted or modified to meet the needs of programs’ specializations regarding “specific population, problem area, method of intervention, perspective or approach to practice” (CSWE 2015, 12). This book is especially useful for students as they begin to learn about social work practice. Field instructors and experienced practitioners have also found the book informative, as it provides an opportunity to reexamine contemporary social work practice theory and to review selected empirically based techniques, long-standing practice principles, and interviewing skills. In describing how concepts may be applied in the real world of social work practice, I have aimed to provide information at a level that is not so abstract that it is unclear, but neither is material presented in so concrete a

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manner that a cookbook-like approach would result. Rather, my aim is to provide information about concepts and practice processes or principles that practitioners can use in a flexible and reflective manner so that together with clients, they can fashion their own unique helping relationship and a pathway for clients to achieve positive results.

SOCIAL WORK PRACTICE

part

1

Conceptual Frameworks for Social Work Practice

1

A View of Holistic Competence in Social Work

is a highly complex activity. It requires practitioners to integrate and apply a wide range of elements in attuned, authentic, and skillful interactions. Mastery of practice involves the ability to bring together the knowledge and value base of the profession with the social worker’s personal self. Social workers develop their own unique expressions of this combination of interrelated factors. For social work students, this view presents a challenging task, as there is much to learn and to assimilate. This book aims to provide an integration of selected generic theoretical concepts, relevant empirically based change processes, longstanding social work practice principles, and communication and interviewing skills for use in direct practice or clinical social work. The first two chapters present a view of holistic competence that captures the essential nature of social work and provides a framework for thinking about one’s learning and development as a professional. social work pr actice

a n i n t e g r at e d v i e w o f p r a c t i c e

Social workers carry out practices or practice behaviors, usually conceived of in overlapping and iterative phases. They develop collaborative relationships with their clients, establish mutually agreed-on goals, and strive for shared understandings of presenting and related issues. Social workers’ assessments guide planning and help them choose interventions to achieve these goals. The client and the social worker continuously consider whether the helping process is effectively progressing toward achieving goals. Such

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feedback helps social workers determine whether their initial understandings and subsequent actions are effective or whether different approaches should be identified and used. All the while, the developing relationship between the client and the social worker may be strengthened or challenged, requiring efforts at repair. While this is often presented as a linear process, in actual practice a looping process unfolds. As client and social worker come to know each other better, and as trust begins to be established, preliminary assessments will be enriched with emerging information. Hence, the focus of the work, the nature of the interventions, and the systems that need to be included may change over time. Each social worker conveys attitudes, behaviors, and a general stance that represent her integration of “a range of knowledge, values, skills, and cognitive and affective processes that include the social worker’s critical thinking, affective reactions, and exercise of judgment in regard to unique practice situations” (CSWE, 2015, 6). In other words, professional knowledge in its broadest sense becomes part of and is powerfully influenced by the social worker’s personal self (Larrison and Korr 2013). As a result, it is a long-standing tradition—one that continues in the present day—that social workers must have a degree of self-awareness and a reflective-critical stance about the way their personal values, assumptions, reactions, and judgments play out in their work. Such a stance is needed so that assessments and interventions are constructed to meet clients’ needs and unique experiences. Interpersonal interactions are the bedrock of practice. It is through the words we use, as well as the attitudes and feelings we convey verbally and nonverbally, that clients and social workers may achieve the goals they set together. Social workers’ communication behaviors and interviewing skills are the primary tools of practice. Social workers need to use them intentionally and flexibly to forge and maintain relationships with clients. The social worker–client relationship is the crucible for the helping and change processes that affect outcome. These processes include conversations in which—through active listening, feedback, and dialogue—social workers’ insights and clients’ perspectives are shared. This open, trusting relationship is a hallmark of professional social work and receives considerable support from empirical studies in related fields (Wampold and Budge 2012). In contemporary diverse societies, both the social worker and the client are likely to reflect multiple dimensions of difference as well as similarity. Such dimensions include, but are not limited to, “age, class, color, culture,

a view of holistic competence in social work

5

disability and ability, ethnicity, gender, gender identity and expression, immigration status, marital status, political ideology, race, religion/spirituality, sex, sexual orientation, and tribal sovereign status” (CSWE 2015, 7). Social workers need to strive to understand and bridge differences so that meaningful relationships can occur. Through a series of studies in a long-standing program of research, our research team developed a theoretical understanding of holistic competence in social work (Bogo et al. 2013, 2006). Based on in-depth interviews with experienced social work field instructors, this understanding went beyond typical views of competence. Competence is usually defined as consisting of knowledge, skills, and attitudes or values. Critics in social work and medicine note that when competence is further specified, it results in ever-growing lists of discrete, specific behavioral skills (Hackett 2001; Kelly and Horder 2001). Competencies are broken down “into the smallest observable units of behavior, creating endless nested lists of abilities that frustrate learners and teachers alike” (Frank et al. 2010, 643) and the organic and evolving nature of professional practice is lost (Hodges and Lingard 2012). Our studies led to a different and more complex view of competence consisting of two interrelated dimensions. As described by Bogo and colleagues (2013): One dimension, metacompetence, refers to higher order, overarching qualities and abilities of a conceptual, interpersonal, and personal/professional nature. This includes students’ cognitive, critical, and self-reflective capacities. The second dimension, procedural competence, refers to performance and the ability to use procedures in various stages of the helping process and includes the ability, for example, in direct practice, to form a collaborative relationship, to carry out an assessment, and to implement interventions with clients and systems. (261)

Furthermore, our data showed the linkage and significant impact of metacompetence on procedural competence. Specifically, cognitive and affective dimensions such as critical thinking, self-awareness, and self-regulation affect the way social workers engage in their actual practice. Our personal reactions and feelings powerfully affect our thinking and the nature of our assessments, rationale for intervention, and use of skill, whether it is intentional and thoughtful or reactive and not purposeful. This view of metacompetence has also been expressed by scholars in related human ser vices and health professions such as management (Fleming 1991; Winterton 2009),

conceptual fr ameworks for social work pr actice

6

Organization and community context Skills

Self-regulation Emotions, reflection, self-awareness

Complex Practice Behavior

Knowledge

Judgment

Generic and specialist, theoretical and empirical

Assumptions, critical thinking, decision making

Professional context – values figur e 1.1 A model of holistic competence in social work. Source: Reprinted with permission from the Council on Social Work Education (CSWE), from Bogo et al. (2014).

medicine (Epstein and Hundert 2002; Fernandez et al. 2012), professional psychology (Hatcher and Lassiter 2007; Weinert 2001), and in studies of over twenty professions (Cheetham and Chivers 1996, 2005). Figure 1.1 provides a diagram that presents this view. Dimensions of holistic competence represented in this figure are discussed in detail later in this chapter and in chapters 2 and 3. While this discussion relates holistic competence to direct practice in social work, this model has been found to be applicable to social work practice at all levels—micro, mezzo, and macro (Regehr et al. 2012). c o m p l e x p r a c t i c e b e h av i o r s a n d h o l i s t i c competence

As can be seen in figure 1.1, the center of the model is complex practice behaviors or complex practices. These key processes or activities constitute what social workers actually do. Most models and texts generally discuss the linked phases of engagement and relationship building, assessment, intervention, and evaluation of practice. Indeed, EPAS 2015 (CSWE 2015, 9)

a view of holistic competence in social work

7

di mens i ons of holi st i c c ompe t e n c e : c ha p t e r  1

Complex Practice Be hav iors Skills The Context of Practice

• The profession • The organization • The community Knowledge

• The role of research

defines these “dynamic and interactive process[es] of social work practice” as they evolve through collaboration between social workers and their clients, in relation to new information and insights that emerge. The way social workers behave is affected by the interrelationships of a number of factors. In common with other helping professions, social workers use a wide range of verbal and nonverbal communication behaviors and interviewing skills to enact the complex practices involved in implementation of the various stages and processes in intervention models. Foundation core skills (at the top left of figure 1.1) are seen when a social worker interacts with clients. Nonverbal behaviors include attending and active listening. Verbal behaviors include asking open- and close-ended questions, seeking clarification, reflection of feelings, and so forth. These skills are discussed in detail in chapter 13. Contextual factors are depicted at the top and bottom of the figure, and the dimensions of competence are portrayed in the four quadrants. Knowledge refers to formal explanatory theories, codified practice theories, and empirically supported intervention models, as well as principles that emanate from practice wisdom. The way in which we use formal knowledge is affected by our own individual knowledge base (Bogo et  al. 2014). It is natural to draw on worldviews, assumptions, and opinions derived from our lived experiences in our personal and professional lives. This personal knowledge base is generally unarticulated and considered to be tacit or implicit. It may operate in an unaware or unconscious manner, but it powerfully affects the

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way we frame, understand, assess, and make decisions regarding the client situations confronted in practice (Munro 2011). This notion of the personal self operating in conjunction with the professional self is a long-standing concept in social work (Brandell 2004; Larrison and Korr 2013). Contributions from neuroscience research further illuminate the ways our emotions affect our cognitions (Immordino-Yang and Damasio 2007; Kahneman 2011). Our emotional responses to information and the experience we have when interacting with clients significantly affect our judgments. In turn these emotional responses are related to our tacit knowledge: what we have learned through our personal and professional experiences, the “truths” that are internalized and that are not easily explicitly identified. Therefore, holistic competence must include the ability to be self-aware of our subjective thinking, feeling, and reactions, especially with regard to the judgments we make. Accordingly, self-awareness and emotional self-regulation when involved in professional practice are important dimensions of holistic competence. (Bogo et al. 2014, 8)

Figure 1.1 aims to capture the fact that an interpersonal practice such as social work involves the nuanced integration of a number of dimensions into an organic or synthetic activity. A metaphor that others have used is baking a cake. Baking a cake involves using a number of ingredients that must be combined in the right amounts in the right sequence and baked at the right temperature for the right amount of time. There is a science and an art in baking and in practicing social work (Merrill, Ayasse, and Stone 2015). Another metaphor is a pyramid, where practice behaviors represent the pinnacle of the activity and are supported by the various components of context, knowledge, skills, self-regulation, and judgment. Honoring the concept of holism, it is important to keep in mind that practice is the result of the social worker’s unique personal and professional integration of professional values, selected concepts, and information filtered through the social worker’s recognition of subjective reactions. As stated in EPAS, “Overall professional competence is multi-dimensional and composed of interrelated competencies. An individual social worker’s competence is seen as developmental and dynamic, changing over time in relation to continuous learning” (CSWE 2015, 6).

a view of holistic competence in social work

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the conte x t of pr actice

Contextual factors influence all social work practice. The following section discusses key aspects of the professional, organizational, and community context. The Profession

All practitioners function within the framework of their respective professions, drawing on their unique knowledge base, values, and mission. In social work, we strive to provide effective ser vice to clients, groups, communities, and organizations to promote social justice and equity. Social workers are highly committed to supporting and bringing about change to enhance individual and social functioning. An enduring theme of the profession includes attention to both the private concerns presented by individuals, families, and communities, and the public issues that exert a profound impact on them. An editorial in Social Work, the journal of the National Association of Social Work, argues for “advancing one social work” recognizing the contributions of micro and macro approaches (BentGoodley 2014, 5). The focus in this text is on micro practice, often referred to as direct practice or clinical practice, that is, working with individuals and families. As in all levels of practice, the aim is to deliver intervention in a systematic, knowledge-directed, relationship-based manner that recognizes the impact of the social worker’s professional use of self (CSWE 2009; Gonzalez and Gelman 2015). A hallmark of the profession is the view that individuals are always understood within the context of their social environment. This environment includes the smallest and most intimate systems, such as couple and family relations, as well as larger systems, such as neighborhoods, communities, and societies. The social environment encompasses societal attitudes, norms, programs, and policies. All of these systems have a profound impact on individual well-being, development through the life course, and social functioning. Related enduring themes of professional social work are commitments to serve oppressed, vulnerable, and marginalized populations; to promote human rights and social justice; to appreciate diversity and difference; and to practice in an antioppressive manner.

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conceptual fr ameworks for social work pr actice

The Educational Policy and Accreditation Standards (EPAS) of the Council on Social Work Education (CSWE) summarizes the purpose of the profession. This statement guides U.S. accredited schools of social work in the design of curriculum to prepare students for practice. The purpose of the social work profession is to promote human and community well-being. Guided by a person-in-environment framework, a global perspective, respect for human diversity, and knowledge based on scientific inquiry, the purpose of social work is actualized through its quest for social and economic justice, the prevention of conditions that limit human rights, the elimination of poverty, and the enhancement of the quality of life for all persons, locally and globally. (CSWE 2015, 5)

In Canada, accredited schools of social work are guided by a similar statement regarding the purpose of the profession. Guided by the principles of fundamental human rights and responsibilities and respect for human diversity, social work seeks to facilitate well-being and participation of people, promote social and economic justice, address structural sources of inequities, and eliminate conditions that infringe human and civil rights. Grounded in reflective practice and engaged in persistent inquiry into theoretical and research bases in the field, social work employs professional approaches and interventions to enhance individual, family, group, community, and population well-being. (CASWE-ACFTSA 2014, 2–3)

In addition, social workers are guided by the code of ethics of their national professional bodies. In the United States, the National Association of Social Workers, and in Canada, the Canadian Association of Social Workers, develop and regularly revise their code of ethics and standards of practice. Although the codes of these two organizations vary somewhat in their content, the values presented are very similar and include dimensions such as service to humanity, pursuit of social justice, respect for the inherent human dignity and worth of the person, the importance of human relationships, integrity in professional practice, and competence. These values reflect the humanistic and altruistic philosophical base of the social work profession (Reamer 2013). They also reflect fundamental beliefs such as the importance of working with people in a way that promotes self-determination and empowerment, and respects diversity and difference. These values in-

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fluence practice in a collaborative, mutually responsible, and antioppressive direction. Finally, social workers are governed by regulatory bodies. State or provincial legislatures in the United States and Canada define in law standards of professional practice for a wide range of health and human ser vices professions. Each jurisdiction establishes regulatory bodies to protect the public through licensing, certification, or registration of those who claim the title of the specific profession (for example, to be able to call oneself a social worker). These licensing or state boards (often called colleges in Canada) also aim to promote excellent and safe practice by identifying the profession’s scope of practice and providing a set of practice standards consistent with its values and ethics. Regulatory bodies identify a number of requirements for licensing or registration, but there is no national or uniform set of entry-level requirements in either the United States or Canada. In common is graduation from an accredited school of social work, and all states in the United States require successful performance on an examination offered through the Association of Social Work Boards. While there has been much discussion in Canada, as of this writing only the province of British Columbia requires an examination. Additional requirements vary by area. In some states, prospective social workers must receive supervision for a set number of hours; in others, supervision requirements relate to the level of practice— bachelor’s, master’s, clinical, and advanced generalist. For those educated outside the United States or Canada, there is usually a process to establish equivalency. These regulatory bodies are mandated by law to protect the public by receiving and investigating complaints against their members. They must deal with issues related to professional misconduct, incompetence, and incapacity of their members, and decide on appropriate discipline, in some instances including remediation. As noted, social work practice is complex and there are many issues confronted by practitioners where there may be a lack of clear direction. Consultation is usually provided by the board or college professional staff to help social workers navigate ethical dilemmas. All social workers should be familiar with the standards of practice and additional guidelines provided by these bodies as they represent another way in which practice knowledge is developed.

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The Organ ization

Most social workers are employed by organizations. The mission and mandate of the employing agency defines their roles and affects the nature of their practice. Organizations in turn reflect the commitment and ability of a society, nation, or local community to address the social and health needs of the population. Societies vary in their values and beliefs about the appropriate role of the state in meeting universal basic human needs. Political ideologies influence elected government representatives who determine how economic resources will be distributed, how all citizens will be supported, how disadvantaged groups will be assisted, and whether refugees or undocumented individuals will have access to ser vices. The mission of the organization defines what programs and ser vices are offered. Social workers may find themselves in organizational contexts that dictate the approaches they will use. Driven by demands for quality and cost-effective ser vices, agencies are increasingly focusing on program evaluation. Accountability expectations demand that we review the effectiveness of our work and strive to discover and use the most helpful and efficient methods. Practice research aims to demonstrate which programs, models, and processes lead to desired outcomes. As empirically validated approaches are articulated and adopted, organizations may be able to help more people meet their needs and goals. The issue of transfer of empirically supported programs, however, has proven to be challenging. Empirically supported models are developed and tested in controlled studies with practitioners who are well trained and supervised so that there is high fidelity in implementing the model. When these approaches are used in community settings, outcomes are not always as robust as in the original studies. This is a result of a variety of factors. In particular, clients in the field tend to be more diverse as compared to the study’s sample, which can affect whether the model is a good fit. When adaptations are made to meet client needs, key ingredients that led to model success may be modified. Agencies also need to provide internal support, coaching, and supervision, so that social workers can become competent and effective in implementation (Fixsen et al. 2009). In resource-strapped agencies, this may not be the case. Unfortunately, agencies may not have the expertise and resources to conduct systematic reviews and select and pilot models based on the best evidence that is also suited to the populations

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they serve. Too often, new models are adopted as a result of ideological shifts or trust in charismatic proponents. Increasingly, social work practice takes place in teams—both teams of social workers and teams with members of various professions. In interprofessional teams, the function, role, and professional activities of the social worker are affected by the way in which the team members organize their work. Where the team is interprofessional in composition there may be more or less separation or overlap in roles. For example, social workers in mental health have experienced other professionals’ interest in psychosocial aspects of health and illness. In contrast, a social worker in an acute surgical unit is likely to have sole responsibility for these issues. Research on interprofessional teams has shown that effective teams provide a home base for members who work together on a daily basis (Bogo et al. 2011). Team members can offer positive relationships when they collaborate and provide informal, useful, and supportive feedback (Soubhi et al. 2009; Xyrichis and Lowton 2008). In primary social work settings, teams can provide helpful education and supportive functions for their members through consultation on specific clients and continuing professional development on generic topics. One study found that when communitybased social workers were confronted with decision making in a range of situations, they were more likely to consult with colleagues than to use evidence-based literature (McLaughlin et al. 2010). This finding was also reported in a study of social workers’ decision-making processes when confronted with their duty to report potential child abuse and neglect (Tufford 2015). Professional social work has always valued the positive impact of staff supervision as a means of accountability regarding agency ser vice to clients and as a way to deliver education and support to practitioners (Kadushin and Harkness 2014). Research on agency-based educationally focused clinical supervision of workers across a range of disciplines supports this longstanding tradition. Reviews of studies found positive outcomes for social workers (Bogo and McKnight 2005; MorBarak et al. 2009). The most useful type of supervision is given by supervisors with content expertise about the specific populations and effective interventions for the particular clients seen by supervisees. This type of supervision influences workers’ sense of professional competence, commitment to developing more effective practice performance, and satisfaction with their jobs (Bogo et al. 2011). Social

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workers report increased intention to remain in their position when supervisors are supportive and validating, and able to teach effective interventions (Collins-Camargo and Royse 2010). The Community

Social work adopts a person-in-environment framework that recognizes that individuals function and are affected by the contexts in which they live. Similarly, social workers practice within the contexts reviewed thus far—the profession and the organization. And both clients and practitioners are strongly influenced by the society and communities in which they grew up and in which they now live. An understanding of the way societal and community forces affect individuals is a distinctive hallmark of social work, one that differentiates it from related helping professions. At the macro- or societal level, all participants in the social ser vice and health systems are affected by societal systems that explicitly define the basic values of the country and the way these values are manifested in policies and programs. Universal entitlements, such as education and health care, vary based on national and regional political interests and the priorities they support. At an implicit level, societal attitudes and structural barriers prevent individuals from access to a range of ser vices and opportunities. Interventions at the macro level aim to illuminate such societal inequality and change attitudes, policies, and programs to achieve social justice and equity. Interventions at the mezzo or community level focus on the local level, in geographical communities and special needs communities. These interventions typically rest on a cogent analysis of structural or external forces and factors that affect social functioning and prevent individuals from achieving their full potential. While it is beyond the scope of this text to examine these practices, it is important for direct social work practitioners to recognize and assess the impact of these societal and community forces on the situations presented by individuals and families. A structural analysis draws attention to historical and political forces that have created current policies at national, regional, and local levels. Moreover, Competency 5, “Engage in Policy Practice” (CSWE 2015), states that all social workers should “understand their role in policy development and implementation within their practice settings at the micro, mezzo, and macro levels and actively engage in policy

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practice to effect change within those settings” (8). Frontline social workers are likely in the best position to identify deficits in resources and programs, as well as barriers and obstacles that the many individuals they work with will confront. They can join with other social workers to determine whether they experience similar issues and participate in alliances to advocate for needed changes. Finally, to clarify, when considering the community’s impact on individuals, community refers to a wide range of reference groups with which individuals may identify; for example, cultural, ethnic, or religious groups; country of origin; neighborhood; special health or ability needs; and so on. Communities reflect a wide range of worldviews, values, norms, and expectations regarding individual, familial, and social functioning. North American society increasingly consists of diverse communities, with variation in the degree of affiliation with shared national perspectives. As individuals grow and develop, community attitudes are filtered and expressed variably through their unique families. Similarly, individuals will vary in the degree to which they identify with and behave in relation to their community and family values and norms. Over the life course, these identifications may change, with more or less connection to these reference groups at different developmental stages. The person-in-environment perspective views individuals as nested within these overlapping systems of society, community, and family. Hence, social workers should take into account the impact of these contexts, for their clients and also for themselves. These contexts will influence a number of perceptions and actions; for example, the way problems are experienced and framed; assumptions about individual and social functioning; and notions about needing, receiving, and offering professional help. These issues related to the context of practice are captured in EPAS 2015 in Competency 1, “Demonstrate Ethical and Professional Behavior”; Competency 2, “Engage Diversity and Difference in Practice”; Competency 3, “Advance Human Rights and Social, Economic, and Environmental Justice”; and Competency 5, “Engage in Policy Practice.” Elements of these competencies will also be discussed in subsequent chapters. Attention will now be directed to the competencies related to the remaining dimensions depicted in figure 1.1. In this chapter, knowledge (see the left side of the figure) will be discussed. Chapter 2 will consider the two dimensions depicted on the right side of the figure: self-regulation and

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judgment. The final chapter of the text is devoted to the topic of skills (see the left side of the figure). knowledge

A hallmark of every profession is the presence of a body of knowledge used by practitioners. Such a knowledge base entitles practitioners to claim expertise in a particular field. Social work is no different in this respect. From its inception, attempts have been made to identify and use relevant theoretical concepts to understand phenomenon and guide planning and intervention. In a complex human endeavor such as social work, the linkage between theory and practice is bidirectional. That is, theory informs practice and the experiences of practice yield insights that promote new theorizing and rejection of previously held concepts. Each profession’s choice of theories reflects what is perceived as important to achieve the profession’s mission. Social work has always focused on the connections and interrelationships between the individual and the social context. Fredric Reamer, a leading social work scholar, captures this well in his statement, “Social workers focus on the private troubles of individual people and the public issues that affect them” (Reamer 2012, 190). This dual and simultaneous focus has persisted throughout the history of social work, as has a concern for those who are oppressed and vulnerable. This perspective guides the selection of theories that constitute the professional knowledge base. And this base is ever-expanding, with new knowledge emanating from research in a wide range of disciplines. Some theories emphasize one aspect of this perspective more than the other; this distinctive feature of the profession is also a source of dynamic tension. While there are various ways of categorizing knowledge for practice, in this text knowledge is conceptualized as occurring at three levels: explanatory, or grand theory; practice theory, or intervention models; and practice principles. The conceptual map shown in figure 1.2 presents a graphic that includes these various levels with some illustrative examples. Overall, social work is concerned with theories that provide explanations of how societal structures may systematically oppress individuals and serve as barriers to social functioning, equitable participation in society, and realization of full human potential. Explanatory concepts used are drawn from disciplines such as psychology, sociology, neuroscience, women’s studies,

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Overarching explanatory theories Systems

Cognitive Psychodynamic/ attachment

Practice models CBT

Emotionfocused

Social constructivism Structural family

Skills/ Techniques Joining Unbalancing Enactments

Cognitive re-structuring Thought records Evocative questions Heightening Softening

Narrative

Externalizing Thickening description Collaborative relationship Strengths

Common factors: Client and extra-therapeutic factors,

Social work principles: Client-centered: start where client is,

relationship, expectancies, and techniques.

go at client’s pace, client as expert on own experience. Communication and interviewing skills

figur e 1.2 An example of a conceptual map. Note: CBT: cognitive behavioral therapy. Source: Adapted from Burnes, Katz, and Bogo (2015).

economics, and political science, among others, and constitute some of the major multidisciplinary theories that inform social work practice. Concerns about human needs and social justice concepts related to diversity, power, and oppression are an important part of the knowledge base. Explanatory theories enable social workers to understand, in depth, the experiences of the individuals and families with whom they work. Theories provide a set of lenses and concepts to guide analysis of practice situations and answers to the questions, Why does this problem exist? and What needs to change for alleviation of the problem? Hence, theoretical explanations inform assessment and provide a rationale for the choice of focus. There are grand theories that aim to explain a vast set of issues, such as psychosocial developmental theories (Erikson 1994), personality theory such as psychodynamic theory (Brandell 2004), systems (Bertalanffy 1969) and ecological (Germain and Gitterman 2008) theories, and so forth. There are also theories that explain selected aspects of the human condition;

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for example, attachment theory is used to explain early and subsequent attempts for connection in relationships (Schore and Schore 2008). Social workers are guided by the person-in-environment perspective and hence, as noted above, are concerned with theories that explain social phenomena, individual phenomena, and the interactions between the two. Direct practice and clinical social work also benefit from theories related to a bio-psychosocial perspective. This perspective focuses on the biological basis of experience, psychological aspects, and social phenomena, and the interrelationships among all three to explain situations related to human behavior and social functioning, health and well-being, and dysfunction (Berzoff and Drisko 2015; Simpson, Williams, and Segall 2007). Guided by a bio-psychosocial perspective, theoretical concepts are sought for understanding behavior with respect to growth, development, and individual and interpersonal functioning in cognitive, affective, and behavioral domains. For example, while psychodynamic theory formed the traditional base for clinical practice (Goldstein 1995, 2001), over time cognitivebehavioral (Beck 1995), family life cycle (Carter and McGoldrick 1989), and sociocultural theories (Foster 1998) have been integrated. More recently, the insights derived from research in cognitive neuroscience have increased understanding of how biological and brain-based mechanisms affect feeling, cognition, and behavior, and are shaped and influenced by interpersonal and contextual factors (Cozolino 2002; Damasio 2005). It is likely that most social workers embrace theoretical complexity and eclecticism, drawing on a variety of theoretical lens to understand and assess the situations they confront. A second level of concepts is known as practice theory or intervention models. These are approaches designed to bring about change and are of special interest for practitioners. Practice theory incorporates the first level of knowledge discussed above, although a practice theory may select only a set of explanatory concepts rather than the entire grand theory. Of interest are concepts related to function and dysfunction, as they provide an explanation of why a problem exists and hence a rationale to identify what needs to change for its alleviation. Intervention models incorporate a theory of change, that is, they provide a description of change processes and address questions such as how change occurs and what the social worker needs to do to facilitate that change. Thus, practice theory answers the questions, Why is there a problem? and How can we bring about change?

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Some models have been widely studied and the presence of evidencebased attestation to their effectiveness is considered important to many practitioners. Not all models lend themselves to empirical investigation and hence, while promising and helpful, may not have a strong set of studies to support their usefulness. Some specific social work models are problemsolving–oriented (Perlman 1957), psychosocial-oriented (Woods and Hollis 2000), task-centered (Reid 1992), and strengths-based (Saleebey 2002). EPAS reinforces this latter model regarding generalist practice as involving social workers who “recognize, support, and build on the strengths and resiliency of all human beings” (CSWE 2015, 11). Social workers borrow from related professions that have developed and tested models. Over time, social workers have been influenced by psychodynamic practice theory (Brandell 2004), cognitive (Beck 1976, 1995) and behavioral theory (Bandura 1986), humanistic theory (Rogers 1951), and postmodern theories (Gergen and Davis 1985). Elements of these various models have been combined into popular approaches, such as cognitive behavioral therapy (Meichenbaum 2013), mindfulness-based cognitive therapy for depression (Segal, Williams, and Teasdale 2013), and dialectical behavior therapy for borderline personality disorders (Linehan 2015). Building on the humanistic tradition in psychology, emotionally focused approaches have gained more attention within psychology (Greenberg 2010). Feminist psychologists have contributed invaluable insights into the psychology of women and have developed models and concepts for psychotherapy (Gilligan 1982; Jordan 2010; Jordan et al. 1991). Postmodern theory and constructivism (Gergen and Davis 1985) provide a conceptual framework for narrative theory used in both individual and family therapy (White 1991; White and Epston 1990). The originators of solution-focused therapy, while educated as social workers, developed this approach for family treatment (Berg 1994; De Shazer 1985, 1988), but it has also been used with individual clients alone. Stimulated by studies claiming the superiority of one model over another, psychologists have conducted meta-analysis of these studies and identified commonalities across models that account for change. Originally proposed by Lambert (1992) and widely disseminated by Duncan et al. (2010), the common factors approach notes that the variance in outcomes in psychotherapy is a result of client and extratherapeutic factors (40  percent, referring to a client’s psychological and social resources), therapeutic relationship (30 percent, referring to features such as empathy,

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warmth, bonding, agreement on goals and tasks), expectancy and placebo effects (15 percent, referring to hope and expectations that clients may have about the likelihood of help forthcoming), and techniques (15  percent, referring to the unique therapeutic approach and techniques of the particular model). Further studies conducted by this group have reinforced the therapist’s catalytic impact. Specifically, greater positive outcomes resulted when therapists consistently sought, received, and used direct feedback from their clients about the nature of the relationship and clients’ perceptions of their progress in achieving their goals (Miller, Hubble, and Duncan 2015). These components and the importance of the collaborative relationship will be discussed in depth in chapter 4. For the current discussion, it is important to consider the extent to which these potent factors are present in each social worker’s knowledge base for practice. The third level in our conceptualization of knowledge consists of a set of principles, tasks, or skills that the practitioner can use to achieve goals. Some intervention models include specific processes, activities, or techniques, or a combination of these components, described in manuals. Other models are expressed at a more general level and practitioners use generic social work principles and skills to implement the various stages in the helping process. Many of these practice principles, also referred to as practice wisdom, have evolved and endured over time. These principles are often based on core client-centered social work values regarding respect, self-determination, and collaboration. Some principles that have withstood the test of time and are still relevant in contemporary practice are start where the client is, go at the client’s pace, and respect that clients are experts on their own experiences. In earlier work, experienced social workers who were becoming field instructors were asked about the theories and models they used to guide their practice. Most respondents reported using many theories and models, and a range of principles and skills based on their own practice experience (Bogo and Vayda 1998; Kenyon 2000). This observation remains current today, as anecdotally social workers report being exposed to a vast and everincreasing body of knowledge, emerging research about social functioning and the human condition, empirically supported models, and approaches disseminated by compelling “master therapists.” It appears that each social worker develops her own knowledge base to guide her professional practice. These models are based on a number of factors, including the dominant social work approaches used during the time the social worker was in

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school, early supervisors’ preferred approaches, par ticu lar models and principles promoted in the employing setting, and the needs and responses of the particular client population. Practitioners are attracted to certain theories and models when they resonate with their own assumptions and beliefs, and may also reject other approaches, seeing them as antithetical to personal and professional values. Since models are only partial approximations of phenomena observed, it is likely that over the course of their career social workers will try to improve or replace elements of their models with better and more useful explanations and approaches. Eclecticism has both its supporters and critics. Practice should be more than a “bag of techniques” applied in a haphazard manner. It is important to understand the underlying assumptions or concepts connected to the models and principles to be used. Having an in-depth familiarity with a limited number of theories and models provides the practitioner with a flexible set of ideas to explain why problems develop and exist, how individuals and situations change, and what the practitioner can do to facilitate that change. These ideas are useful for practitioners and, when shared with clients, promote collaboration. Concepts, models, and principles guide information gathering that leads to forming joint understandings and assessments with clients. They assist the social worker in discussing proposed interventions with clients, thus providing transparency. Clients are able to participate actively in framing issues and choosing interventions, thus enhancing the goodness of fit between client values and preferences and the social worker’s choice of approach. As a result of these factors, models provide a direction for intervention. The conceptual map in figure 1.2 presents an example of a number of explanatory theories, practice theory or intervention models, and the related skills or techniques associated with each model. This map also includes common factors, generic social work practice principles, and interviewing skills. This figure is only one example, however, of how these levels of knowledge can be put together. A useful exercise for students and experienced social workers is to identify the dominant elements in their own approach at the level of explanatory theory, practice theory and intervention models, practice principles, key skills, and any other significant features. Such an exercise leads to articulating one’s own professional practice model. The role of research in informing social work practice has been a focus of discussion and debate, especially in the past few decades. Social workers

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are committed to using the most effective approaches to bring about positive client outcomes. How to achieve this has occupied the profession for many years. Bruce Thyer, a leader in promoting research for practice, provides an excellent review of the history of research in social work practice (2009). Nomenclature can lead to confusion in understanding the various terms and approaches. Drisko and Grady (2015) usefully distinguish between product and process. Evidence-supported treatments are products established as effective through intervention research studies. Such models and programs are also referred to as empirically supported interventions. (Confusion in terms arises as some funders refer to such programs and models as evidence-supported or evidence-based programs.) Evidence-based practice, however, refers to a process that brings together the best research evidence with clients’ values and preferences and social workers’ clinical expertise. Many have argued for the necessity of developing an empirical, scientifically sound knowledge base to guide practice. Well-designed intervention studies would provide information about what works, with whom, and under what circumstances. The goal is to identify the practices used in social work, defined as “behavior that can be volitionally manipulated and purposefully engaged in to achieve a professionally relevant condition” (Proctor 2010, 256). Earlier, there were scant useful studies on which practitioners could draw. There has been a significant and promising trend in this regard since the beginning of the twenty-first century, however. In 1999, Rosen and colleagues noted that most published studies contributed to descriptive knowledge of populations or explanatory theory, with only 7 percent of papers published in a sample of leading social work journals focused on intervention (Rosen, Proctor, and Staudt 1999). Reid and Fortune (2003) conducted a systematic review and analysis of empirically tested social work intervention programs in direct practice. Of the 107 studies reviewed, group programs accounted for the majority (59  percent), with individual intervention used in 20  percent, family used in 9  percent, and mixed methods in the remainder. The authors found two distinct types of effective programs; the group type was more prevalent and consisted of structured cognitive-behavioral interventions that used skills training, education, and group processes. The second type was mainly individual and resembled a case-management approach with concrete ser vices and use of relationship. Reid and Fortune (2003) concluded that although a number of studies exist, they do not reflect “the world of everyday practice [where]

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one finds considerable attention to any number of approaches that one finds little of in these tested programs—for example, generalist, ecological, solution-focused, and psychodynamic” (70). Furthermore, they observed that while the majority of studies were about group interventions, the great majority of social work practice is conducted in an individual format. More recently, however, reviews of relevant practice research studies show a changing scene. Howard and Garland (2015) examined trends in the number and types of social work publications between 1984 and 2014. They found a significant increase in research publications in general as well as in the numbers of meta-analyses, systematic reviews, literature reviews, treatment outcomes, and clinical trial reports. These reviewers comment, however, that “these types of studies remain disappointingly small in number” (181). Thyer has been a leading proponent of the ethical imperative for social workers to use interventions that have demonstrated effectiveness based on rigorous empirical studies of client outcomes (Thyer and Myers 1998, 1999). In a compilation of a bibliography of randomized controlled studies conducted by social workers, over 740 studies over the period of 1949 to 2013 are presented (Thyer 2015). Thyer speculates that earlier reviews, such as those noted above, may not have identified many of these studies, as the articles were not published in social work journals but rather in those of other disciplines. Finally, DePanfilis and Herman (2015), in an editorial on intervention research in a special issue of the Journal of the Society for Social Work and Research, note the growing number of high-quality effectiveness studies addressing a wide range of change strategies for populations of concern to the profession. They conclude that more and more scholars are conducting rigorous and carefully implemented research that “will provide crucial guidance as the social work profession strives to identify and implement feasible and effective solutions to society’s most pressing problems” (464). Similar to related health fields, especially medicine, evidence-based practice has gained attention in social work. Key sources for learning about this approach in social work are offered in Gambrill (1990) and Gibbs (2002). A comprehensive definition is “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual [clients]” (Sackett et al. 1996, 71) and “the integration of best research evidence with clinical expertise and [client] values” (Sackett et al. 2000, 1). Thyer (2013) describes the process as involving social workers in identifying a practice question relevant to the practice situation they confront,

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systematically searching for relevant empirical literature, and critically appraising the research evidence to determine what interventions have the greatest amount of scientific support. Such interventions would be considered in relation to the social worker’s own clinical expertise and judgment; the context of the practice and ethics; and the clients’ values, preferences, expectations, circumstances, and culture. The latter is a crucial step, as it provides transparency and collaboration with the client, and involves him in a way that enables him to learn about the possible intervention and make an informed choice about whether to proceed or not. The final step is to implement and evaluate the outcomes of the practice decision. This step is similar to the principle described earlier of seeking continuous feedback from clients about the progress of the work. These approaches to using research to inform practice in part reflect the dominant positivist paradigm in contemporary health science professions and are both ethically and intellectually appealing. Certainly, social workers’ confidence that they can offer helpful services is improved if they have a rigorously developed knowledge base on which to rely. There are some practical and ideological issues, however, that mediate unconditional adoption of this approach. Evidence-based practice is easily applicable to practice models that can be articulated, defined in treatment manuals, and tested through controlled experiments. In the mental health field, this approach has yielded support for behavioral models, but is less easily applied to models that are not as readily defined in operational terms. As a result, many types of approaches are not studied in the same manner and hence are not available in the empirical literature (Adams, Matto, and LeCroy 2009). A further criticism is that evidence of effectiveness comes from studies that are conducted on samples that do not fully represent the population of clients served in everyday social work practice in community settings (Adams, Matto, and LeCroy 2009; Raw 1998). Samples in many research studies use criteria that often exclude clients with multiple presenting problems and symptoms. Given the vast number of factors in individuals’ lives and in families, groups, and communities, it is impossible to completely predict outcomes. As Gitterman and Knight (2013) observe, social work is concerned with clients who are significantly affected by their social context and such issues as “poverty, unemployment, oppression, racism, homelessness, and community violence” (71). An understanding of this complexity and an appreciation of the crucial impact of contextual factors may be

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more appropriate for social workers (Bolland and Atherton 1999). In a naturalistic study of cross-cultural counseling, we found that many of the clients who approached the participating community agencies for assistance had a wide range of complex problems that included combinations of issues such as family conflict, social isolation and relationship problems, violence, depression, and need for employment (Tsang, Bogo, and George 2003). Furthermore, outcomes reported in studies are for those clients who participate in the full program being tested and who comply with the approach. Generally, the studies do not investigate the clients who drop out. As a result, the samples may represent a more motivated group of clients than those seen in social workers’ practice. Finally, a challenge remains with respect to utilization of the ever-expanding body of information. How can practitioners in agencies that are resource challenged gain efficient access to such knowledge, as well as the competence and skills needed to effectively use what may be unfamiliar intervention approaches? Over time, social work scholars and practitioners have argued that in a profession that is concerned with humanism and ethical dilemmas, artistry is as much a concern as science (Goldstein 1990, 1999). The art of social work, like that of any other professional practice, is elusive and difficult to define. It can refer to a range of dimensions and usually includes curiosity, creativity and innovation, reflection-in-action (Schon 1983), and flexible use of self in relation to the uniqueness of the client. These dimensions are discussed further in this text, both in chapter 2 in discussing holistic competence as involving use of self of the social worker and in chapter 4 regarding the impact of the social worker’s personality in forming the relationship. Rather than creating a false dichotomy between science and art, Grady and Keenan (2014) propose seeing art and science as intertwined and interdependent. Drawing on information from multiple sources—from clients, empirical findings, and their own practice expertise—social workers use their own judgment to drive their work. Social workers tend to recognize the limits of sole reliance on any one theory or model (with or without research support) to guide professional work. Rather, it is important to learn how to use practice knowledge derived from many sources in a flexible way as a potential lens for understanding and working with a client. An example of this type of integration is seen in the primacy given in social work to the working relationship. The vast amount of research on

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common factors demonstrates the powerful influence of the working relationship between the practitioner and client (Duncan et al. 2010). Hence, any intervention the social worker chooses should be nested within the interpersonal process between the two. This involves attention to relationship development, maintenance, rupture, recovery, and repair. In this way, practitioners use evidence in their practices. The social worker will, however, need to use the art of practice to build relationships with each client based on the client’s unique characteristics and needs. Attention will need to be placed on the ebb and flow of this relationship as the various phases inherent in a change or supportive process unfolds. Social workers also draw on knowledge relevant to the populations they serve. This can include information about client characteristics and issues. Practicing with children with diabetes, for example, would require medical knowledge about the condition and its impact on families, as well as potential prognostic factors that are likely to emerge over the life course. Knowledge of relevant resources, programs, and policies are crucial so that families can be helped to navigate the complexities of social ser vice and health delivery systems. Gaining access to entitlements is difficult, and social workers may be able to cut through “red tape” and persistently support and advocate for individual clients. They can also advocate with and on behalf of at-risk populations for the development of necessary programs and ser vices. Therefore, they need to be highly knowledgeable about the specific conditions that clients present with, from housing, employment, health, and educational needs, to those with special situations. To end this section on the use of knowledge, practitioners and social work students may wish to return to the conceptual map in figure 1.2 discussed earlier. One can examine their preferred theories, models, and techniques, and think about whether there is empirical evidence to support the various components. In the absence of research, what are the influences that have led to the choice of various components? This chapter presented and discussed elements in a model of holistic competence for social work. Key points that were made related to the notion of holism, which posits that practice consists of the nuanced integration of explicit and implicit ideas, processed through the personal and professional preferences of the social worker, and through the dynamic interactions with clients and their situations. Although competence always directs attention to what is actually done in practice, it is influenced by

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numerous dimensions that are not obviously apparent. Accordingly, in this chapter attention was paid to the context within which practice takes place and the ways professional, organizational, and societal factors influence what can be offered and accepted. Finally, the explicit knowledge base for practice was considered, including the many levels of explanatory and practice theory, models, and techniques and skills. The role of research in guiding practice was discussed. While social work as a discipline is conducting more and more intervention studies, some have argued that the “art” of practice must be acknowledged and integrated as well.

2

Holistic Competence: Cognitive and Affective Processes

on holistic competence as depicted in figure 1.1 in chapter 1. Recall the central premise of holistic competence: social work practice competence is evident as the practitioner uses a set of communication behaviors and interviewing skills to carry out complex practices or practice behaviors as she interacts with the client. These nonverbal and verbal behaviors are what we see when we observe social workers in their practice. These practices are informed by the social worker’s professional, organizational, and community context. Social workers use knowledge from a variety of sources, including explanatory and grand theories, practice theory or intervention models, research evidence, practice wisdom characterized as practice principles, and information about the population. This is the traditional view of competence—that it consists of the application of knowledge, values, and skills to practice situations (Hodges and Lingard 2012). Based on a program of research that explored views of professional competence, it became apparent that such a view omits the active involvement of the professional self. How social workers use knowledge, values, and skills is based on the ways they bring their own cognitive and affective capacities to bear on interpreting and reacting to the experiences they encounter in practice. We have referred to these dimensions as metacompetencies, that is, “higher order, overarching qualities and abilities of a conceptual, interpersonal, and personal/professional nature. This includes our cognitive, critical, and self-reflective capacities” (Bogo et al. 2013, 261). In further research studies, our team examined the links between proce-

this chap ter continues the focus

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holi s ti c compe t e n c e d i me n si on s: c ha pt er  2

Cognitive Pro cesses and Professional Judgment

• Use of Knowledge • Critical Thinking • Implicit Knowledge • Mindfulness • Impact of Context Affective Pro cess, Self, and Emotional Self- Regulation

• Social Identity • Emotional Self- Regulation • Reflective Practice and Self-Awareness

dural competence, what can be observed and rated when observing a practice, and metacompetence, what social workers expressed in structured reflections elicited immediately after a simulated interview (Bogo et  al. 2012; Katz et  al. 2014; Logie, Bogo, and Katz 2015; Tufford, Bogo, and Asakura 2015). Analyses of these reflections led to the conceptualization of holistic competence as presented in figure 1.1 in chapter 1. Metacompetencies that emerged are depicted separately on the right side of figure 1.1: an affective dimension including self-regulation based on the social worker’s reflective capacity and self-awareness of emotions and their impact on practice, and a cognitive dimension including judgment emanating from the worker’s personal assumptions, critical thinking, and decision making. For clarity, these dimensions are discussed separately. It is important to remember, however, that cognitive and affective processes operate in an iterative and interrelated manner. Competence is viewed similarly in EPAS 2015: “EPAS recognizes a holistic view of competence; that is, the demonstration of competence is informed by knowledge, values, skills, and cognitive and affective processes that include the social worker’s critical thinking, affective reactions, and exercise of judgment in regard to unique practice situations” (CSWE 2015, 6). Cognitive and affective processes are identified within the description of the nine competencies.

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Active involvement of the social worker’s self is paramount, for there are a myriad of internal dynamics at play as social workers bring their own assumptions and emotional reactions to bear on the client narratives they listen to and the interpersonal interactions with which they are involved. Operating at various levels of awareness, social work practice is affected by the impact of practitioners’ emotional reactions to information and interactions. They make sense of these experiences using internalized schemas to understand human behavior, drawing from the knowledge base discussed earlier as well as from their tacit knowledge. To reiterate, tacit knowledge refers to assumptions, learned over the course of a person’s life, which are internalized and not easily articulated. cognitive processes and professional judgment Use of Knowledge

An important turning point in scholarship on and theorizing about professional practice occurred when Donald Schon (1983, 1987) questioned the dominance and limits of a positivist perspective. He labeled the notion that professionals simply apply theory to practice as technical rationality. Schon studied practitioners from a range of professions while engaged in their work and noted that they encounter many situations that do not respond to technical, rational, or predictable techniques. Instead, practitioners face unique and complex problems that do not easily fit into existing explanatory categories. These situations challenge a view of professionals that solely depicts them as having certainty about procedures and outcomes as they apply expert knowledge in their practice. In addition, professionals are often confronted with situations in which conflicts in values render technical responses insufficient. For example, a school social worker meets with an adolescent boy who is aggressive and having difficulties in class with peers and his teacher. The social worker knows that the best evidence shows that a cognitive behavioral group approach is effective for aggressive adolescent boys. Yet she also knows that the boy’s mother died six months ago and that his father is having trouble managing as a single parent of three children and has discussed the possibility of this boy temporarily moving in with relatives who live in a nearby town. Furthermore, the pressure of serving many schools with large student populations results in little time for the school social worker to provide continuous long-term inter-

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vention. This situation presents numerous issues at an individual, family, and systems level that are beyond a group intervention and require referral to and collaboration with agencies that provide prolonged ser vice. Moreover, the client is a young adolescent boy who feels that others are making decisions about his life and not seeking his opinion. His active role in establishing his goals in any ser vice plan will be crucial. With the complexities in this practice example, a competent social worker will need more than the ability to apply empirically supported models to practice. The social worker will need to think systemically; understand the impact of multiple factors on the adolescent’s thinking, feelings, and behavior; and be able to work with the boy, his father, and the classroom teacher to focus on what needs to be addressed. Since her involvement may be limited by agency policy, she will also need to advocate for youth in similar situations who require more help than is available within this setting. While the social worker will contribute her knowledge about interventions that work, she will also contribute her expertise in working with people in a process that helps them identify and work on troubling issues in their lives. Social workers practice with contingencies, exceptions, and unforeseen events that require them to use general ideas insofar as they can be of help in understanding unique, individual circumstances. By virtue of recognizing individual diversity, social workers are more often dealing with exceptions to the theory rather than an ideal case that neatly fits the categories. Schon (1983, 1987) proposed the reflective practice paradigm to capture the way the intuitive know-how of practitioners is brought to bear in their work. When practitioners are confronted with the uniqueness of particular cases, they appear to engage in a type of “on-the-spot inquiry” (Schon 1987, 40) and consider what is occurring and what actions are and are not successful. This reflection-in-action draws on past experiences with similar situations, formal theories and their general principles, and intuition to arrive at new insights and, hence, new action. Unlike the epistemology of technical rationality, reflection-in-action is nonlinear: it happens in the moment and recognizes that practitioners’ experience, wisdom, and insight operate in a way that allows them to improvise. Although this capacity is sometimes referred to as intuition, it is far more than that. Rather, it is a mark of professional expertise, that is, the ability to quickly appraise a situation and decide what course of action to take, without going through a  deliberate reasoning process. Of interest is that a British social work

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scholar, Hugh England (1986) presented a similar view, although it is not apparent that he was influenced by Schon. England (1986) stated that the integration of theory and practice is a unique and intuitive process in which social workers do not simply apply formulae. Rather they use their knowledge to construct coherence derived from the complex situations they see before them. Similarly, educational researcher and scholar Michael Eraut observed that use of knowledge consists of explicit, conscious, and deliberate efforts, as well as contributions from that which is implicit or tacit, out of awareness, and not easily represented and described (Eraut 2000). This perspective is appealing, as it appears to reflect the nature of social work practice. It has presented challenges, however, especially for teaching new social workers. The difficulty arises from the challenge in describing the process experienced practitioners use to bring explicit knowledge frameworks and their implicit knowledge into their professional activities. In chapter 1, it was noted that when experienced social workers were asked directly about the theory or approaches they use in their work they often responded that their practice is eclectic or intuitive (Bogo and Vayda 1998). Through a structured dialogue, however, practitioners were able to stand back from their practice, critically reflect on it, and offer descriptions of some of the implicit components or tacit knowledge that underlies and guides their actions in an interview. In a qualitative study addressing how field instructors teach social work students to integrate theory and practice, Kenyon (2000) found that social workers did not separate theory from practice as is done in university-based courses. They did not clearly identify the theories they used, nor did they describe a systematic application of concepts in practice. Instead, they described a process in which, from the very first interaction with clients, they were making meaning of the information they received from the client and the information they gleaned from their participation with and observation of the client. These understandings, which social workers described in everyday language, revealed their continuous engagement in building a theory about the case. When pressed by the research interviewer, they could describe aspects of their work and the rationale for actions taken. In these descriptions, formal theories were obvious, but were not labeled as such. They were integrated into the workers’ descriptions of their practice, however. Through reflection in the research interview, they described a process in which two activities happened simultaneously: they were actively involved as a participant with the

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client at the same time that they were reflecting on what was transpiring. Insights the workers gleaned from this reflection would then play a part in directing the next steps they took in the interview—to proceed or to change course. This process was flowing, cumulative, and integrated. Schon (1987) referred to this activity as “reflection-in-action” and noted: “Skillful improvisers often become tongue-tied or give obviously inadequate accounts when asked to say what they do. Clearly, it is one thing to be able to reflect-inaction and quite another to be able to reflect on our reflection-in-action so as to produce a good verbal description of it” (31). One can conclude that practitioners accumulate a vast reservoir of knowledge, experiences, and skills over many years. Influences on this knowledge base come from many sources and include significant learning from course and field instructors during social work studies that includes instruction on particu lar theories and empirically supported models. These instructors may also have served as role models in their interactions with students, may have offered descriptions of their own use of theory in practice, and were perhaps inspirational practice teachers. Many practitioners credit their field instructors and clinical supervisors in their early years of agency employment as having had the greatest influence on their learning. Observing skilled colleagues and attending workshops are other important sources for continuous learning. From these experiences, each practitioner appears to incorporate her own set of concepts or ideas and professional behaviors and skills based on what makes sense to her and feels congruent with her sense of self. This initial core of knowledge and skills constitutes a unique professional practice model that serves as a foundation for the particular social worker. Over time, some parts may be rejected and replaced with new conceptual building blocks. Reflecting on one’s practice with a critical eye enables social workers to evaluate their work and examine the effect of specific actions on their clients, leading to the development of some generalized principles. As these generalizations are used in subsequent situations, they may be refined or, if their effect proves to be limited, discarded. Through subsequent experience, more pieces of knowledge are incorporated into the worker’s practice to create an intricate, complex, multilayered framework. Clearly, this is an evolving long-term effort to construct, deconstruct, and rebuild one’s professional practice model. It is an iterative process, one that is stimulated by being in practice. The result is similar to a richly colored tapestry, for the

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practitioner’s knowledge base is made up of many different threads; one cannot easily extract particular strands without distorting the whole. When practitioners consciously examine and deconstruct their practice, however, they are able to identify some of those underlying or implicit values, concepts, and beliefs. Social workers’ knowledge building for practice likely evolves in a less-thanconscious way, stimulated by opportunities to present and discuss their work with others. Practitioners identify that teaching, such as in field instruction, is a motivator to think critically about their practice and identify what they do and why (Bogo and Power 1992; Globerman and Bogo 2003). The model of holistic competence presented in this text emanated from research conducted at the University of Toronto, Factor-Inwentash Faculty of Social Work (Bogo et al., 2011; 2012; 2017; Regehr et al., 2010). These studies used a similar methodology. Students and experienced social work practitioners interviewed simulated clients portrayed by actors trained to represent typical client situations. Immediately following the interviews, participants responded to a series of reflective questions designed to reveal their understanding of the case, the knowledge they were using to assess the presenting problem and to plan further interventions, their emotional reactions to the situation, and their assessment of their practice. For a full description of the methods used in four studies, see the following: two studies on generic social work involving students and practitioners are described in Bogo et al. (2011, 2012); a study on child welfare workers assessing risk of child maltreatment is described in Regehr et al. (2010); a study on mental health social workers and students assessing suicide risk is described in Bogo et al. (2017). Analysis of the reflections in these four studies yielded insights into the ways practitioners and students conceptualize their practice, engage in critical thinking, and make judgments about the presenting problem and the ways they should intervene. Great variation was found in the way our study participants used conceptual knowledge to analyze the issues in the various simulated situations and to examine and evaluate their own practice. Some student participants actively used the various types of knowledge discussed in the previous chapter: explanatory theory, practice theory or intervention models, or practice principles. For some, there was a rich, textured, indepth analysis that drew on these various constructs, demonstrating the ability to think conceptually and critically, and link cognition and intentional action. Others used only one level of concepts, usually practice the-

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ory and principles. Yet for others there was little use of knowledge; their descriptions were concrete and on the surface provided little evidence of abstract or critical thinking (Bogo et al. 2013). A striking finding was that the choice of an explanatory concept had a profound impact on guiding the interview and may lead to premature assessment conclusions. In an analysis of a potential child neglect case, for example, participants reported on their use of one of three explanatory frameworks to assess the situation and to guide their interventions. A third of the participants detected the possibility of neglect and inquired about relevant client behavior; another third focused on the client’s concern that she was a bad mother as she had difficulty with the baby’s crying. These participants largely focused on providing empathy and normalizing the situation and did not inquire about, and hence missed, the signs of neglect and possible abandonment of the baby. The final third of the participants conceptualized the situation as a possible postpartum depression and used this formulation to guide the information they subsequently sought about the client’s mental state and behavior; they also missed the issue of neglect (Tufford, Bogo, and Asakura 2015). The research team was especially interested to see whether participants understood how diversity and difference could affect the way the situation was understood and how such understanding could influence engagement and assessment. (Although the study was designed prior to the current EPAS, these dimensions are consistent with aspects of competencies 1, 2, 6, and 7.) As a result, all scenarios included a variety of visible or expressed dimensions of diversity and included clients such as a widowed mother from a South American country, a Jamaican Canadian adolescent fearful of her family’s reaction about her coming out as a lesbian, a frail elderly woman contemplating a move to assisted living, and a recent immigrant young mother from Eastern Europe. The analysis found that participants ranged along a continuum from those able to recognize culturally based issues relevant to the client or salient aspects of difference as it unfolded in the interaction with the social worker, to participants who recognized these diversity issues but were not able to use that awareness in their practice, to those who minimized or ignored these dynamics (Bogo et  al. 2013). When participants acknowledged diversity issues, they engaged in thoughtful reflection and discussion about the client’s experience, how the student might be perceived due to difference, culturally based interpretations of the situation, and systemic and structural barriers and influences on the situation. These

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participant reflections showed not only conceptual understanding but also deliberate thought about how these insights could be used in practice. For example, respondents spoke about letting clients tell their story; being openminded and curious; and inquiring about clients’ values, expectations, and norms “back home.” In addition, they were mindful about avoiding premature conclusions that might be caused by their lack of knowledge or unexamined assumptions connected to any social identity dimension. Participants in another group were aware of many of these issues but stated that they were not able to use this understanding due to their own discomfort, lack of enough knowledge, or not wanting to appear as if they were stereotyping the client. A further analysis of participant responses to the Jamaican Canadian client revealed that their lack of time, confidence, or knowledge led to avoidance of engaging with issues associated with coming out and hence the client’s concerns were not responded to or addressed in any depth (Logie et al. 2015). The gap in knowledge was explained in relation to not knowing what terms to use and lack of familiarity with LGBQQ (lesbian, gay, bisexual, queer, and questioning) issues and appropriate practices. Critical Thinking

These studies’ findings lead to numerous implications regarding cognitive processing. The way practitioners use knowledge impacts the way they conduct interviews and ultimately the practice decisions they make. First, as discussed in the previous chapter, social workers need to have a wide-ranging knowledge base to assist them in understanding client situations and in using that understanding to guide their practice. Second, they need to consider how they use that knowledge base, that is, what impacts the way they select or ignore potentially useful ideas and information. How does a choice of one theoretical perspective guide the information they seek and therefore cause them to omit inquiring about other potentially important information? What are their own processes of critical thinking? Do they reflect on their practice, share their experiences with colleagues and supervisors to gather insights, use feedback from others, or exclusively rely on their own judgments? These are important questions to consider when examining the nature of cognitive processing in social work practice. Critical thinking is a term used frequently in social work when discussing cognitive processing. The term apparently has many meanings in the

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general literature, in literature in related professions such as education and nursing, and in social work. Some of the definitions may conflict with each other. A critical review found consensus for social work on the following point: “for social work, critical thinking is a process of practical reasoning, aimed at correct action” (Mathias 2015, 468). Two different perspectives were evident in the literature, however. One perspective views critical thinking as being based in scientific reasoning and uses a definition of it that is similar to that offered in EPAS 2008 (CSWE 2008). Although EPAS 2015 (CSWE 2015) does not identify critical thinking as a separate competence, and hence does not define the term, it is integrated throughout the nine competencies. The definition in EPAS 2008 (CSWE 2008) states: Apply critical thinking to inform and communicate professional judgments. Social workers are knowledgeable about the principles of logic, scientific inquiry, and reasoned discernment. They use critical thinking augmented by creativity and curiosity. Critical thinking also requires the synthesis and communication of relevant information. Social workers •

•

•

distinguish, appraise, and integrate multiple sources of knowledge, including research-based knowledge, and practice wisdom; analyze models of assessment, prevention, intervention, and evaluation; and demonstrate effective oral and written communication in working with individuals, families, groups, organizations, communities, and colleagues. (4)

Another definition of critical thinking arises from social constructionism and involves recognizing “the values inextricably embedded in facts, helping to ensure that practice is aligned with good values” (Mathias 2015, 469), which implies social work values. With respect to critical thinking about, for example, assessment models, this perspective includes “questioning the values and power dynamics assumed or perpetuated by the model” (Mathias 2015, 470). Postmodernism and social constructivism acknowledge multiple realities and clients’ active participation in interpreting their own lived experience and what they might define as a problem and a way of addressing it (Dean 1993). As a result, critical thinking in social work must be more than the practitioner’s solitary activity; instead, it should be an interactive process of meaning making between the worker and the client. Mathias (2015) calls

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for more scholarly discussion of these two epistemological positions about how facts and values should be considered in practical reasoning. Implicit Knowledge

Thus far, the discussion of implicit knowledge has focused on what social workers learn and internalize through professional practice while also alluding to aspects of implicit knowledge of a personal nature, acquired over the life course. Educational theorists such as Eraut (2000) and Kolb (1984) note that our experiences become integrated into our memory, contribute to our general knowledge, and can operate at a level of which we are not fully aware. Influenced by our life experience, the context within which one grows, and the meanings attributed to events, individuals incorporate, modify, or reject values, norms, expectations, and assumptions associated with the human condition, optimal social functioning, and ideas about change. These dimensions constitute an individual’s worldview, personal constructs, or schemas (Eraut 2000; Kelly 2013), and include emotional reactions to events. Polyani (1967), used the term tacit knowledge to refer to this expansive reservoir of knowledge that we all possess. Our analysis of students’ reflections in the simulated interviews showed that they used personal and tacit knowledge. Many students easily drew parallels between the simulated client situations and their own personal experiences that bore similarities to them (Katz et al. 2014). Indeed, when asked to analyze the simulated problem, some students drew on their own personal experiences rather than on theoretical concepts presented in their courses. In a scenario with an elderly client facing multiple losses and considering moving to an assisted living facility, for example, many students made reference to their personal experiences with grandparents, their own family members’ responses to their grandparents’ need for assistance, and to religious or ethnic views about intergenerational relationships and appropriate forms of care. Their analysis and plans for how to help the simulated client drew explicitly from the personal knowledge derived from those situations. Although students had learned about concepts associated with life course development, aging in contemporary society, and transitions between home and institutional living, they made no mention of these concepts when reflecting on the scenario. When considering the role of personal or implicit knowledge in professional work, two important caveats emerge. First, although this form of

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knowledge can operate effortlessly and spontaneously, it may simply reflect practitioners’ personal biases and therefore may not be valid for use in professional situations. Second, personal knowledge might be somewhat removed from the practitioner’s conscious awareness. Practitioners must engage in reflection and self-awareness to identify the sources they draw on to reach particular conclusions and to examine the ways they make judgments in professional practice (Ruch 2002). While reflection is often seen as a solitary activity, following Brookfield’s (1998) observation that individuals use their “own interpretive filters to become aware of [their] own interpretive filters” (200), it may be more useful for practitioners to use clinical supervision or discussion with peers to reveal these assumptions, worldviews, and cognitions. Linking reflections to observations is also important. Schon (1983) noted that in professional work, as in our daily life, a type of know-how is demonstrated. Such knowledge may be less available to articulation but may become evident when observed. For example, when watching an experienced practitioner interviewing a client who initially appears tense, scared, and provides few answers, one may observe the following: The practitioner bends and flexes in a subtle way, gently discussing nonthreatening topics, and uses encouraging nonverbal gestures, until she perceives that the client is adopting a more relaxed body posture and is making more frequent eye contact. The practitioner may then proceed to ask more emotionally difficult questions, sensing from her observations based on her past experience (and hence implicit knowledge) that the client may be ready to respond. An observer may be able to describe this process, label the skills used, and detect the principles followed; for the practitioner, however, it is more likely that this type of knowing-in-action when engaging clients is carried out almost automatically rather than in a deliberate, conscious way that plans each step. As a result, effective social workers are able to act and engage in a flexible and agile manner. Mindfulness

In considering cognitive processes, social workers can benefit from the extensive literature and research on mindfulness practices. Kabat-Zinn (2003) introduced mindfulness-based stress reduction (MBSR) in behavioral medicine over twenty-five years ago. There is considerable evidence for the effectiveness of mindfulness in reducing chronic pain, helping people

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cope with stress-related difficulties, and facilitating recovery in individuals with depression (Segal, Williams, and Teasdale 2013). Mindfulness programs are also present in schools, workplaces, and prisons (Kabat-Zinn 2003). Mishna and Bogo (2007) suggest that social work educators may find reflective practice and mindfulness useful when discussions of power, privilege, and oppression lead to heightened tensions in contemporary classrooms. The aim of mindfulness is to attend to the moment-to-moment flow of experience with a receptive and nonjudging awareness. In the words of Kabat-Zinn, it entails “cultivating and refining our innate capacity for paying attention and for a deep, penetrative seeing/sensing of the interconnectedness of apparently separate aspects of experience, many of which tend to hover beneath our ordinary level of awareness regarding both inner and outer experience” (1990, 15). The preceding discussion of cognitive processing noted the ubiquitous and automatic nature of reactivity. Mindfulness could provide a way to disengage the quick links we make among perceptions, interpretations, and responses. Greater awareness can facilitate an intentional practice in which practitioners choose their responses rather than responding in a habitual and “mindless” manner. This view of oneself as a calm participant-observer appears to support the practitioner’s ability to use reflection-in-action. The practitioner needs to be both engaged and active in the present moment with the client while also maintaining an adequate level of awareness and attention to observe and think about what is occurring. Students and practitioners who use contemplative practices report that they increase attention, awareness, and intentionality (Birnbaum 2008; Gockel et al. 2013). This may be one approach to facilitate reflection-in-action that leads to changes to practice behavior in the moment, in contrast to reflections that contribute to thinking about practice after the fact. Impact of Context

Social work researchers and practitioners in England and Ireland have commented extensively on the impact of societal and agency cultures in statutory sectors, especially child protection. They point out that practice in this area involves ambiguity and uncertainty, and pressures to determine risk to children (Munro 2011; Ruch 2007). Responding to public inquiries, practitioners have adopted a managerial approach that causes them to

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focus on accountability indicators, paradoxically at times at the expense of offering a client-centered ser vice. In this environment, Munro (2011) recommended that social workers reclaim their expertise in human ser vice work. She notes the importance of reflecting on practice experience—to have “time and attention given to mulling over the experience and learning from it” (90). Such reflection is ideally conducted with peers or supervisors, as one cannot always see one’s own blind spots. Furthermore, Munro observes that in contemporary organization life, people are always busy, engaged, and occupied, thus producing a “crowded life,” with little time for the type of examination of their own cognitive processes that have been discussed thus far. As a result, organizations, teams, and supervisors need to provide quiet spaces where critical reflection can occur. Such reflection would provide the place for practitioners to examine their assumptions and judgments about the decisions they make, including the way their own emotional responses influence their conclusions.

a f f e c t i v e p r o c e s s e s , s e l f, a n d e m o t i o n a l s e l f - r e g u l at i o n

Thus far, the focus of the discussion on internal processes has been on the cognitive aspects of metacompetence. This next section addresses affective aspects, but it is false to think about these two processes separately, as they are integral to each other. Social work scholars have long recognized that emotions play a powerful role in thinking and behavior. Recall the discussion in chapter 1 about the social worker’s personal self in relation to holistic competence. To reiterate: Our emotional responses to information and the experience we have when interacting with clients significantly affect our judgments. In turn these emotional responses are related to our tacit knowledge: what we have learned through our personal and professional experiences, the “truths” that are internalized and that are not easily explicitly identified. Therefore, holistic competence must include the ability to be self-aware of our subjective thinking, feeling, and reactions, especially with regard to the judgments we make. Accordingly, self-awareness and emotional self-regulation when involved in professional practice are important dimensions of holistic competence. (Bogo et al. 2014, 8)

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Discussion in chapter 1 also noted that current neuroscience research supports this view (Barrett and Satpute 2013; Immordino-Yang and Damasio 2007; Kahneman 2011). Put another way, professional knowledge in its broadest sense becomes part of and is powerfully influenced by the social worker’s personal self (Larrison and Korr 2013). All of our personal attributes and characteristics are present in everyday life, including in our work. Many factors shape practitioners’ personalities, and their personalities in turn affect their work and comfort level in working with various clients. Personal issues related to the past and present operate as active ingredients in practitioners’ interpersonal encounters with clients. As a result, social workers must strive for self-awareness about and a self-critiquing stance on the way their personal values, assumptions, and emotional reactions are played out in practice. Such a stance is needed so that practitioners formulate assessments and devise interventions to meet clients’ needs and unique experiences rather than basing them on their own unexamined reactions. Social Identity

In North America, social work is increasingly practiced in contexts of diversity and difference. Social workers and their clients often come from different ethnic, racial, religious, and class backgrounds. As a result of global migration, natural disasters, and wars, there are many refugees from different countries of origin arriving in the United States. Competency 2  in EPAS (CSWE 2015), “Engage Diversity and Difference in Practice,” notes: “The dimensions of diversity are understood as the intersectionality of multiple factors including but not limited to age, class, color, culture, disability and ability, ethnicity, gender, gender identity and expression, immigration status, marital status, political ideology, race, religion/spirituality, sex, sexual orientation, and tribal sovereign status” (7). This statement recognizes the complex interplay among these many dimensions. For example, gender is informed by ethnicity, which can be informed by locality, which can inform how one thinks about and practices religion, which in turn may shape views about sexual orientation (Hardy and Laszloffy 1995). Cultures that affect individuals change over time. As feminism has resulted in more equitable policies for women in the workforce, for example, young females experience their gender and career choices differently than women did in previous generations. Similarly, affirmative action policies and programs

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increasingly address structural barriers to equitable access to education and employment for African Americans. Legislation that requires institutions to accommodate the needs of individuals with physical, mental health, and educational challenges also resulted in more accessibility to participation in broader society for groups that often previously experienced marginalization and exclusion. These societal changes affect the hopes, dreams, and expectations of individuals who, in some measure, feel that they are part of these groups. In a discussion of social work practice in the context of diversity and social justice, Guttierez and Ortega (2016) offer the insight that we must view cultural complexity as the ordinary rather than the exception. Hence, our practice should be framed as finding processes that help us negotiate differences with our clients, rather than viewing differences as constraining factors. And practitioners must have heightened awareness of power differences and the privileging of expert knowledge in relation to clients’ lived experiences and deeply held convictions. These authors make the point that they are not disparaging practitioners’ professional knowledge, practice methods, or ethics; rather, they provide guidance to be used in conjunction with an attitude of cultural humility. Such a perspective gives primacy not to extensive detailed knowledge of any particular identity characteristic but rather to self-awareness and respect for different worldviews (Ortega and Faller 2011). The term self-reflexivity refers to practitioners’ awareness of how these social identity factors impact the personal self and the ways values, assumptions, and worldviews serve as standards and norms by which judgments about human well-being and social justice are made. With this awareness, opinions previously characterized as universal are now seen as locally constituted narratives. Although practitioners are not always aware of how such issues affect their thoughts, feelings, and behavior in practice, these dynamics often “ bubble beneath the surface” and operate to some degree in the assessments they make and the interventions they recommend. Furthermore, in a multicultural and highly diverse society, particular social identity or cultural characteristics of both the client and the social worker are often associated with privilege and power, or with deprivation and oppression. In a highly racialized society, for example, people may experience others attributing to them a range of stereotypes about their background, opportunities, and possibilities based on the color of their skin. When the

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worker and client appear to be members of different and distinct groups, each participant may carry societal messages and internalized experiences of advantage or disadvantage into their encounter. Practitioners need to be sensitive to and aware of the ways these experiences and assumptions operate; they influence our expectations of clients’ behavior and attitudes. Awareness is not sufficient, however; social workers also need to be able to work effectively with issues of diversity. The discussion of internal cognitive and affective processes and diversity has been presented separately thus far, as they have developed from different theoretical perspectives. In reality, the way practitioners think and feel about situations in which diversity comes into play is intertwined. Their experiences in their personal and professional lives influence their evolving perceptions and reactions. In any discussion of use of self, it is crucial to recognize that individual social workers internalize social identity factors in unique ways. Social identity characteristics such as age, gender, ethnicity, sexual orientation, economic status, ability, and so on are processed in personal ways that are influenced by unique family and community histories, as well as by personality characteristics and styles. Social work students bring their individual personalities, social identity characteristics, experiences, and values to their social work studies. As discussed throughout this chapter, competence involves the way students and practitioners think and feel about their own lived experiences, the values and schemas they draw from those experiences, and their level of awareness in this regard, especially regarding how these dimensions operate in their practice, in both helpful and unhelpful ways. Lived experiences include not only those of one individual but also those of their significant extended family and reference group members. Emotional Self- Regulation

Neuroscience research further highlights the intricate links among feeling, thinking, and doing (Barrett and Satpute 2013; Damasio 2005). In a series of studies, we have found that social work students as well as experienced practitioners are significantly affected by what we have termed their state of emotional self-regulation; this state in turn affects their cognitive processing and their behavior with clients. Emotional self-regulation refers to the ability to stay calm in the face of experiences that could provoke a person in a variety of ways and lead to a range of negative feelings. For example,

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some participants in a study assessing suicide risk in simulated clients reported that when they felt anxious, confused, and stressed, they were not able to conduct the interview in an organized and systematic way, nor could they remember or use the frameworks for suicide assessment that they had mastered (Bogo, Regehr, et al. 2017). Simulated client behaviors such as not providing information that was relevant to the interviewer’s questions, unwillingness to make eye contact with the interviewer, and lack of responsiveness to the worker’s engagement efforts in general had an unsettling effect on student participants. Some students and practitioners perceived that their own emotional state affected their inability to draw on knowledge frameworks and conduct a focused interview. In contrast were participants who, despite being exposed to the same client behavior, were able to stay calm even though they were not experienced or expert in conducting suicide risk assessments of clients in the age group (adolescent) in the simulation. Being centered enabled them to think about and draw on their relevant knowledge, and transfer and adapt its use to the current scenario. Similar findings emerged in a study using generic social work scenarios. Reported reflections revealed that participants could understand the dynamics presented by a range of simulated clients, but participants whose emotional reactions rendered them dysregulated were “unable to use conceptual knowledge and to enact procedural competencies” (Bogo et al. 2013, 270). In a study of beginning students in a master of social work (MSW) program interviewing a simulated client, students’ postinterview reflections revealed that their own comfort and emotional regulation was influential in their ability to stay focused on and connect with the client (Katz et al. 2014). Students who were able to remain emotionally regulated were able to use the knowledge and skills they had just learned in an intensive practice course to perform complex practice tasks such as engagement and arriving at a joint assessment. In contrast were students who were not able to manage their emotional reactions, and hence found they were limited in their ability to draw on their knowledge and use their skills. As discussed in chapter 1 regarding the interrelationships among thinking, feeling, and performing, cognitive neuroscience research shows that emotional responses to a range of phenomena affect thinking and behavior in practice. In addition, a consistent finding across our studies is that some students and practitioners experienced emotional disequilibrium as a result of interacting with clients who were experiencing intense emotions or

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difficulties, or when faced with situations in which they did not feel competent or confident. Indeed, emotional dysregulation rendered many participants vulnerable in a number of ways; they report that they were less able to draw on, use, transfer, or adapt their knowledge base, or practice wisdom and skills, in contingencies presented in a somewhat unfamiliar situation (Bogo, Tsang, and Lee 2011). Although it is not surprising that beginning students would feel this way, it is a noteworthy finding for experienced practitioners. It is therefore important to include self-awareness of one’s self-state as a dimension of holistic competence. Awareness includes being attentive to our internal experience and identifying states of anxiety and discomfort, as well as states of calm, interest, and attunement to others. In this regard, it is useful to identify specific issues, triggers, and potential situations that can lead to feeling off balance in practice. In addition, it is very useful to identify factors that produce a sense of being centered, engaged, and positively stimulated by one’s work. Social work literature describes various effective methods to achieve these outcomes. A review of these methods is found in chapter 3, which notes the contributions of individual, peer, and group supervision and consultation; mindfulness and meditation; and self-care approaches. Reflective Practice and Self- Awareness

Practitioners should have an ongoing commitment to be mindful of their subtle feelings and thoughts that emerge when working with clients. A stance that values self-awareness helps practitioners learn more about themselves and develop more understanding and acceptance of the links between their external experiences and internal reactions, including the effect of personality styles and identification with social identity factors. Ultimately, the aim is to be more able to work with a broader range of clients and situations. Through self-awareness, practitioners can remain genuine as well as intentional and purposeful in their practice, rather than being reactive to situations they experience as anxiety provoking. Although clinical social workers may use the concepts of transference and countertransference, the generic social work terminology appears to favor the term use of self. Nevertheless, all agree that the development of increasing self-knowledge may be one of the most crucial aspects of lifelong learning for professionals. Edwards and Bess (1998) point out how important it is for social workers to have a systematic inventory of “personal traits

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and characteristic behaviors which come to them as naturally as breathing. They must be able to identify specifically how they act and what they say that is unique to themselves as persons in relation with others and that conveys the essence of their inner selves to their clients” (97). They recommend that social workers examine their own personal solutions to the challenges they have faced in their lives and how these solutions reflect underlying principles and beliefs about social functioning. Not to be overlooked is to also identify what one enjoys about being a social worker. In summary, holistic competence must include the intricate connections between the worker’s cognitive and affective processing in relation to the use of knowledge and practice behaviors and skills in relevant contexts. Cognitive processing and reasoning occur while practitioners are interacting with clients in sessions and during reflection after an interview. This involves conscious, deliberate reflection that integrates the various dimensions discussed in this section: the professional knowledge selected and used, a consideration of alternate frameworks, the role of tacit and personal knowledge, and an awareness of critical thinking. Affective processing involves an in-depth self-awareness, preferably during the session, but also after the session. Knowledge of self includes dimensions related to practitioners’ worldviews and the internal working models and schemas they use to determine what is functional, what needs to change, and how that change might occur. Self-knowledge is ever evolving and is a product of the way practitioners incorporate or reject the lessons learned from their affiliations and identifications with a range of social identity characteristics over their life course. Finally, the practitioner should pay attention to knowing oneself and the situations and triggers that engender dysregulation, as well as those that promote calm and confidence. When all of the dimensions of holistic competence are brought together, it is more likely that practitioners will be able to work in a collaborative, client-centered manner. Although this text begins with a focus on worker competence, it is important to recognize that collaboration with the client is a primary feature of social work practice. Practitioners will promote an interactive process that enables the client’s full participation. The client’s issues, circumstances, and reactions influence each step in the process. Practitioners must be flexible and able to provide leadership and a systematic, focused approach while at the same time demonstrating the ability to work with the client in an inclusive and responsive manner.

3

Learning to Practice

challenges for students le arning to pr actice

The first two chapters in this text presented a model of holistic competence derived from extensive studies of social workers engaged in practice. The model illustrates the complexity of practitioners’ work as it involves the interrelationships of numerous domains. Furthermore, it is congruent with the view of competence expressed in EPAS 2015 (CSWE 2015). This chapter focuses on learning and examines how students and practitioners can extract the most meaningful results from experiences when in school and in future professional development. As expressed in EPAS, “Social workers recognize the importance of life-long learning and are committed to continually updating their skills to ensure they are relevant and effective” (CSWE 2015, 7). It is understandable that when students first embark on their social work studies, their initial desire is for clear, specific, and orderly guidelines and techniques that will help them in their practice with clients in the field. There is a strong desire to learn to do practice, rather than to study about practice. To claim the legitimacy of a profession, however, it is imperative to recognize that social work is knowledge directed and evidence based; these dimensions provide the foundation for intentional and purposeful practice. Lee Shulman, a leading education scholar, has pointed out three key features of professions and hence of professional education: to teach students to think, perform, and act with integrity within the context of the particular profession (Shulman 2005). As Shulman so perceptively notes: professional schools face a singular challenge: their pedagogies must measure up to the standards not just of the academy, but also of the particular

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professions. Professional education is not education for understanding alone; it is preparation for accomplished and responsible practice in the ser vice of others. It is preparation for “good work.” Professionals must learn abundant amounts of theory and vast bodies of knowledge. They must come to understand in order to act, and they must act in order to serve. (53)

Students in all professional programs face the challenging task of developing competence in fields that are rapidly evolving and face ever increasing new knowledge. It is therefore useful for students to keep in mind that the development of competence will occur over time, through continuous learning. Embracing a mind-set that includes openness to new learning, curiosity, and critical thinking is necessary for ongoing professional development. Hence, it is important for students to recognize that their formal education will provide them with a firm foundation of generalist or core competencies and the capacity for future self-directed learning. Possessing a foundation of core competencies ensures that social workers are cognizant of the processes needed to individualize each practice situation, transferring and adapting general principles according to the uniqueness and contingencies they encounter. And these competencies provide the basis on which to develop competence in specialized practice. Beginning students are faced with an additional challenge. They are developing their competence at the same time that they are attempting to offer an effective intervention. Although this is true of learners in all professions, it does not lessen the fact that many students experience anxiety and lose confidence about their ability to be helpful. This fuels the search for concrete solutions and approaches that might better help clients. Many social work students are attracted to professional education because of their natural helping abilities. Once in university programs, they begin the process of critically examining what they have been doing intuitively. Deconstructing their usual way of operating can result in questioning themselves and experiencing a blow to self-esteem. Anecdotally, many students, especially those with work experience in the social services, report a phase of self-doubt and even wondering whether the profession is a good fit for them. It is useful to recognize this experience as a normal stage of professional learning, one that is especially likely to occur when one begins to appreciate the work’s complexity (Dreyfus and Dreyfus 1986).

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Experiential Learning Theory and Learning Styles

Experiential learning theory has gained acceptance within the field of social work as a useful way to think about learning about and from professional practice. David Kolb (1984) built on insights from leading theorists such as Dewey (1938) and Lewin (1951), and articulated the way individuals create knowledge by transforming their experiences. The theory has been appealing for social work educators, perhaps because much theoretical knowledge in social work has traditionally been presented in an abstract manner that does not lead to clear guidance for practice activity. Think, for example, of principles such as promoting client self-determination, going at the pace of the client, and engaging with a nonjudgmental attitude. By putting such notions into action, one actually begins to make concepts personally meaningful. Experiential learning theory hinges on the notion that learning is an ongoing process that occurs through experience, reflecting on that experience, and theorizing about the experience, which in turn results in further actions. Kolb (1984; Kolb and Kolb 2005) describes four major modes of learning. The first mode, referred to as concrete experience, emphasizes that individuals learn by engaging in specific experiences. Experiences provide a rich source of information from which one can extrapolate and learn. The next mode, called reflective observation, emphasizes learning by watching and listening. The learner observes, and carefully and thoughtfully examines issues from a number of perspectives. In a patient manner, the learner arrives at judgments based on these observations. This phase is important, as simply having an experience does not necessarily result in new learning; instead, insights and new learning emanate from the cognitive processes involved in thinking critically about the experience. The next mode, referred to as abstract conceptualization, involves logically analyzing the experience and applying ideas. The learner develops an intellectual understanding of a situation by using theoretical concepts. Such exploration can lead to greater depth in analysis, producing implications for future actions. During the last mode of learning, referred to as active experimentation, the learner takes a practical approach and learns by doing. Doing then provides the concrete experience that stimulates the continuing cycle of learning. It should be noted that although these modes of learning are presented as a cycle, they are not sequential—learners will begin at various points in the

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cycle and ideally consider all modes to enhance their learning. In addition, there are two continua in this model: one that moves from concrete to abstract, and one that moves from passive to active. A number of educational theorists have noted that people learn differently and have different learning styles. The concept of learning styles describes a student in terms of those educational conditions under which he is most likely to learn (Hunt 1987). Many inventories exist to help students conduct a self-assessment of their own learning style. A brief review of some of the key concepts can help students get a sense of their preferred style and how that might operate as they approach the challenging task of achieving holistic competence. A further issue is that no learning style is static; learning styles change depending on such factors as the context and purpose of learning, and the nature of the subject. For example, one might learn statistics in a manner that is different from the way one learns how to interview. Motivation also plays a key role. If practitioners must learn something new to practice their profession effectively and earn their livelihoods, they may be more focused and persistent than when learning a hobby or a new sport. The four modes in the experiential learning cycle described by Kolb (1985; Kolb and Kolb 2005) can also be used to describe preferred learning styles. The Kolb conceptualization has been used in studies of social workers, students, and faculty members (Raschick, Maypole, and Day 1998; Wolfsfeld and Haj-Yahia 2010). With respect to learning how to practice, some social work students will want to begin by recalling their own experiences in interviews and identifying what was and what was not helpful. This personal recollection of concrete experiences can provide a meaningful point of departure for learning new material. Others will want to begin by watching experienced social workers interview through live observation or by reviewing video recordings. The chance to reflect on what they have observed brings conceptual material to life. Still other students will want to read extensively and engage in discussion to develop an abstract intellectual understanding of practice principles and related behaviors. Finally, there are many students who learn best by doing. Actively experimenting with new skills through role plays, simulations, or actual interviews with clients will provide the stimulus and data for gaining new competencies. Educators acknowledge that it is appropriate to begin the learning process by using a student’s preferred learning style. Optimal professional learning, however, includes developing the ability to use all domains of Kolb’s cycle.

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ref lecti ve exer c i se : le a r n i n g st y le

Take some time to think about yourself as a learner. Think about learning environments in classes, work situations, and hobbies. Recall aspects of these environments that you believe helped you learn. Recall aspects that you believe hindered your learning. Identify the ways you prefer to learn. Think about how you can work with instructors and classmates to fashion learning environments that will meet your learning style preferences and are also conducive to using a range of styles. Are there learning formats that are uncomfortable for you? Try to identify what is challenging and why. Identify some learning goals for yourself to help you move out of your comfort zone. Note what you would need from peers and instructors to learn productively using such formats.

Other learning style dimensions can be seen not as finite types, but as points on a continuum, such as preferences for more or less structure, or preferences for more direction from the teacher as contrasted with more participation from the students. Some learners value an educational environment that is led by the teacher and is highly structured, with materials, readings, lectures, and exercises provided in an organized manner. At the other end of the continuum is a nonstructured environment in which teachers and students negotiate how learning is to take place, how participants will be involved, and the expectations of the teacher and the learners’ roles. Adult education and active learning approaches, which are popular in social work programs, may be experienced as less structured. Preferences for various styles may vary based on the student’s stage of learning. When one is a novice, for example, more structure and a teacherled approach may be more welcomed than in later stages of learning when the student is aiming to develop more autonomy and self-reliance prior to graduation. Preferences are also associated with past learning experiences. With more internationally educated students in North American classrooms, there will be class members who have been socialized in traditional educational systems in which the expectation is that students learn by listening to expert instructors. Active learning and engagement in experiential activities may be new and uncomfortable for some students. Instructors need to explain the rationale for the particular methods, format of instruction, and expectations for all participants.

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Field Education

In social work programs, the field practicum has been the primary venue for students to learn to practice. Researchers have developed an extensive body of literature that identifies the best practices in this important domain of socialization in and preparation for the profession (Bogo 2010; Hendricks, Finch, and Franks 2013; Hunter, Moen, and Raskin 2016). Students and alumni continuously underscore its importance, which is understandable when it is viewed through the lens of experiential learning theory, as it is through actually practicing and receiving feedback that practitioners truly learn what social work practice entails. Since 2008, the Educational Policy and Accreditation Standards of the Council on Social Work Education has deemed field education the signature pedagogy of social work (CSWE, 2015). The intent of field education is to integrate the theoretical and conceptual contribution of the classroom with the practical world of the practice setting. It is a basic precept of social work education that the two interrelated components of curriculum—classroom and field—are of equal importance within the curriculum, and each contributes to the development of the requisite competencies of professional practice. (12)

Systematic Use of Simulation

More recently, social work educators and researchers have examined the potential of using structured, systematically designed human simulations to develop and assess holistic competence (Bogo et al. 2014; Logie et al. 2013). Using well-defined conceptualizations of competence, they have identified learning outcomes, that is, competencies that students can learn and demonstrate through practice and reflection using standardized scenarios. Educators design simulations that depict authentic situations that social workers encounter in their practice. Actors are trained to portray the clients and participants in such situations. Using simulations, instructors can explicitly identify the underlying theoretical concepts and empirical findings relevant to understanding the situation and assist students in linking theory and practice by analyzing the scenario using the lens of various approaches. Intervention models or practice principles are also identified by

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the instructor to guide students’ behavior. Students can conduct segments of an interview and receive focused and specific feedback from instructors. Such feedback can identify positive and skillful behaviors, provide constructive suggestions about what could be done better, and offer a rationale for the suggestions. Theory and practice are linked when instructors and students examine practice performance using a conceptual framework. Deliberate practice is a term developed through the extensive work of Anders Ericsson, a psychologist who has studied how individuals attain expert performance (Ericsson 2004; Ericsson, Krampe, and Tesh-Romer 1993). In essence, better performance is achieved by focusing in a deliberate way on improving one’s performance in a particular area. The focus comes from receiving specific feedback from a coach. Based on observation, the coach provides an unbiased view of the performance in question. The student is then able to practice again in a deliberate manner, aiming to utilize the coach’s feedback, until she achieves the desired performance level. Research on deliberate practice in the related field of psychotherapy offers empirical support for using this approach in social work education. A sample of social workers, psychologists, counselors, and marriage and family therapists were asked about the activities they used to improve their practice (Chow et  al. 2015). Activities included, for example, supervision with and without review of session recordings, live supervision, reviewing recordings of sessions on their own and with peers, discussing sessions and therapy in general with peers, thinking about sessions, writing notes about sessions, reading journals and therapeutic materials, attending workshops, and participating in self-care activities. The study examined the relationship between therapist activities and clinical outcomes, with the latter assessed on a standardized measure of clients’ symptoms, functioning, and risk. Results indicated that the “amount of time therapists spent alone in DP [deliberate practice], was significantly related to outcomes” (341). Deliberate practice was operationally defined as the amount of time practitioners spent focusing on improving their therapeutic skills outside of work, including their perception of the cognitive effort undertaken in this activity. Of interest is the finding that reviewing recordings of their sessions required more cognitive effort than other activities. Drawing on similar findings from studies of performance in other fields, the researchers strongly recommend that practitioners review recordings of their interviews to identify errors and then intentionally focus on practicing to improve specific skills.

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Social work students are highly motivated to learn how to practice and this evidence-based recommendation clearly provides an effective guideline. Put simply, students should find many ways of practicing the competencies they are learning and should review their own video recordings of those efforts to identify their strengths and areas that need further development. Their subsequent practice should be targeted and intentional, focusing on increasing the effective use of areas identified as needing work. This activity can be done on one’s own, but receiving feedback from peers and instructors will greatly facilitate learning. A substantial research literature in psychology and health professions’ education seems to show that many individuals can be inaccurate in their self-assessments (Baxter and Norman 2011; Davis et al. 2006; Eva and Regehr 2005). A similar finding in social work was reported by Rawlings (2012), who found that student scores on a self-efficacy measure did not predict their performance on a skill-based measure. Many individuals either underrate or overrate their performance. The term “unskilled and unaware” was coined by psychologists Kruger and Dunning (1999), who conducted a number of studies on a range of tasks and performances. Individuals who received high scores on their performance from raters underestimated themselves. They were, however, able to recalibrate their self-assessments more accurately after viewing others’ strong performances. There were also individuals who were able to accurately self-assess. Of interest were individuals who overrated their performance, even after viewing examples of others’ strong performances. In a study of medical residents, Hodges, Regehr, and Martin (2001) found the same phenomena. Kruger and Dunning (1999) explain this dynamic by arguing that if individuals do not have the metacognitive skills needed to understand what constitutes a preferred performance, they will have difficulty distinguishing between the quality of their own performance and that which is desired. This explanation resonates with our view of holistic competence. Specifically, cognitive processing of relevant knowledge is intricately connected to the use of that knowledge. One cannot demonstrate effective practice behaviors and skills if one does not understand the concept that guides the performance. Therefore, teaching aims to integrate the various dimensions of competence by linking concepts and practice, metacognition, and behavior. Instructors need to clearly articulate the links between concepts and actions. As students conceptualize their work they integrate and apply

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explanatory theory to understand the substantive issues they encounter and they analyze their practice through the lens of models and principles, they are more likely to accurately assess their performance behaviors. Role play with student peers enacting the role of a client is used in most social work programs. The use of human simulation with trained actors can add a more authentic dimension. Health professions’ educators and researchers have made extensive use of human simulation, in part drawing on the notion of deliberate practice. They conclude that it is a safe and effective way for a range of practitioners to learn to improve specific professional competencies without adverse effects for patients (McGaghie et al. 2011; Trumble 2012; Weaver 2011). Medical educators and researchers LeBlanc et al. (2011) emphasize the benefits of “effortful repetitive practice of the activity to a mastery level in combination with external constructive feedback” (4). Logie et al.’s (2013) critical appraisal of using simulation in social work found that while the research base is in its early stage of development, students and instructors alike in all eighteen studies reviewed had extremely positive views about its contribution to learning. Studies conducted at the University of Toronto on the use of simulation in assessing student competence through the Objective Structured Clinical Examination (OSCE) also found high levels of satisfaction with the method (Bogo et al., 2012). The great majority of students (92 percent) in these studies valued the experience as contributing to their learning and would recommend it to other students. Specifically, they believed the experience helped them integrate knowledge, improve skills, and increase confidence in working with clients in the field practicum (Bogo et al. 2012). Learning, Per for mance, and Anxiety

There are some social work students, however, who find that being observed when they conduct an interview raises their anxiety and leaves them feeling dysregulated, unable to use their knowledge to focus on intentional practice. Similarly, a review of nursing and medical education literature found that some students experienced elevated anxiety about being observed and the possibility of receiving negative feedback, which negatively affected their learning and performance. On the other hand, other students reported that the heightened anxiety was helpful in providing motivation and focus for their learning (Nielsen and Harder 2013).

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Instructors and students can take actions to address such anxiety. Nielsen and Harder’s (2013) review found the learning environment to be crucial. Consistent with principles used in social work programs, supportive instructors create productive environments that are safe and involve low risk since mistakes are expected (Bogo et al. 2014). Other contextual activities that can lessen anxiety are orientation to and preparation for the simulation, clarity about what is expected of all participants, and training in how to give constructive feedback. When instructors provided opportunities for students to practice the skills through role play with classmates in a private setting prior to a human simulation, students’ anxiety was reduced. Writing about the imperative of self-care for nursing students, Hutchinson and Goodin (2013) recommend that students learn to use strategies such as mindfulness, deep breathing, and reflection to address their performance anxiety in simulations. Professional practice in helping professions is increasingly conducted in public spaces; it is therefore important for students to learn how to manage their personal reactions since they will be observed once in the field setting. Learning to function in front of others in safe classrooms and labs is an especially helpful way for students to grasp foundation skills. These skills and an open mind-set about being observed in practice can then be transferred to pressured clinical and other work environments students will likely encounter in their professional lives. This discussion of challenges students face as they learn to practice would not be complete without returning to the earlier discussion of self-awareness in the previous chapter. Recall that research in neuroscience and learning has demonstrated that the cognitive processes in thinking, forming judgments, and making decisions are powerfully influenced by emotions (Barrett and Satpute 2013; Damasio 2005; Immordino-Yang and Damasio 2007; Kahneman 2011). Emotional arousal level and reaction to experiences and new material affect attention and focus, what people are open to taking in and what they tune out, and what they automatically reject. For that reason, to maximize learning, all practitioners need to develop a keen awareness of their reactivity and learn what distracts from, interferes with, and blocks learning (for example, performance anxiety, material that stirs up difficult thoughts and feelings about personal issues, and challenges to one’s own strongly held political or religious views). It is wise to cultivate a willingness to set aside previously held assumptions and allow contradictory ideas to be entertained, and even held simultaneously. Such a mind-set fosters the

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practitioner’s openness to absorbing ideas that may be challenging and the ability to respond thoughtfully rather than reacting prematurely; it also provides the potential for helpful new ideas to emerge. Ellen Katz (personal communication, 2016), an experienced clinician and social work educator, recommends an exercise following a period of learning. In this exercise, participants reflect on and record the following: physical experiences in the body (related to posture, body sensations, breath), specific emotions (joy, fear, terror, boredom, and others), states of mind (concentrated, heavy, energetic, spacious, and others), judgments (the concrete thoughts on which one’s feelings and state of mind are focused), knowledge (concrete theoretical concepts learned), and particu lar skills. Based on these reflections, she recommends that students periodically pause their learning activities and give thought to identifying how they are feeling (for example, lost, eager, wishing to seek more knowledge about specifics), summarizing what they have learned during the past week, and formulating their learning goals for the coming week. s e l f - awa r e n e s s , w e l l- b e i n g , a n d s e l f - c a r e

Social work practice can be highly gratifying and rewarding. Practitioners choose this profession based on personal values, interests, and a commitment to make the world a better place by providing ser vice to others and changing oppressive circumstances. To achieve and maintain helpfulness to clients, practitioners need to feel energetic and generally experience a state of well-being. In a Canadian study of seven hundred social workers, Graham and Shier (2010) conducted in-depth interviews with thirteen respondents who had the highest scores on a measure of subjective well-being. A number of factors emerged as important to those interviewed, including the availability of a variety of practice roles and engagement in activities such as pursuing social justice interests; working with a range of populations; and being able to combine practice, research and teaching, and working with multiple disciplines. This sort of work contributed to individuals’ sense of identity and personal satisfaction. Rather than becoming overwhelmed with the challenges of social work, these respondents were able to reflect on their practice and develop a thoughtful appreciation of the boundaries and limitations of what they were and were not able to accomplish. Organizations that promote and encourage positive and supportive relationships

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in the workplace with peers, mentors, and supervisors, and provide opportunities for professional development also contributed to these respondents’ sense of well-being. Finally, participants who reported feelings of well-being also reported a sense of alignment between social work values and perspectives and their own professional identities and views of their professional selves. At the same time that professional work contributes to one’s life satisfaction, it can nevertheless also take a toll on emotional well-being, physical health, and interpersonal functioning (Cox and Steiner 2013). In light of this, self-care for professionals has received increased attention in this century. Although much of the research and literature applies to practicing social workers, it is also useful for students. Modern life in universities moves at a fast pace with academic demands and numerous deadlines for students. Attending social work education programs can be all-consuming and it is easy to lose sight of the importance of engaging in activities and finding strategies that promote wellness. Social work students need to understand themselves, their reactions, and the impact of the contexts in which they operate, in class and in field. A vast professional and self-help literature provides an array of coping strategies. As in social work practice, the choice of approaches should be individualized. For students, it is never too early to experiment with a number of self-care activities with the aim of developing a useful repertoire to draw on throughout one’s professional career. The self-care literature provides conceptual understanding of key dynamics and the multiple factors that can affect us, as well as strategies for social workers and organizations that wish to promote and maintain an energized and effective workforce. Figley (1995) introduced the term compassion fatigue to describe the emotional distress sometimes experienced by those who treat individuals who have experienced trauma such as abuse, combat, domestic violence, and so forth. Figley (1995) noted that practitioners who had listened to numerous narratives about trauma and were attuned to clients’ feelings sometimes displayed a range of psychological and physical symptoms. This concept is similar to vicarious traumatization, which was introduced by Saakvitne and Pearlman (1996). They noted that practitioners who work with clients who have been traumatized by events such as physical or sexual abuse, torture, war, rape, or assault may find themselves feeling unsettled after a considerable time spent listening to difficult narratives

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and empathizing with clients’ pain. Connecting with others’ extreme vulnerability can evoke difficult feelings in the practitioner and challenge one’s sense of safety and meaning in one’s own life (Johnson 2002). Some practitioners report intrusive imagery in their thoughts that reflects elements of the stories their clients have told them. They may have nightmares or experience difficulty sleeping; suffer from headaches or nausea; feel emotionally numb, vulnerable, or unsafe; or have difficulty trusting others. Researchers studying a range of helping professionals have identified this form of secondary trauma caused by listening to clients’ narratives about trauma. This finding has led professional and ser vice organizations to examine and promote ways practitioners can identify what they are experiencing in professional work and access a range of educational, supportive, or therapeutic resources that may enable them to minimize personal occupational stress. Both on a personal/professional and organizational level, the aim is to prevent burnout, a condition that can evolve over a period of time and results in emotional exhaustion; cynicism characterized by a negative attitude toward clients and the ser vice offered; and feeling incompetent, which leads to a lack of achievement and productivity at work (Maslach, Schaufeli, and Leiter 2001). Based on extensive empirical work, burnout is now seen as resulting from multiple factors in interaction with each other. This view is congruent with social work’s ecological systemic perspective. The match between individual and organizational characteristics in relation to the following factors has been found to be relevant: workload, control over needed resources or over the way the work should be carried out, reward, community, fairness, and values. Despite the recognition that a practitioner’s individual experiences of stress and burnout are related to situational and organizational factors as well as to the goodness of fit between individual and organizational characteristics, much of the literature focuses on interventions that individuals can use, often labeled as self-care. Experienced social workers describe a range of strategies that help them accept the feelings and thoughts that emerge from their work and with the potential experience of emotional depletion. These strategies can help the practitioner contain the emotional flooding and preoccupation that sometimes occurs during active involvement with others who are in pain. Successful strategies help maintain energy, empathic presence, interest, and commitment. Some suggested approaches for self-care follow.

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Developing Physical Well- Being

Since much of social work practice is sedentary, it is useful for practitioners to develop a lifestyle that helps maintain health and fitness. Health practitioners recommend being aware of the tendency to be inactive and taking steps to stand up and move around periodically. In addition, social workers benefit from physical activities such as regular walking, playing sports, or participating in exercise classes. Others report on the relaxation and fitness they achieve through a regular meditation practice, doing yoga, or using relaxation and deep breathing exercises. Developing Psychological and Emotional Well- Being

The usefulness of self-reflection was noted previously and a format for engaging in such a practice was provided. Students can experiment with a number of strategies to determine which ones are most helpful for them through the course of their social work studies and beyond into their careers. Some activities that can be helpful are journaling, the meditative activities described above regarding physical self-care, and engaging in pleasurable leisure activities that bring positivity and joy into one’s life. Research conducted by Barbara Fredrickson has highlighted the importance of positivity as a necessary balance to the negativity and stress practitioners may encounter as a by-product of life in contemporary society (Fredrickson and Branigan 2003). Fredrickson offers a simple inventory that can help practitioners gage their current emotional state at https://www.positivityratio.com/index.php. Many social workers, counselors, and psychotherapists engage in their own personal therapy as a way of developing deeper understanding of situations that prove difficult. Therapy provides insights and support, and can lead to changes in thinking, feeling, and behavior that improve personal and professional functioning and well-being. Religiosity and the Development of Spiritual Well- Being

There is considerable evidence that praying, meditating, and participating in spiritual communities contributes positively to individuals’ health and subjective sense of well-being (Green and Elliott 2010). In a further analysis of their findings on the subjective well-being of social workers, Graham

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and Shier (2011) examined the role of spiritually based aspects of their respondents’ life experiences. They found the presence of a “reflective component where participants are making sense of their individual worlds and coming to terms with how those experiences impact their well-being, positively and negatively . . . participants identified the practice of making sense of experiences as contributing to their overall subjective well-being. Also, in most cases participants maintained similar spiritual practices to continue to understand their experiences throughout time” (257). Primary Relationships

Since much of social work practice centers on helping others, social workers need to balance the way they give and receive emotional support in their personal, intimate, family, social, and work relationships. Often the role of caretaker or nurturer comes naturally to social workers, and they can find themselves taking a similar role in personal interactions with family, friends, and colleagues. It is especially important for practitioners to know how to ask for help or support in close relationships. It is equally important to have enjoyable social relationships that are characterized by doing things that are pleasurable. Too often practitioners’ lives become imbalanced and an abundance of work, duties, and responsibilities creates stress and demoralization. The School of Social Work at the University at Buffalo provides a wealth of self-care materials that can help alleviate such imbalance, which can be accessed at http://www.socialwork.buffalo.edu/self-care. Context, Teams, and Supervision

That intensive professional work with people in difficulty and pain is stressful cannot be denied. The organizational contexts practitioners work in have a profound impact on their well-being. Staff groups and teams, supervisors, and administrators can create nutritive environments in which there is educational supervision, mentoring, and encouragement of creativity, development, and learning. Or, organizations can demand increasing accountability that detracts from client engagement, creates unrealistic work productivity norms, and fosters an environment in which practitioners are expected to take risks in the absence of structures and personnel that support frontline staff. Social workers need to use their knowledge and skill to

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assess both the opportunities for and constraints to bringing about organizational change and creating positive work environments. It is vitally important that student learners and practitioners have emotionally supportive professional relationships in which they can be open about their struggles, mistakes, and crises of confidence. Such relationships provide important opportunities for learning, especially with respect to how practice situations are experienced personally. When practitioners feel understood by colleagues, meaningful dialogue can occur about professional challenges and they can gain a more realistic appreciation of their own strengths and limits. Sensing that one is a part of a professional and collegial community promotes the vitality and energy that all social workers need. The importance of supportive teams was found in a study of conditions that students report as productive for group supervision (Bogo, Globerman, and Sussman 2004a, 2004b). Peers who were empathically attuned to each other’s concerns, were emotionally connected, and offered support were essential. This relational base provided the necessary conditions for presenting difficult practice problems as well as for self-disclosure about students’ practice. Feedback and subsequent learning flourished when these conditions were present. Students reported that competition among students about performance and nonresponsiveness to a student’s struggles were corrosive experiences. These conditions seemed to lead to silence in the group, a guarded and self-protective stance, and a retreat from learning. Similarly, for experienced practitioners, the importance of supportive organizational contexts was found in a study of key elements that a range of mental health professionals, including social workers, deemed important for maintaining and furthering their professional competence and job satisfaction (Bogo et al. 2011). Three interconnected dimensions identified in this realm were access to supervisors who had expert knowledge about the needs of and possible appropriate interventions for the specific populations; interprofessional teams that provide a home base, support, positive relationships, and informal feedback; and program managers who expect and an organizational culture that fosters high-quality performance while providing the necessary training to help workers meet these expectations. Effective supervision has been shown to contribute to positive social worker outcomes such as job retention and lower rates of turnover, commitment to the organization, increased job satisfaction, enhanced psychological

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well-being, and, indirectly, to better ser vice for clients (MorBarak et al. 2009; Powell 1991). MorBarak et al. (2009) conducted a meta-analysis of twenty-seven studies of supervision in child welfare, social work, and mental health that found three dimensions of supervision that contributed to these outcomes: the supervisor’s competence as an expert and the ability to provide assistance to the worker with the practice tasks; the provision of socioemotional support; and positive interpersonal interactions, or relationships, between supervisor and worker. Conversely, when workers experience supervision negatively, it contributes to unfavorable outcomes such as increased intention to leave and turnover; job stress and burnout; and diminished psychological well-being, sometimes resulting in depression and anxiety. Unfortunately, supervision is no longer the norm for all new social work graduates in their first job. When supervision is provided, it is important that it include not only attention to administrative matters but also to the educational aspects of practice in the agency. When agencies do not provide this type of supervision, it is especially important for new social workers to find learning opportunities that will contribute to their professional development. In this era, with an ever-expanding knowledge base for practice, it is professionally responsible and can be energizing to see oneself as a lifelong learner. Individual supervision helps the practitioner apply new learning directly to the case situations with which she is engaged. Group consultation, including with colleagues who are more experienced, provides practitioners with an opportunity to learn from others. There are also a wide range of workshops, continuing education or online courses, and professional literature readings that provide practitioners with opportunities for new learning, help keep them “fresh,” and stimulate professional growth. The Match Between Individual Needs and Orga nizational Context

Maslach and Goldberg (1998) note that individual strategies that focus on self-care have limitations when applied to someone experiencing workplacegenerated stress and burnout. Unlike other aspects of their lives, employees in organizations have much less control over the circumstances that produce stress. Maslach and Goldberg suggest that both philosophical and pragmatic reasons account for the predominant focus in organizations on the individual, such as attributing burnout to the individual’s personality, commit-

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ment, and sense of responsibility. Furthermore, it may be less resource intensive to provide workshops and employee assistance to change individual social workers than to attempt large system organizational change. Research on burnout conducted by Maslach, Schaufeli, and Leiter (2001) has shown that a mismatch between individual and organizational characteristics is a strong contributor to burnout. Practitioners therefore need to assess the degree to which there is a fit between their needs and expectations and those of their employing organization. Maslach, Schaufeli, and Leiter (2001) identify six key factors that can contribute to worker burnout. First, a workload that the worker experiences as problematic is a key factor that can contribute to worker exhaustion and includes not only the volume of work in relation to the individual’s energy level but also whether the practitioner has competency and interest in the type of work assigned. Second, across many occupations, the degree of control an individual prefers to maintain and the degree of control they are actually able to exert is also an important factor that can have an impact on whether a worker experiences burnout. A worker’s control over the resources needed to carry out required professional tasks is especially important in this regard. Mismatch between the worker’s level of responsibility in carrying out job duties and his level of authority can also contribute to exhaustion. For example, child welfare workers with responsibility for ensuring child safety can be overwhelmed when they do not have the time to make regular home visits. Time constraints are related to not having the authority to refuse taking on new cases assigned to them. A third factor that can affect whether a worker experiences burnout is the availability of rewards that she values, not only in the form of salary and benefits but also social rewards such as appreciation and recognition by peers and supervisors, and intrinsic rewards such as the ability to experience pride in work performed. Lack of adequate rewards can leave a worker feeling demoralized. A fourth factor that can contribute to worker burnout is a mismatch between the worker’s expectation of being part of a professional community and the climate in the organization. For individuals who value a sense of positive emotional connection, sharing and providing task assistance are important factors in preventing burnout. Conversely, “what is most destructive of community is chronic and unresolved conflict with others on the job . . . [which] produces constant negative feelings of frustration and hostility, and reduces the likelihood of social support” (Maslach et al. 2001, 415). The fifth factor that can

ref lecti ve exer c i se : se lf- i n - c on t e xt

Take some time to reflect on your current life circumstances as follows: For each category, identify both the strengths and the challenges or issues you are experiencing. What would you need to do to improve your sense of well- being? What would others need to do? Is that likely to happen? Organ ization:

• Human resource policies and practices regarding personal leaves, conditions of employment, career advancement, and development opportunities.

• Relationships with coworkers, supervisor, employer. • Team atmosphere, degree of collegiality, collaboration, and competition. • Goodness of fit between your values and ways of working and the organization’s expectations about work. Relationships:

• Intimate partner. • Children. • Family of origin. • Extended family members. • Friendships and other significant social relationships. • Any other significant relationships. Physical Well- Being:

• What activities do you engage in that are restful, stimulating, or nourishing? Are you doing enough of what you like? Are you getting enough sleep?

• Do you engage in activities that are ultimately deleterious to your health, such as smoking, excessive drinking or use of drugs, or unhealthy eating? Psychological and Emotional Well- Being

• Do you engage in activities that encourage self- reflection and calming, such as supportive supervision, personal therapy, meditation and mindfulness, religious or spiritual practices, relaxation exercises, or journaling?

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contribute to burnout is lack of fairness and equity in workload, salary levels, appropriate responses to workers’ concerns, and transparent grievance procedures. Maslach et  al. (2001) note that the perception that one is treated in an unfair manner is both emotionally upsetting and engenders feelings of cynicism about the integrity of the workplace. Finally, the sixth factor that can lead to burnout is conflict between the worker’s values and those of the organization. A marked gap between the organization’s rhetoric with respect to values and its everyday practice can contribute to a worker’s feelings of disillusionment. Clearly, this analysis of burnout reveals its complexity and explains the wide range of workers’ individual reactions to the same organizational culture. t h e i n t e g r at i o n o f t h e o r y a n d pr actice (itp) loop model

Bogo and Vayda (1998; Bogo 2010) described a process for reviewing the thoughts, attitudes, values, and feelings that affect what social workers do in practice as a vehicle to promote field learning. The Integration of Theory and Practice (ITP) Loop Model is presented in figure 3.1. It has been used extensively in field education to assist students and their instructors to critically reflect on practice and to conceptualize and prepare for subsequent interventions (Moen, Leley, and Denis 2016). Social work educators have also applied this model in debriefing simulations and when teaching practice in classrooms, as it can address the various dimensions of holistic competence. The material that will be presented in subsequent chapters can be viewed through this loop model as the reader examines the ideas presented. A loop is used to illustrate the cumulative, ongoing, and repeated activities of thinking about a practice situation, the feelings elicited, and the action taken. Each phase of the loop affects the next in an interactive fashion. While the figure implies a stagelike process, in practice each phase flows into and out of each other. Retrieval refers to recall of the salient facts of a practice situation. As discussed in chapter 1, an enduring theme in social work is its focus on the person-in-situation or person-in-environment framework, which is also referred to as the ecological-systems perspective. This perspective has endured as a metaphor for capturing the profession’s central emphasis: the personalsituational-societal nexus that involves examining the interactions and

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Professional response

Reflection Retrieval

Linkage

figur e 3.1 The Integration of Theory and Practice (ITP) Loop Model. Source: Adapted from Bogo and Vayda (1998); Bogo (2010).

mutual affects between individuals and their social and physical contexts. Such a paradigm guides the social worker to recall and attend to specific phenomena as well as certain types of information for assessment, and to address both individual and contextual elements in intervention. Environmental factors in the client’s immediate life circumstances and in broader society provide important information for the social worker. These include the economic, political, and social macro issues that can affect the availability of entitlements for financial assistance and access to health and social ser vices and quality education. In addition, mezzo issues such as the characteristics of the client’s neighborhood or community, including its resources, supports, challenges, and whether the client experiences a sense of safety there, also provide the practitioner with important information. In addition, it is always impor tant to consider how diverse social identity factors play a role in individuals’ lives, including how they affect their internal thoughts and feelings as well as their participation in social relations and institutions. Understanding how structural barriers and stigma can lead to discrimination, oppression, and lack of equal access to resources and opportunities is crucial in formulating effective interventions. Finally, the practitioner must take into account the characteristics of the programs and ser vices provided by the worker’s organization and the ser vice delivery system. Guided by specific theories of human behavior and models of practice, social workers also retrieve bio-psychosocial information. If using individual models, for example, this may include information about the individual’s definition of the problem and his behavior, feelings, and/or thoughts. If using family systems models, the focus may be on key relationships among family members, patterns of interactions, and family roles and

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structure. If using antioppressive models, the focus may be on client’s experiences of marginalization and structural barriers to their well-being and social functioning. Supported by both empirical findings and practice wisdom, the relationship between the client and the social worker, that is, the working alliance, is a crucial area of focus in all direct social work practice. This topic will be discussed at length in the following chapters. Currently it is noted as an important focus for the worker, who gathers process data about the interactions between the client and worker from their first encounter and throughout the time they work together. Students of social work often achieve retrieval of information and process dynamics through written records such as reflections in course work and process recordings in field education. There is considerable literature and research from related disciplines, such as cognitive science, that highlights the human tendency to distort recollections, rendering us inaccurate reporters (Croskerry, Singhal, and Mamede 2013). With the ease of video recording on handheld devices, it is preferable and strongly recommended that students record and review their practice interactions whenever possible. Maintaining confidentiality and protection of clients is always of paramount concern and agency protocols must always be followed. Reflection refers to the social worker standing back from the interview and considering her own personal associations with various aspects of the practice situation. This activity was discussed at length in chapter 2 and encompasses practitioners developing awareness of their cognitive and affective processes, and identifying and managing implicit and explicit assumptions that contribute to their thinking, feeling, and reacting. In reflection, conscious, systematic examination aims to uncover how the personal self and the professional self operate in practice. Such examination alerts practitioners to the multiple sources of meanings and feelings that are evoked by offering a helping ser vice through this type of interpersonal work; it also stimulates them to become conscious of the dynamics that may lie behind their actions. Social workers face practice situations that may provoke strong personal feelings and reactions. Client problems include, for example, loss of loved ones; abuse and violence in intimate relationships; physical and emotional trauma; chronic and deteriorating physical illness; and living in depriving, dangerous, and harsh environments. Practitioners are typically attracted to

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ref lecti ve exer c i se : se lf- awa r e n e ss

Many of the thoughts and feelings that prac tition ers experience are typical of most workers. Some reactions have a more personal meaning. Take a moment to think about some of the practice situations that you have found most challenging. If you have had little experience, what do you imagine would be most challenging for you? What thoughts, feelings, and reactions are stirred up in you? For example, a student in practicum in a general hospital reflected on how seeing so many ill and dying patients left her feeling sad in interviews and less able to offer helpful professional responses to her clients. It is impor tant to distinguish to what extent reactions such as these are typical, that is, similar to what most social workers in this position would experience, and to what extent they are unique and personal. In discussing this reaction with other students and her field instructor, the student became aware that her reaction was a usual one for many health professionals when they begin work in a hospital. If, on the other hand, reflection helps the student recognize that sad feelings are evoking memories of a recent or current loss of a loved relative or friend, then the meaning of her reactions is an individual one.

social work out of a desire to help others and it is likely that poignant and upsetting client circumstances will evoke a range of strong feelings such as compassion, a sense of responsibility, anger, anxiety, and so forth. In addition to using self-reflection and personal work, such as therapy, practitioners can seek supervision from qualified supervisors and consultation with peers and more experienced colleagues to become familiar with and manage their own reactions. The above reflective exercise can assist practitioners in developing self-knowledge. Social workers encounter many practice situations in which the client is presenting issues similar to those the practitioner has experienced. For example, many clients value receiving ser vice in ethnospecific settings with social workers who speak the language of the client population. These workers may confront client experiences similar to those that they, or members of their extended family, have dealt with, such as challenges associated with immigration and dislocation, underemployment, racism, and prejudice. Sharing comparable life circumstances can assist in building relationships and understanding the client’s experience in an authentic and genuine way.

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Yet it may also cloud the worker’s ability to assess and intervene helpfully, especially when the client’s reactions to similar situations differ from the worker’s, and the practitioner finds herself using her reactions and adaptations as the standard by which to assess the client’s situation. For example, a worker may value the fact that when her extended family first immigrated to North America, they supported each other financially, pooled their earnings from employment, and lived in one home. When faced with a client who resists the help of her extended family, preferring to extract herself from a traditional living arrangement and obligations to her elders, this social worker may find that she is subtly critical and not supportive of the client’s decision to live on her own. Over time, practitioners develop effective ways to contain personal reactions in the interview. Generally, the process begins by becoming aware of what one is feeling and experiencing in the moment. A social worker might ask himself, “What is going on in me right now?” This query can evoke a range of thoughts and feelings. This is followed by conscious cognitive reflection that sorts out the following: •

•

•

Is the social worker reacting as most practitioners would to what the client is saying or doing, either the content or the process? For example, regarding content, listening to a client talking about being physically abused by a violent partner would lead most practitioners to feeling upset. Regarding process, interviewing a violent partner who denies his role in the aggression and angrily states that he was provoked is likely to result in the social worker feeling angry and perhaps somewhat frightened. Is the social worker reacting in the working relationship as she usually does in personal relationships? For example, some workers do not like hostile people; they try to avoid them in their personal life and find them threatening in their practice. Is the social worker reacting to issues that are troubling to him currently or that he associates with problems he experienced in the past that are evoked by the client’s presentation? The worker may easily see the links between these issues or he may not be fully aware of them and should pay closer attention to his reactions after the interview. For example, a worker who is undergoing a divorce may find working with a couple contemplating separation to be an anxiety-producing experience. A worker who grew up feeling responsible for her parents and younger siblings in her family of origin

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may find herself feeling overly responsible for and preoccupied by the ongoing suicidal ideation of a depressed client.

Pondering the insights the social worker gains by asking these questions will help him sort out to what extent his reactions are by-products of the work and warrant discussion in supervision or with peers, and to what extent these issues may benefit from personal development and therapy. Ideally, this reflective process helps the practitioner to differentiate between the personal self and the professional self, and enables him to reengage in the interview in a more client-focused way. By attending to aspects of the personal self evoked by work with the client, the practitioner is in a better position to produce a reasoned response that is helpful to the client. Linkage refers to the way social workers use the profession’s knowledge base to understand and guide their practice. The types of knowledge they draw on were reviewed in chapter  1 and include generic and specialized knowledge, that which is empirically based and explicit, notions drawn from practice wisdom, and that which is implicit. Social workers use theories and concepts to assess and gain understanding about individuals and their situations. They then make decisions about creating an intervention plan and, with the client’s participation, develop it. These plans include who should be involved, what resources can be offered, and what approaches used. When linkage is used in a systematic manner, the social worker identifies and labels concepts and principles drawn from a knowledge base. These concepts can potentially explain the practice data and the worker’s subjective reactions that have been uncovered through reflection. The explanations and hypotheses that emerge from the assessment will in turn lead to directions for the next phase, which is referred to as professional response. Linkage involves practitioners in an iterative process that moves between the facts and dynamics of the practice situation, and the theoretical concepts and practice models that might explain phenomena and suggest interventions. By connecting theory and practice in this way, social workers gain new practice-related insights and come to understand abstract ideas in a grounded manner. While some social workers will use specialized models such as those referred to earlier for particular situations, they also draw from a set of core social work theoretical concepts and practice principles. Three fundamental themes have been discussed thus far. First the ecosystems perspective that views the person-in-environment is key to the way social workers

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understand situations presented by clients. Social workers recognize that change throughout the life course is possible and that assisting individuals to experience environments that are more nurturing and supportive can significantly affect their well-being. Interventions aim to change interactions in small systems, such as between clients and intimate partners or family members. Social workers also understand the impact of macro forces such as poverty, unemployment, and systemic oppression on individuals, and use advocacy on a case-by-case level while remaining committed to political and social change to achieve equity and social justice at the systemic level. To think systemically means recognizing that while ser vices are designed to meet clients’ needs, agency policies and procedures and the way the team members interact with each other and with clients can enable good practice or create barriers to helpful ser vices. A second theme is the importance of the social worker’s self in the way practice is conceived and carried out. This theme has been discussed extensively in the previous chapter as well as in this chapter above. A third theme acknowledges the impact of diversity and social identity factors on issues of marginalization, oppression, power, and privilege. This theme is discussed at length in chapter 5. A fourth enduring theme is recognition that a satisfactory working relationship between the practitioner and the client is a crucial ingredient in providing helpful ser vice and effective social work supports an approach in which clients play as full a role as possible. While this theme has been evident in the text thus far, relationship dynamics are addressed in further detail in chapters 4, 5, and 6. A fifth theme embraced by professional social work is a strengths perspective, as it focuses on the human capacity to overcome adversity and clients’ inner capacities, resilience, competence, and creativity. Consistent with long-standing social work values, this perspective is captured in the following EPAS statement: “Generalist practitioners . . . recognize, support, and build on the strengths and resiliency of all human beings” (CSWE 2015, 11). This outlook stands in contrast to one that primarily focuses on clients’ pathology, deficits, and problem-saturated accounts (Saleebey 2002). Saleebey (1992) eloquently stated: “Individuals have survived . . . They have taken steps, summed up resources, and coped. We need to know what they have done, how they have done it, what they have learned from doing it, what resources (inner and outer) were available in their struggle to surmount their troubles. People are always working on their situations, even if

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just deciding to be resigned to them; as helpers we must tap into that work, elucidate it, find and build on its possibilities” (171–172). Recognizing that clients are experiencing an active process of coping and surviving, the social worker seeks to understand the factors contributing to that resilience and works consistently to amplify and expand those capacities (Cowger 1994). Saleebey (2002) states, “The formula is simple: Mobilize clients’ strengths (talents, capacities, resources) in the ser vice of achieving their goals and visions and the clients will have a better quality of life on their terms” (1–2). A strengths focus takes into consideration the power dynamics between those seeking help and those providing it, and can potentially reinforce client competence and aid in collaboration between the practitioner and the client. The message conveyed is that the client is the primary force for change and has the capacity to overcome issues. The professional plays a facilitating role by supporting the client’s efforts to deal with their situation and providing focus in the discussion, which elicits the client’s personal agency or self-healing efforts and abilities. In this formulation, “the relationship is helpful because it provides a safe, sheltered ‘space’ in which clients can take a deep breath, consider their problems in context, brainstorm with another person, gain perspective, examine their ‘bad sides,’ make mistakes, generate new alternatives, re-experience old wounds and problematic issues, think, analyze, recover the strength to re-confront life, and try new behaviors” (Tallman and Bohart 1999, 102). A strengths perspective ensures that during the assessment phase, the practitioner’s and client’s attention will focus not only on problems, needs, and gaps but will also include a search for examples of successful coping and of instances when the client gained successful mastery over a troubling situation. A strengths perspective should not be equated with giving the client a false and inflated view of self, or communicating naive possibilities through “positive thinking.” Rather, by eliciting information from the client about the times he was able to deal with a situation effectively, both the practitioner and the client share a common, specific, articulated understanding of the client’s actual past successes. The social worker then focuses on how he can help the client harness and amplify these internal strengths and resources to deal with the current situation at hand. The question becomes, how can the client’s own resilience, ability, and competence be brought into the present situation and what role can the worker play to assist in that process? A strengths perspective is discussed in more detail in chapter 11.

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A sixth theme in social work concepts is empowerment. Traditionally, the goal of practice has not been limited to helping the client take action and change the presenting problem but has included helping the client build internal capacities to deal with current and future issues in his life. As a result, the practitioner does not “do for the client” but enables him to “do for himself.” To achieve this goal, it may be necessary for the practitioner to help the client modify internal factors that impede growth and development. For example, low self-esteem and poor self-confidence can inhibit an individual from actively trying to change his significant environment or relationships. The individual might avoid challenging situations, but if he deals with them successfully when encountered, they may contribute to his self-confidence and a sense of mastery. The habitual use of defensive styles that protect one from experiencing anxiety and vulnerability may also limit assertiveness or behaving in ways that might result in achieving one’s full potential and having interpersonal needs better met. Direct practitioners also build capacity by helping individuals learn how to be assertive and advocate for themselves in an influential manner. Contemporary empowerment theory includes awareness of power. Gutierrez, DeLois, and GlenMaye (1995) view the goal of the change process as increasing the actual power of the client or community in the interests of taking action, at multiple levels, to address problems they currently face and prevent similar ones in the future. In this respect, this perspective is consistent with the person-in-environment perspective, as it sees personal well-being as significantly affected by issues on many levels, particularly at the level of the community and society. An empowerment focus recognizes the deleterious nature of powerlessness and in practice aims to develop personal and interpersonal power so that individuals can take action to change factors in their external environments. Empowerment practice occurs through a variety of processes. These include, at an individual level, selfawareness and conscientization, or critical consciousness-raising, which identifies how external structures are oppressive, thus linking the personal and the political (Freire 2007). Education includes an analysis of structural barriers, conditions, and dynamics that maintain the status quo and contribute to discrimination and oppression. Empowerment practice provides clients with the skills to address barriers and gain access to information and resources, and incorporates a strengths approach. On an interpersonal and community level, the aim is to develop relationships for mutual aid

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and to foster social action for social justice. This can be accomplished by participating in groups, community mobilization, and social justice movements for collective action (Christens 2014; Finn and Jacobson 2008). Engaging in social action aims to challenge and change social policies that oppress people. Professional response is the selection of a plan that will inform the next steps in a practice situation. Ideally, the practitioner develops and offers an intentional response based on reflection in the current moment or retrospectively, and incorporates insights from linkage to the knowledge base. Since there may be a number of issues to address, the response involves partializing the overall problem situation and selecting the highest-priority concern. For the client to achieve significant internal change, generally a prolonged period of engagement in a helping process is warranted. Currently, both agency-based social work practitioners and private practitioners are affected significantly by the policies of managed care organizations and insurance or third-party payment plans. An emphasis on cost containment often limits practitioners’ interventions to short-term contacts with clients (Mirabito 2012). Social workers’ assessments must therefore focus on external and internal determinants of clients’ presenting problems. For example, when lack of information about resources and how to access them is at issue, social workers can provide information and encourage and guide clients to take action. These processes can be used in short-term work and build clients’ self-confidence and internal capacities to affect their environments. When more pervasive and long-standing internal factors play a significant role in limiting an individual’s functioning, however, social workers will need to more actively seek ser vices that provide a more sustained helping process. It is crucial for practitioners to maintain an ongoing reflective mind-set and evaluate progress both within and after sessions with clients. As Schon (1983, 1987) has observed, when the practitioner’s reflection occurs during the interview it engages her in two activities simultaneously: interacting with the client while thinking about the process and outcome. Hence, the practitioner is present and attuned to what is transpiring while at the same time thinking about how the current discussion may be contributing to a future positive outcome for the client. The practitioner’s reflective evaluation can also take place after the interview is over, through retrieval and analysis of the practice situation. This

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can be done alone, with peers and instructors in practice classes and integrative seminars, or during supervision or consultation with colleagues via case presentations or review of audio-recorded or video-recorded interview segments. The goal is to critically examine whether what is being offered to the client is helpful and what alternative interventions may be more effective. The practitioner may hypothesize to some degree and a variety of conceptual lens can be useful for thinking about the situation from diverse perspectives with their related interventions. The practitioner can analyze the role of cognitive and affective processes, illuminating blind spots, biases, emotional reactions, and errors in judgment. Evaluation guides practitioners to consider the extent to which their original understandings and assessments were limited or accurate. As the process of working together with the client proceeds, new information is revealed, additional insights are gained, and the working alliance between the practitioner and client unfolds. The social worker repeatedly goes through the loop of retrieval, reflection, linkage, response, and evaluation, and may offer additional plans and responses as new understandings and circumstances emerge. Increasingly, in social work and related mental health and human ser vices, demands for accountability require that practitioners are able to defend what they do and articulate how it produces change or enhanced well-being for the client. Methods for evaluating practice are discussed in chapters 4, 9, and 11. Bogo and Vayda (1998) provide an example of using the stages in the loop model to examine and plan practice. First, using the retrieval stage, they describe pertinent facts in a family situation from the perspective of the practitioner, a white female social worker in her midforties who is working in a women’s shelter. The practitioner describes the client as a thirtyfour-year-old woman with three children, two girls, ages six and eight, and a ten-year-old boy. Her parents and many members of her large extended family emigrated from India as children and live in the same city. This woman has experienced physical abuse by her husband numerous times and has sought refuge in the shelter twice in the past year and a half. She then returned to her husband, in part due to the influence of her parents and brothers, who believe that is the right thing to do. She has a tenth-grade education and has never worked outside the home. After a few interviews, the social worker uses reflection to examine her thoughts and feelings about, and reactions to, this woman. The client’s

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situation is in some way reminiscent of the practitioner’s. The practitioner too had been in a heterosexual common-law relationship that had become abusive when her partner increased his alcohol consumption. Counseling helped her to leave that relationship, support herself with a daytime job, and complete her social work studies on a part-time basis. By reflecting on the differences between herself and her client, the practitioner recognizes that her middle-class background, educational opportunities, and knowledge of how to get the help she needed allowed her to leave the abusive situation. She is aware of her impatience with the client for having returned to her husband and of her subtle negative judgments of the client. In distinguishing her own experiences and opportunities from those of the client, she feels more ready to listen to the client and try to understand and empathize with her situation. The practitioner uses linkage to draw on social work’s diverse knowledge base, including information about cycles of abuse, the impact of police practices in charging an abuser, and attitudes toward marital stability in the client’s ethnic community. She can also access the practice and empirical literature on approaches to working with women living in violent situations and can, together with the client, develop support and safety planning strategies, utilizing both informal and formal sources. Successful approaches that involve extended family members identified as supportive can be used, as can resources for financial support, subsidized housing, vocational training, and day care for children. The next professional response involves formulating an intervention plan that takes all of the above factors into account and begins with a discussion with the client about what choices she feels are immediately necessary and possible. Since the client is strongly considering returning to her husband, a safety plan for herself and her children must be developed that could include neighbors, extended family, and police. The client has commented frequently that her parents, brothers, and cousins are close. In summary, this chapter focused on the many challenges facing social work students as they learn to practice in a way that leads toward gaining holistic competence. Since social work is a practicing profession, challenges were considered through the lens of experiential and active learning theory. Such a perspective accords well with the model of holistic competence and attends not only to knowledge, values, and skills but also to the intricacy of the way the social worker’s self is pivotal in learning and in practice. Litera-

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ture on the effectiveness of using simulation to promote deliberate practice in attaining skilled performance was discussed in conjunction with the related challenges of managing self-regulation. Involving peers and instructors in one’s learning is strongly recommended to facilitate self-awareness and more accurate self-assessment. Since learning about and performing social work can both contribute to life satisfaction and challenge emotional well-being, activities and factors contributing to self-care were reviewed. Finally, the Integration of Theory and Practice Loop Model, used extensively in field education, was presented as a process model that can assist students in learning in courses, labs, and seminars. A final word about learning to practice is warranted. Any text can only describe practice; it is only in the actual doing of practice that ideas take more shape, are experienced, truly learned, and can become part of the social worker’s professional self. Social work education has long recognized this axiom about learning, and programs aim to educate competent social workers by providing students with academic courses, simulated learning experiences, and supervised educational experiences in the field. Many of the processes discussed in this chapter are applicable in and consistent with best practices for field education: strong positive learning environments and supportive relationships with field instructors; observation of experienced social workers and being observed by instructors, with opportunities for debriefing and discussion centered on conceptual frameworks; multiple practice experiences with focused feedback based on observation and reflective discussions between students and field instructors that integrate theory, practice, and use of self (Bogo 2015). Students, course instructors, and field instructors may wish to use some of the concepts presented in this text so that a similar terminology and nomenclature can facilitate teaching and learning across the domains of the classroom, the field, and integrative seminars. Similarly, experienced practitioners may wish to review their work captured on audio recordings or video recordings on their own, with peers or a supervisor, and use the concepts presented in this text as a framework to guide reflection, feedback, self-assessment, and planning subsequent interventions for clients. The process of learning and refining practice is continuous, and approaches suggested in this chapter can contribute to lifelong learning for students and experienced practitioners.

4

The Helping Relationship: Conceptual and Empirical Contributions in this text is that the social work interview is the medium through which much of social work practice takes place. It provides the context in which ser vices are delivered as social workers engage in complex practices such as relationship building, developing joint assessments, and providing intervention. The next three chapters consider various crucial aspects of relationship building. The model of holistic competence presented in this text highlights that practice consists of multiple interrelated dimensions. Chapters  4 through 7 present these dimensions as they relate to relationship building. Attempts are made to link the information presented with the cognitive and affective processes that all practitioners engage in, more or less consciously, as they strive to provide the most helpful working relationships to clients. The specific dimensions considered are: key pieces of knowledge derived from theorizing as well as from empirical studies in a range of relevant disciplines (the focus of this chapter); how this knowledge can be integrated with perspectives on practice in the context of diversity and difference (the focus of chapter 5); principles gleaned from years of social work writing, generally known as practice wisdom (the focus of chapters 6 and 7). a key premise

the crucial contex t for helping

What is unique about professional social work helping relationships that affects the social worker’s interactions with clients? Many beginning practitioners wish to provide immediate help to clients and conceive of social

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work practice as consisting of listening, getting the facts, and then offering advice or assistance through a problem-solving approach. Effective social work practice, however, emanates from a mission to enhance social functioning by alleviating external conditions and addressing individual factors that affect well-being. A systematic helping process unfolds within a unique type of professional collaborative relationship, with the goal always to serve the best interests of the client. This book places the working relationship at the core of practice and focuses on the process that unfolds as the practitioner fosters a clientcentered interpersonal relationship whereby the social worker provides the necessary conditions that a particular client needs at a specific moment in time. As the practitioner interacts with the client, they share information, develop joint perspectives or assessments, and plan and implement interventions. A strong body of evidence supports the conclusion that the working relationship is the most crucial determinant of client outcomes (Norcross 2011; Wampold and Budge 2012; Wampold and Imel 2015). Helping relationships don’t just happen; they develop over time and may experience ruptures and repairs as the participants work together in the interests of the client. During development of the working relationship, behaviors, feelings, thoughts, and meanings are experienced, described, explored, and reexamined. A continuous cycle of helping involves the client and the social worker in a collaborative effort to produce change. Promoting well-being is not exclusively reliant on the interpersonal aspects of the helping process. The social environmental and supports in the client’s life are crucial in this regard. Programs and ser vices can address and fill important gaps through providing missing concrete and social resources. The difference social workers in direct practice can make, however, in large measure takes place in the interview, and the working relationship between the client and worker provides the crucial foundation on which social work intervention is built. The importance of relationship building and engagement are evident in EPAS (CSWE 2015) and are clearly articulated in Competency 6, “Engage with Individuals, Families, Groups, Organizations, and Communities.” EPAS statements include the following: Social workers value the importance of human relationships. (8) Social workers understand how their personal experiences and affective reactions may impact their ability to effectively engage with diverse clients

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and constituencies. Social workers value principles of relationship-building and inter-professional collaboration to facilitate engagement with clients, constituencies, and other professionals as appropriate. Social workers: apply knowledge of human behav ior and the social environment, person-inenvironment, and other multidisciplinary theoretical frameworks to engage with clients and constituencies; and use empathy, reflection, and interpersonal skills to effectively engage diverse clients and constituencies. (9)

The Importance of Pro cess

Social workers know a great deal about the process of helping. The term process refers to a sequence of interactions that takes place between the client and the social worker over a period of time. More specifically, it refers to the way the two relate to each other as they discuss the situation that brought the client to the social worker. It also refers to the way they relate to each other as they approach their task of working together. This aspect of the process includes verbal and nonverbal behaviors, and overt and covert messages. Covert messages refers to underlying meanings of messages that may be inferred or observed from the way each person reacts to the other. Practitioners reflect on the process from the position of both participant and observer, and they do so simultaneously, which entails moving in and out of the interactional field. It also involves a dynamic tension between the way the worker behaves in her usual way (the personal self ) and the way she behaves as a disciplined and purposeful professional (the professional self ) (Edwards and Bess 1998). Using the awareness-in-action approach discussed in earlier chapters, social workers are more likely to provide responses that are intentional and developed to achieve goals rather than offering unexamined reactions that reflect their spontaneous emotional responses. For example, a social worker preparing a foster child for his second move in nine months is aware that the child’s anger at her is eliciting personal feelings of annoyance. The social worker identifies her own annoyance; she has spent hours finding and preparing a new home for this child. She also reflects on how hard it is for the child to experience another rejection and is able to respond to him with compassion rather than act on her own irritation. Her reaction is a normal one that warrants recognition and perhaps discussion with a colleague or supervisor. What is important is that this personal reaction is reflected on,

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understood, and thereby contained. The worker is then able to provide what the client needs—support and understanding. Change occurs through a process that comes about by providing a relationship context in which individuals and families can examine their needs, strengths, abilities, and supports. They can also be helped to identify the challenges, obstacles, and problems that interfere with or block achieving their goals, improving their relationships, and realizing more adaptive social functioning. Clients face many constraints and challenges, including those that are environmental, interpersonal, and individual. Regarding the environment, for example, clients may lack resources or knowledge about how to obtain necessary assets, or they may experience harassment and exclusion based on social location and personal characteristics. Interpersonal challenges occur when social networks and relationships engender conflict. Relationships may be nonsupportive, place unrealistic demands on individuals, or are abusive and provoke negative and harmful behaviors. Constraints may also be of an individual nature when issues of self-esteem, self-defeating thoughts, or fears of disrupting an uncomfortable, but known, status quo keep an individual trapped in a situation that does not meet her needs. Of special interest to social workers is the goodness of fit (Germain and Gitterman 2008) between clients’ needs, rights, capacities, and aspirations, and their social, economic, and physical environments. The hallmark of effective social work practice is the professional’s expertise in guiding helping or therapeutic conversations that encourage clients to tap into their inner strengths and abilities such that they are able to gain understanding about the issues with which they are struggling and find alternative ways of thinking, feeling, or acting in relation to them. Social workers provide “a space and a place” where practitioners and clients working together can examine the clients’ problems, the persons involved in these problems, and the relevant external forces and circumstances associated with them. The emphasis is on maximizing the client’s participation as the two individuals collaborate in an effective intervention. A helping “space and place” appears to assist clients to explore and experience their own thoughts and feelings at deeper levels. In an ethnographic study of therapy for family problems, researchers interviewed clients about the factors they believed helped them to change (Gehart-Brooks and Lyle 1998). Clients reported that they developed a more complete understanding of their situation through the process of talking it out with an attentive,

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supportive professional. Participants experienced relief expressing themselves to a professional who listened to their narratives and validated their experiences. Professionals were seen as objective, since they were not personally affected by the content under discussion. Change derived from the dialogue between the client and the practitioner, and the helpfulness of the practitioners’ questions, which included both simple questions that clarified the details and dynamics of the problem and questions that challenged clients’ assumptions and positions. It is interesting to note that clients viewed therapists’ suggestions as helpful, but almost never followed up on them. Rather, clients described how, through dialogue, they were able to arrive at their own new perspectives. The give-and-take in the conversations stimulated clients’ thinking. This in turn led to new perspectives and behavioral, emotional, and cognitive changes. The researchers concluded that within the context of an accepting, supportive working relationship, clients experience enough safety and trust to be open to considering alternative ways of looking at the presenting troubling situation and issues associated with it. This collaborative approach appears to help clients generate their own interpretations and new perspectives that make sense to them. A Site of Cross- Cultural Engagement

Collaboration between the practitioner and client is even more crucial in North American communities that are characterized by great differences in their population due to a vast array of factors that contribute to salient aspects of individuals’ identities and belief systems. Especially in societies with a history of slavery or where dominant majority groups have oppressed members of minority groups, historical and political aspects of power and privilege are relevant factors in interpersonal relationships. A humanistic perspective leads us to recognize that there are many commonalities among all individuals and this perspective informs this chapter, which examines generic concepts relevant for professional relationships in social work. Diversity perspectives must be given a central place in the profession’s understanding of relationships, however. Accordingly, the discussion of relationships in this chapter will focus on universal principles. The following chapter, chapter 5, examines diversity issues in practice in great detail. Principles are offered to assist social workers in individualizing clients and integrating into their practice alliance approaches that have proved effective.

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Although practitioners and scholars accord importance to the working relationship in social work, there has been scant new theorizing since the early research conceptualizations. In those formulations, the key characteristics of a helping relationship were determined to be warmth, acceptance, empathy, caring concern, and genuineness (Biestek 1957; Northen 1995; Perlman 1957, 1979; Woods and Hollis 2000). The practitioner’s nonjudgmental stance and positive regard were also seen as necessary to produce the trust and mutual respect that leads to collaboration on agreed-on goals (Biestek 1957; Northen 1995; Perlman 1957, 1979; Woods and Hollis 2000). These relationship components contribute to the emotional bonding between the client and the social worker, a dimension associated with forming a positive working alliance. Such an alliance in turn contributes to positive client outcomes. Early social work theorists defined the helping relationship as one in which the practitioner was highly present and attentive and created a real relationship (Edwards and Bess 1998). Coady (1993, 1999) reviewed social work literature and empirical studies in related fields, and concluded that the ability to develop and maintain this type of relationship still remains the cornerstone of helping. He recommends that social workers find ways of expressing this “heart/mind-set” (Coady 1999, 70) in their own unique and natural ways. Both historically and in contemporary practice theory, there is support for the importance of a humanistic, caring presence in professional practice. Concerned about the growing impact of evidence-based practice, a leading social work scholar at the time, Howard Goldstein (1990), argued that practitioners should not overlook the humanistic and artistic aspects of their work as they strive for more theoretical, empirical, and technical complexity. In a similar vein, Weick (1999) argued for a return to the roots of social work as a caring, relational profession. The important characteristics of social work relationships are presented in virtually all current texts on social work practice (see, for example, Compton, Galaway, and Cournoyer 2005; Hepworth et al. 2010; Kadushin and Kadushin 2013; Murphy and Dillon 2015). Although definitions of particular aspects of the relationship vary, they all reflect qualities similar to those presented in Coady’s (1999) literature review; these qualities will be discussed in detail in chapter 6.

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Theoretical concepts in social work are formulations about phenomena related to the human condition and to processes of change. When empirical findings support these formulations, practitioners can have confidence in their potential usefulness for practice. This is the case with the concept of the relationship. There are now abundant empirical findings to support the importance of relationship in bringing about change (Norcross 2011; Wampold and Imel 2015). It is not surprising that this is the case because when an individual is in a relationship in which she feels understood and safe, there are opportunities for positive growth. In a working relationship with such characteristics, there is a greater likelihood that a client will be more open and share salient features of the situation, even when those features are painful. With additional relevant information, the practitioner can arrive at a more informed assessment and focus on the important factors. Moreover, in a positive relationship, a client will feel enough support to allow himself to be vulnerable, to explore issues heretofore avoided, and to take risks and attempt new behaviors. c o n t r i b u t i o n s f r o m p s yc h o dy n a m i c t h e o r y

Psychodynamic theories have influenced how social workers conceive of their practice, especially regarding the nature of the working relationship with clients. While specific intellectual streams in this tradition vary, some general concepts enrich our understanding of interpersonal processes. As Mishna, van Wert, and Asakura state: “It is through the therapeutic relationship that the therapist provides the client with empathy and new types of emotional and relational experiences . . . [so that the client] gains a deepened understanding of the self and others, recognizes his or her strengths and challenges and develops or increases capacities to cope more effectively” (2013, 291). Transference and Countertransference

The concepts of transference and countertransference provide useful ways to understand how personal and developmental issues can operate in practice. Traditionally, the term transference referred to that part of the client’s experience of the relationship that is a manifestation of his intrapsychic dynamics or personality. The term countertransference referred to a social worker’s

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reactions to features of the client, including their behavior with the worker and their narrative, which elicited worker’s feelings, thoughts, and behaviors that derived from their own history, dynamics and personal conflicts. The implication was that these reactions would impede the therapeutic process. Within the psychoanalytic tradition, this classical view was replaced by writers such as Racker (1968) and Winnicott (1956), who recognized that therapists experience the totality of the client and the therapy, and that this experience is not solely a reflection of therapists’ unresolved issues but is a normal by-product of intense engagement in interpersonal work. Furthermore, they observed that subjective reactions could be a useful source of data to better understand the client. Hence, for social workers, both transference and countertransference refer to all the ways both the client and the worker experience each other within the context of the working relationship. This current experience is shaped by their respective personalities and characteristic ways of feeling, processing information, and creating meaning in relationships. These dynamics are largely unconscious and hence the client and worker are not directly aware of them. Therefore, either participant may behave in ways, both positive and negative, that do not appear to be warranted by the present interactions or purpose of their meeting. Rather, influences from both the past and from current experiences have become internalized and manifest themselves in the way each individual participates in the helping relationship. Psychoanalytic theory has evolved to emphasize the relational context in which psychological or intrapsychic phenomena exist; therapy is created and shaped by the interaction between both the client and the therapist (Mitchell 1988; Stolorow 1994). Beginning with the seminal work of Heinz Kohut (1971), self psychology argued that individuals’ basic needs centered on empathic connections with others, particularly with caregivers. Empathy is considered central to both development and to the therapeutic process. The term selfobject is used to refer to persons or objects that are required to fulfill certain functions that enable individuals to maintain a cohesive sense of self and well-being in childhood, throughout the life cycle, and in therapy. Kohut considered it important for therapists to be self-scrutinizing to remain empathically attuned to clients’ selfobject needs. Therapists’ empathic failures are understood as being rooted in their vulnerabilities that stem from their own current or past selfobject needs, which may be intensified when working with a particular client. Social work scholars such as

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Palombo (1985) and Goldstein (2001) brought self-psychology theory into clinical social work practice. Contributions from intersubjectivity theory in psychoanalysis provide other useful concepts to understand “the interplay between the differently organized subjective worlds of the observer and the observed” (Atwood and Stolorow 1984, 41). Both pathological and healthy human development and processes of change arise from and are maintained by the interactions of two subjectivities, be it parent and child, or client and therapist (Orange, Atwood, and Stolorow 1997). A moderate view of realism is proposed by Orange (1995), who recognizes that inevitably each person’s perspective can only be a partial one; through dialogue with others, a broader view may be gained. Relational Theory, Attachment, and the Helping Relationship

Miehls (2011) notes the shift from the traditional view of development as an individual activity “aided by the presence of a caregiving other” (402) to a view that recognizes the mutual influence the client and caregiver exert on one another through their interactions. Intellectual contributions from attachment theory and the British object relations school (for example, Bowlby 1969, 1988; Fairbairn 1952; Winnicott 1965), the American interpersonal school (Sullivan 1953), the American object relations theorists (Kernberg 1993), self psychology (Kohut 1984), and self-in-relation theory (Jordan 1997; Miller 1987) all point to a similar conclusion: “Relationships with other people shape the structure of the mind (internal world) of individuals and . . . these important attachment relationships shape the personality of individuals” (Miehls 2011, 402). Social work practice has been especially influenced by the seminal work of John Bowlby (1969), who highlighted that human relatedness is a primary and basic biological need. Relational theorists such as Fairbairn (1952) and Mitchell (1988) emphasize that individuals crave intense attachments and will form, seek, and strive to maintain relatedness in their personal lives and in therapy. Early relational experiences are internalized and form a basic relational configuration or internal working model that includes the dimensions of the self, the other, and the transactional patterns (Bowlby 1969; Mitchell 1988). Although internal working models are formed in the context of earliest relationships, throughout adulthood they are maintained or reconstructed through experiences and interactions with signifi-

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cant others, such as peer group members, intimate partners, significant extended family members, mentors, employers, and friends. An individual’s internal working model that includes beliefs about his needs and the likelihood that he will be offered others’ emotional availability and responsiveness are carried forward into new relationships and affect current behavior. To the extent that they lead to predictable and repetitive behavioral patterns that elicit characteristic responses in others, these expectations or internal working models are reinforced and will persist. These models and patterns are carried into helping or therapeutic encounters, where they can be experienced and examined, and new relationship experiences can be constructed. Hence, transference and countertransference can be understood as the enactment of internal working models on the part of both clients and social workers. Two practice concepts arise from this work: (1) the client’s way of relating reflects her underlying beliefs and ideas about relationships, including what she expects to experience in a helping relationship; and (2) the client’s characteristic ways of relating will also be seen in how she relates to the practitioner. Hence, the working relationship has the potential to help the client change his beliefs about relationships by offering a different relationship experience. There is a vast literature on relational concepts, attachment theory, and supporting empirical studies that is beyond the scope of this text. Rather, selected ideas that can be useful in practice are presented here and readers are encouraged to pursue the work of relational and attachment theorists and researchers. These concepts help practitioners understand why key relational components such as empathy and emotional bonding are so critical to effective practice. Individuals Have Basic Beliefs About Relationships

Bowlby (1988) proposed that humans have basic needs for care, nurturance, and emotional connection, and an infant’s attachment to his mother or substitute caregiver arises from numerous responses to the infant’s needs. Accessible and responsive caregivers provide the infant with a sense of attachment, and this in turn leads to the development of secure bonds. Attachment and caregiving are affected by such factors as parental characteristics, children’s characteristics such as temperament, the fit between children’s needs and caregivers’ capacities, and stresses and supports in the external environment.

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Ainsworth et al. (1978) studied the relationship between children and their caregivers, and identified three attachment styles as measured in the Strange Situation: secure, insecure-avoidant, and insecure-ambivalent. A fourth style, disorganized/disoriented, was identified by Main and Solomon (1986). From early experiences with caretakers, individuals develop notions about self, other, and relationships, referred to as internal working models of attachment, relationship schemas, or scripts (Bretherton 1993). These internal working models are internal representations that have thoughts and feelings associated with them. They constitute our self-image, especially about our worth, lovability, dependency, effectiveness, and sense of self as good or bad. These models about others include expectations about their availability and accessibility, dependability, lovingness, caring, responsiveness, cooperativeness, and trustworthiness. Relationship models include what we expect as patterns in relationships—for example, that relationships are easy and rewarding, or that they need to be “worked on” to prove gratifying, or that they are essentially dangerous and exploitative. These relationship models predispose us to habitual forms of relating to others, or of demonstrating our attachment styles in significant and intimate relationships. Attachment styles can change throughout a person’s life course based on life experiences in the family and with significant others. For example, when stable caregiving patterns are disrupted because of illness, unemployment, war, forced relocation, or other traumatic and disruptive events, attachment styles can be affected. When unstable caregivers’ life experiences change and enable them to be more present and available, or when more giving and available individuals become part of the caregiving system, more secure attachment styles may develop. Important mediating factors that affect the development and persistence of particular attachment styles are the individual’s temperament and resilience, and the characteristics of caregivers and significant others in the social environment (Landy 2002). Individuals’ Ways of Relating to Others Reflects the Internal Working Model

An individual’s internalized ideas about self, other, and what one can expect in a relationship come to bear in relating to significant others in current situations. Attachment styles are especially evident when adults seek emotional connection in intimate interpersonal relationships. Internal

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working models are revealed as we engage in habitual patterns regarding the expectations we have of others, our appraisals and interpretations of their actions, and the emotions that are evoked as we interact in new relationships (Hazan and Shaver 1987; Johnson, Makinen, and Millikin 2001; Johnson and Whiffen 1999). As noted above, Ainsworth et al. (1978) and then Main (Main and Solomon 1986) identified attachment styles in children. Researchers have studied attachment in adults and have found that in general adult attachment styles are associated with specific relationship behaviors and concerns (Kirkpatrick and Hazan 1994; Simpson 1990). For example, securely attached individuals are more trusting, committed, and satisfied in their relationships. Those with avoidant attachment styles tend to avoid commitment and intimacy and are less trusting of partners. Those with preoccupied attachment styles are concerned with their partners’ predictability, trustworthiness, and dependability. The concept of attachment has been included in research and clinical practice with couple relationships in association with the innovative emotionally focused couples therapy model developed by Sue Johnson (Johnson 2004). Attachment styles describe some predominant trends that can assist us in gaining understanding about consistent thoughts, feelings, and behaviors on the part of an individual in relationships. They are not absolutes, however, and individuals may demonstrate a range of styles, especially when they are under stress or when threatened with loss of a meaningful relationship. It is useful to think systemically and accord importance to ongoing significant interactions, for our internal life develops and changes in relation to our external experiences: we are affecting and being affected by others. As we participate in interactions with significant others and take in new information and experiences, we can change our internal working models. Repetitive positive or negative themes that emerge in relationships with partners, peers, mentors, and employers can confirm or disconfirm an individual’s internal working model of self and relationships. Individuals Relate to the Helper in Ways That Reflect Internal Working Models About Relationships

Practitioners aim to understand the impact of early and current attachment and loss with the aim of changing clients’ thoughts, feelings, and

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behaviors (Bowlby 1988). As with all significant relationships, individual ways of making sense of and behaving in important interpersonal relationships can be displayed in the way the client relates to the helper. The client expects the practitioner to respond in ways that confirm his internal working models and expectations of self and of other. This is especially so if the client approaches the social worker with the expectation that assistance of some form will be provided. The professional relationship can be seen as analogous to a caregiving relationship. The parallels are especially obvious when an individual needs more assistance from another, such as during a time of distress. When the practitioner offers availability and responsiveness, the client is likely to experience some degree of comfort. Such responsiveness would be offered in a selective manner depending on the attachment style of the client. The Practitioner Is Not a Neutral Participant in the Relationship with Clients: They Cocreate the Relationship

Using a relational lens, practitioners recognize that their own subjective reactions influence the experience and development of the relationship. Interactions between two subjectivities proceed such that each influences the other. Consistent with the importance accorded to self-awareness throughout this text, practitioners need to be highly attuned to their own responses so that they can use the relationship to enhance clients’ attainment of best possible outcomes. Prac ti tion ers Can Help Clients Develop Alternative Internal Working Models About Relationships

The following practice principles are associated with this type of in-depth work. They can also be used in more general ways in all forms of direct social work practice, regardless of the particular theoretical model applied. First, the social worker aims to understand the client’s view of self and other, and his expectations of relationships. Such understanding develops from two sources. The first source is the client’s narrative, or discussion of his past and current experiences. The second is the practitioner’s reflections on the current interactions with the client and the associated feelings and thoughts engendered in the worker. Attachment researchers posit that

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models are kept stable when others behave in a way that confirms them (Hazan and Shaver 1994). The worker’s self-awareness is therefore crucial because it ensures that the practitioner is able to distinguish between her own idiosyncratic or countertransference response to the client and what might be others’ typical responses to the client’s behavior in relationships. With an understanding of the client’s expectations, the worker is better able to avoid reacting in a way that will confirm the client’s most negative expectations. By refraining from behaving in a way that reinforces the client’s typical personal relationship experiences, the worker provides an opportunity for a new type of interaction experience to occur. Ideally, new learning from this therapeutic relationship generalizes to expectations and behavior in the client’s significant personal relationships. Second, to the extent that the helping relationship is emotionally engaging and continues over some prolonged period of time, it has the potential to change internal working models by providing a secure base. The practitioner can provide the empathic qualities that demonstrate accessibility, interest, and responsiveness by simply being there for the client in a way that is different from others in his life (Howe 1995). This description of a relationship draws from the concept of a holding environment, that is, a place where there is enough affirmation of the individual and her worth that anxiety-producing thoughts, feelings, and situations can be explored and better understood. The concept of the holding environment derives from the work of Winnicott (1958, 1965), who used terms such as the good enough mother and holding environment to refer to the ways a mother is able to offer emotional security to her developing infant and child. Winnicott drew analogies between these concepts and psychoanalysis, and similarities to social work clinical processes are discussed by Applegate and Bonovitz (1995) and Brandell (2004). When the client feels enough acceptance and security in the social work relationship, she can disclose uncomfortable aspects of her life. Discussion of painful issues may stimulate potent feelings of anxiety, rage, or sadness, which the client experiences as overwhelming. Within a connected and calming holding environment, practitioners can offer sustaining and supporting responses so that feelings do not overpower the client but rather are contained. Therapeutic responses emanate from genuineness and concern, empathic listening, and a nonjudgmental stance. When such attitudes and behaviors engender a feeling of safety in the client, she may be able to become more reflective about her

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situation and the feelings associated with it; engage in a mutual search for understanding with the practitioner; and, ultimately, reprocess experiences and examine choices. The offer of support and assistance to the client in the form of the social worker’s steady, consistent availability leads to trust. This may build slowly over time, through numerous contacts and interactions with the practitioner, or it may arise when the practitioner offers support and instrumental help in a time of great need. Influenced by the client’s internal working model and the social worker’s reactions to the client, the working relationship may be tested with behavior that may be provocative to the worker. As the worker is able to reflect on her own reactions and is able to remain attuned and present, she can provide a new relationship experience for the client. This new relationship encounter becomes emotionally important to the client, is internalized, and provides the client with new beliefs or alternative internal working models about self and other that are now available for use in future social interactions. Third, when client and practitioner can work together over some period of time, within the context of this secure and trusting relationship, the client can explore in some depth past relationships and the thoughts, feelings, and behaviors associated with them. The client can examine how past and current experiences are linked, including whether salient themes from the past are active in the here and now in interactions between the social worker and client. Since discussions of past relationships may stir up painful emotions, the client’s experience and growing expectation that the worker will provide an empathic and nonjudgmental response provides comfort (Sable 1992). The opportunity to experience open communication in an atmosphere of acceptance and interest demonstrates what a close relationship can be like. The practitioner’s behavior is an example of how professionals, using attachment and relational concepts as a theoretical base, are able to engage differently with each client to meet their specific needs. Furthermore, as the practitioner draws explicit connections between the past and the present, the client develops an expanded understanding or a new narrative about his history, development, and recent insights into his own personality and ways of relating to others. This new learning can in turn be used in personal relationships in the client’s life. In summary, contemporary views of transference and countertransference rest on an assumption that early experiences are formed in an interac-

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tive social field; occur between people; are internalized; and are seen in an individual’s thoughts, feelings, and behaviors in subsequent relationships throughout the life cycle and in therapeutic or helping situations. These intrapsychic and interactional patterns then tend to operate in subsequent interpersonal experiences by serving as a lens through which an individual’s and others’ thoughts, feelings, and behaviors in relationships are experienced and understood. Similarly, these dynamics are also evident in encounters with social workers, where there is an expectation of help. Using these concepts, it is clear that social workers are not objective or neutral participants, as these concepts come to bear on both parties in the helping relationship. Social workers bring their own histories and their subjectivities into the working relationship and must understand the way their internal working models and reactions contribute to or impede the working relationship dynamics, and ultimately, the success of the therapeutic work. Neuroscience and Social Work

In the twenty-first century, social work and related human ser vice professions have begun to include findings from extensive new research in neuroscience. The focus has been on understanding the neurobiological foundations of human behavior and implications for the helping process. Of significance in this chapter is the perspective that “relationships are crucial to brain development and neural functioning throughout the life cycle” (Fishbane 2007, 396). The interdisciplinary field of social neuroscience or interpersonal neurobiology has evolved, bringing more in-depth understanding of and empirical support for the role of caregiving and attachment in human development and the related characteristics of caregiving and attachment in professional helping relationships (Siegel 2003). These notions are congruent with theorizing in social work and provide data to support some long-standing practice principles. Drawing on neuroscience research, Miehls and Applegate (2014) draw parallels between the role caregivers play in assisting developing children to deal constructively with affect regulation and the role practitioners play in this regard with clients. They note that in both instances, information is transmitted in implicit (right brain) and explicit (left brain) ways. Relationships between practitioners and clients are similarly built on these communication pathways, and each participant attunes to the nonverbal

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and verbal messages conveyed. Through therapeutic conversations that involve mutual dialogue in which possible interpretations of the client’s situation are offered and examined, the practitioner and client can develop insight and the client’s own capacities for reflection and self-regulation are enhanced. A long standing practice principle recognizes that helping clients put feelings into words is a useful way to understand and change perceptions and emotional reactions. This principle is now supported by neurocognitive researchers who have been able to identify the neuronal pathways for this process through neuroimaging studies (Lieberman et al. 2007). Siegel (2003) draws on studies such as this to note the importance of naming an emotion to tame the emotion, thus making it more amenable to conscious thought and intentional actions. The sensitively attuned treatment relationship is a highly empathic one— and one that holds the promise of corrective experiences for adult clients. Crucial for the development of trust in the treatment relationship, the clinician’s understanding that her nonverbal right-brain attunement with her client’s right-brain activity leads to satisfying and healing affect synchronizing possibilities. The functions of the clinician change over the course of the treatment relationship. More active in the early phase of treatment, the clinician attends to left-brain processes by assisting the client to recognize, feel, and manage affective states. With increasing capacity to be aware of her own affective states, the client becomes more able to self-regulate emotions while in the presence of the clinician and others in her relational environment. Responding to this shift, the clinician can focus more directly on right-brain processes that promote conscious insight and the creation of new patterns of interactions with others. Clients can then alter their internal representations of relationships and redesign their views of self and others in interpersonal exchanges—all while altering associated brain structures. (154)

Consistent with social work’s attention to client’s emotional lives, interpersonal neurobiology emphasizes the importance of the practitioner’s attunement so that clients can “feel felt” (Siegel 2010, 138). Siegel (2003) notes the importance of “attunement of right-to-right hemisphere” (38), which can “evoke an uncomfortable emotional resonance in the therapist, who needs to be centered and able to identify and manage his or her own reactivity”

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(Fishbane 2007, 406). Again, this is consistent with social work’s longstanding emphasis on use of self and self-awareness as a fundamental feature of holistic competence. Insights from neuroscience are discussed in greater depth in subsequent chapters on change processes. c o m m o n fa c t o r s : e m p i r i c a l s u p p o r t f o r t h e i m p o r ta n c e o f t h e r e l at i o n s h i p

As noted, despite the centrality of the relationship concept in social work, there has been little empirical investigation in this realm. Research in social work practice has largely focused on the effectiveness of various intervention models and emphasized measuring outcomes (Poulin and Young 1997; Reid and Fortune 2003). Study of the role of the relationship in helping has largely been undertaken by disciplines such as psychology, counseling, and psychiatry through studies of a range of variables that affect outcomes in psychotherapy. These variables include client expectations and presenting symptoms, interventions associated with specialized models, and the relationship (often referred to as alliance in these disciplines) between practitioners and their clients. Studies have been conducted in a variety of settings and with a range of practitioners, including social workers. There may be differences in ideology, theory, and nomenclature among professional disciplines, but there are sufficient similarities between the study populations and their presenting problems and those that social workers encounter, and the actual practice models they use, that attention to this work is warranted. Findings from these studies have produced knowledge that is useful to social workers and can be easily adapted. Originally, researchers conducted outcome studies to demonstrate the effectiveness and superiority of a specific intervention model (Bachelor and Horvath 1999; Lambert and Bergin 1994; Orlinsky, Grawe, and Parks 1994). In a number of meta-analytic studies, they concluded that psychotherapeutic or counseling interventions are effective and that no particular treatment model is more effective than another for a range of individual problems (Norcross 2011; Wampold and Imel 2015); rather, all models produce “approximately equal benefits generally” (Ahn and Wampold 2001, 254). This conclusion spawned an extensive discussion in the psychology and psychotherapy literature on the common factors that exist across specialized models, such as those that are psychodynamic, cognitive-behavioral, and

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humanistic. The reasoning was that if one model is not superior to another and all models produce change, then features common to all approaches rather than the specific activities of discrete ones account for improvement. Researchers have identified these common factors through considerable theorizing and meta-analyses. Drawing on the conclusions offered by researchers such as Grencavage and Norcross (1990) and Lambert and Barley (2002), and the seminal theorizing of Frank and Frank (1991), the factors can be conceptualized as outlined in the following subsections. Client and Extratherapeutic Factors

Client and extratherapeutic factors refer to characteristics of the client or the client’s social situation and environment that support the achievement of intervention goals. That is, they are factors outside of the practitioner– client interview activities. Client factors refer to the client’s strengths, such as individual personality, including cognitive and appraisal skills; selfregulation; defenses and coping mechanisms; resilience; and temperamental and dispositional factors. The client’s interpersonal skills and the capacity to give and take in interpersonal relationships, the ability to talk about a situation with another, and the ability to identify a specific area to work on are also important client contributions to the therapeutic work. Outcomes are also affected by individual and family history and development, the presence and impact of stress and trauma, and the severity and history of a problem or condition. For example, where there is long-standing addiction, persistent mental illness, or a history of severe childhood abuse, these conditions will significantly affect the individual’s growth and personality development, ability to achieve satisfying interpersonal relationships, and general well-being. Extratherapeutic factors also refer to the client’s social situation and environmental factors that can positively or negatively affect the impact of the professional help being provided. Lambert’s (1992) interesting finding that these client and extratherapeutic factors account for 40 percent of the variance in outcome provides strong empirical support for the importance that social work practice theory has always accorded to understanding and intervening in the environment. In both assessment and intervention, attention should be paid to three elements: (1) the client; (2) the relevant social environment, including family, friends, neighborhood, community, organizations, informal and formal networks and social supports, and work

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colleagues; and (3) the transactions between the two. These elements constitute the extratherapeutic factors that could be enhanced, supported, or brought into the intervention plan for examination and action to facilitate the client’s progress. Conversely, when the client experiences these relationships as exploitative, undermining, or troublesome, the focus may then be to help the client separate from these systems. Expectancy, Belief, or Hope

Belief or hope refers to the client’s expectation that the helping process and interventions offered will be effective and bring about change in his life, or at least provide some support or relief. When the client believes that the practitioner knows how to help and that the methods will work, there is a potent impact on change outcomes. In other words, the client experiences the helper and the helping process as credible and expects to gain something of value from it; hence, it is important that the practitioner understand the client’s worldview and beliefs about the problem situation and what is needed to bring about change in his life. Especially when working in contexts of diversity, if the client believes that the approach the practitioner offers is deficient, foolish, or lacking an important component, then hope and confidence will be absent. The practitioner must also believe that the intervention she is providing is based on an appropriate rationale and is likely to be effective. A rationale provides an intellectual base to guide practice. And a belief in the work can serve an important role in self-care, as it provides a foundation that may protect practitioners from feeling overwhelmed, confused, and disheartened when confronted with the vicissitudes of practice. Of course, convictions and beliefs about the effectiveness of interventions should not be held so rigidly that alternate approaches are not tried when there is a lack of progress. Finally, it is likely that the development and maintenance of hope, belief, and expectation operates in concert with the working relationship; as the work yields positive results, the client’s confidence in the practitioner develops and both client and worker become more optimistic about making more progress. The Context of the Helping Relationship

The context of the helping relationship refers to the environment in which the professional activity takes place; ideally clients should view this setting

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as conducive to providing helpful ser vices (Frank and Frank 1991). When an institution has a positive reputation this confers an expectation that individual practitioners’ work with their clients will be productive. Many settings such as mental health clinics, family ser vice agencies, and community settings that specialize in serving specific populations have such reputations. Institutional reputation may be negatively perceived for clients who are mandated to attend due to interpersonal family violence or child maltreatment. Clients may initially perceive these institutions as intrusive, threatening, and as holding the power to remove their children or incarcerate the individual. Hence, this positive common factor, while applicable in many counseling encounters, is compromised in mandated social work services. As a result, in such situations social workers must focus on developing the other significant factors to counterbalance clients’ negative views of court-ordered counseling. The Helping Relationship

The helping relationship refers to a working relationship between a practitioner and a client in which there is an expectation that the client will self-disclose or confide important information and that the practitioner’s involvement is for the benefit of the client. The relationship consists of a number of attributes: an empathic and available practitioner, a sense of emotional bonding between client and social worker, and agreement on goals and tasks. Lambert (1992) found that 30  percent of the variance in outcome across models was accounted for by relationship factors. Other meta-analyses found a moderately strong relationship between alliances and outcomes in psychotherapy (Horvath and Symonds 1991; Lambert and Barley 2002; Martin, Garske, and Davis 2000). The characteristics of these relationships mirror those described in the social work literature and include “caring, empathy, warmth, acceptance, mutual affirmation, and encouragement of risk taking and mastery” (Hubble, Duncan, and Miller 1999, 9). Procedures and Techniques

Procedures and techniques are based on the explanatory concepts and intervention methods associated with specialized practice approaches. Techniques provide the link between the concepts in the model and the actions

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and stance the practitioner should take in the actual work to bring about change. Although the central point of the common factors analysis is that generally all models are effective, practitioners who adopt this perspective can still view specialized models and the procedures or processes associated with them as playing a significant role. Procedures and techniques provide practitioners with a coherent framework that includes a rationale for their work based on ways of understanding human functioning and problems, processes for bringing about change or offering relief, and skills or techniques for bringing about that change. Procedures provide structure, focus, and a plan for the work, which have all been shown to be important for a positive outcome (Mohl 1995). Some researchers have suggested that models can be thought of as healing rituals. According to Jerome Frank, for example, an early proponent of the common factors approach, “the success of all techniques depends on the patient’s sense of alliance with an actual or symbolic healer” (Frank and Frank 1991, xv). Hence, technique is important, as it supports the working relationship and the expectation that the practitioner has special knowledge and is able to provide something of value to the client. Wampold (2001) elaborates on this idea, stating that practitioners need to know about and use specific techniques while remembering that “it is the healing context and the meaning that the client gives to the experience that are important” (219). This explanation supports the importance of practitioners acknowledging indigenous knowledge and healing practices in ethnocultural and religious communities. Hubble, Duncan, and Miller (1999) argue that models and techniques are useful insofar as they enhance the common factors that lead to change: the strengths and resources of clients and their environments, the relationship between client and worker, and the client’s hope and expectation that the collaborative work with the practitioner will result in positive change. They conclude that clients are best served when the model chosen fits with the client’s view of why there is a problem and how problems are changed. The model should utilize and build on the client’s strengths, and should fit with the client’s goals, hopes, and expectations. With respect to this chapter’s focus on the relationship, these researchers note the importance of learning to provide a working relationship best suited to the particular client’s needs (Lambert and Barley 2002). Furthermore, they note that the common factors of empathy, warmth, and the

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relationship are more highly associated with positive outcomes for clients than are the interventions of particular intervention models. They conclude: “Decades of research indicate that the provision of therapy is an interpersonal process in which a main curative component is the nature of the therapeutic relationship. Clinicians must remember that this is the foundation of our efforts to help others” (Lambert and Barley 2002, 357). These studies provide a compelling argument for training social workers and other helping professionals to be proficient in providing and enabling these common factors. Ahn and Wampold (2001) note, “the importance of interviewing skills, establishment of a therapeutic relationship, and the core facilitative conditions . . . is supported by the empirical evidence” (255). Duncan et al. (2010) observe that since relationship factors are so influential, professionals need to develop their own style as they work with these therapeutic factors in their practice and partner with clients to assess the fit between what is offered and what the client finds helpful. In this era in which the profession prizes empirically based intervention models for social work (Thyer 2000), it is important to note that the finding that the relationship affects outcome supports long-standing beliefs, theories, and practices that accord the relationship centrality in social work practice. Furthermore, the characteristics of helpful relationships emerging from these empirical studies and meta-analyses mirror those characteristics of the relationship presented in the social work literature (Coady 1999; Perlman 1979), in humanistic and client-centered psychology (Greenberg, Rice, and Elliot 1993; Rogers 1957), and in psychoanalytic self psychology (Kohut 1957, 1984; Wolf 1988). To summarize, they include empathy, warmth, acceptance, and validation, which create a feeling of safety for the client. Within such a relationship, practitioners can encourage the client to engage in the sort of risk taking and mastery that leads to positive change (Hubble et al. 1999). Drisko (2004) observed that social work literature has been slow to integrate information about common factors. This is surprising for two reasons. First, the research referred to above, conducted by psychologists mainly in psychotherapy outcome research, has been available for decades. Second, the common factors identified in this body of literature provides support for key social work perspectives, including the view of the importance of extratherapeutic factors, specifically the resources and opportunities in the client’s environment and the primacy of the client–worker relationship. In

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a thorough review of the evidence base for this approach, Drisko (2013) draws attention to support for key social work practice principles such as “starting where the client is, working collaboratively with the client, emphasizing empowerment, paying attention to diversity, and understanding and formulating how each unique client understands the presenting problem and its origins” (409). While the common factors approach has been discussed in relation to therapeutic work, Cameron and Keenan (2010) have also proposed the usefulness of a common factors perspective in generalist practice. In summary, this chapter considered some enduring and emerging conceptual underpinnings to explain why the professional relationship is considered so important in social work practice. It provides the crucible within which the work takes place, and it reflects social work’s values of working with people in their best interests. Of interest is the strong empirical base that supports these long-held principles of social work practice, evidence gleaned mainly from researchers in psychology and psychotherapy. As a result, practitioners have a wide range of concepts to use in building and maintaining this crucial context for growth, development, and change.

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on holistic competence and the ways social workers can use knowledge, values, and skills while heightening their awareness of their own cognitive and affective processes so they can provide the complex and crucial practices, including development of robust, respectful, and collaborative working relationships, that lead to successful engagement with clients and effective ser vice. In contemporary North American societies, this discussion must be placed within the context of our diverse communities. For centuries, war, natural disasters, and the search for opportunity have led people to North America as immigrants or refugees. When entering a new country, people are challenged with adjusting to a new society and new ways of living and behaving, and often must learn a foreign language. Individuals acculturate in idiosyncratic ways as they deal with the tensions between their former ways of living and the demands and circumstances of their current life in a new country. Based on both internal and external factors, each individual client will present with his or her adaptation to making a transition and, to some extent, living in two worlds. For example, an immigrant woman from China requests service for her husband, whom she reports as depressed in recent months. She describes the couples’ experience since arriving in Los Angeles eight months prior. Since she speaks enough English to hold down an office job, living in Los Angeles has provided her with more financial and personal freedom than she had in Beijing, where she and her husband lived with her in-laws in close quarters. Previously, she was expected to care for her husband and his parents while also working

this chap ter continues the focus

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outside the home. Her husband, formerly a manager in a factory, is unable to find similar employment because of his limited English-language skills and therefore finds it necessary to work as an unskilled worker in the food industry. He experiences this job as demeaning and immigration as a disappointment. He mourns the loss of his work position, his social status, and his significant connection to extended family members. In this family, immigration and settlement have provided new opportunities for the female member but marginalized and oppressive conditions for the male member. The wife’s description of her husband’s depression can only be fully understood by placing it in the context of profound changes to his sense of self, family, and community in the new country. Individuals may identify with a variety of groups based on a number of intersecting diversities. Feminist scholars recognize the multiple diversities within the category of woman and that while there are shared common features, there are also vast differences between various women (Kemp and Brandwein 2010). For example, compare the opportunities and challenges of a single African American mother struggling financially with sole responsibility for supporting her two children, a middle-class, professionally educated dual career mixed ethnicity lesbian couple who wish to have a child, and an elderly immigrant Iranian widow living with her acculturated Western-educated adult children. From the very beginning of professional social work in North America, social workers engaged with individuals from diverse backgrounds and were confronted with differences between themselves and the communities they served. Differences included the range of factors identified in EPAS Competency 2, “Engage Diversity and Difference in Practice”: “intersectionality of multiple factors including but not limited to age, class, color, culture, disability and ability, ethnicity, gender, gender identity and expression, immigration status, marital status, political ideology, race, religion/ spirituality, sex, sexual orientation, and tribal sovereign status” (CSWE 2015, 7). Drawing from social work’s value base, practitioners were expected to convey respect, individualize, accept all people, and practice in a nonjudgmental manner. Social work began to recognize the limitations of this generic approach and a more complex view of diversity emerged, with pioneer contributors such as Pinderhughes (1989) and Green (1995) leading us to consider the impact of culture and societal institutionalized racism. With respect to culture, scholars introduced the notion that individuals’

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(including clients’ and social workers’) worldviews, values, assumptions, expectations, preferences, and the meanings used to interpret personal and social experiences, including help seeking, are profoundly shaped by the groups and communities with which they identify (Green, 1995; Pinderhughes, 1989; Sue, Ivey, and Pedersen, 1996). The concept of cultural competence provides guidelines for practice that highlight the importance of social workers’ ability to work respectfully and comfortably with diversity. With respect to racism, the profession recognized that historical and structural discrimination, especially regarding the African American experience, led to institutionalized and internalized oppression, discrimination, marginalization, and powerlessness. In addition, the impact of privilege and power led to the recognition of the many ways social workers’ assumptions and associated behaviors could further oppress the people they were trying to assist. These perspectives stimulated more in-depth analysis of the impact of structural conditions and barriers on individual well-being, attempts to practice in an antioppressive manner, and commitment to social justice and equity. c u lt u r e a n d d i v e r s i t y

Initially, in practice and in the literature, culture was largely associated with ethnicity and scholars produced a number of texts that provided descriptions of the history, dominant themes, and characteristics of ethnic groups represented in the American population (see, for example, Lum 1999; McGoldrick, Giordano, and Pearce 1996). These contributions drew attention to differences among groups along a number of dimensions such as norms and expectations about what constitutes a good life; appropriate behaviors at various stages of development, and in particular familial and societal roles for men and women; how problems are experienced and defined; and attitudes about help seeking and forms of informal and professional help. Many early texts discussed general concepts and unique aspects of four major ethnic groups: African American, Native American, AsianPacific American, and Hispanic Americans. Ethnicity and culture were seen as a client characteristic rather than a dimension of identity and experience shared by both clients and social workers. By framing the literature in this manner, the stereotype of the white worker as the professional and the client as a member of a minority group was reinforced. Such a depiction distorts the real ity that helping professionals all have ethnic and cultural affiliations

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that affect their work; indeed, many social workers are members of visible minority groups, and many clients are from the majority and dominant groups in the society. Hence, it is more accurate to recognize ethnicity as a personal dimension of all people. This cultural literacy approach highlights the influential effect of ethnicity on clients. Ethnicity will influence how clients frame the issues they believe are appropriate to bring to social workers, the helping processes they perceive as useful, and the desired outcomes. Cultural literacy has been critiqued, however, due to a number of limitations. First, it tends to treat ethnicity as static and stable. Descriptions of particular ethnic groups often appear frozen in time, although they may have been relevant during an earlier period. Descriptions may omit recent changes in a particular country that would affect more recent immigrants. Globalization, increased world travel, the advent of the Internet, and social media usage have also spread popular cultural forms around the world. Universal similarities due to this spread of popular culture may be overlooked in the interests of describing unique features of each ethnic group. A second critique of the cultural literacy approach is that it ignores within-group differences and hence is less useful to practitioners in their actual work with individual clients (Dyche and Zayas 1995). The approach can sometimes lead to the assumption that individuals are simply representations of their cultures, when in fact, families socialize their children to various aspects of their reference groups, and an individual in turn may identify with some dimensions of the reference group and reject others. Furthermore, families in any group are not universally similar and they mediate interpretations of ethnic forms. Although information about ethnicity may provide some sense of broad themes, it can also produce simplistic overgeneralizations about groups of people that actually perpetuate incorrect stereotypes and support prejudicial attitudes. It is only through understanding the client’s internalized culture (Ho 1995) that a helping professional can begin to understand diversity issues for a particular client. Ho (1995) introduced the notion of internalized culture, referring to what the client believes and identifies with that may be taken from a number of cultural systems, such as ethnicity, age, sexual orientation, and class. Finally, a third critique of the cultural literacy approach is a pragmatic one. Since global migration and internationalization have produced communities that comprise people from a vast number of groups and countries, it is nearly

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impossible for any helping professional to be knowledgeable enough about the history and experiences of such a large number of ethnic groups. More general practice principles for working across ethnic and cultural differences are needed. Social work scholars have also expanded the meaning of culture as referring primarily to ethnicity and have used the term diversity to reflect the many salient social identity characteristics that affect our thoughts, feelings, and behaviors. As noted in the EPAS definition above, these characteristics include age, class, color, culture, disability and ability, ethnicity, gender, gender identity and expression, immigration status, marital status, political ideology, race, religion/spirituality, sex, sexual orientation, and tribal sovereign status. Hence, a professional interview can be seen as a potential site of engagement, with a number of diversity factors present between a social worker and a client, each with a range of salient social identity characteristics, and with both similarities and differences. As we have pointed out elsewhere, individual social identity factors may in some way play out, in more or less obvious and overt ways, as social workers and clients work toward forming a working relationship, arriving at a joint assessment, and carrying out meaningful interventions (Bogo, Tsang, and Lee 2011). Individuals, then, are seen not as stereotypic representatives of a single social group or culture. Rather, each individual reflects unique differences in their identification with and internalization of aspects of their reference groups. As noted in the EPAS definition of Competency 2, “Engage Diversity and Difference in Practice” (CSWE 2015), social workers need to take an approach in which they see and present themselves as learners and engage clients in a way that supports them as experts of their own experiences; this requires workers to explicitly communicate to clients that they will need to learn about salient dimensions of clients’ reference groups from the clients themselves. Writing about understanding ethnic difference, Dyche and Zayas (1995, 2001) proposed an experiential and phenomenological approach that can be applied more generally. In this approach, the social worker adopts a position of curiosity and naïveté, and tries to listen to and learn from clients about the salient and pertinent features of self, including the cultural self. This perspective is congruent with contemporary theories that view reality as socially constructed, and hence encourage appreciation for the existence of diverse worldviews and the multiple realities that affect individuals (Kohli, Huber, and Faul 2010). Human behavior is fraught with contradic-

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tions. Identity and connection to a range of reference groups is not static and fixed; practitioners therefore need to move beyond “the tendency to think in terms of common and fixed characteristics” (Dean 2001, 625). Reductionist conclusions about the way groups of people think and behave can unwittingly support prejudicial and stereotypical judgments, and result in more limited responses by practitioners. Writing about difference with respect to culture, social work scholars propose principles that are relevant to working with diversity. In their discussion of a cultural humility perspective, Guttierez and Ortega (2016) emphasize the importance of respect for points of view that are culturally based and different from that of the social worker. Consistent with previous discussions of self-awareness in this text, these authors argue that social workers must acknowledge how their own cultural perspectives can be privileged (Ortega and Faller 2011). The power inherent in the social worker’s role can result in a diminution of attention to the client’s lived experience. Gutierrez and Ortega note that “culturally humble practitioners do not simply acknowledge their limitations or resist overestimating their qualities but find value in the knowledge and experiences shaped by the realities of others outside of their self ” (Guttierez and Ortega 2016, 139). When social workers encounter significant differences between themselves and their clients, it is understandable that this may result in feelings of discomfort and confusion. This in turn can have an important bearing on the ability to develop the emotional bond that is so crucial to relationship building (Lee 2011). The client may also experience feelings of distance and disconnection as she picks up the social worker’s affect. These observations are supported with data from a project using an objective structured clinical examination to assess performance on a simulated interview followed by immediate reflection on that performance (Logie, Bogo, and Katz 2015). This simulated client scenario was designed to present a range of intersecting diversities and differences with respect to the interviewers, including differences in age, ethnicity, gender, gender identity and expression, race, religion/spirituality, and sexual orientation. The simulated client was a Jamaican Canadian late adolescent concerned about coming out as a lesbian to her deeply religious family, whom she expected would be highly critical and rejecting. We found social work practitioners and students stating that they felt “ill-equipped” to respond empathically and effectively to her concerns (Logie, Bogo, and Katz 2015, 315). Lack of competence to enact

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gay affirmative practice varied in relation to “attitudes (managing personal reactions), knowledge (addressing diversity; terminology and information), and skills (readiness; challenging heterosexism)” (315). In contrast, some practitioners are able to deal with their discomfort in a productive manner. In qualitative exploratory research with social worker practitioners identified by their peers as effective in practicing cross-culturally, Clark (2003) found that these clinicians spoke of “puzzles, worries, and ambiguities” (96) that triggered their sense of needing to do something different than their usual practice. Rather than searching for specific cultural knowledge outside of the counseling relationship, these practitioners considered how they might “enter into the context of complexity—the messy swamp—and try to create a space for mutual understanding in the midst of it” (Clark 2003, 96). They drew on the epistemology of practice provided by Schon (1983) and the notion of reflective practice, discussed earlier in this text. Committed to building a collaborative working relationship, these practitioners emphasized the importance of attunement and feedback, that is, “continuously checking out their emerging understandings and interpretations with the client, offering tentative hunches, seeking confirmation, disconfirmation, or modification by the clients themselves” (Clark 2003, 109–110). Another practice the practitioners used was explicitly asking clients to tell them what they needed to know to understand the client. Such a request needed to be framed within a rationale—specifically, that the social worker wanted to understand the client’s perspective and current and past societal, community, and familial context. They believed that a balance needed to be achieved between not overly emphasizing differences between themselves and their clients and creating a space in which they would honor “the client’s voice, of shedding the cloak of the expert who knows best, and of mutually negotiating the direction of the conversation” (Clark 2003, 127). Other principles emerging from their practice wisdom included listening carefully to client narratives as a metaphor or pathway to more deeply explore their core beliefs and values, and drawing the links between individual stories to broader historical and sociocultural issues. All the while, these practitioners attended to clients’ nonverbal behaviors that indicated confusion or lack of understanding of the worker’s comments. These workers also made direct verbal requests to their clients to let them know whether the social worker’s emerging understanding was congruent with what the client was sharing.

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A further set of practice principles emerged from a process-outcome research study of cross-cultural practice (Tsang, Bogo, and Lee 2011). These researchers used a naturalistic, multifaceted design to identify actual clinical processes that were associated with positive outcomes. Clients and social workers in public community agencies participated in the study and a wide range of diverse dyads enrolled. There was diversity among study participants with respect to a range of dimensions, including age, gender, sexual orientation, religious affiliation, ethnicity, and race, which was typical of the population in the metropolitan area. For a complete discussion of the study and procedures, see Tsang, Bogo, and George (2003). In-depth analysis of first sessions revealed three interconnected processes that contributed to engagement with the social worker and were associated with positive outcomes at the completion of counseling. These processes have been presented in Tsang, Bogo, and Lee (2011), and are summarized here. The first process entailed the practitioner’s ability to communicate her cognitive understanding of the key concern that underlies the presenting issue. Some clients presented the overt and underlying concerns quite clearly, and the social worker was able to paraphrase this in a way that conveyed to the client that the worker understood the key issues the client wished to address. For others, while the client presented many issues (for example, death of a friend, a burglary at her home, a disappointing encounter with her birth mother), the worker was able to succinctly reflect that the client had recently experienced losses and disappointments, and acknowledged to the client, “that hurts.” For others, the client may have been less explicit or it may have taken the worker almost the entire interview to fully capture the client’s concerns. What appeared to be crucial was the client’s perception that the worker understood his concerns. The second process entailed emotional attunement and responsiveness to the client in the first session. The practitioner’s effective responsiveness led clients to further disclose, thus leading to joint understanding and the beginning of emotional bonding between the client and the practitioner. In contrast were negative outcome cases in which social workers did not respond to clients’ emotions, changed the subject, asked for more factual information, or attempted to provide education and a cognitive rationale for the way the client was feeling. The two processes discussed above can be seen as generic best practices that are not unique to working within contexts of diversity. It is worthwhile

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to note that “cultural competence is embedded within clinicians’ overall general practice abilities with respect to factors such as seeking joint understanding with clients about their concerns, and relationship dynamics including self-awareness, understanding transference and countertransference phenomena, and therapeutic use of self. Cross-cultural practice is therefore embedded within the clinician’s usual stance, knowledge, and ability to work with process” (Bogo, Tsang, and Lee 2011, 710). Practices specific to culture and diversity that emerged from the study were consistent with the theoretical and clinical literature reviewed earlier. Social workers asked clients directly about their sociocultural contexts and did so in a manner that conveyed interest and a desire to learn how the client’s significant lived experiences had been internalized and were currently important. Analysis of nine cases did not indicate that cultural concerns were a focus of the work. Of interest in follow-up sessions, however, were client reports that in the context of a positive relationship with a worker who opened up discussion of these factors, the client became more conscious of differences in gender and sexual orientation between the worker and client. There were instances in the first session when clients spoke about ethnic and cultural differences in relation to the presenting clinical issue. For example, a client spoke of his anxiety about his struggles about telling his traditional Chinese family that he is romantically and seriously involved with a woman who is not Chinese. In such a case, the client needed to educate the practitioner about how his family views matters such as marrying outside one’s group. In positive outcome cases, the social worker provided an accepting space for such disclosures, using active listening and seeking information. Moreover, the worker conveyed interest in learning about these important contextual factors that contributed to the client’s distress. In another analysis of these interviews, Keenan (2004) found similarly that discussion of sociocultural content was linked to clinical concerns. For example, a young male client recovering from his first episode of psychiatric illness spoke poignantly about his feeling of rejection from his Japanese family. He attributed this to stigma related to mental illness in his community—stigma that was seen in his sister’s avoidance of community events, as she felt shamed by his illness and feared being shunned by community members. In these examples of cross-cultural practice, social workers used a range of generic skills to further the conversation related to culture and diversity.

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Skills included open-ended questions, tentatively phrased reflections of the content of the client’s narrative and his associated expressed or implied feelings, exploring in depth the relevant issues of concern to the client, and offering tentatively worded explanations. Practitioners validated clients’ perceptions and provided appropriate information to them. Social workers sought feedback from their clients to verify that their understanding accorded with the client’s narratives. In contrast were instances when practitioners did not engage well with culturally important content in client narratives. In a negative outcome case, the client discussed her sense of being an outsider because she was adopted and her adoptive family was fundamentalist Christian while she attended a secular public school. The social worker did not perceive that this experience remained palpable for the client into her present life, influencing her self-worth and confusion about her identity. Instead, the worker pursued her own agenda and collected facts about the client’s current situation, thus missing the chance to explore with the client her central dynamic issues. A similar pattern was found by Lee and Horvath (2014), who used microanalytic techniques to closely track a practitioner’s responses when her clients explicitly raised culturally based content regarding the presenting problem. These researchers provide examples of actual interactions that demonstrate how a generally engaged and responsive practitioner provides minimal responses (“umh, yeah, right,” 207) with no exploration or expansion. These instances of lack of responses occurred when clients offered culturally based explanations for a family member acting out, discussed the way that such behavior would be handled in a culturally appropriate way within their reference group (as contrasted with what might be deemed a typical North American style), or expressed concerns about their immigration status. Despite the literature reviewed above that recommends attunement to and interest in hearing and exploring how clients’ culturally embedded issues are evident in presenting and ongoing problems, these few studies show that such practices do not always occur. Lee (2011) argues that a two-person psychology is needed that views cultural work as part of the development of the therapeutic relationship, contributed to by both the practitioner and the social worker. Practitioners need to take the initiative to conduct sensitive discussions about cultural differences that may make a difference in the joint work. When disjuncture arises due to

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misunderstanding, it is the responsibility of the worker to avoid defensive postures or avoidance and instead pursue dialogue to arrive at enough mutual understanding to jointly pursue the goals, tasks, and bonding associated with positive alliances and outcomes. In summary, recognizing the complexity of identity, helping professionals have increasingly moved to embrace an approach that acknowledges a wide range of social identity factors and intersecting diversities, the importance and meaning clients give to these factors, and their impact on people’s lives. Competence in social work includes being able to work effectively with individuals from backgrounds and with characteristics different from one’s own. In this chapter, relevant process-outcome and qualitative research was reviewed to extract practice principles. The overriding conclusion is that highly specific information related to identity and reference groups is best obtained from the client, including the role it plays and how important it is in each individual’s unique life course and presenting concerns. With a reflective and collaborative stance, practitioners sensitively explore salient information, taking cues from the client. A balance is needed to ensure that the work is client centered and responsive, rather than seen as intrusive or tangential. Using generic practice processes, an open narrative space is created in which clients can discuss their presenting and underlying concerns, as well as their diverse experiences and realities (Tsang, Bogo, and Lee 2011). Even when there are multiple differences between client and social worker, collaboration can result in enough compatibility or agreement on goals and tasks to ensure effective therapeutic work. The goal is for clients to feel that they will be understood, cared for, and valued despite differences in background, current affiliations, and identity. Practitioners can aim for a highly attuned awareness of these factors in the client’s narrative. Such attunement will in turn contribute to social workers’ understandings and assessments, forging the working relationship, and deciding on the focus of intervention. b e g i n n i n g w i t h o u r s e lv e s

A collaborative approach to the working relationship between practitioner and client has been recommended through this text; hence, the contributions and perceptions of both participants to the work that brings them together warrants examination. Germane to a discussion of diversity is the

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recognition that clients will have perceptions of social workers that may be based on their experiences with people from groups similar to those of the worker. Consequently, the worker may be confused by client behavior that does not seem easily understandable in the current context. It may reflect positive or negative experiences with dominant or powerful members of the social worker’s reference group, based on visible or inferred characteristics. The behavior may also reflect cultural attitudes about help seeking and expectations about professionals’ behavior. The client’s previous experiences and attitudes may be brought into the practice encounter. The client’s expectations may remain unspoken—expectations that an individual will be treated with disrespect, judged harshly, and not given fair treatment. And, similarly for the social worker, as noted throughout the discussion of holistic competence, self-awareness of one’s own worldview and internal working models is crucial. In this instance, the practitioner’s tacit knowledge is viewed through what he has learned from his own cultural and social reference groups, including acknowledgments of his biases and prejudices (Kohli et  al. 2010). Countertransference, which was discussed earlier in this text, is a useful concept in this analysis. As in any interpersonal relationship, in the therapeutic working relationship, both participants—the client and the social worker—bring knowledge, understandings, and feelings that operate at conscious and unconscious levels of awareness. Systemic and interactional perspectives draw our attention to the ways the two participants work together to create a helping unit, to arrive at shared meaning about why they are meeting, and to bring about positive change in the client’s life or to offer assistance in some way. The social worker’s approach while attempting to develop bonding and collaboration with the client is enriched by an understanding that diverse experiences (referring to a wide range of intersecting characteristics such as race, ethnicity, culture, class, age, gender, sexual orientation, ability, and so forth) operate in this interactional field, as do personality issues generally subsumed under the concept of countertransference phenomena. To achieve competence in practice with clients who may be different from oneself in a variety of ways, it is important to start by developing an understanding of oneself in this regard. To illustrate this using the concept of ethnic or cultural identities, this involves recognizing that many of our beliefs, attitudes, assumptions, and values reflect a worldview derived from the sociocultural communities with which we identify. Values are further

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mediated by the way one’s family of origin interpreted and enacted their ethnic heritage. Furthermore, as Ho (1995) noted, individuals may both incorporate and reject aspects of these dimensions in developing one’s own internalized culture and identity. This includes not only seeing oneself as an ethnic being but also identifying other characteristics and significant systems that may be important to identity, such as class, sexual orientation, or religion. It is also noteworthy that social work theory reflects Western values of self-efficacy, autonomy, and individualization that may be in conflict with primary values and models of self and family held by clients from other parts of the world. North American social workers’ preferred practice models also reflect these Western perspectives, which come from the culture of the profession (Foster 1998). The practitioner’s development of self-awareness would then include learning about oneself as a cultural being and being tuned in to the surface and obvious ways one constructs and evaluates reality. Practitioners also need to retrieve and explore cultural constructs that they are not aware of but that operate as potent lenses influencing the judgments they make. These lenses constitute practitioners’ personal and tacit knowledge and are, in some way, used to assess and guide interaction with clients who are different from them. At another level are the stereotypes, prejudices, and idealizations that social workers have about people from specific groups. For example, many students in social work programs report that growing up in white, middle-class, communities has provided little experience in interacting with and having close relationships with people of color, people living in poverty, and people living in dangerous neighborhoods. When receiving practicum assignments with clients from such demographics and living in such situations, these students’ energy must be focused on understanding the nature and origins of the attitudes, expectations, and feelings they bring into these encounters. They also need to become aware of others’ experience of racism and privilege that accrues to skin color. While the beginning social work student, faced with her own fears and uncertainties about her skills as a social worker, might not feel powerful in her relationship with her new client, she needs to be cognizant of the legacy that links color, power and privilege, and oppression and disadvantage in American society. Foster (1998) has identified a range of reactions to the recognition of one’s own privilege, including denial of difference, excessive focus on cultural issues, guilt and pity, and ambivalence. Practitioners working with clients

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who experience oppression in their lives may experience overidentification, distancing, ambivalence, guilt about their own success, hope, or despair. In a diverse society, it is not surprising that individuals experience tension and conflict about their ethnic and cultural identities. Members of a particular group in a society will experience both pride and shame by virtue of how aspects of their culture are viewed by other members of these groups as well as by the broader society. Furthermore, through participation in mainstream institutions such as public education, through employment in large organizations, through social media sites, and through reading newspapers and watching television and movies, individuals are exposed to ways of thinking and behaving that may challenge familial and community values and norms. Exposure to worldviews that are contradictory to one’s original positions can result in responses ranging from increased conviction and identification with one’s original positions to confusion and ambivalence about one’s beliefs, to adopting new perspectives that seem more personally appealing. Indeed, our adult self evolves over time and can be seen as comprising a multilayered internalized culture that is unique to each of us (Ho 1995). These comments about internalized culture can be seen as universal and applicable to both clients and social workers. When practitioners attend to the cultural dimensions of clients’ experience, their own ambivalences, questions, and struggles about their internalized culture may be evoked. Once again, the search for awareness of the underlying beliefs, feelings, and reactions that influence behavior and expectations in our personal and professional life becomes important. When practitioners add a cultural and diversity perspective to their understanding of countertransference, it enlarges and enriches the way they perceive human behavior. Learning about this aspect of “self ” is not achieved quickly; it is an ongoing process that involves considerable thought and deep introspection. As social workers, the focus is on linking the ways societal and familial definitions and values about diversity manifest themselves on an individual level. social justice and equit y

Thinking about diversity requires more than just thinking about difference; it involves understanding power dynamics within a social context. A leading social work scholar, Michael Reisch (2007), notes that definitions

ref lecti ve exer c i se : c u lt u r e

The following activities provide a stimulus for self- reflection. A series of questions focus especially on the cultural aspect of the self. Much can be gained by discussing these topics with others in one’s reference group(s) such as, family, friends, community members, and student or professional colleagues. Using these questions with classmates from dif ferent backgrounds can be especially instructive as students can compare similarities and differences in their backgrounds and current positions. Often, as we try to explain ourselves to others, we are able to crystallize our thinking and gain impor tant insights. The following questions adapted from Nakanishi and Ritter (1992) have proven useful in guiding recall and exploration of the self-in- cultural context:

• On your own, consider the messages you were taught as a child about your culture, the world, and acceptable standards of be havior. What were the stories or sayings that were used to convey these messages? Think about categories such as gender roles, sexual orientation, parent– child relationships, extended family relationships, expression of emotion, attitudes toward community members and toward “outsiders,” sources of help, religion, economic success, political parties, the legal system. Add other topics that you feel are impor tant.

• Compare your understanding of your cultural lessons with others from a similar background. This activity will provide the opportunity to sort out those aspects of one’s heritage that are cultural and those that are unique traditions of a subgroup or one’s own family. There is a mediating effect from other factors, such as class or caste, country of origin, geographic locality where one grew up, sexual orientation, religion, and so on, that renders a universalistic view of culture as limited. For example, the cultural experience of a recent immigrant, upper- class, university- educated woman from India has both similarities with and differences from that of a second- generation Indo-American adolescent girl in a working- class family.

• Compare your understanding of your cultural lessons with others from a dif ferent background. These discussions will help to highlight similarities as well as differences between cultural groups. Consider how these dynamics might be experienced in practice. Some examples to reflect on are the tensions surrounding dif ferent expectations about when one can seek help from outsiders, ideas about appropriate gender roles, attitudes about same- sex relationships, and preferred child- rearing practices.

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(continued)

• While early family and community teachings have great impact, individuals also construct their own self- definitions that may also change throughout the life cycle. Consider your own reference groups at this point in your life. Have they remained stable or have they changed? What factors have affected this? To what extent do you have dif ferent self- definitions based on the context that you are in? For example, a middle-aged second- generation Italian woman describes herself in dif ferent ways when with her elderly immigrant parents, celebrating Christmas with her brothers and sisters and their children, and in her long-term lesbian relationship.

• How comfortable are you currently with people who are dif ferent from you along various dimensions of identity? What par tic ular aspects of diversity lead you to feel uncomfortable? For instance, does your discomfort have to do with class, color/race, religious, or sexual orientation difference?

• What feelings and attitudes are elicited when you are confronted with practice situations that do not accord with and challenge your values? How do you manage your strong emotions and reactions? How have you learned to engage with clients in a way that is genuine, shows interest, and is respectful?

and theoretical roots related to the profession’s use of the term social justice and equity vary. Nevertheless, the concept has focused attention on the way structural processes fuel intersecting forms of oppression, marginalize individuals and communities, and create inequality, discrimination, and prejudice. Competency 3, “Advance Human Rights and Social, Economic, and Environmental Justice” (CSWE 2015) in EPAS discusses the links among human rights, oppression, and theories of human need and social justice. Generally, the focus is on understanding structural barriers, the processes that maintain injustices, and the way power dynamics operate within a social context. Such analysis can lead to strategies for macro interventions. It is important for direct practice social workers to have an appreciation of these issues and the way they influence their clients’ lives. As noted earlier, in chapter 1, Competency 5, “Engage in Policy Practice,” involves social workers in macro interventions that use critical analysis to arrive at preferred policies and practices, and ultimately to advocate for social change via coalitions and alliances with like-minded groups.

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By virtue of visible characteristics, individuals are perceived as belonging to social groups that have varying degrees of privilege and access to power. For example, depending on the context, children and the elderly have less power than young to middle-aged adults, and upper-class and middle-class people have more power than working-class people or those on welfare. Groups of people are treated differently in society, with some groups experiencing systemic discrimination and oppression by virtue of identifiable physical characteristics. There are also invisible characteristics that, when known, may present barriers to individuals, such as sexual orientation, health conditions, or disabilities that are not obvious, and affiliation with particu lar religious groups. Whether or not to disclose the particular characteristic, whether those with power will be accepting and fair, or hostile and punitive, are matters with which individuals often struggle in many aspects of their daily lives. Green (1995) eloquently states: “Cultural, racial, and sexual orientation differences are not problems in and of themselves. Prejudice, discrimination, and other forms of aggressive intercultural conflict based on these differences are problems” (100). Therefore, social workers interested in developing effective collaborative relationships with all clients need to go beyond awareness and sensitivity. An understanding of privilege, power, intergroup relationships, and oppression and their effects on individuals’ well-being is also needed to better understand the dynamics of practice across difference. Power is defined as the capacity to influence for one’s own benefit the forces that affect one’s life (Pinderhughes 1989). Social work theorists have explored notions of empowerment and propose that there are multiple aspects of power and oppression: historical, societal, political, interpersonal, and personal (Gutierrez, Parsons, and Cox 1998). As noted earlier, clients may come from groups that have had negative experiences with oppression and a lack of equal access to societal resources and opportunities to fully participate in societal institutions. Therefore, when clients are ordered by a court to attend a treatment program, they may feel that once again they have little influence over their own lives. Frequently, access to legal entitlements for welfare, health, or educational benefits and ser vices are obstructed by complicated bureaucratic procedures. It is understandable that individuals who are constantly struggling to meet basic family needs will experience a pervasive sense of anger and depletion, feeling worn down by oppressive and nonresponsive systems. Feelings of powerlessness and re-

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sentment may be transposed into interactions with the social worker. Indeed, personal, familial, and community experiences of oppression can influence individuals in a variety of ways. Despite the best intentions of an individual social worker and her desire to be respectful and understanding, the client may perceive her as being representative of a particular group simply by virtue of visible characteristics such as the color of her skin. The group may be a more dominant one or one with less power in relevant contexts for the client. Gender will also intersect with other characteristics; for example, a social worker who is white and male may have a different impact on a female black client compared with a male white client. Most social workers do not feel that they have significant power. The profession is associated with its mission to assist disadvantaged populations and this value does not hold high status and influence in modern societies in which economic prosperity is highly valued. Nevertheless, in the context of agency practice, social workers do have power by virtue of the mandate of their organization, the role they perform, their access to resources, the knowledge they have, and the assistance they can provide. Furthermore, in ser vices that are court mandated, such as child protection, custody and access assessments, and probation, social workers’ assessments and recommendations have profound implications for individuals and their families. They can affect, for example, whether children will be taken from their birth mother and father, whether a father will have access to his children, or whether a parent must attend a drug treatment program. Social workers are committed to becoming cognizant of the ascribed and achieved personal and professional privileges they enjoy. In some regions in the United States, privilege and skin color are closely linked. As noted throughout this discussion, social workers need to be sensitive to the way the client perceives these issues. They also need to be aware of their own feelings about the privileges they have and those they do not have. When workers come from dominant and more powerful groups in society, they may experience a range of feelings such as guilt or ambivalence when working with clients from less powerful and high-status groups. When the social worker is from a group with less societal power and is working with clients from more advantaged communities, he may experience a range of reactions, from deference to subtle hostility to overt antagonism. Social justice concepts recognize that effective ser vice is a function not only of what transpires in the social worker and client interaction but is

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ref lecti ve exer c i se : pow e r a n d pr i v i le ge

When the practitioner is equipped with a fuller understanding of oneself as a cultural being in a social context, the social work interview can be viewed as a site of engagement bridging differences. Take some time to consider the following on your own or discuss these issues with colleagues who are similar or dif ferent from yourself in reference group affiliation. McMahon (1996) suggests some of the following useful questions:

• What were your experiences in your neighborhood with reference groups that were dif ferent from your own? What were your family’s attitudes and experiences with these groups? What stories were you told and what advice were you given about socializing, conflict, and power relations?

• What are your early memories of meeting people from reference groups dif ferent from your own? Which aspects were positive and which were negative?

• How aware are you of the dynamics of privilege, or lack of it, in your life course? • Recall and examine an experience in which you realized you had power over another.

• Recall and examine an experience in which you realized another person had power over you. How might your perception and experience of power and powerlessness demonstrate itself in your work with clients?

also a product of societal and organizational contexts. Deprived environments, communities at risk, unsafe housing, poverty, and poor health reflect sociopolitical issues that require attention and change. Similarly, agency policies and programs may not be culturally appropriate or may not provide resources that are useful to clients. Agencies’ boards, managers, and frontline workers may be more or less representative of the populations they are meant to serve. Social workers practicing at the direct ser vice level must attend to these contextual factors in the larger systems that affect the nature of the ser vices they can offer to clients. The social change aspect of social work’s mission directs practitioners to not limit interventions to the client system but to also act both independently and in alliances with others as advocates for change.

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Most organizations have introduced antidiscrimination policies and continuing education in an effort to create organizations and personnel that can provide ser vice to the entire population. Tsang and George (1998) queried whether the political atmosphere and demands surrounding cultural appreciation provide an effective learning context. As with any matter relating to personal aspects of the self in the professional role, social workers benefit from clinical supervision, peer consultation, and continuing professional development activities that are conducted in a supportive environment. In a study of an educational program designed to increase the cultural competence of practicing social workers, Williams (2002) found that the creation of a safe learning environment was extremely important to the participants. Since these social workers were part of the same organization and worked together during and after the training, they were attuned to the potential impact of the learning experiences on their subsequent relationships. Williams (2002) notes that difference is a topic with the potential for controversy and its discussion can be highly emotional and traumatic for course attendees; they may fear reprisals from fellow learners, and experience tensions due to the demographic and social identity heterogeneity in the room. Others have noted that when these dynamics in training groups for cultural competence are unmanaged, they have the potential to divide learners and inhibit participation (Garcia and Soest 2000). Practitioners require supportive spaces in which they can engage in critical reflection on their work in an open and honest manner. It is crucial to identify and explore strong emotional responses and deeply held opinions that can result from intensive work in situations of diversity. The aim is to promote greater understanding of situations that evoked particular client and worker reactions, and develop facilitative client-centered responses. Aware of power dynamics in direct practice, Keenan (2004) draws on critical theory to deconstruct power dynamics and recommends that social workers engage in a continual reflexive process. Using the analogy of a backstitch in sewing, she advocates “a continuous process of questioning one’s interpretations of experience (of oneself and others) and one’s actions in the ser vice of effective listening to, questioning, and understanding self and others” (545). A similar stance is presented by other clinical theorists who use postmodern and critical perspectives to gain understanding about the relationships between the self and sociocultural forces (Kondrat 1999; Miehls and Moffat 2000).

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In summary, social work practice takes place in an increasingly diverse society. Social work as a profession is committed to enhancing social justice and equity at community and societal levels. Practitioners should therefore endeavor to find the most helpful ways to work with clients who are both similar to and different from themselves in demographic and social identities. Competent practitioners are aware that diversity and its challenges arise from societal and cultural issues within their own communities and within the larger society, which shapes individuals’ values, thoughts, and behaviors. Valuing diversity is a respectful stance that is consistent with social work values and acknowledges many worldviews. The key points in this chapter rest on the realization that while culture and social identity factors are an important force affecting individuals’ thoughts, behaviors, and reactions, social workers must individualize each client and their situation. Individualization enables practitioners to understand the specific ways cultural and social identity issues can exert an important influence in one’s life. Accordingly, many clinicians and researchers recommend presenting themselves as learners and engage clients in a way that supports them as experts of their own experiences. In such an approach, curiosity, openmindedness, and comfort in exploring cultural and social identity factors are guiding practice principles. A perspective of cultural humility acknowledges differences in beliefs and behaviors, and emphasizes the importance of workers’ self-reflexivity so they do not automatically privilege their own culturally based viewpoints. Self-reflexivity or cultural self-awareness provides an additional lens through which practitioners can understand the way their worldview and assumptions influence their practice, including reactions, judgments, and decision making with regard to intervention. Moreover, practitioners who adopt such an approach appreciate the values emanating from individuals’ realities and experiences that are different from their own. As in all collaborative work, the relationship between client and social worker is crucial—a theme that has been reiterated throughout this text. With respect to diversity, the practice principle that emerges is that practitioners must pay attention to the ways internalized culturally based experiences of both the client and worker are played out in practice. An analysis of power, privilege, and oppression enlarges notions regarding culture, diversity, and difference. Such a perspective takes into account the fact that the various populations in society do not have equal voice or access to re-

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sources. A diversity perspective is more than a celebration of difference; it is synonymous with advocating for social justice. Political, social, and organizational change is often needed to bring about large-scale change. Since social workers in direct practice are part of this broader context, it is crucial to recognize how their social and cultural locations are part of their personal and professional contributions to addressing power dynamics in their work. It is through building collaborative relationships with clients that these values can be achieved.

6

The Helping Relationship: From Theory to Practice

have examined a number of dimensions related to the collaborative working relationship in social work. In chapter 4, key theoretical and empirical contributions were discussed, as they provide a conceptual foundation for the type of relationship that social workers strive to develop with their clients. As noted in chapter four, the characteristics of such a relationship are included in the definition of competencies in EPAS (CSWE 2015), particularly in Competency 6, which states, “Social workers value the importance of human relationships” (8), and proceeds to identify dimensions such as “principles of relationship-building” . . . “use empathy, reflection, and interpersonal skills to effectively engage diverse clients and constituencies” (9). In chapter 5, working with diversity and difference are accorded an important focus, consistent with Competency 2, “Engage Diversity and Difference” (CSWE 2015), and the focus in Competency 6, “Engage with Individuals, Families, Groups, Organizations, and Communities.” Such an emphasis recognizes that the context of contemporary practice in North America requires practitioners who are interested in, comfortable with, and have the ability to work with populations from a wide range of communities and with individuals possessing multiple and intersecting social identity characteristics. The current chapter extends the discussion of generic relationship factors, drawing on the practice experience and practice wisdom of generations of social workers. Contributions from a similar concept, the therapeutic alliance, are also included, as they support and extend material discussed in chapter 4. the previous t wo chapters

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key components

As noted earlier, many social work students have entered educational programs due to their “natural ability” to form helpful relationships with friends, colleagues, and family members, and are accustomed to others seeking their advice and input when faced with problems. It is understandable, then, for them to wonder about the ways a professional social work relationship differs from the way they usually conduct themselves. Three features distinguish the professional social work relationship: (1) it is client centered, (2) the social worker remains aware of the many ways he contributes personally and professionally to the outcome, and (3) the social worker’s behavior is therefore intentional and purposeful. First, the exclusive purpose of the working relationship is to provide service to the client. In other words, the work is client centered and focused on helping the client to tell his story, identify his needs, and consider what can be done to alleviate current concerns. This is different from reciprocal relationships in which there is give and take, and it is expected that the interests and needs of both parties will be met. Although social workers learn from and are often inspired by the strengths and resilience of their clients, this learning is a by-product, not a goal, of the work. Rather, the role of the social worker is to use her knowledge and expertise solely in the client’s interest. The aim is to provide the context for growth and change to occur for the client. The professional relationship, across all helping professions, is conceived of as different from a social, sexual, or business relationship. By virtue of the influence the worker may have over the client, if the worker engages in dual or multiple relationships with the client, a conflict of interest occurs. Each professional body develops a code of ethics and standards of practice to protect clients from dual or multiple relationships with the practitioner. Practitioners have the responsibility to behave ethically and to not violate the boundary between a professional relationship and other types of relationships. Whenever professional helpers are uncertain about their feelings or actions with respect to upholding this standard, they are advised to seek assistance from supervisors or consultants. In addition to maintaining an exclusive focus on the needs of the client, a second component needed for an effective professional relationship is the social worker’s awareness of what she is contributing to the practice situation, both personally and professionally. Recall earlier discussions in this

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text regarding the contemporary view of transference and countertransference as encompassing all the ways the client and the worker experience each other in the working relationship that is shaped by their respective personalities, cultures, and characteristic ways of feeling, processing information, and creating meaning in relationships. Some of these dynamics are unconscious and hence the practitioner and worker are not directly aware of them, whereas other dynamics are familiar and known to them from their past history. A range of characteristics and reactions are carried forward into practitioners’ professional work. The nature of the working relationship that can be developed in any dyad of client and social worker is affected by these issues. Through self-awareness, practitioners can tease out the extent to which their internal emotional states and personal reactions reflect their own personality or are responses to interactions with clients. When self-awareness is not sufficient, social workers seek supervision and consultation. Within the interview, practitioners need to adopt a stance in which they are both a participant and an observer of self and other. This is a complex requirement, one that is far different from the spontaneous, undisciplined, and natural way we participate, for example, in friendships and family relationships. This position includes being genuinely involved with the client in an honest, present, and active way, while at the same time being aware of the impact of the client’s narrative on one’s own thoughts, feelings, and immediate spontaneous judgments. Personal reactions can provide helpful data about the practice situation, or they may represent personal values and issues in the social worker’s life that could interfere with client progress if they are shared before they are examined and understood. A continuous process of development of self-knowledge helps practitioners stay client centered and energized by their work, rather than reactive, anxious, or emotionally depleted. In addition to a focus on the client and self-awareness of the practitioner, a third component of a professional relationship is the practitioner’s goal to behave in an intentional way. That is, the practitioner’s comments originate from thinking about the current process and how it can achieve the desired outcome. As noted earlier in the text, the working relationship context has been shown to significantly affect whether clients gain from professional intervention (Bachelor and Horvath 1999; Norcross 2011). It is therefore important that practitioners stay attuned to whether the client is experiencing the relationship as helpful and focused on his goals. The

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worker then uses this information to guide her remarks and interventions. This intentional activity integrates thinking and action, and is evidenced in the practitioner’s behavior in the interview. As such, it is different from the unplanned reactions and natural responses that characterize individuals’ typical personal interactions with friends and family. This chapter focuses on general principles and processes that social workers can use to guide their efforts in building and maintaining the working relationship. Based on the information on the working relationship in the preceding chapters, this discussion focuses on the key components of relationship building: warmth and caring concern, acceptance, genuineness, and empathy. Part 3 of the text presents communication behaviors and interviewing skills that social workers actually use in providing these components. It is important to recognize that any text can only present ideas at a level of abstraction that requires practitioners to individualize the concept and tailor its use to the unique needs of each client. Furthermore, the way a concept or principle takes shape in practice is through the social worker’s verbal and nonverbal behaviors, interviewing skills, and personal style. A recurrent theme in this text is the necessity of developing a comfortable personal-professional style. The practitioner’s steady mindful attitude about his own internal cognitive and affective processes can help him monitor his personal associations with what the client is saying; it can also help him better empathize and gain insight into another’s experience. Awareness can help restrain practitioners from simply reacting to clients and instead encourage their search for a facilitative response. The more practitioners know about themselves, the more likely they are to be able to gain insight into what clients may be reacting to or struggling with, and how they are contributing, positively and negatively, to the goal of client service. The goal of self-awareness in the context of professional practice is for the practitioner to use self-knowledge in the ser vice of the client. For example, a social worker knows that she tends to feel responsible for “fixing problems.” When confronted with a client with long-standing difficulties who expresses hopelessness about making any progress, the social worker will spend extra time with the client, often leaving her feeling depleted. With insight, the worker can recognize how her own place in her family of origin has been internalized and is being stimulated and enacted in her work with her client. She can also recognize how she might be reacting to the client’s subtle comment that other workers were more available. These insights can assist the

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ref lecti ve exer c i se : i ssu e s i n for m i n g the helpi ng re lat i on shi p • What specific characteristics of certain clients might make it more difficult for you to form relationships with them? What sort of client experience would be hard for you to relate to or would create a barrier to empathy?

• What specific characteristics do you have that might make it difficult for clients to form relationships with you?

• With what sorts of clients might you easily form relationships? What common experiences might you share with the client that could serve to facilitate a connection? What risks might occur in forming relationships with those individuals?

social worker in both assessment and intervention, leading her to partialize the client problems so that she does not attempt to work on every issue presented but rather to choose one or two topics to address, and set appropriate limits for interview length and the time frame for ser vice. In earlier chapters, strategies to develop self-awareness were presented. The above questions can also be useful and are based on those developed by Faye Mishna, an experienced clinician and social work educator and researcher (personal communication, 2003). wa r m t h a n d c a r i n g c o n c e r n

Warmth refers to the social worker’s friendly attitude, which, when accompanied by concern, conveys an interest in the client’s well-being. The worker is sincerely interested in the client and the difficulties he is experiencing. She conveys her commitment to finding possible ways of helping him alleviate his problems and arrive at a better situation. Personal, emotional, and painful individual issues are considered, as well as the client’s social, economic, cultural, and physical circumstances. When needed programs or ser vices are difficult to obtain, concerned workers persistently search for resources and advocate for their clients. Some clients will have difficulty engaging with a worker; they may remain silent and minimally responsive in initial meetings, or struggle to convey pressing issues. Concerned work-

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ers understand that the client’s behavior may reflect an aspect of the distress or difficulty that has brought him to the ser vice and therefore patiently stay involved. Warmth and caring concern are, to some extent, elusive qualities to demonstrate because they reflect the internal feelings of the social worker and her idiosyncratic ways of self-expression. Students often wonder how they can be warm, concerned, and interested while maintaining professional boundaries and distance. Too often, professionalism is incorrectly equated with a cool, aloof, distant, and impersonal demeanor. The challenge is to be professional, which means being appropriately objective and using specialized knowledge and skills, while at the same time demonstrating genuine human concern, interest, and warmth. a c c e p ta n c e

Social work values and practice theory support the importance of the next cluster of characteristics under discussion, which are variously referred to as acceptance, positive regard, respect for all people, or a nonjudgmental attitude (Hepworth et al. 2010). The profession’s values are rooted in concern about individual well-being and social justice. More specifically, among the core values are individual worth, dignity, and respect for people (Reamer 2012). Respect refers to showing concern for and esteem toward another person. Proctor and Davis (1994) emphasize that in professional relationships in which the worker is white and the client is black, social workers need to be cognizant of their clients’ experiences in everyday life. They note that being recipients of disrespect and lack of goodwill is a feature of many clients’ lives and strongly recommend that social workers use respectful behaviors such as addressing clients by their full names, giving clients full and undivided attention, listening attentively, and not disrupting the session by answering the telephone or being distracted and looking at electronic devices during the meeting. Practitioners can show respect and consideration through such basic activities as starting and ending sessions on time. Privacy is important for clients to feel that their confidentiality is respected and a meeting space should be arranged with this in mind. The space must also provide a comfortable setting, one that is free from barriers to communication. In hospitals and residential settings, workers can show respect by knocking on a patient’s door rather than entering the room

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without permission. Workers also show respect when they provide clients with a rationale for the questions they will ask and the information they will require. In addition, practitioners can also encourage clients to ask any questions they have about the helping process and agency programs and services. While respectful behaviors are universally important, Proctor and Davis (1994) point out that they can be especially important for practitioners aiming to build bridges across racial differences. Traditional and contemporary writers in social work agree on a fundamental issue to keep in mind when practicing acceptance and positive regard: the importance of accepting and valuing the client while at the same time not approving of particular behaviors. Acceptance rests on the belief that all people have the right to be heard, understood, and helped, and therefore social workers value people as they are (Perlman 1979), appreciate and affirm clients as unique individuals (Murphy and Dillon 2015), and offer warm goodwill (Woods and Hollis 2000). To achieve this stance, two issues need clarification. One is the practice of valuing the person while not valuing client behavior that is harmful to the client’s own well-being or other people’s well-being. With respect to the client’s behavior, social work theorists are in clear agreement that acceptance does not mean that social workers also approve of, condone, like, or agree with negative client behaviors. Thus, the dictum to adopt a nonjudgmental stance is made with regard to individuals’ essential human nature. This still preserves the social worker’s commitment to social justice and equity, and to taking a stand with regard to behaviors that are violent, oppressive, or degrade others, are illegal, or are a danger to the client. When social workers practice with clients who do not voluntarily seek their ser vices, acceptance becomes a crucial feature of the work. Practice with involuntary clients is discussed at length in the next chapter. It is important to note that qualitative studies of clients with lengthy experiences with mandated ser vice and bureaucracies underscored the importance of worker acceptance of clients—in contrast to clients’ experiences with workers they viewed as hostile, judgmental, and rude (Drake 1994). Clients’ provided heartfelt comments of great fondness for those worker– client relationships in which there was “a feeling of being accepted for who they were, of not being criticized for failures in life or as clients” (Ribner and Knei-Paz 2002), or for workers’ attitudes that clients characterized as “seeing and relating to the client as an ordinary person with understandable problems” (de Boer and Coady 2007, 35).

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Psychologists within the experiential tradition in psychotherapy have also described the importance of a therapeutic attitude of unconditional valuing (Greenberg, Rice, and Elliott 1993). At a basic level, the clinician’s positive regard toward the client has the potential to counteract the client’s own negative feelings and thoughts about himself. In this approach, change is produced by the client experiencing and processing important feelings and thoughts. The client can more fully turn his attention to these therapeutic activities when not distracted by concerns about the clinician’s judgments about the client’s thoughts and feelings. When the client experiences unconditional valuing from the clinician, he feels heard, understood, and accepted, and has confidence that any interpersonal misunderstandings can be resolved between them. This perspective appears congruent with social work values and is useful for those aspects of practice that focus on the client’s internal and interpersonal life. The second issue that affects social workers’ ability to maintain a nonjudgmental stance is the way they work with their personal and social attributes that affect building a relationship. A universal truism is that we all constantly make judgments as we engage in human interaction. To reiterate the theme presented in earlier chapters, as practitioners develop their professional selves, they aim to identify and understand the values, attitudes, and standards that are present at a more or less conscious level, what personal meaning they have for them, and how they are present in their professional judgments and preferred actions. These processes are captured in the concept of holistic competence as attention to cognitive and affective processes. As discussed in the previous chapter, as the social work profession has become increasingly aware of diversity, self-awareness is also understood within the context of intergroup dynamics as well as historical and current forces of oppression and sources of power and empowerment. The challenge for the individual worker is to be aware of one’s own social location and the privileges and barriers that accrue from it. How do factors such as gender, race, ethnicity, sexual orientation, religion, class, and ability frame the way the worker views specific clients and, in turn, the way clients view the worker who is different from them in some way? Although the individual social worker may believe that he approaches all clients in an open and equal manner, by virtue of his social location and a host of characteristics that he embodies and may display, he will be perceived as having more or less privilege. In some instances, clients will generalize from their experiences with others from the workers’ reference group and may be wary,

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wondering whether the relationship will repeat previous oppressive and disempowering encounters. In other instances, clients might evaluate these differences positively, again based on generalizing from previous encounters, or, they might not view differences as being significant at all. The question is, does the difference make a difference in this encounter, and if so, in what way? Practitioners then need to consider how they can engage the client to work with them to address and resolve these issues. An understanding of social location, privilege, power, oppression, and exclusion can assist practitioners in understanding the importance and limits of the working relationship qualities of offering positive regard, acceptance, respect, and a nonjudgmental stance. As noted earlier, social workers need to be self-reflective about the way visible characteristics such as the color of one’s skin is interpreted within their society. How has skin color affected their own experiences of privilege and power or disadvantage and oppression? How have these dynamics operated in their lives in a range of social contexts, such as with family and friends, and in educational and employment environments? Have there been situations in which they benefited from visible characteristics or situations in which they were marginalized because of it? Social workers need to also understand how they have made sense of these experiences, the meaning they ascribed to incidents, and whether such experiences of rejection or privilege influence their current thinking, feelings, and behavior. Although social work as a profession prizes social justice and equity, at an individual level self-reflection may reveal situations in which factors such as skin color, class, socioeconomic status, sexual orientation, and so forth have provided and continue to provide benefit to the social worker. To what extent have societal attitudes and beliefs about personal and social entitlement been absorbed by and play out as implicit and unexamined attitudes in social work practice? Pinderhughes (1989), a social work pioneer in addressing such issues, cautioned that when social workers from backgrounds of privilege listen to and appreciate others’ narratives about oppression, they need to learn to manage their own feelings of guilt or shame, which can affect their perceptions and judgment. Reflecting on the foregoing description of the characteristics of professional relationships, it is apparent that the social work literature as well as literature in related helping professions describes an ideal toward which practitioners can only continually strive. In chapters 2 and 3, concepts and methods for developing the self-awareness that assists practitioners to move

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toward these ideals were presented. It may be helpful to those new to social work to recognize that learning is an ongoing and lifelong process that has the potential to lead to increased self-knowledge and practice effectiveness. The process is iterative and includes formulation, action, reflection, and reformulation. It involves thinking about and planning for practice, interacting with clients, reflecting on practice, resurfacing salient personal and social issues that affect practice, and then reworking issues. In this way, social workers develop the personal self through professional activities. This is both the challenge and joy of being a social worker. When clients feel that the worker has positive regard for them, emotional bonding, which is so crucial to forming a positive alliance, has a chance to occur. If clients feel connected to the practitioner, they may be more able to consider his contributions to their work on key issues. Contributions include offering support and information, and exploring and challenging thoughts, feelings, and behaviors (Hepworth et al. 2010; Woods and Hollis 2000). If there is not enough of a bond in the relationship, clients are more likely to experience the practitioner’s challenges as criticism, blame, or confrontation, which can lead to self-protective reactions or withdrawal. Rather than achieving open discussion and examination, the opposite occurs. Recall the discussion in chapter 4 of the way attachment theory and the concept of the holding environment can inform our understanding of the power of the relationship in the helping process. The following example illustrates many of the concepts discussed in chapters 4 and 5, and those discussed thus far in this chapter. A psychiatrist and marital counselor referred a female in her midforties to the social worker for individual counseling to help her deal with the discovery of her husband’s year-long affair. Members of this family were originally from a Middle Eastern country and immigrated or sought refugee status in the United States over the past twenty-five years. As a teenager, the client sought refugee status on a visit to her older brother and his family. Subsequently, her widowed mother and younger brothers and sister joined the family. Following cultural convention, the client was introduced to a number of young men whom the family deemed appropriate for marriage, and after a few such meetings chose to marry her present husband, expecting that they would both come to respect each other over time. Her family believed that he would be a good husband and one who would take good care of her. The couple has been married for twenty years and report that they are Westernized in many respects.

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After an initial period of turmoil following the discovery of the affair, the couple decided to remain together, in part because their culture and specific community frowns on divorce. They have begun to attend couples therapy and the husband has decided to end his affair, and states that he hopes to become a faithful husband. However, he complains of his wife’s continuing anger and bitterness toward him, and subsequent avoidance and distance. The family consists of four children who range in age from five to sixteen. In couples therapy, the husband states that she is too involved with the children and does not concern herself enough with his needs. Upon learning of his affair, the wife was extremely distraught, could not sleep, and on her family doctor’s recommendation saw a psychiatrist and is taking antidepressant medication. In the first individual session, the client shares her perception that she is experiencing pressure on many fronts to “get over” the husband’s affair— from her own extended family members, from psychiatric interventions, and in couples therapy, where the focus is on moving forward. In individual counseling, the social worker adopts a stance of listening, encouraging the client to explore her feelings, and reflects to the client the hurt and pain she expresses. The social worker adopts a cultural learner stance to explore in depth the meaning for the client of what the client labels “my community’s attitudes about men, women, affairs, and divorce.” In many meetings, the client is extremely distraught and tearful, and rages about the way her life has developed. The worker responds with respect and validation; she is supportive and involved in her presence, availability, and the reflective and empathic comments she makes. Over a few sessions, the client states that she feels that the individual counseling is “for her” and the only place where she is able to talk about how she feels and not be told to do something with those feelings—“get over them, put them aside, or carry on.” Ultimately, the helping context allows her to explore and express her rage at her husband’s betrayal and her anger at the cultural dictates and extended family values that have left her so dependent on her husband. As she progresses, she also examines her anger and sadness about the ways she has accommodated others’ needs and ignored her own. As she and the social worker proceed to examine possible future choices and reflect on their collaborative work, the client comments that what has helped her the most is that she could count on the practitioner to “be there and understand me, not tell me what I should be feeling or doing.”

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Thus far, we have discussed two groups of working relationship characteristics: (1) warmth and caring concern; and (2) acceptance, positive regard, respect, and a nonjudgmental attitude. Why are these characteristics so important for the helping process? When people are confronted with a problem and recognize that they must seek help, they usually feel distressed and vulnerable. When individuals are ordered by a court or required by their employers to seek help, they experience a loss of autonomy and the ability to control their own lives. They may also experience positive anticipation and hope that they will receive something of value, and some sense of relief simply by taking the first step to try to do something about a situation or problem that is troubling to them. Hence, in the initial meeting with the professional, potential clients may experience a range of emotions, from anxiety, skepticism, and helplessness, to optimism, hope, and positive expectation. By providing the qualities of the working relationship discussed thus far, the worker can begin to build an emotionally supportive connection with the client. The client’s experience of these facilitative qualities in the working relationship appears to operate as a necessary step toward producing an atmosphere in which clients feel safe enough to risk discussing and exploring their anxiety-provoking or painful issues. The development of such a relationship involves sensitivity to timing. As in any interpersonal relationship, safety and trust do not develop instantly. Rather, it is through ongoing experiences that we learn about the other’s trustworthiness. We learn whether the social worker will be constant and reliable in her emotional availability, accepting attitudes, and client-centered behaviors. In short-term interventions, where the work is limited by time constraints, social workers need to be even more skilled at demonstrating these qualities in a way that helps clients to develop trust more quickly than in situations that are open-ended. The link between relationship building and intervention in actual practice is less linear than the description offered thus far might suggest. Practice is a process, that is, a series of interactions that takes place over time and that progresses through stages in which the worker and client gain greater familiarity with each other. As in any dyad, the behaviors of each person affect the other and produce subtle, mutual adaptations as the participants cocreate a working relationship. For example, if the social worker is able to convey respect and challenge at the same time, she may be able to demonstrate to clients that she is committed to them and cares about the things

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they do that are, for example, self-defeating. If the client then reacts with anger, the worker who can listen to the client, understand the anger but not react defensively to it, and continue to work with him demonstrates “staying power” in the face of uncomfortable interactions. It is the worker’s ability to work with these two dimensions—support and challenge—while remaining involved that builds trust. Again, note the similarity to the concept of the holding environment (Winnicott 1965). The following activities and behaviors are some basic ways social workers convey warmth and caring concern, acceptance, positive regard, respect, and a nonjudgmental attitude. These interview behaviors emanate from a strong commitment to social work’s humanistic and liberal values. They reflect a belief that all people have intrinsic worth and dignity and that the uniqueness and individuality of each person is of value (Hepworth et al. 2010). Without a stance grounded in this value, these interviewing skills can seem mechanistic and hollow. genuineness

Carl Rogers (1951) is credited with introducing a humanistic approach to psychology and his work has been influential in related helping professions, including social work. He proposed three core conditions for helping: empathy, warmth, and genuineness or congruence. The attitude of warmth, as described in the social work literature, was presented previously. Empathy will be discussed later in this chapter. Genuineness refers to being open, “real,” and sincere in the helping relationship. While behaving in an authentic manner, however, the social worker is still functioning within a professional context. This involves the challenge of “being real,” but in a way that ensures that the therapeutic work is client focused and facilitates positive outcomes. Professionalism should not mean being phony and hiding oneself behind an aloof, distant, expert mask, nor does it mean impulsively sharing feelings and impressions. Rather, it is a “disciplined spontaneity based on the therapist’s accurate self-awareness of his or her deeper levels of experience . . . [that is] shared in a facilitative manner at a therapeutically appropriate moment” (Greenberg et al. 1993, 20). Another aspect of genuineness refers to being honest in a responsible and nondefensive manner. Especially when social workers are delivering bureaucratic or court-ordered decisions and know this information may be

relati ons hi p- b u i ld i n g ac t i v i t i e s a n d b e h av i o rs • Attend to the client’s need to feel comfortable by being on time, holding interviews where it is conve nient for the client, such as in a home visit. If holding an office interview, arrange the meeting place in a way that will be comfortable for the client (Compton, Galaway, and Cournoyer 2005).

• Convey concern through constancy and availability. This includes returning clients’ telephone calls or e- mails promptly, following through on tasks such as providing information, making a referral, and obtaining promised resources.

• Offer nonverbal be haviors such as a warm smile, a welcoming and attentive gaze, an expression that accords with the client’s feelings—all of which convey interest.

• Offer verbal be haviors such as frequent words of encouragement and speaking with a warm, friendly, and interested tone as you ask questions and provide information or offer comments (Kadushin and Kadushin 2013).

• Active and attentive listening and communicating in verbal and nonverbal ways show that the social worker is intent on understanding the situation as the client experiences and understands it. This stance contrasts with an overly structured or constricted one in which the worker pres ents herself as an expert, seeks to obtain only certain information, and offers premature judgments, interpretations, and solutions.

• Convey ac ceptance through paraphrasing and restating what the client has said in a way that demonstrates the social worker’s concern that he has understood what the client has expressed. Use an open and accepting tone, inviting clarification from the client.

• Allow time and emotional space for clients to tell their stories free from judgment by the social worker.

• Adopt a mindful, reflective stance in the interview, using self-awareness so that one offers intentional responses to clients rather than unpro cessed reactions. Self- observation is not solely limited to personality issues but also to understanding how social factors connected to diversity and power are linked to personal and pres ent relationship building for the client and the worker.

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disappointing to the client, an honest recognition and communication of their own feelings can reflect their sensitivity. Clients of child welfare services reported how much they valued workers’ honesty and genuine interest in them (Drake 1994), and “soft, mindful and judicious use of power” (de Boer and Coady 2007, 35). For example, a social worker who states that she will try hard to work together with the family even though she knows they would prefer that she not be there might note to the family that she would feel the same way in their shoes. Genuineness also includes knowing one’s own limits; if a worker cannot answer a question, it is important that he convey this lack of knowledge and seek out the information rather than provide vague or inaccurate responses. Similar to findings about clients required to work with child welfare authorities, Ribner and Knei-Paz (2002) found that clients of social welfare institutions valued social workers who softened their experience of feeling “needy.” Such workers did not deny the reality of the client’s situation or the requirements and limits of welfare provision. The respondents deemed workers helpful when they were genuinely involved with them as people and did not see them simply as problems. For example, genuine workers inquired about the clients’ lives in general, not only about financial- and employment-related issues, and showed interest in clients’ pleasures and hopes for the future. Finally, it is not unusual to have second thoughts after an interview is over. Through reflection, practitioners can reevaluate a session and gain new perspectives on the client and their work together. After this reevaluation, the practitioner can return to the next meeting with the client and reveal that they wonder whether they misunderstood the client’s comments and reopen a discussion. Social workers who admit they drew inaccurate conclusions or made unhelpful comments can apologize, and in this way, demonstrate genuineness. Two stages of genuineness were suggested by Carkhuff (1993), an early and influential researcher in this area. The first stage occurs at the beginning of any human interaction and includes conventional and natural ways of responding to people in relationships. This can be thought of as a quasisocial stage, with general comments and inquiries offered in a natural way. In the second stage, as a result of working together over some period of time, greater understanding of each other likely has developed. Practitioners can then more freely be themselves, modeling an openness that can help

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clients also achieve openness and share information important to the work. Congruence refers to the consistency among the social worker’s attitudes, feelings, and behaviors. For example, if the worker feels warmly toward the client and is concerned about her, these attitudes will be demonstrated through the kind of questions the practitioner poses and the remarks he makes, such as asking about the client’s well-being in a friendly and interested way at the beginning of the session. In this scenario, the client is likely to experience an authentic and real connection with the practitioner. Conversely, if the worker verbalizes his concern but does not demonstrate it in his behavior, the client will understandably question how committed the worker truly is to helping. For example, a worker providing counseling to a couple for their relationship difficulties discusses with them that there appears to be considerable stress as a result of both parents working outside the home to support the family and their need for child care for their young school-aged children. When the couple states that they have not been able to find affordable after-school care for their children, the worker states that she will look into this. The worker does not follow up with this promise, however, and the couple wonders whether she is really interested in them or simply views them as “another case.” To achieve this stance of genuineness and congruence, practitioners need to understand the internal processes that interfere with their ability to be fully present with and available to the client. When practitioners are preoccupied by their own thoughts, feelings, and judgments, it is more difficult to be authentic and genuine with the client. For example, when social workers feel overwhelmed by the complexity of a client’s circumstances, out of a desire to be helpful, they may offer reassurance that is false or at best conveys only a superficial understanding of the multiple factors operating in a client’s life. As discussed in chapter 2, an ongoing process of reflection and self-awareness helps practitioners attend to and understand their own feelings and reactions to the client, develop ways to deal productively with issues, and achieve greater comfort in practice. Along with personal work such as in therapy, supervision with an experienced social worker and consultation with colleagues are all potential resources in this process. These activities enable practitioners to integrate the personal and professional self, and achieve a level of authenticity that is comfortable for them and helpful to clients. Constraints to offering facilitative relationship conditions may involve other issues besides the practitioner’s reactions to the client; concerns about

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oneself, for example, might be spilling over into the work. Students, for instance, report that they become preoccupied with their knowledge level and competence in the interview. While trying to understand what the client is saying, they become self-conscious about their skills and uncertain about what topic to focus on and what questions or comments are appropriate to offer. These concerns are likely to break the connection with the client. Finally, the organizational work environment exerts a powerful impact on all human ser vice professionals. Increasing expectations about worker productivity and workload may create unrealistic pressures that interfere with the practitioner’s ability to be centered and present with the client in interviews. For example, social workers and allied health professionals in a large mental health and addiction facility discussed their reluctance to raise issues in supervision related to their challenges in forming working relationships with hard-to-reach clients for fear of being laid off in the ongoing round of staff cuts due to the institution’s financial constraints (Bogo et al. 2011). All of these factors can impede being genuine in the interview. Despite all good intentions and professional tools, it is inevitable that practitioners will have negative feelings or judgments about some clients that interfere with their ability to be truly present with and available to the client. Social workers struggle with the boundary between genuineness and professional restraint. Although being authentic implies sharing perceptions with clients, these may be destructive to the client if they are not made in a purposeful and considered manner. Murphy and Dillon (2003) capture the complexity in drawing a distinction between genuineness and total honesty. They state, “We need to be selective, always considering the impact that our remarks and behaviors have on our clients” (83). In summary, as with other elements that are important for building an effective working relationship, genuineness is an ideal orientation to which practitioners should strive. Genuineness can best be understood when practitioners remind themselves that it should be practiced in the ser vice of the professional role. Practitioners’ self-awareness helps them differentiate between their internal reactions, the client’s contribution, and the processes that result from the interaction between the two. Ultimately, the practitioners’s genuineness should be controlled, as it is offered to advance the client’s progress toward meeting his goals.

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e m pat h y

In the preceding discussion of genuineness, the contributions of Carl Rogers (1951, 1957) were noted. Rogers asserted that the core conditions of empathy, warmth, and genuineness were not only necessary but also sufficient for activating the healing and growth potential of clients. The important role that these core factors play has been demonstrated in a number of research studies conducted on the outcomes of psychological counseling and psychotherapy. However, the contention that these conditions by themselves are sufficient for positive intervention outcomes has not been supported (Bachelor and Horvath 1999). Although these studies have been critiqued for measurement limitations, researchers do agree that these core conditions are associated with positive outcomes (Horvath 2000) and facilitate the change process across all counseling and psychotherapy models. As discussed in chapter 4, they can be considered as common factors across all helping interventions. Social workers recognize the important impact of environmental factors on well-being and positive change, and hence have not totally adopted Rogers’s theoretical formulation. However, they have seen the congruence between Rogers’s emphasis on the crucial role of the working relationship and social work’s perspective that the working relationship forms both the foundation and the context for change. Furthermore, his delineation of helping relationship characteristics parallels social work’s century-old humanistic, client-centered focus. It is understandable that social workers have been interested in the theoretical contributions from and research studies conducted in humanistic and experiential psychology. Indeed, this well-articulated body of knowledge fits well with social work’s clientcentered values and can be usefully integrated into social work practice. The Rogerian working relationship stance emanates from his belief in the importance of helping clients become aware of their inner experiences and the feelings and meanings that are connected to their behavior (Hill and O’Brien 2014). Rogers believed that a client’s subjective experience guides his behavior. Hence, the only effective way for the helper to be of assistance is to gain an understanding of the client’s internal life. This entails reaching for an emotional and intellectual appreciation of the internal frame of reference from which the client interprets and experiences himself and his situation. It requires that the practitioner act as both participant

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and observer. As participant, empathy involves aiming to experience the client’s subjective perspective—to feel as she feels. As observer, empathy involves remaining separate enough from the client’s feelings that the practitioner can better understand the client’s situation. As Murphy and Dillon (2003) observe, empathy is “the ability to immerse oneself in another’s experience without losing one’s own sense of self” (88). It appears that empathy serves two purposes: (1) through an attentive focus on the client and his experience, a bond is forged; and (2) in-depth information is obtained about the client. Within the humanistic and experiential tradition of psychology, Greenberg, Rice, and Elliot (1993) presented a contemporary elaboration of the concept. In their description of empathic attunement, they state: Clients build a stronger sense of their own experience by having their experience recognized, responded to, and thereby validated by their therapists. Having one’s own feelings understood and accurately reflected back to oneself in both a verbal and nonverbal manner helps one to experience the feeling more fully and with increased confidence that “this is really what I am feeling.” Feelings are often inchoate, emerging from a highly subjective, idiosyncratic, inner world for which there is no formal descriptive language. When the experience is symbolized and shared, it is confirmed as being what it is by the other’s understanding of it. (20)

The practitioner’s achievement of empathy requires a consistent focus on the client and some degree of artistry. From the client’s perspective, having one’s experience understood is essential in creating an alliance. Greenberg, Rice, and Elliot were writing in 1993, but subsequent neuroscience research, discussed in chapters 4 and 10, supports this view of the importance of addressing feelings in social work (Siegel 2003). Within the psychoanalytic tradition of self psychology, the concept of empathy was further articulated by Kohut (1984). All individuals need empathic connections with others, particularly empathic responsiveness from caregivers to normative developmental needs. Kohut further theorized that the need for others to fulfill a range of psychological functions endures beyond childhood and throughout life. Similarly, empathy is central in the helping process. Empathy is defined as the therapist’s ability to engage in “vicarious introspection” by immersing oneself into clients’ experiences to gain understanding about how they perceive and feel about their lives. As

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the practitioner strives for focused empathic attunement, her inevitable empathic failures that occur along the way provide opportunities to further examine and understand the subjective perspective of the client (Wolf 1988). Empathic breaks, for instance, that cause clients to feel disappointed, misunderstood, or fearful that the therapist wants to abandon them offer emotional data that can lead to understanding and change. In common across theoretical perspectives about empathy is the postulation that two components of empathy facilitate the helping process: understanding and communication. The clinician strives through the dialogue to recognize the client’s thoughts and feelings, and then to communicate that understanding to the client. He offers hunches, reflections, and comments in a tentative way in the ser vice of building joint understanding. The practitioner’s empathic comment offered in such a way demonstrates his desire to understand the client’s inner frame of reference through active listening, following or tracking the client, and trying to identify themes and patterns throughout the client’s narrative. To truly listen, without evaluating or attempting to interpret the issues from the vantage point of any particular theoretical framework, the clinician needs to be nonjudgmental, focused on the client, and not distracted or preoccupied with her own inner issues or beliefs about preferred directions for possible interventions for the client. As the practitioner develops an appreciation of the client’s affective and cognitive experience, he also tries to find the words to share his understanding. The worker aims to express the essence of what the client is struggling with and to share that in a respectful way that invites dialogue. In an analysis of the strengths and limitations of empathy, Clark (2003) notes that the conceptualization of empathy as a tool of sustained mutual inquiry is often overlooked. Rather than the worker searching for an “accurate” reflection of the client’s feeling and thinking, empathic comments can be viewed as an important aspect of interpersonal communication between client and worker. Empathic comments serve the goal of collaboration, as the worker aims to arrive at a joint understanding with the client of what the problem or issues are that are troubling, and ultimately what may be areas for work. Again, with a warm, accepting, and respectful stance on the part of the practitioner, the client can agree or disagree with his empathic comments. When the communication appears meaningful, the client will feel validated and supported through feeling understood. When the client disagrees, where

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there is a growing bond and trust with the practitioner, the client is more able to directly verbalize or indicate disagreement in some way. Together, the client and social worker can continue their dialogue moving forward until they find enough meaningful shared understanding. This type of empathic communication is more than simply reflecting what is expressed and what is seen; it especially involves exploring what is implied. Topics and issues may be bubbling beneath the surface and are troubling to the client even though he is not able to easily articulate them. By attending to nonverbal expressions of joy or pain, to evidence of discomfort, such as rapid breathing, flushing, clenching fists, and the beginning of tears, a sensitive social worker can empathetically guide the conversation. Working together, the practitioner and client can explore the client’s underlying thoughts and issues about which there is guilt, shame, conflict, or mixed feelings. Recall the discussion in chapter 3 regarding the way a focused reflection can help students sensitize themselves to greater self-attunement and use that information to connect with and understand clients. Ellen Katz (personal communication, 2016) recommends reflecting in the moment on one’s own physical experiences in the body (related to posture, body sensations, breath), specific emotions (joy, fear, terror, boredom), states of mind (concentrated, heavy, energetic, spacious), and judgments (the concrete thoughts on which feelings and state of mind are focused). In this way, the practitioner may potentially glean hunches about what the client is experiencing and how they may better connect. Timing also plays a part in arriving at understanding about another person. As the client and worker have many interchanges, the social worker will learn more about the client’s experiences, issues, and interpretations of life circumstances and the present situation. More information assists the worker to better understand the client’s internal life, and hence to respond in ways that are more attuned to the client. Moreover, clients may appreciate the worker’s sustained attempts at understanding them as being helpful in and of themselves. These processes do not happen immediately. It is reasonable that in any relationship, individuals need to feel relatively confident that when they disclose painful or difficult thoughts and feelings, the other will respond supportively and empathically. This would especially be so in a professional relationship in which the practitioner is unknown to the client. Over a period of time and with multiple experiences with the

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worker, the client comes to trust that he will not be shamed, judged negatively, or humiliated. The client’s expectation of safety, however, does not develop until a number of such experiences have occurred. Empathy and Diversity

Chapter 5 focused on practice with diversity and difference, and the importance of recognizing the limits of universal human feelings and reactions. To act as if all human experience is universal may prevent us from learning about clients’ diverse and unique worldviews or cultural frames of reference (Green 1995). Hence, it is important that social workers acknowledge their limitations and that they need to work collaboratively, respectfully, and with humility as cultural learners (Guttierez and Ortega 2016; Ortega and Faller 2011). As noted frequently in the discussion of holistic competence throughout this text, to take this position requires practitioners to be aware of their own values, attitudes, and judgments, and to be sensitive to how these assumptions are part of their personal and cultural belief system and operate in more or less overt or subtle ways in their practice. As Schon (1987) so elegantly described, in all professional practice, practitioners operate in a zone of complexity and uncertainty in which uniqueness and diversity pose a challenge to so-called universal theories and practices. The hallmark of this type of professional work is the ability to tolerate ambiguity and remain committed to understanding the client’s particularities. To reiterate, through active listening and inquiry, the social worker aims to convey that it is important for the worker to understand the client’s views. Rather than assume commonality by tuning into one’s own feelings, the worker adopts a learner’s stance and seeks to discover the underlying personal and cultural meanings behind the client’s concerns, paying attention to key words, metaphors, and other linguistic elements as entry points into exploration of implicit meanings. The worker uses this type of empathy as a communication device as he conveys what he thinks he has heard and invites feedback. Through a joint dialogue, enough shared understanding of the client’s situation develops so that some helpful activities can be suggested by the practitioner and taken up by the client. This stance not only serves the goal of assessment but also builds the working relationship as the worker demonstrates his keen interest in learning about the client’s unique personal, cultural, and societal frame of reference.

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Many examples of this type of learning approach emerged in our research on cross-cultural counseling (Tsang, Bogo, and George 2003). In an agency dealing with adolescents, a social worker saw a mother and daughter together to help them deal with the adolescent’s failing performance in school and the conflict between them due to such issues as setting a curfew on which they could both agree. As the worker began the discussion of curfew with them, she inquired about the mother’s experiences as a teenager. The mother was an immigrant from an urban center in Africa and had been raised with standards that prohibited a teenage girl from going out without being accompanied by a relative. She had always therefore been accompanied by a brother and they would return early in the evening. The social worker invited mother and daughter to contrast their experiences. The teenager was born and raised in North America and believed, with great conviction, that she was an independent person, well able to go out alone in the evening. The interviewer asked the mother how growing up with those standards had affected her. The mother went on to explain how she had been able to accommodate since “that was the way it was for everyone”; however, she had convinced her parents to allow her to attend school in Europe after completing high school, and even though she lived with close family friends, she had enjoyed considerable autonomy then. As the worker drew the parallel between the mother’s and the daughter’s similarity in seeing themselves as able to take care of themselves, mother and daughter softened their oppositional positions and began to talk and listen to each other more openly. During this discussion, the worker took the opportunity to ask the clients to let her know whether during their time together she said something that did not make sense because it was not true of their culture. She elaborated, asking them to tell her should they feel there were things she needed to know to understand them and their situation. The Client’s Perspective

How are the social worker’s qualities and behaviors affected by the client and how do the client’s responses to the worker in turn affect their ability to develop a productive working relationship? Horvath (2000; Horvath and Bedi 2002) observes that studies on the effectiveness of counseling and psychotherapy reveal that it is not the worker’s actual behavior as measured by objective observers that accounts for positive gains; it is the client’s subjective

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evaluation of the relationship with the worker that is associated with success. Hence, it is important that the practitioner attend to how the client experiences both the working relationship and the worker’s understanding of the client’s situation. The practitioner should make efforts to obtain feedback from the client about how he evaluates the helpfulness of the worker. Furthermore, not all clients experience and evaluate the dimensions of empathy in a similar manner. In a study of clients’ perceptions of the therapist’s empathy, Bachelor (1988) found that the empathy offered by practitioners was experienced and valued differently among a client sample that was drawn from a community clinic population. She identified four distinct styles. A large number of clients (44  percent) valued empathic responses that conveyed an intellectual or cognitive understanding of their innermost experience or subjective state. Thirty percent of clients valued communications that were affectively oriented, that is, that conveyed that the helper was emotionally involved with the client and feeling the same way she was. The third style was labeled sharing and was reported by 18 percent of clients as the worker sharing personal opinions or experiences that were related to the issues confronted by the client. Finally, 7 percent referred to nurturant empathy and valued the supportive, attentive, and caring presence of the practitioner. In a related study, Bachelor (1995) again found that clients varied regarding the value they attributed to empathy in professional relationships. Close to half of the sample valued the qualities of facilitative relationships, such as respect, a nonjudgmental attitude, empathic understanding, and attentive listening. Another 40 percent of respondents described a positive relationship as one that resulted in greater self-understanding. They attributed gains in their self-awareness to their therapists’ clarifications on issues they discussed. Only 10 percent of clients viewed a positive relationship as a collaborative effort in which both the therapist and the client have joint responsibility for bringing about change. These studies suggest that it is unwise for practitioners to assume that all clients will experience the empathy they offer in the same way. Clearly, there are individual appraisals and preferences. The general facilitative relationship characteristics of warmth, caring concern, acceptance, positive regard, respect, and a nonjudgmental attitude are likely to provide a useful starting point for work with all clients. As social workers strive to use the principle of individualizing the client and the client’s situation, it is useful to remember that clients do not value equally the various aspects of empathy.

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Some will prefer a focus on cognitive understanding, others on emotional attunement, and others on support and nurturance. And some clients are less concerned with an empathic stance and instead prefer a worker who provides considerable self-disclosure. Differences in clients’ preferences about the practitioner’s style may also include the degree of formality versus informality; the degree of warmth and friendliness as contrasted with a more neutral style; the degree of direction, structure, and verbal input on the worker’s part; and the balance between support and challenge the practitioner offers (Norcross 1993). Moreover, clients may change their preferences through the course of the helping process, especially as more familiarity and trust develops between the client and the practitioner. This group of research studies suggests that it may be helpful for practitioners to be attuned to the way each individual client responds to their stance, behaviors, and comments in the interview. The nature of the relationship may need to be negotiated initially and over time as comfort and familiarity are established. Practitioners will therefore need to develop a flexible repertoire of relationship stances that suit different clients’ needs and expectations so that they can bend and adapt aspects of their interpersonal style to achieve a more optimal fit with each client. This principle is similar to the social work notion of differential use of self, which refers to the ability of experienced, competent practitioners to use different aspects of their personal and professional styles in a variety of ways to tailor how they build connections with various clients. Some examples of such tailoring are being more verbally active with less verbal clients and more nondirective with clients who are able to more easily express issues of concern and what they need; being able to provide a calm, centered space and place to help clients contain their distressed emotions and manage clients’ dysregulation; being able to move quickly and act in a range of roles in an emergency, and in longer-term involvement, being able to proceed slowly and patiently; knowing when to be challenging and confront client issues and when to sit back, listen, and say little; being able to work with both adolescents and adults, varying the use of language, degree of formality, and stance to accord with the client’s age group; and knowing when to use humor and when to remain serious. The following activities and behaviors are some of the ways social workers facilitate empathic communication in the ser vice of building working relationships and developing enough shared understanding of the client’s situation to enable effective helping.

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empathy: i nterv i e w i n g ac t i v i t i e s a n d be h av i o rs • Listen actively to client’s words and attend to the client’s nonverbal expressions.

• Provide nonverbal be haviors that convey a keen interest in listening and understanding.

• Follow the client’s lead and pace; respond to the issue about which the client is concerned.

• Ask the client about the relationships, cultural reference groups, and values that are impor tant to him.

• Reflect on the client’s meanings and feelings with reference to his cultural context.

• Communicate tentative understanding of thoughts and feelings in a way that invites and leads to dialogue.

ther apeutic alliance

Psychotherapy researchers have reconceptualized the concept of the working relationship as a therapeutic alliance and pinpoint its salient dimensions. Bordin (1979, 1994) provided a definition of the therapeutic alliance that goes beyond the traditional social work notion of relationship. This conceptualization has been used in designing measures for research purposes, as well as in understanding relationship in clinical practice. Rather than viewing the relationship as composed of characteristics and qualities that the social worker offers, such as warmth, empathy, genuineness, a nonjudgmental attitude, respect, and so forth, Bordin proposed three interactional factors that constitute the therapeutic alliance: (1) an emotional bond or connection, (2) agreement on the tasks that will be used, and (3) agreement on goals to be achieved. The concept encompasses the interactive dynamics between and the collaborative processes undertaken by the worker and the client—again, a concept that is highly congruent with social work practice theory and values. The first factor, the bond, refers to the emotional quality of the relationship between the client and the social worker. It includes the degree to which the client believes that the worker understands, respects, and values him (Safran and Muran 2000). When a bond is formed, the client feels

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connected to the social worker in a way that is meaningful and important. The bond encompasses the worker’s empathic attunement to and understanding of a client’s thoughts and feelings, acceptance, and a nonjudgmental stance. It provides the emotional base that holds the relationship together as the client and worker experience the progress and setbacks of intervention. For example, an adolescent client new to the country had been encouraged by her social worker to initiate conversations with classmates to show her interest in making friends. The client tells the worker, angrily and tearfully, that no one responded to her efforts and that she felt like a fool and more of an outsider. This client feels that she can tell her worker that her advice was useless, and that the worker does not understand what it is like to be different. Because an emotional bond has been established, the client believes that the worker will listen and keep trying to help her. In the absence of such a bond, the client may blame the worker for giving bad advice or simply not return. The second factor in the therapeutic alliance is the goal of intervention, which refers to the general objectives of the work and the degree of agreement between client and practitioner about the purpose of meeting together. In social work, the principle of “starting where the client is” refers to giving primacy to the client’s choice of the issues to work on. Individual social workers also have their own view of optimal social functioning and this plays a role in contracting. For example, a client in an acute hospital might expect the social worker to help him exclusively with discharge planning and admission into a rehabilitation setting close to his home. The social worker might view this objective as only one part of the goals of working together. Other goals might be helping the client adjust to the psychological and social implications of a serious accident that resulted in paralysis and permanent loss of function. The worker views meeting a client’s expressed immediate needs as important and valid. Providing concrete resources may constitute sufficient ser vice for the client at this stage of his adjustment, or it may solidify his perception of the social worker as a valued helper with whom he can work to deal with other aspects of his physical condition. As noted as a contextual factor affecting holistic competence, however, most social work practice takes place within an organization or ser vice program. The acute hospital may limit the amount and span of time that the social worker can devote to the client, and in this way, set limits on what goals can be addressed. In practice, these three perspectives—the

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client’s needs and wishes, the social worker’s knowledge and assessment, and the organization’s policy—must be negotiated in setting goals. Over time, goals of intervention may change and new tasks or activities will be introduced. For example, while working with a young couple referred by Child Protective Ser vices to help them learn parenting skills, a social worker in a community agency may discover that the father’s employability is limited by his lack of literacy. The worker may also initiate an assessment to determine whether the client may have a learning disability or refer him to an adult literacy program. The third factor in the therapeutic alliance, the task of intervention, refers to the activities, methods, or procedures of the particular intervention plan. It may include the roles and responsibilities of both the client and the social worker in bringing about change and the degree of agreement between them. For example, the parents of a child who is having difficulty controlling his anger might expect that the social worker will see the child individually or in a play therapy group. The social worker may agree and also recommend regular family sessions as an important part of bringing about change. Although the parents may be reluctant to participate, if enough of a bond has developed, they may be able to discuss their mixed feelings and then accept the worker’s recommendation. This three-part formulation of the therapeutic alliance provides a multidimensional view of working effectively with clients. At the beginning of the relationship, when there is little emotional bonding, it is likely that agreement on goals and tasks is of great importance as the worker has not yet established the credibility to reframe or enlarge the work together. As the bond increases, however, the client may become more hopeful about achieving additional goals. This can lead the social worker and client to develop new plans, which include engaging in activities about which the client may have initially felt skeptical. Similarly, as progress unfolds as a result of successful interventions, the relational bond is strengthened. In this respect, the three components of the therapeutic alliance are mediated by each other, and together produce the facilitative conditions for growth and change. For example, a young father was initially too embarrassed to discuss his inability to read with the worker. As he and his wife learned parenting skills from the social worker and found her to be helpful, caring, and nonjudgmental, he was able to become open about his frustration regarding his lack of employment prospects. With encouragement from the

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worker, he began to attend classes to learn how to read. His wife was supportive of his time away from the family, as she had been actively involved in developing this plan. It is not unusual despite the best efforts of all participants for progress to be slow or not evident at all. When a bond exists between the practitioner and client, they can discuss this without the client feeling blamed or judged. Together they can explore factors that may have been overlooked, information that might have been withheld, or deep-seated attitudes and feelings that are not easily modified. Practitioner–client discussions about a lack of progress can strengthen the relational bond when the practitioner demonstrates her commitment to facilitating the client’s progress. c o l l a b o r at i o n a n d pa r t n e r s h i p

Concepts drawn from intersubjective, systems, and interpersonal neurobiology theory consistently note that two individuals in a dyad will interact in a recursive manner, with each person exerting mutual influence on the other person’s thoughts, feelings, and behaviors. In specialized approaches, the relationship may be defined more specifically, but all models support the importance of a positive relationship. It may be useful to think of a continuum with respect to the degree of collaboration and mutuality in decision making between social worker and client. Models can be placed at various points along the continuum. For example, in behavioral and cognitive behavioral approaches, the worker’s expertise, professional knowledge, and leadership is recognized and acknowledged. Such models are highly structured and include a thorough assessment that results in an individually tailored action plan (Beck 2011). On the other end of the continuum are postmodern approaches that stress the client as the expert on her own life. In this model, the worker enters into conversations with the client with the aim of searching for joint understanding (McNamee and Gergen 1992). As discussed previously, when working in contexts of diversity and difference, when worker and client differ in social identity characteristics there must be a high level of collaboration so that the worker can develop enough shared understanding of the client’s issues that meaningful ser vice can be offered (Dyche and Zayas 1995; Tsang and Bogo 1997). Given this perspective, whatever inputs the social worker ultimately offers, even if the worker believes she is providing the best elements for an

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effective therapeutic alliance to develop, the client will determine whether that is so. With a notion of therapeutic alliance expanded beyond an emotional connection to include agreement on goals and tasks, the interactional viewpoint is established. Therefore, social workers need to actively seek out clients’ initial and ongoing viewpoints about their work together. Much can be learned by focusing attention on clients’ overt and subtle reactions to workers’ interventions. Some clients prefer a working relationship that is more formal than informal; some find a focus on internal aspects of their life more helpful than a focus on external ones. Some clients favor an approach that is oriented toward behavior, others to thoughts and explanations, and others to feelings. For example, the social worker observed that her young adult male client avoided eye contact and offered little elaboration of his responses whenever she asked about his past relationships in his family of origin. Although his presenting concern was how to tell his parents that he was living in a gay relationship, talking about past family relationships caused him discomfort. Recognizing this, the worker could make this explicit or maintain a focus exclusively on the present. By introducing her observation that talking about past family relationships seemed to cause him distress, the client could further explore his discomfort (that he felt he had disappointed his parents in his educational and career choices, and “coming out” to them would be another disappointment). Or, the client could provide information about his view of change (that he believed that long excursions into his past would take a lot of time and not help him with the immediate concerns he was facing). Social workers can also make the collaborative process more explicit and specifically explain the importance of client feedback and evaluation of the work together from the very beginning and throughout their time together. Clients are likely to feel that they may have some influence on the process and the worker will likely glean useful information. When a number of intersecting diversity factors are present, such information can provide important insights into what methods may be most helpful. In the first session, practitioners can state that the work will involve the client’s active participation in setting goals and tasks. The practitioner and client can discuss the usefulness of regular feedback about the process, especially whether the client finds the social worker to be understanding, affirming, and helpful. Practitioners can also include regular and periodic discussion of these aspects. Instruments developed for research purposes

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specify the factors associated with alliance and can serve as a point of departure for such discussions; they can also be used to evaluate the relationship and process aspects of the work. Duncan et al. (2010) developed two brief easily administered measures; the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). Each scale consists of four items and clients indicate on a continuum their perception of specific and overall progress, and how they viewed their experience of the working relationship. With respect to outcomes, the items seek information about the client’s sense of progress in his personal well-being and in interpersonal and social relationships. With respect to the alliance, the items seek information about the client’s viewpoints about the working relationship with the practitioner, the focus on goals and topics the client wished to address, and the goodness of fit with the practitioner’s approach. Campbell and Hemsley (2009) found that these scales demonstrate good reliability and concurrent validity when compared with more complicated and longer scales. Many social ser vice and mental health agencies have adopted these instruments and workers administer them at the end of each session, and discuss them with their clients. The information provided enables the worker to gain important information, and if necessary to steer the process in a direction that is more client centered. Although there has not been a great deal of empirical work in social work, Poulin and Young (1997) developed the Helping Relationship Inventory (HRI). This instrument reflects the alliance components of task, goals, and bond as defined by Bordin (1979), and also incorporates important social work activities to help clients access ser vices such as advocacy, linkage, and coordination. Two groupings of items were found. The first was a structural component consisting of questions about the extent to which the social worker and client discussed specific issues and how much input the client felt he had. The specific issues were goals, problems or concerns, how client and worker would work together, actions the client would take, actions the social worker would take, and how progress would be assessed. The second was an interpersonal component consisting of questions about the client’s perception that the worker helped the client think more clearly about himself and his difficulties, instilled belief in the client, was similar to the client in some ways and had similar views, and inspired hope. The researchers referred to the interpersonal component as an inspiring or motivating factor.

alli ance bui ldi n g: i n t e rv i e w i n g ac t i v i t i e s and be hav i ors • Elicit the client’s expectations and hopes about receiving help, preferred goals to work on, problems to be addressed, and how the social worker and client will work together.

• Regularly inquire about the client’s perceptions and experiences about how the work is progressing. What is helpful? What is not helpful? What is missing? What does the client believe would help? Does the client feel understood? Are the worker and client talking about topics that are impor tant to the client? Does the worker’s way of proceeding make sense to the client? The use of structured self- report questionnaires at the end of sessions can facilitate discussion of alliance components.

• Be attentive to the client’s reactions to what the worker provides in the session, such as how comments, questions, and suggestions are received.

• Follow up on between- session plans and inquire whether they were carried out and with what effect. If plans were not carried out, explore whether this was a result of alliance factors, such as lack of agreement on tasks.

• When clients request ele ments in the working relationship or in interventions that would be pos sible and appropriate, workers should attempt to implement them. For example, when a client requests that in addition to discussing job seeking that the worker also tell him what he should actually say and do during a job interview, he can be engaged in role playing.

• When clients request ele ments in the relationship or in interventions that are not appropriate, workers should discuss this and invite clients to work with them to find alternative pos sible solutions. When a client who feels isolated asks the worker to go to a movie with her, for example, rather than merely explaining that this is not pos sible, the worker can redirect focus to how the client can connect with others in her life so that isolation and loneliness are alleviated. It can also be helpful when the worker talks about the unusual nature of therapeutic relationships and acknowledges the client’s frustration or disappointment with its limits.

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As with the ORS and SRS, this inventory can be used in both research and practice to evaluate the strength of the working relationship and to facilitate discussion about it. Students and their clients independently and simultaneously complete versions of the HRI and discuss the results at the next session. The researchers report that students and their clients discussed items with marked differences or with ratings that were lower than those of most items (Poulin and Young 1997). Using the inventory served as a structured way to evaluate and redirect practice. It helped identify additional areas of concern and made discussion of the working alliance explicit. Social workers who seek and use feedback from clients have the opportunity to truly individualize their practice. This entails adapting the worker’s stance, intervention activities, and expectations. Workers need knowledge of and comfort with a range of therapeutic behaviors and a versatile and flexible stance. This perspective seems congruent with the contemporary practice realities that take diversity into account, as discussed earlier. This view of practice is grounded in principles of collaboration, mutuality, and partnership. Social workers do not “do things” to clients; instead, the worker and client come together to engage in activities that help the client meet his goals. Therefore, a reasonable starting point is to learn what the client wants to achieve and hopes will be different as a result of meeting with the worker (Hubble, Duncan, and Miller 1999). Goals are often expressed in vague and general terms, especially in initial meetings. It is therefore useful to break goals down into manageable parts or, as a longstanding social work practice principle states, to partialize the problem. Goals may expand or become more specific as the client shares additional information and accompanying insights emerge. Hence, it is important to see this type of work as a dynamic and evolving process. The activities and interviewing behaviors in the box on page 157 are some of the ways that practitioners facilitate the alliance (Bachelor and Horvath 1999; Hubble, Duncan, and Miller 1999; Young and Poulin 1998). This chapter built on salient conceptual and empirical studies in social work, psychotherapy, and psychology that have influenced practice. Of interest is the congruence with practice wisdom created by social workers over many generations. Such knowledge frameworks can inform practice and provide an intellectual foundation for guiding the way practitioners use their professional self in enacting the complex practices of relationship building and maintenance.

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are ever evolving as new knowledge is developed. Practice is also affected by societal changes such as the increasing diversity of populations as a result of global migration. In addition, the pervasive use of information and communication technologies (ICTs) raises new complex practice issues. This chapter will review some long-standing and more recent issues that all social workers must take into account. theoretical concep ts and pr actice principles

self-disclosure

The human tendency to value self-disclosure is supported by empirical work in cognitive psychology and neuroscience (Tamir and Mitchell 2012). Studies show that humans frequently share personal thoughts and feelings, and this experience is rewarding (Collins and Miller 1994). The pervasive use of the Internet and the popularity of communicating through social media have dramatically changed social interaction. It has become common practice to reveal information about personal experiences and to find information about others by searching the Web. This current societal environment affects the way social work practitioners think about self-disclosure (Mishna et al. 2012). Scholars propose that self-disclosure promotes social bonds and alliances, and elicits feedback from others. Practitioners know this to be the case in their work with clients; trust leads to more client self-disclosure and more disclosure promotes connection in relationships and more trust.

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Social workers also share the human tendency to self-disclose. As the literature reveals, social workers continue to grapple with the question of the appropriateness of their self-disclosing to their clients. There is controversy about whether this is helpful, with different opinions about its effectiveness, usually reflecting practitioners’ theoretical models (Gibson 2012). Unfortunately, there is a dearth of useful empirical studies to help clarify the issues and provide data to sort out the different claims made in particular positions. Ethical principles about avoiding dual relationships also guide practitioners’ decisions about self-disclosure. Regardless of whether or not social workers intentionally self-disclose, clients can easily seek information about the worker using the Internet. A study of psychology trainees’ use of social networking sites to post personal information found that 81  percent of the sample participants used such sites. Most used security measures to limit access to personal information, but a significant portion—21  percent—did not (Lehavot, Barnett, and Powers 2010). If clients wish to find information about a practitioner, it is now far easier to do so than it used to be. Social workers have to be thoughtful about the nature of the material they post through the Internet and social media sites, and recognize the potential impact such information may have on their professional work. Gibson (2012) observes that practitioners need to make decisions about whether and how to engage with social networking, online advertising, or even publication. What might once have been unlikely to catch clients’ attention, such as journal contribution or even a charitable donation, can now be retrieved within a matter of seconds. Practitioners should proceed from the assumption that their clients know far more about them than they have ever intentionally disclosed, and that clients may then choose to broadcast further information online. New conversations may be required, and therapists may need to actively manage their online profiles. (294)

There are other ways social workers reveal information about themselves, such as by the way they dress, whether they wear a wedding ring, the pictures and decorations they place in their offices, and so on. Self-disclosures arising out of spontaneous and unconscious processes are likely to happen and the earlier extensive discussions about self-awareness can assist workers in this regard. Ethical principles about appropriate professional standards and behavior apply. For example, it is not appropriate for social workers to

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share their personal fantasies or social, sexual, or financial circumstances (Reamer 2001). When a practitioner feels a desire to share a private incident or personal feelings with a particular client, he should examine his motivation and what client material has triggered this impulse. What is the goal of the disclosure? Would the client value the social worker’s self-disclosure in relation to the issue under discussion? Does the worker believe that it will convey empathy, increase the bond, or motivate the client to take a course of action? Does it arise from an attempt to highlight similarities between the worker and client or to lessen a power differential? Is it likely to achieve the goal of lessening a power differential? Reflecting on these dynamics may illuminate motivations that are more personal and related to the worker’s emotional or relational needs and are incidental to the client’s case. For example, a young female social worker confronted with an older depressed male in an outpatient psychiatric day program reacted with irritation to the client’s boastfulness about his family’s high status. She disclosed to the client that her parents also lived in the same neighborhood and belonged to the same religious and social organizations. Although this disclosure may have been cloaked in the guise of promoting similarity, further reflection revealed that it stemmed from her perception that the client was elevating himself above the largely lower middle-class staff. It was not helpful to the client, however, who responded to her disclosure with concerns about the confidentiality of their sessions. The worker’s reflection revealed her understanding that the client felt shamed about his depression and experienced a palpable blow to his self-esteem. His statements about his background were attempts to bolster his shaky sense of self and convey to the staff that he was “more than a psych patient.” Traditional psychoanalytic and psychodynamic approaches viewed self-disclosure as reflecting social worker countertransference. Rather than share personal information about themselves or respond to clients’ requests for information about their personal lives, practitioners explored the client’s motivation for asking a particular question. For example, if the practitioner stated that the next regular session would be cancelled as he would be away and the client asked where the worker was going, rather than immediately provide that information the worker would explore the client’s thoughts and feelings about the worker’s absence. The focus would remain on the client’s reactions, which might reveal his concern about a growing

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dependency on the worker or a fear that the worker was interviewing for a job in another city and would abandon him. The rationale for avoiding a factual response to the question was that it might close the topic or divert attention from the important issue, the client’s reaction to the worker’s absence, to a superficial discussion of vacation plans. In contrast, in clientcentered and humanistic approaches self-disclosure was considered an aspect of authenticity and essential to demonstrating genuineness and positive regard (Wells 1994). Similarly, feminist theorists use self-disclosure to equalize the power differential between the client and the worker (Henretty and Levitt 2010), and to transmit feminist values and foster a sense of solidarity (Mahalik, Van Ormer, and Simi 2000). Clinical social work theorists drawing on self-psychology have proposed that self-disclosure can promote empathic attunement and responsiveness when used in a thoughtful and intentional way to strengthen the relationship bond (Goldstein 1994; Palombo 1987). Self-disclosure is categorized in at least three ways. Practitioners share information with clients that they believe fosters participation and collaboration. Hence, social workers might spontaneously, or in response to a client’s query, share factual information such as the school they graduated from, how long they have been with the agency, their marital status, whether they have children, and where they were born and grew up as children. A second type of self-disclosure occurs when the worker shares thoughts, feelings, or reactions when in a situation similar to that of the client. For example, a client is undergoing medical investigation for cancer and the worker has had such an experience in the past. In discussions of the client’s situation, the worker discloses aspects of her own thoughts, feelings, and reactions as she dealt with the medical system; with friends, relatives, and coworkers; and with her own anxieties and fears. A final type of self-disclosure relates to the worker’s more personal response to a client’s story. For example, a client who has been assaulted in a deserted subway tells the worker that she is now afraid to go on the subway alone. The worker responds that she would have the same reaction as the client—that the client’s fears are emotionally understandable to the worker. Recall the earlier discussion of diversity and the importance of striving to understand the client’s experiences when they are very different from those of the social worker. In an attempt to work across differences, social workers may use self-disclosure to demonstrate similarity with the hope of

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creating an emotional bond and connection or to provide role modeling. The worker’s sharing of his own experiences of difficulty may enhance the client’s confidence that even though they are different, there may be enough common experiences to promote joint understanding. For example, an African American male social worker in his late thirties has been working with a Native American woman in her midtwenties through her employee assistance program. She has received a promotion as a section head and presents with feelings of general anxiety. The client was raised on a reserve not far from the medium-sized urban center where she attended university, excelled in her management and business courses, and later found employment in a large financial institution. As the worker came to learn about the client’s family and community history, he observed that, similar to himself, this client was now operating in an environment in which she was a minority and felt pressured to demonstrate her capabilities, especially since being recognized for her achievements and receiving a promotion. The worker had experienced similar feelings through his graduate education as he was aware of the high expectations he placed on himself and that his family reinforced. Through success at his work and by developing greater understanding of the interplay between historical factors regarding marginalization and oppression and his own personal and family history and experience, he came to feel comfortable with himself and his accomplishments. During his work with this client, he introduced his personal narrative over time, in relation to the issues and feelings raised by the client. The client later reflected that hearing about the worker’s similar struggles was inspirational and gave her much hope. Self-disclosures that are not well thought out, however, can have a negative effect on the therapeutic relationship. In the interests of leveling a power differential with a thirty-five-year-old immigrant male from Sri Lanka, a twenty-five-year-old female student in a government sponsored vocational retraining program discussed difficulties adjusting to life in a new country and the downward employment mobility the client was experiencing. The student shared her experience moving from the western part of the country to a large eastern city for university education and how disorienting it had been for her. The client was deeply offended by this disclosure, feeling that it trivialized his experience. He forcefully told the student that she had no idea what it was like to be a visible minority in a country in which white people made decisions about who gets jobs and who gets into

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government programs. He elaborated that even though he spoke English perfectly, locally born people reacted to “his accent” and often stated that they could not understand him. This client viewed the student’s attempts to draw similarities between them as simplistic. He believed that the privileges she held by virtue of her upbringing and skin color limited adequate empathy from his perspective of his struggle with the disadvantages and barriers he faced daily. When considering using self-disclosure, practitioners can also consider the client’s expectations. For example, if the client, by virtue of age, culture, or class expects the worker to adopt a formal posture, then self-disclosure may be ineffective in forging an effective working relationship and may undermine the credibility the worker needs to establish. On the other hand, when clients are unfamiliar with social and health ser vices, the social worker’s disclosure of information that the client is requesting or might benefit from demonstrates respect and can provide useful data about the social worker’s educational background, what the worker’s role consists of, and how she might be of help. As noted above, the worker’s comments about similarities between worker and client can in some instances interfere with bonding. If the worker has had some meaningful interactions with the client’s culture, however, through personal associations or living in the client’s country of origin, this may assist in building a working relationship. As practitioners learn about and come to know their clients over time, they can better anticipate the potential effect of self-disclosing comments. Timing remains a central factor in achieving an optimal equilibrium in the practitioner-client dyad. Gibson (2012) draws on the metaphor of achieving the “fine balance” introduced by Rasmussen and Mishna (2008) in their discussion of instructor self-disclosure when teaching about social work practice. A balance suggests not revealing too much while also not withholding all information about oneself. It is worth considering whether and under what conditions selfdisclosure in face-to-face interaction in an interview may be helpful. The guiding principle in much of the literature in social work and related helping professions gives primacy to the potential usefulness of the practitioner’s self-disclosure to the client and the importance of its intentionality. Practitioners can assess, to some degree, the impact of an intervention by observing how the client responds to it; this is also true with self-disclosure (Hill and Knox 2002). Client responses may be immediate or may have an

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impact on the work over a longer period of time. The client may think about the content of the social worker’s self-disclosure after the interview, which in turn may influence the way the client is processing the issue under consideration. The client may value the fact that the worker shared information with her, which enhances bonding in the relationship. The following reflective guidelines are useful to evaluate the impact of the social worker’s self-disclosure on the client (Murphy and Dillon 2003). Consider how the client made sense of the information, any feelings he had about it, and whether it affected the working relationship. Also consider whether the self-disclosure achieved the desired effect, whether the worker should discuss directly with the client her reaction to the disclosure, and whether it was useful. In summary, self-disclosures may serve to enhance the relationship bond, normalize or validate client reactions, and provide alternative ways of thinking or behaving in difficult situations. The guiding principle for their use is that the practitioner believes that the information will assist the client. Therefore, social workers need to examine their own motivation for sharing personal information and whether it arises from their own personal need or from a legitimate assessment of its potential usefulness to the client. The practitioner should also consider whether the information will burden the client and lead him to avoid sharing certain types of information with the worker in the future, as well as whether it will confuse the client about the boundaries in the working relationship and the focus of the meetings. For example, a female social worker shared personal information about having been sexually harassed at her workplace, a situation similar to the one the client was facing. She revealed that she struggled with the situation on her own and was very fearful to take action. Finally, she explained that she had filed a formal complaint at her work setting that produced a positive outcome for her. The client became confused with this revelation. Was the worker suggesting that the client do the same? Would she think less of the client if she did not follow through? Why was the worker telling the client such personal information? Did she want to become her friend? For another client, however, such a revelation was extremely helpful because it made her feel that she was not alone and that others, including the social worker, whom she respects, have dealt with similar situations successfully. In this case, the client felt supported by this self-disclosure and empowered to act.

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Reamer (2001, 2003) has written extensively on ethics in social work practice and noted that too much self-disclosure can inadvertently stimulate boundary crossing. These dynamics are examined in the following section on ethics and the working relationship. e t h i c s a n d t h e s o c i a l w o r k r e l at i o n s h i p

The overriding characteristic of ethical professional practice is that the working relationship with the client is carried out exclusively for the purpose of addressing the client’s needs, not the worker’s needs. The following practices assist in maintaining this focus: a structure is set for interviews, including their frequency; the meeting takes place in a formal setting; a focus is agreed on; and procedures are used that other professionals would agree reflect contemporary ethical and practice principles. Contacts that take place outside of the formal setting are consistent with practice in the agency and follow procedures and guidelines. For example, social workers in outpatient mental health settings, child welfare intake, and community care for the elderly regularly meet clients in their homes. Many agencies expect practitioners to file a schedule of their visits with the office. These visits are consistent with patterns of ser vice delivery in the setting and do not cross a boundary into a friendship relationship. In some situations, the client will offer a beverage as a welcoming gesture and it is appropriate to accept this. Social workers may also meet with clients in informal settings. For example, a social worker has accompanied an upset adolescent to a meeting with the principal at her high school to discuss an alternative plan to expelling the student for truancy. After the meeting, the social worker might meet with the adolescent to debrief its outcome in a nearby coffee shop. Social workers in medical settings may take a family member to the cafeteria to meet following an upsetting experience with a terminally ill relative. Although these interviews are held in informal settings, their purpose is to assist clients with their immediate emotional needs in a setting that is convenient and also affords enough confidentiality. Regardless of setting, it is useful to bear in mind Murphy and Dillon’s (2003) statement: “The clinical relationship, while friendly in tone, is to be maintained as a working one, not as a friendship and not as a prelude to a friendship. Sexual contact between clients and clinicians is strictly prohibited” (248).

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Boundary-crossing issues can occur when practitioners face potential conflicts of interest stemming from dual or multiple relationships. Social workers’ relationships with clients are based on their roles as helping professionals. Practitioners have a fiduciary relationship to their clients. Fiduciary relationships emanate from the trust that clients must place in professionals because of professional specialized knowledge and the unequal power in the relationship. Dual relationships arise when social workers also assume a second role with clients, such as friend, employer, teacher, business associate, family member, or sex partner (Kagle and Giebelhausen 1994). While some issues of boundary crossing are very clear, others are not. Reamer (2001) defines boundary violations as follows: “A boundary violation occurs when a practitioner engages in a dual relationship with a client or colleague that is exploitative, manipulative, deceptive, or coercive” (5). They arise from the worker’s personal emotional needs and manifests itself in many ways, such as forming friendships with clients, engaging in personal self-disclosure with clients, affectionate communication with clients, and seeking out clients through community groups and activities. Examples of such violations are sexual involvement with current clients, gaining client acceptance for fraudulent billing for reimbursement of ser vices, or influencing clients to provide them with expensive gifts or include the social worker in their will. These situations put the social worker in a conflict of interest between two roles: the worker’s duty to serve the best interests of the client is compromised by his aim to serve his own interest in a sexual or business relationship. Similarly, Brown (1994), writing from a feminist perspective, points out that boundary violations include situations in which “the client becomes an object for the satisfaction of certain needs and desires on the part of the therapist” (33)—needs for sexual gratification, for entertainment, for information, or for a source of intimacy. When the practitioner’s needs take precedence over the client’s and the worker behaves in an impulsive and self-centered manner, there is greater risk of distorting what can be considered helpful to the client. Engaging in personal relationships after therapy has ended is also problematic since the two parties do not enter as equals. The previous hierarchical nature of the relationship casts a shadow over the present, and former clients can more easily be exploited. Furthermore, while the client may gain a friend, he loses a counselor as he can no longer return for ser vice should the need arise. The code of ethics of professional associations such

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as the National Association of Social Workers (NASW), the Canadian Association of Social Workers, and the American Association of Marital and Family Therapists specifically prohibit dual relationships and situations in which practitioners are in a conflict of interest that compromises their ability to serve the best interests of their clients. In a study of NASW code violations over ten years, Strom-Gottfried (2000) found that boundary violations account for as much as 56 percent of all ethical complaints. Reamer (2001) comments that self-disclosure can become problematic when “sharing personal details may be a way to set this process [boundary crossings] in motion” (110). Self-disclosures arising out of the practitioner’s unmet emotional and relational needs or excessive self-disclosure may convey the worker’s wish for a personal relationship with the client. Personal sharing in such circumstances is clearly inappropriate. There are, however, circumstances similar to the example of the counselor in the employee assistance program presented earlier in which “practitioners may self-disclose for more altruistic purposes, deliberately and judiciously choosing to share personal details—usually modest in scope—in an effort to empathize with clients, offer clients support, align with clients, and provide a constructive role model that clients may use in their efforts to address their own issues” (Reamer 2001, 166). Reamer concludes that when it is unclear whose interests are being served, the ethical principle that guides self-disclosure is “that it is done for the client’s benefit within the context of the therapeutic process” (112). Ethical issues are analyzed in a thoughtful paper by Ringel and Mishna (2007), who argue that students need opportunities in practice classes to openly ponder ethical dilemmas they encounter with clients in their field practicum. Since ethical guidelines are frequently presented in prescriptive terms, they observe that it is difficult for students to talk about situations in which they were troubled or confused, or in fact bent the rules. Drawing from student case examples, they discuss ethics related to three situations: gift giving and receiving (when to accept, what types of gifts to accept), flexibility or formality in the treatment frame (whether to meet clients outside the office), and continuing to see clients after termination (especially when termination occurs when the student’s practicum ends rather than when the client’s needs have been met). Ringel and Mishna (2007) offer useful practice guidelines to assist practitioners in thinking through appropriate responses to these ethical dilemmas about boundary issues. With respect to

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the first issue, gift giving and receiving, students and practitioners are advised to consider the following: what role self-awareness or countertransference factors are playing; the stage of treatment and the symbolic meaning of the gift (for example, a modest gift at termination has a different meaning than a lavish gift during a difficult middle stage); the client’s cultural background and values whereby a small token at particular times is conventional and would be considered impolite if rejected; gender considerations such that a gift from a male client to a female worker may be considered a seductive gesture; and the personal meaning of the gift for the client. With regard to the second issue, flexibility and formality in the treatment frame, Ringel and Mishna (2007) advocate opportunities for discussion and reflection in academic classes, with field instructors, and, ultimately, in consultation with seasoned professionals, to explore the particular challenges and potential gains or difficulties if one agrees to or declines a client’s request for extra treatment meetings such as going for lunch, taking a walk together, or attending a graduation, wedding, or family celebration. Ethical issues related to termination will be discussed subsequently in the chapter on termination. u s i n g i n f o r m at i o n a n d c o m m u n i c at i o n t e c h n o l o g i e s ( i c t ) i n fa c e - t o - fa c e p r a c t i c e

Contemporary society involves the pervasive use of information and communication technologies (ICTs) in all aspects of life, and as a result, the social work literature, agencies, professional organizations, and practitioners are actively examining its potentially helpful use. In addition, ICT communications can place both clients and social workers in difficult situations, and hence it is important to learn about their benefits and risks when considering how to productively use them as an adjunct to face-toface practice. There are a number of ways clients can gain access to psychosocial information, counseling ser vices, and self-help programs through the Internet and social media sites. The focus in this discussion is on the use of ICTs when the work together is primarily face-to-face. In two linked studies, Mishna and colleagues (Mishna, Bogo, and Root 2014; Mishna et al. 2012) studied social workers’ experiences, yielding some potential practice guidelines. In the first study, data was collected in 2009 and 2010 prior to the

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huge growth in the use of handheld devices. Practitioners in the study reported that they were caught off guard when clients initiated contact with them using e-mail and frequently found themselves responding to messages sent at all times of the day and night. From analysis of numerous examples from the participating practitioners, the researchers concluded that the use of ICTs had “crept” into clinical practice (Mishna et al. 2012). The social workers recognized that using ICT for administrative scheduling was useful and now a part of the new reality of practice. In other words, they could not adhere to a policy of no cyber communication. Other benefits included easier access to ser vices for clients with mobility or hearing challenges. The participants also provided examples of instances in which ICT communication further solidified the benefits of the working relationship between sessions. This observation is similar to benefits noted by other researchers; written communications are available for review and reflection (Wright 2002), and provide material to the practitioner so that she can anticipate and provide time to address issues in the next meeting in line with the client’s concerns and goals (Perron et al. 2010). Participating social workers in the Mishna et al. study (2012) were, however, concerned about experiences that started as simple administrative arrangements for scheduling meetings but then led to a slippery slope in which more extensive clinical matters were raised, opening what some called a “Pandora’s box” (281). This might include, for example, parents or children easily gaining access to confidential information meant only for the social worker. Another example would be a couples counseling case in which there was an agreement that all communication with the social worker would be joint and the worker receives information from one member of a couple who did not want this material shared with their partner. Delay in responding to an e-mail or misinterpreting the social worker’s written messages were other examples of experiences that adversely affected the working relationship. These workers felt some degree of pressure to engage in cyber communication, often outside of agency hours. To some extent, this left them feeling burdened and lacking in structured boundaries around their work. Ethical issues regarding confidentiality and lack of boundaries when using ICT in social work practice have been identified in the social work literature (Mattison 2012; Reamer 2013). Although many workers only use secure agency servers, others have used their own personal e-mail or text addresses. Reamer (2013) warns about the lack of confidentiality when net-

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works and devices are not encrypted. In the second study conducted by Mishna, Bogo, and Root (2014), data was collected four years later. The researchers found participating social workers were more aware of the issues surrounding ICT use with clients. They were more knowledgeable about ICT and provided numerous examples that demonstrated their concern with the ways some clients made themselves vulnerable in their use of ICT, especially clients involved with custody and access disputes or with investigations for disability insurance claims. These practitioners felt responsible to include psychoeducation when relevant as part of their work with particular clients. Many spoke to their clients about what is appropriate to put into electronic posts. In both studies and in clinical papers about ICT use in practice, the issue of boundary crossings and violations is a consistent theme (Mattison 2012; Mishna et al. 2012, 2014; Reamer 2013). Mattison (2012) comments on the ways communicating in this medium can result in unclear boundaries, misunderstandings about the nature of the professional relationship, and risks of creating dual relationships. This is due to open-ended accessibility to online communications, response times, and the informal and personal ways messages can be written. To reduce legal liability for the social worker, scholars writing on the topic recommend the use of an informed consent procedure (Mattison 2012; Reamer 2013). In such procedures the practitioner provides information about the risks and benefits of ICT use, including guidelines about appropriate topics for discussion, expected response times, limitations to privacy and confidentiality in the absence of encrypted and secure servers, and the potential for misinterpretation of communications. Social work’s professional associations have worked together internationally under the sponsorship of the Association of Social Work Boards to appoint an international technology task force, led by Professor Fred Reamer, a leader in social work ethics. In 2015, the Model Regulatory Standards for Technology and Social Work Practice were published (Association of Social Work Boards 2015). In addition, four leading social work organizations—the National Association of Social Workers, the Association of Social Work Boards, the Council on Social Work Education, and the Clinical Social Work Association—collaborated over a period of two years in the development of a document that will guide all social workers in their use of technology. The report Standards for Technology in Social

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Work Practice can be accessed at https://www.socialworkers.org/practice /standards/NASWTechnologyStandards.pdf. Social workers should become familiar with this important document that covers key issues regarding this important method of communicating with clients. The Educational Policy and Accreditation Standards of the Council on Social Work Education also recognizes the need for graduates to be competent in using cyber technology in practice, as noted in Competency 1, “Demonstrate Ethical and Professional Behavior”: “Social workers also understand emerging forms of technology and the ethical use of technology in social work practice. . . . Social workers . . . use technology ethically and appropriately to facilitate practice outcomes” (CSWE 2015, 7). r e l at i o n s h i p b u i l d i n g w i t h i n v o l u n ta r y c l i e n t s

Relationship building has been discussed thus far with regard to clients who initiate contact with a social worker or who accept a referral and have some interest in seeking help from a professional. Social workers also practice with clients who have been ordered by a court or pressured by another person to seek professional help. Social workers in the criminal justice system, child protection, and mental health ser vices frequently work with clients who were ordered to attend a specific intervention program or seek counseling to avoid a jail sentence, to gain access to their children, or to leave a mental hospital and live in the community. Interventions can include, for example, anger management groups for violent and abusive men, group and individual programs for alcoholism and drug addiction, regular individual counseling about work adjustment and social relationships, parenting skills for young parents whose children have been apprehended, and rehabilitation programs for people living in sheltered housing. Many other clients are not mandated by courts to seek social work ser vices but have been urged to do so at the behest of others. Some examples of such cases are children and adolescents who are referred by a teacher as a result of aggressive behavior in a class or when the teacher has observed some signs of internal distress; employees who are referred because of their absenteeism, depression, or suspected alcoholism; partners who believe that counseling will help them with mood or behavior issues in an intimate relationship; and friends and family who are concerned about an individual’s behavior that they deem self-destructive.

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Being told by an institution, an employer, a friend, or family member that one is deficient in some way and needs professional help is generally experienced as an attack on self-esteem and self-determination. Individuals will have a range of emotional reactions such as anger, depression, and confusion, and often feel victimized, demoralized, and demeaned. It is a challenge for practitioners to offer the qualities necessary for an effective working relationship discussed in the previous chapters in the face of the client’s anger, hostility, or defensiveness. In such circumstances, social workers need to simultaneously understand and balance two dimensions: first, how the client experiences and understands his situation and the reasons he is seeing the worker, and second, the nature of the client’s behavior and how it is a threat to others (Rooney 2002). A nonjudgmental stance can be achieved by striving to understand the person in his context. In the face of the client’s anger and rejection of the worker and the ser vice she is trying to offer, professionals can become defensive and characterize clients in negative and pejorative ways, sometimes labeling them as “unmotivated” or “resistant.” Practitioners’ assumptions, judgments, and worldviews may be revealed in these immediate emotional and behavioral reactions to clients who are not cooperative. It is preferable that practitioners adopt the stance recommended by Ivanoff, Blythe, and Tripodi (1994) that social workers reflect on and examine their personal views and how they are manifest in their work with these clients. When court-ordered clients differ from social workers with respect to socioeconomic class, race, and ethnicity, past experiences may be further exacerbated by the power of larger systems, such as the criminal justice system. Past experiences include clients’ reactions to instances of oppression and lack of empowerment and workers’ experiences of privilege and power. Structural and systemic discrimination can severely interfere with the worker’s ability to be client centered and humanistic in practice. These reflections are consistent with the earlier discussion of holistic competence and the need for workers’ consistent attention to the ways their cognitive and affective processes operate in both tacit and explicit ways that influence their practice. Social workers practicing in the field of child welfare note the challenge of developing a helping relationship with parents who have been found to abuse or neglect their vulnerable children (Yatchmenoff 2005). In a study of the perceptions of both child welfare workers and clients, Drake (1994) found that although workers recognized the importance of positive working

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relationships and were knowledgeable about their various components, they were not consistently able to offer the necessary conditions to build them. This observation was echoed by many clients who reported experiences with workers whom they found to be disrespectful, judgmental, and demeaning. There are, however, studies that have identified the qualities in mandated worker–client dyads that were seen positively. De Boer and Coady (2007) conducted a creative study of six worker–client dyads in a child protection agency in Ontario, Canada, in which both participants independently agreed that even though there had been “hostility, distrust and avoidance” (34), there had also been “mutual liking, respect, collaboration”—key elements that researchers identified as necessary for building an effective working relationship. It is important to note that these relationships had experienced periods of conflict and difficulty, but it was still possible for the social worker and client to develop and maintain a positive alliance. Through numerous in-depth research interviews, two dimensions emerged as key to the promotion of effective relationships with these mandated clients; first, the practitioner’s judicious use of power, and second, the practitioner’s humanistic attitude. The first dimension, a “soft, mindful and judicious use of power” (35), is more than a set of techniques; rather, it is a particular approach that includes awareness of one’s own power and the expectation that clients would have reason to be fearful, defensive, and angry as they entered into counseling. Adoption of this stance accords with a finding from a study conducted in British Columbia, Canada, by Oliver and Charles (2015a) that investigated how 225 child protection workers applied a strengths-based solution-focused approach in the worker–client relationship in the face of their statutory responsibilities. A successful approach that was described by only a few workers involved “navigating a shifting balance of collaboration and authority in worker–client relationships based on transparency, impartial judgement, attentiveness to the worker–client interaction, and the value that clients were fellow human beings” (1009). The last quality, recognizing the humanity of clients, echoes deBoer and Coady’s (2007) second dimension, a humanistic attitude. Demonstrating a humanistic attitude entailed interacting with the client in an authentic and friendly way, and as discussed above, thoughtfully using self-disclosure in the interests of developing an effective connection. Similarly, Drake (1994) and Ribner and Knei-Paz (2002) found that clients valued social workers who were informal and would “go the extra mile.” Other researchers have noted that social

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workers were somewhat uncomfortable discussing the ways they felt they stretched “traditional professional ways-of-being” (deBoer and Coady 2007, 35). It can be daunting for new social workers to learn how to balance their responsibility for child safety and the associated professional authority while also showing compassion for adult clients who have been found to have abused or neglected children. Managing the tension inherent in this dilemma has been described as “enacting firm, fair and friendly practice” (Oliver and Charles 2015a, 1009). Recall the key components of the therapeutic alliance discussed earlier: the emotional bond, agreement on goals, and agreement on tasks. Examining these factors when practicing with clients mandated for ser vice reveals the necessity of adapting practice principles to enhance the potency of these components. With respect to creating an emotional bond, some social work scholars have argued that because of the social control aspect of mandated ser vices it is unrealistic to expect clients to engage in a typical collaborative and generally positive helping relationship. Rather than aiming for a relationship of trust or openness, they recommend establishing a practical working relationship (Cingolani 1984; Slonim-Nevo 1996). Experienced practitioners are less pessimistic, however. For example, Borash (2002), reflecting on twenty-five years of working with court-ordered clients, recommends offering empathy regarding the client’s initial reluctance and hostility as a way to engage and develop a bond. Instead of attempting to deal with denial and other defenses directly, in this approach the practitioner offers comments such as “It must be hard being forced into a program that you don’t think you need” (21) and “It sure makes sense to me that you wouldn’t take kindly to being forced into a group and that, if you really thought that others were trying to change you, you would resist” (22). These sorts of comments begin to mirror and validate the client’s experience and feelings. They slowly build some degree of safety that allows involuntary clients to risk letting down their guard enough to share some of the vulnerability and pain underlying the presenting problems and behaviors. The bond has also been shown to be of crucial importance in a study by Knei-Paz (2009) of distressed clients (including cases in which there were child protection concerns) receiving counseling at social ser vice agencies who reported that trust in and a feeling of closeness with the practitioner led to significant relief from the stress of being ordered to attend sessions and reported positive changes in problematic family relations.

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Regarding achieving agreement on goals, social workers need to acknowledge the fact that initially it is not likely that this will be easily achievable with involuntary clients. The client is attending counseling sessions because someone else has identified the presenting problem and ordered or coerced him to attend. The client’s goal may be to find a way to avoid continuing, or she may agree that there is a problem, but may not agree that it is the one for which she was referred. For example, an employee referred to the company employee assistance program for absenteeism and counseling about alcohol consumption agrees that absenteeism is a problem but attributes it to stress from an increased workload and a demanding supervisor rather than excessive alcohol use. In such cases, there needs to be some period of discussion between the social worker and client during which the client has the chance to reflect on the question of goals, to weigh the pros and cons of change, and to consider whether it is in his own interest to participate in the counseling. Such a discussion may result in a hesitant realization that there is some overlap between the client’s desires and the ser vice goals. For example, a male client was ordered by the court to attend an anger management group because of his violent abuse of his spouse. He was able to eventually identify that he wanted less acrimony in his marriage and that if he could learn something in the program that would help him and his wife, then perhaps the group could be useful. The research on working with involuntary clients reveals that when clients acknowledge that changes are in their own best interest, the gains made are consolidated more so than when they are made to comply with the demands of external agencies or to attain rewards (Ribner and Knei-Paz 2002; Rooney 1992). The third factor in the alliance concept directs practitioners to work toward achieving agreement on tasks. With court-ordered clients, however, there are likely to be many tasks that are not negotiable. The literature recommends that the social worker clarify from the outset her dual role within the system that has mandated the intervention (Behroozi 1992; Ivanoff, Blythe, and Tripodi 1994; Regehr and Antle 1997; Rooney 1992). The following should be described: the expectations of the program or ser vice; the role of the social worker, including her authority and under what circumstances that authority will be exercised; what is expected of the client; time lines and potential consequences; the worker’s reporting responsibilities; and limits to confidentiality. Drawing on extensive practice experience, Waldman (1999) introduces the work on tasks by reframing counseling as

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“providing a podium for clients to tell their stories, to be heard, as well as a space for conversations that may reveal new behaviors” (507), which can be used in future stressful situations to prevent repeated involvement with police and child protection authorities. Consistent with the alliance concept with voluntary clients, in which aspects of the intervention are negotiable, the social worker should strive to involve the involuntary client as fully as possible in discussion and inquire about how he views attending sessions, what he thinks he can gain, what activities make sense to him, and what issues are important to discuss. r e l at i o n s h i p m a i n t e n a n c e a n d t h e d u t y t o r e p o r t

Before leaving the discussion of work with involuntary clients, it is important to consider situations in which social workers must go beyond the limits of confidentiality because of safety issues. For example, when providing a wide range of family-oriented ser vices, social workers may identify suspected child maltreatment, which requires a report to child protection authorities. In such cases, social workers are confronted with the tension created by reporting suspected child abuse while also maintaining a relationship with the family so that they can continue to provide ongoing care and psychosocial support to address conditions contributing to maltreatment (Tufford 2016). Some social workers decide not to report but to continue to work intensively with the family. This puts them at risk for sanctions and criminal and civil liability. Workers who do report are faced with attempting to repair the significant rupture to the working relationship. Despite clients being initially told about the limits of confidentiality with respect to others’ and their own safety, it is not unusual for clients to react with great distress when this situation actually occurs. Tufford (2016) studied over 450 social workers and elicited their practice experience regarding approaches they used when needing to report. They faced a range of client reactions, including anger, defensiveness, blame, and disagreement with the social worker’s interpretation. The working relationship became tenuous as clients expressed feeling suspicious of the worker’s motives, judged, betrayed, and alienated; some clients, on the other hand, expressed relief and understood the reasons for the report. The impact of reporting on the working relationship varied and ranged from withdrawing from seeing the social worker to continuing sessions.

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When clients continued with sessions, there was sometimes loss of trust in the social worker that resulted in a strained and tense working relationship. In other instances, the working relationship was strengthened as the worker was able to offer a clear and honest explanation of the reasons for the report, provided education about the next steps to be expected with respect to the child protection agency, and offered support throughout the process. The worker offered these latter behaviors in an empathic manner that conveyed recognition and validation of the client’s distress. t o wa r d u n d e r s ta n d i n g c h a n g e

Before leaving this book’s first section on conceptual frameworks for practice, it is useful to consider questions about change processes. How does change come about, both naturally and when individuals are working with a professional? What is it that leads clients to feel that professionals have assisted them in changing their situations, attitudes, feelings, and behaviors? Even when change is not possible, what transpires in the helping encounter that leads clients to feel supported through times of great stress or loss? Chapter  1 presented the person-in-environment framework (CSWE 2015) that provides a broad perspective for understanding the interactions between various levels of systems that contribute to a problem and should logically lead to identifying what needs to change (Germain and Gitterman 2008). Since the earliest days of the social work profession, practitioners have developed a number of general practice principles to guide change efforts. These principles reflect ideas derived from humanistic values, beliefs about the human condition, and insights emanating from practice experience. These principles are described in widely used social work texts such as Compton, Galaway, and Cournoyer (2005); Hepworth et al. (2010); and Murphy and Dillon (2015). Representative of practice wisdom are principles such as start where the client is; go at the client’s pace; value the selfdetermination of the client; support growth and development; provide an accepting, nonjudgmental relationship as the basis for helping; recognize that the client is the expert on the client’s life and experiences; partialize the problems presented; and intervene to change social and economic factors in the client’s environment that affect well-being. The common factors approach, discussed in chapter  4, has also contributed to understanding the importance of generic factors such as the client’s resources, the helping

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relationship, hope and expectation, and techniques of particular models (Grencavage and Norcross 1990; Lambert and Barley 2002). Specialized Models

A range of specialized theories and models provide particular explanations of human and social function and dysfunction, which in turn serve as the underlying rationale for a series of change processes. Some of these models are exclusive to social work and others were developed in related human ser vice professions, and social work has incorporated them in professional literature and practice. While there are hundreds of specialized models, Brandell (2011) and Walsh (2013) present a selection of approaches that social workers have embraced. Key theoretical concepts and specialized approaches that have had the greatest impact on practice were referred to in chapter 1 and key themes in the literature are summarized in chapter 3. Specialized approaches provide a particular way of understanding human and social functioning, defining problems or difficulties, and presenting change strategies. Models vary in the degree of empirical support available to support them. They also vary in their specificity about change principles and techniques. Some models provide abstract discussion about principles with the expectation that practitioners will find their own ways to enact these principles and meet clients’ unique needs. Other models provide guidelines and techniques that may be found in treatment manuals. When choosing to learn about and use specialized models, social workers should investigate the specific body of literature to determine the extent to which the context, sample, and methodology of a study warrant confidence in its conclusions and whether the findings can be generalized to the population and situations they confront. There are many ways of achieving positive outcomes and a range of approaches may be used successfully. Although most texts present models as if they are separate and discrete, few practitioners are purists who adhere to only one model. For example, in a national study of a random sample of experienced clinical social workers, respondents reported using an average of eight theoretical formulations in their practice (Timberlake, Sabatino, and Martin 1997). The choice of approach was accounted for by the interplay of the nature of the client’s problem, the targets of intervention, and the time frame available for work.

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Thoughts, Feelings, Be hav ior, and Somatic Sensations

Models also vary in their attention to behavior, cognition, feelings, or somatic sensations. Many models increasingly recognize that these various components are not separate entities but rather operate in a cyclical and interrelated fashion. The helping process is more powerful when all aspects of human experience are taken into account (Hill and O’Brien 2014). In the interests of individualizing practice and finding approaches that make sense to the client, the social worker may emphasize one dimension over another, attempting to find ways to more harmoniously match the particular client’s way of experiencing the world. This principle is not only congruent with the discussion of practice in the context of diversity and difference but is also important for collaborative relational-based work. Per sis tence and Change

Direct social work practitioners appreciate that individuals have developed characteristic ways of coping with internal and external forces throughout their lives. They recognize that individuals have a personality style that has evolved over time (Goldstein 1995; Howe 1995). This unique style results from genetic factors and temperamental predispositions; internal schemas based on lived experiences; and familial, cultural, social identity, and community norms and mores. Given social work values of adopting a nonjudgmental stance and a strengths approach, social workers assume that an individual’s emotional, cognitive, and behavioral patterns reflect his best attempts to grow, develop, and meet the challenges of his life. However, styles that may have served a person well in earlier stages of his life may be less useful, or even problematic, during later phases. For example, an individual who has lived in a series of foster homes may have developed a strong sense of independence and self-reliance that helped him deal emotionally with multiple moves. This style may interfere, however, with this individual’s desire for closeness and intimacy in an adult relationship. Social workers believe that individuals have the cognitive capacity to reflect on their own internal emotional dynamics, to develop insight, and to change habitual patterns. Change is affected by internal factors such as motivation, self-esteem, hope and belief, and the ability to self-regulate. External factors also influence change, including opportunities and barriers

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in the individual’s significant interpersonal relationships such as those with intimate partners, nuclear and extended family members, close friends, and peers. Work environments can also exert a potent influence on an individual’s change efforts. For example, becoming more assertive can be rewarded and encouraged by family members, friends, or employers, or can be discouraged or even punished. u n d e r s ta n d i n g c h a n g e f r o m t h e c l i e n t ’s p e r s p e c t i v e

In characterizing client motivation, practitioners often view clients as either motivated or unmotivated. This perspective obscures the fact that embarking on a change process is complex. It is not unusual for people seeking help to have mixed feelings and motivations regarding change. Although an individual’s troublesome behavior and painful situations may cause great distress, the familiar may be more comfortable than the unknown, and as a result, one may conclude that change is not possible or necessary. Change is strange and may involve loss. Many individuals experience fear and despair when they consider change in an interpersonal relationship, even one that causes great difficulty and pain. Skilled practitioners respect the anxiety and ambivalence that people face when confronted with their own self-defeating behaviors. Furthermore, as noted earlier, social workers are often working with clients who are mandated by others for service and may not share the view that they need to change. Understanding the processes that individuals go through as they change thoughts, feelings, and behaviors requires more complex ways of thinking about concepts such as motivation, resistance, and ambivalence. There are many theories of change based on the conceptual propositions of particular models. The transtheoretical model is presented here as it is based on a comparative analysis of over three hundred theories of psychotherapy (Prochaska, Redding, and Evers 2008). For over thirty years, Prochaska and colleagues studied thousands of individuals, some of whom were undergoing therapy and others who were engaged in change on their own (Prochaska, DiClemente, and Norcross 1992; Prochaska and Norcross 2002). Individuals in the studies were dealing with problems such as depression, marital discord, eating disorders, smoking, alcoholism, and compliance with child protection requirements. Regardless of familial and cultural

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Stages of Change

• Precontemplation • Contemplation • Preparation • Action • Maintenance • Termination

background, the problem faced, or whether or not they were receiving professional help, the researchers identified six stages of change through which individuals progressed: precontemplation, contemplation, preparation, action, maintenance, and termination. Understanding an individual client’s stage regarding change can guide practice. Social workers can select appropriate helping processes, practice principles, interventions, and interviewing skills to help the person progress through the par ticu lar stage. The following discussion examines client characteristics of each stage and recommended interventions. Precontemplation

During the precontemplation stage, the individual does not intend to change the problematic behavior in the near future (for example, in the next six months). A number of reasons may account for this position. The individual may lack awareness that a problem exists or may not acknowledge the consequences of his behavior for himself or others. For example, many couples enter couples therapy reporting a long period during which one party has identified a problem and was unable to gain the attention and agreement of the other that a concern was serious enough to warrant professional help. When individuals have tried to change on their own and have not been successful, they may feel defeated about the prospect of another attempt. Another example concerns individuals faced with an addiction who often have tried numerous treatment programs and still find themselves struggling to curtail their use of alcohol, drugs, or tobacco.

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Individuals entering counseling for weight loss also often experience a precontemplation stage. Prochaska (1999) observes that people who go into therapy at this stage often do so because of external pressures, such as from a marital partner who threatens to leave unless the spouse seeks counseling, an employer who makes continued employment contingent on cessation of alcohol consumption, or a court order that requires a previously volatile and threatening father to enter therapy before access to his children will be permitted. Despite attending a first session when the client is in the precontemplation stage, practitioners need to assess the client’s readiness to change before discussing an action plan. Too often practitioners falsely assume that the client’s attendance means that they are ready to embark on using recommended interventions. Direct questions that address the client’s readiness for change inquire about whether the individual thinks that any of his behaviors are a problem and when he intends to change those actions. Hubble, Duncan, and Miller (1999) recommend “creating a climate in the interview where the client can consider, explore, and appreciate the benefits of changing” (430). Practitioners should offer observations and interpretations that gently raise awareness of difficulties as an appropriate intervention at this stage (Lebow 2002). The social worker can help the client become aware of the factors impinging on the problem and both the potential positive and potential negative consequences of change. It is not productive at this stage to provide a lot of information about possible interventions since the client is not ready to absorb it. A reasonable outcome of this stage occurs when the individual begins, albeit in a hesitant manner, to consider and express that perhaps change may be desirable. Based on a meta-analysis of studies, it was estimated that 40  percent of individuals studied were in this precontemplation stage, 40 percent were in the stage of contemplation, and only 20  percent were ready to take action (Norcross, Krebs, and Prochaska 2011). Contemplation

During the contemplation stage, individuals state that they intend to change within the next six months. At this point, people are more aware of the positives of changing, but they are also conscious of the drawbacks, the efforts, and energy required. Ambivalence is characteristic here and “yes,

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but” (Hubble, Duncan, and Miller 1999, 414) is a frequent response. During this stage, clients frequently move back and forth in thinking about and planning to take some action. Practitioners need to be patient and support the client as she considers the pros and cons of making a change. For example, practitioners who work with women living in abusive and destructive relationships are aware of the enormous emotional, social, and financial costs, as well as the potential benefits, to women who separate from abusive partners. They understand that many women will need a protracted period of time in which to consider whether leaving or staying in the relationship is best for them. A patient and supportive stance may be difficult for the social worker to maintain in settings that are limited to providing short-term contacts. When practitioners pressure the client to prematurely undertake an action plan, however, there is likely to be little follow-through on action steps, or a rupture in the alliance occurs and the client drops out and stops attending sessions. Prochaska (1999) recommends setting realistic goals such as helping individuals move out of a “stuck place” (252). This can be accomplished by exploring the client’s ambivalent feelings, the positives and negatives associated with changing, and fears and catastrophic expectations. Practitioners can offer a “space and place” where, through reflection and discussion, individuals sort out conflicting and competing motivations, wishes, and concerns. Preparation

During the preparation stage, the individual intends to take some action, usually within the next month. Small changes in behavior and thinking may be reported, along with some sporadic change efforts. Applying the stage model to working with families in which there has been child abuse and neglect, Prochaska and Prochaska (2002) give examples such as parents in this stage stating: “I have questions for my caseworker about taking care of my kids” . . . “If I don’t change, I will never be the kind of parent my children need” (380). In comparison, when in the precontemplation stage, these parents denied they had any responsibility for the presence of the child welfare authorities in their lives and resented their intrusion. During the contemplation phase, these parents began to acknowledge they had a problem and needed to work on it.

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If in the preparation phase, the developing plan includes seeking professional help then the individual is now likely to be amenable to short-term intervention. It is at this point that the individual can be seen as a client or consumer of ser vice. The practitioner can utilize the principles of preliminary joint planning, discussed in greater detail in the next chapter, to involve and engage the client. Some activities are identifying general and specific goals, and determining the focus for change—the individual, the environment, or both. A crucial aspect of building a helping relationship at this point is reaching agreement about the tasks and expectations of both the social worker and client. Client ambivalence is still a feature during this stage, and it is helpful for practitioners to point out the client’s strengths and previous successful change efforts. Consistent with a collaborative approach, clients can be actively involved in choosing strategies by examining alternatives and considering their potential impact. Action

During the action phase, the client is committed to change and is focused on taking action to alter his behavior, his environment, or the relationship between the two to modify the problematic issues. Action-oriented intervention models that specify tasks for the client to achieve are useful during this stage. (Processes and tasks of the middle stages are discussed in detail in chapter 9.) As observed earlier, change is difficult and can stir up ambivalent feelings in the client. Therefore, this phase can be challenging and requires persistence and tenacity on the part of the client, and support and encouragement from the practitioner. Stage theories are presented in a linear fashion for purposes of explication. To better reflect actual experience, stages are conceived of as a spiral with movement forward and backward (Prochaska and Prochaska 2002). The colloquial expression “two steps forward and one step backward” captures this phenomenon. Since fluctuation and uneven progress is a common feature of change efforts, it is useful when practitioners normalize this experience even before it occurs. When individuals experience difficulty maintaining progress, they may feel a range of emotions from anger, to embarrassment, to guilt, and may become demoralized and lose hope. An understanding and sustaining professional relationship remains crucial at this point.

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Maintenance

During the maintenance stage, the focus is on consolidating gains and building on strengths and successes. Meetings with the practitioner are less frequent and a longer time span between sessions helps the client evaluate whether new behaviors and attitudes are easily maintained in everyday life or whether particular strategies need to be further developed. In the interests of building the client’s capacity to deal with future issues independently when counseling is terminated, this phase also includes developing relapse prevention approaches. For example, the practitioner can help the client to anticipate what he can do differently in the future when experiencing environmental, social, health, or emotional pressures and distress. Termination

During the termination stage, individuals no longer have any thought of engaging in the problem behavior that was the initial focus of change. They feel enough confidence that the changes that have been made are permanent and will not reoccur even when confronted with environmental and personal stressors. From his studies, Prochaska (1999) found that only 20  percent of individuals who formerly abused alcohol or smoked had arrived at this stage. He suggests that for many people, the stage of maintenance may be more realistic. In the maintenance stage, there is a continuous awareness of threats to retaining new adaptations and a conscious attempt to use new thoughts, behaviors, and supports to maintain these changes. Practice Princi ples Based on Stages of Change

An understanding of the stages of change from the client’s perspective provides insights into an impor tant dynamic that can affect outcome. Many models provide principles and techniques directly aimed at changing presenting and underlying problems. Less explicit attention has been given to underlying, implicit, and potent dynamics about how the client perceives the need to change and the experience of trying, failing, and attempting to try again. Prochaska’s work illuminates these dynamics and provides invaluable guidelines for practice. The following text box summa-

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Practice Princi ples

• Assess and determine the client’s stage of change by asking whether he or she thinks a par ticular behavior is a problem and when he or she intends to change it.

• Offer a stance that accords with the client’s stage. Prochaska’s finding that the vast majority of clients entering intervention programs are not yet ready to engage in the action stage is compelling. Therefore, when clients are in the precontemplation or contemplation phase, expend considerable time reflecting with them on the issues, and the costs and benefits of change for them. A reflective stance that aims to understand the situation from the client’s perspective is one that proceeds at the client’s pace.

• Set the stage for change by helping clients pro gress through each stage, rather than prematurely working on action strategies from the outset. Set realistic goals for each stage. Acknowledge that breaking out of the “stuck phase” of precontemplation is a worthwhile goal in itself.

• Expect mixed feelings about change and anticipate that issues will need to be repeatedly examined with the client in a patient manner.

• Use awareness and consciousness- raising pro cesses for the early stages and change pro cesses for the action phase. Assuming clients are ready for action and premature use of be hav ior change approaches often results in a mismatch that leads to the client dropping out of counseling.

• Define the pro cess of change as one that moves forward and back through stages, help clients understand this phenomenon, and plan for ways to minimize loss of pro gress and associated feelings of discouragement.

• Use a wide range of change pro cesses to achieve goals.

rizes practice principles suggested by Prochaska and Prochaska (2002) and Norcross, Krebs, and Prochaska (2011). Currently, in most social work and mental health settings, the amount of time available for the client and practitioner to work together is dependent on the funding formula as expressed in agency policy. This contextual variable presents the most difficult challenge for practitioners, as most models have been conceptualized as if the client’s needs and pace were the major determinant of the duration of the intervention—not the administrative

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agreements dictated by funders. Change generally does not happen quickly. Usually it is slow, with small steps taken over time. To conclude this section, we note that key concepts that inform contemporary social work practice have been discussed in earlier chapters as well as in this chapter. Individuals’ lives are intricately linked to their social context, including their social and physical environments. Individuals are diverse along many personal and social identity characteristics including age, gender, sexual orientation, ethnicity, ability, and so forth. Privilege and disadvantage are related to social dimensions such as race, class, and gender, and influence individuals’ access to power or experiences of oppression. The professional relationship provides the crucial context for change and it is through a collaborative partnership with clients that help is offered and used. A strengths perspective empowers clients through the use of interventions to address not only presenting issues but also to build clients’ capacities to deal with future issues. A number of special issues impinge on social workers’ ability to enact holistic competence. These issues relate to many dimensions of workers’ behavior and characteristics, such as the way they understand their cognitive and affective processes or use the self in their practice, how they communicate in the age of the Internet, how professional ethics are enacted, and their ability to find the most effective and useful processes to meet the unique needs of each client. The client, however, accounts for the lion’s share of what can be achieved; her view of the problem, her perception of the social worker, her stage of change, and her personal and social circumstances, barriers, and resources have a crucial bearing on the therapeutic outcome. With a belief in the human potential for growth and change, social workers and their clients can work together to achieve the goals they have set.

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2

The Helping Process in Social Work Practice

8

Beginnings

are stages in the helping process was originally articulated in the social work literature before the empirical findings about change, presented in the last chapter, had made an impact on social workers. The empirical work of Prochaska and colleagues (Prochaska and Norcross 2002) provides support for the stages and their associated processes and tasks, and increase our confidence in social work’s repertoire of helping procedures. Across most practice models, the helping process is conceived of as one that is systematic and proceeds through stages (also referred to as phases). That is, the interaction between the social worker and client is not haphazard or random; it is intentional and purposeful. The worker provides focus and direction to achieve the goals that the worker and client establish jointly. As noted earlier, structure, focus, and a plan contribute to positive outcomes for clients (Mohl 1995). Definitions and tasks of each stage vary according to specific models. However, social work practice texts generally group phases and tasks into preparatory, initial, middle, and end stages (Compton, Galaway, and Cournoyer 2005; Hepworth et al. 2010). EPAS also addresses the concept of phases in presenting competencies 6 through 9 (CSWE 2015). Competency 6 presents the dimensions of engagement that have been discussed at length in chapters  4 through 7 and is continued in the discussion of relevant processes that will be presented in this chapter. Competency 7 presents the dimensions of assessment that will be discussed in chapter 9. Competency 8 presents the dimensions of intervention that will be discussed in chapters 10 and 11. Competency 9 presents the dimensions of evaluation that will be included in chapter 12. t h e n o t i o n t h at t h e r e

s tages i n the h e lpi n g pr o c e ss a n d a ssoc i at e d ta s k s

Beginning stage:

• Preparatory stage 

Preparing the setting



Preparing the social worker

• Initial stage 

Engaging the client  Discussing confidentiality  Establishing that a ser vice is requested  Relationship building  Information gathering by helping clients tell their story  Integrating a diversity perspective

• Toward developing shared understanding: Assessment and formulation  Gathering relevant data  Analyzing the data: Toward formulation  Preliminary joint goal setting and planning Middle stage:

• Ongoing support and case management • Pro cesses for bringing about change 

Developing an expanded understanding



Working in depth to link emotion, cognition, and be hav ior



Identifying strengths and addressing obstacles



Developing new perspectives



Taking action

• Attending to pro cess: Maintaining the working relationship • Attending to content: Monitoring and supporting goal achievement Endings:

• Review progress • Consolidate gains • Plan for next steps • Process the emotional bond

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All professional encounters are organized around a purpose and tasks. At the same time, and usually through the same behaviors, the social worker and client relate to each other interpersonally. The term process has frequently been used in this text. Recall that in discussing the working relationship in chapter 4, process is used to refer “to a sequence of interactions that takes place between the client and the social worker over a period of time. More specifically, it refers to the way the two relate to each other as they discuss the situation that brought the client to the social worker. It also refers to the way they relate to each other as they approach their task of working together. This includes the verbal and nonverbal, the overt and covert, or underlying meanings of messages that may be inferred or observed from the way each person is behaving.” All inferences are only educated guesses or hypotheses that ultimately can only be verified if examined and discussed. The two themes, building and sustaining a collaborative relationship and working on tasks or content are interwoven, each affecting the other in a progressive and reciprocal manner. For example, as the client develops increasing confidence in the social worker’s ideas and ability to help, he may become more open about expressing underlying fears and vulnerabilities. With the worker’s support and encouragement, the client may also become more able to try behaviors he previously experienced as too threatening. Conversely, if the client deems the discussion in the sessions as irrelevant to his concerns, he may view the worker as not really listening or understanding, and hence not interested in him. Competent practitioners pay close attention to both themes throughout all stages. The themes are artificially separated for the purpose of presentation here. In practice, they both proceed at the same time. Particular concepts inform each stage and the tasks, activities, and processes chosen reflect the practitioner’s thoughts about what is necessary at specific times to bring about change. In discussing how social workers use professional knowledge in chapter 3, the activity of linkage was introduced. Linkage refers to the way social workers identify and label knowledge that can potentially explain the practice situation and provide directions for intervention. For example, using concepts and practice principles about building a working relationship in the early stage of practice, the social worker will listen attentively to the client, trying to convey empathy and gain an initial understanding of what is being said, seeking the client’s response to the worker’s hunches and exploring what the client expects from

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the social worker. With an understanding of stages of change, the social worker will try to determine what stage the client is in before moving on to joint planning and action strategies. Since the task of the early stage is developing understandings of the practice situation, various theories of human behavior and the social environment may be used interchangeably to develop potential ways of addressing the following questions: What is the issue, what is the nature of the client’s situation, and why is there a problem at this time? During the middle phase, when the emphasis is on active helping and change, practice principles and models that offer change strategies are more likely to be used in linkage to provide direction for the practitioner’s next responses. Different skill sets are needed at different stages in the process. For example, during the early phase the social worker may use more reflective listening, questions, clarification, and validation. During the middle phase, skills such as exploring meanings and feelings in depth, normalizing experiences, providing support and validation, and challenging assumptions and beliefs may be more prevalent. The tasks of each stage provide focus for the work. Through differential use of interviewing skills, practitioners maintain this focus. Although this discussion might suggest that there is an orderly progression through the stages of change, in fact the helping process is more accurately viewed as iterative, that is, activities are generally not fully accomplished at one time. Instead, they are repeated through subsequent discussions, yielding increased understanding as issues are explored in greater depth. For example, information gathering and arriving at shared understandings of the issues is characteristic of the early stage of the work. As the client comes to know the social worker better and develops some trust in the safety and support offered in the relationship, however, the client is more likely to confide in the worker and share important information that was initially withheld. This new information may change the way intervention proceeds. Furthermore, through in-depth exploration, which is characteristic of the middle phase, new insights may emerge that will affect the earlier agreements about the goals and the direction of the work. It is useful, then, to view the stages as overlapping, spiraling or cycling back and forth. The stages of change framework can provide structure, focus, and guidelines; at the same time, it is important to remember that the helping process is fluid and flexible.

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t h e b e g i n n i n g s ta g e

The beginning phase sets the stage for the subsequent work and is seen as important because first encounters have a significant impact on the client’s decision about whether to continue to seek agency ser vices. The aim of the beginning stage is to develop a working relationship with the client and enough shared understanding or an agreed-on assessment that some shortand long-terms goals can be established and preliminary planning can occur. To achieve these aims, the worker strives to provide a comfortable and welcoming environment so that the client can begin to share the salient aspects of the situation that he is confronting. The worker and client will jointly examine that situation in light of the agency’s ser vice capabilities to determine whether there is a good enough fit to meet the client’s needs. By engaging in these activities, the client will experience what the setting provides and become familiar with how the worker proceeds, thus gaining a sense of how the helping process works. p r e pa r at o r y s ta g e

Given the importance of beginnings, social workers should spend some time thinking about and preparing for the first meeting with each new client. A number of factors impinge on the first interview, and it is worthwhile to review those aspects that can be planned for in advance. The following discussion reviews these factors, which are summarized in the text box. Presession preparation continues throughout each stage as the social worker reflects on, evaluates, and links her specific hypotheses and questions about a particular client to concepts, intervention models, and practice research that may help her to better understand and work with this client. As discussed in chapter 3, the integration of theory and practice loop provides an organizing framework for reviewing each session and preparing for the focus of the following interview. p r e pa r i n g t h e s e t t i n g A Welcoming Agency

The client’s early experience of the helping process occurs on the telephone at intake and when he comes to the agency for a first appointment. Social

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preparatory s tage • Preparing the setting 

A welcoming agency



Creating a private space



Minimizing distractions and interruptions



Being mindful of clients’ cultural norms



Anticipating linguistic needs



Considering safety issues

• Preparing the social worker 

Examining pertinent information



Reflecting on one’s own thoughts and feelings

workers should be aware of the clients’ experiences when they telephone for ser vice. What is the reception they receive—are they able to speak to an employee or do they encounter a recorded message? Are appointments provided quickly or is there a long wait? If the agency has a Web site, is it easily accessible and does it clearly convey important information? What messages are given in the waiting room? Is the reading material only in English or is it offered in other languages for clients who may not speak English? Do the pictures on the wall reflect the population served by the setting? Is the waiting room well maintained and welcoming, or is it in need of a fresh coat of paint and new, comfortable furniture? These physical attributes of the setting convey powerful messages about respect for the people who are requesting ser vice. If necessary, social workers can bring about changes in the organization to improve intake procedures and the physical aspects of the setting that will more positively affect client experiences. Creating a Private Space

Ideally, the worker and client meet in a setting that is comfortable, private, and conveys an atmosphere of calm. A calm, quiet environment helps create a space in which a client can share important matters, engage in a dialogue, experience and share hitherto avoided emotions, and reflect on important issues. In fact, many social work interviews occur in settings

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that are not private, quiet, or free from distractions. For example, social workers meet with clients in their homes, in a corridor in an institutional setting, in a kitchen in a foster home, in a cafeteria, or in an open space in a community center. Regardless of the setting, the practitioner should try to approximate the features of a contained and private space. If the social worker meets the client in an office, ideally it has good lighting and ventilation, a moderate temperature, and comfortable furniture. A private and sound-proofed office provides confidentiality. The area has enough space to accommodate all the participants in the interview without anyone being cramped or having their personal space invaded. The room is large enough to accommodate wheelchairs or walkers. Furniture is arranged to emphasize collaboration; desks are not barriers or symbols of power, nor are workers seated in chairs that are greater in height than those of the client. In some settings, offices are shared and the worker must arrange in advance for a private interview room for the session. Offering a beverage to clients can enhance a welcoming atmosphere. When social workers find themselves in settings other than an office, they will try to arrange for the setting to provide some privacy. In informal community settings, the worker may meet the client in a cafeteria or a lounge. Although such a setting may be comfortable, there is a lack of privacy and there may be frequent interruptions. A table in a corner can provide some degree of contained space. Social workers in hospitals often meet with clients and their families in a hospital room where there are other patients. Curtains can be used to section off rooms, but voices can still be heard between the sections. Many patients are ambulatory or can be assisted in a wheelchair or walker to move to a more private area. The social worker will make arrangements in advance with the ward staff so that he is prepared and not searching for assistance at the time of the interview. Minimizing Distractions and Interruptions

Active listening and attending closely to what the client is saying are impor tant interviewing skills. To maintain focus and concentration, it is useful to aim to minimize distractions and interruptions. Many social workers turn off the telephone during an interview or do not answer the telephone when it rings. If an extremely important call is expected and must be received, it is respectful to tell the client about that at the start of

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the meeting. Electronic devices have become a feature of modern-day life and it is not unusual for clients and social workers to carry handheld devices with them and overtly or surreptitiously regularly glance at them, or even read incoming texts or e-mails. Clearly, this is inappropriate behavior on the part of the social worker. It is also distracting for both the client and worker if the client regularly engages in this practice. It is therefore useful at the beginning of the session to provide the rationale to the client for putting away their devices. Unless the client is expecting an important message or call, this request conveys that the full attention of both participants is an important feature of the working relationship. When on a home visit, a television is distracting; social workers can request that it be turned off or that the meeting take place in a quieter room. It is important to explain that this request is being made so that there will be few distractions from hearing and understanding the issues under discussion. When there are young children present in the home, it is likely that the client’s attention will be divided between speaking to the social worker and attending to the children. Depending on the nature of the ser vice the agency offers, child care arrangements at the office or in the home will free the client up to be fully involved in the interview. This is a more useful alternative than trying to maintain focus while caring for the children. Being Mindful of Clients’ Cultural Norms

A range of norms governs the way an individual deems it appropriate to interact with professionals. Behaviors also differ depending on whether the interview is conducted in an office environment or on a home visit. For example, sitting in a face-to-face posture where direct eye contact is maintained is not uniformly comfortable. When receiving visitors into one’s home, there are different customs about appropriate dress, whether shoes are worn or removed at the entrance, and whether food is offered and accepted. In an interview in a home, the social worker is a guest and does not have the degree of control she has in her own office. Workers need to be open to clients’ customs, which may be different from their own. Awareness and understanding of their own comfort and discomfort levels about a range of behaviors is important. Practitioners strive to balance showing respect for clients while attending to their own comfort levels. For example, if a client has prepared a beverage for the worker that the worker does not want to drink for the

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worker’s own personal or health reasons, she can tactfully thank the client and if appropriate also briefly explain the reason for her refusal. Anticipating Linguistic Needs

Social workers are generally aware of the characteristics of the population they serve and whether interpretation from English will be needed. To provide equitable access to needed ser vices, trained interpreters are needed. In advance of meeting a new client, the worker should know what the language needs may be and arrange for an appropriate interpreter. Often in crisis or emergency situations a family member or staff member who speaks the client’s language is enlisted as an informal interpreter. This arrangement is far from ideal; the client may censor the information shared or the interpreter may not accurately convey the client’s intended meanings. Interpretation for human ser vice interactions is challenging as nuances may be lost. Interpreters need to be trained to understand their role as a valuable conduit between the client and the practitioner and must be committed to conveying the client’s intended communications, not their understanding of what the client has said. In other words, it can be challenging for interpreters to simply translate directly what the client has said and they may be tempted, consciously or not, to insert their construal of the client’s situation and needs. On the other hand, they need to assist the practitioner to appreciate the nuances, context, beliefs, and values reflected in clients’ narratives that are perhaps not explicitly stated. Verbal and nonverbal communications need to be expressed. Interpreters must agree to maintain confidentiality with respect to the information they access and clients should also be informed that the interpreter is present in a professional capacity. Especially where there are small communities of those who share linguistic and cultural backgrounds, ethical standards about the professional role and relationship of the interpreter need to be clarified and understood by all participants (Hepworth et al. 2010). The introduction of a third party into the interaction between the client and social worker will change the pace of the session dramatically, as all communications must be translated and some statements will require even further elaboration to be understood. Patience, training of interpreters, and some acquaintance on the part of the social worker with the client’s country of origin are helpful features. When using an interpreter, the worker should

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plan for a longer session and be cognizant of how much can realistically be covered. Priority should be given to conveying important information such as results from psychological testing, details about a medical procedure, or standards about child-rearing practices (Murphy and Dillon 2003). Considering Safety Issues

The interview space and location should be structured to provide safety for the social worker and the client. Agencies have procedures that ensure that workers and their clients are not at risk if they meet in offices after usual business hours, or when entering and leaving the building. When working with clients with a history of violence, the worker should ensure that others are present in the setting. If the worker is concerned about the potential for violence, she may wish to sit close to the office door or conduct the interview with an open door. Social workers can find themselves meeting clients for interviews in locations that pose a safety risk. Examples of this are parks and restaurants in high-crime neighborhoods. While a client’s apartment may be safe, elevators and corridors in some high-rise buildings are not. Social workers may find themselves vacillating between appropriately minimizing risks and being overly cautious. Decisions about safety should be addressed with colleagues and supervisors. Agencies have safety and risk management policies, protocols, and guidelines that personnel can use in determining what are safe and unsafe situations, and when a worker should be accompanied by a colleague during an interview rather than attending alone. p r e pa r i n g t h e s o c i a l w o r k e r Examining Pertinent Information

There is controversy about how much information helping professionals should have before their first meeting with the client. On the one hand, there may be a wealth of useful information available that could assist the practitioner in facilitating engagement with the client and providing effective ser vice. On the other hand, the existing information may be incorrect or biased, thus leading the worker to an inaccurate perception of the individual and his situation. Social workers employed in organizations are expected to review existing information in the agency records from the intake worker and referring agents and from any other relevant source, such as family or community

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members. In preparing for the first meeting with the client, rather than making premature judgments based on this information, the worker should maintain an open mind and critical skepticism about how the information was gathered and in what context, and what alternative meanings it may have. For example, clients who challenge the nature of a ser vice offered may be labeled as hostile or resistant when in fact the client may have taken the initiative to point out gaps in ser vice and advocate for his own needs. When clients have already given information to intake workers, they expect that the social worker will have that data and they may not want to repeat it again. When the client is required by law to see the social worker or there is a referral from a team member, the social worker will need to find out whether the client has this information. Even when the client has been told about the reasons for referral, it is important to hear from him what his understanding is of those reasons. If the client does not have the referral information, the social worker needs to prepare for how she will share it with the client. Two guidelines are useful: first, the client will benefit from a succinct summary of what is already known, and second, the social worker should make it clear that she is interested in hearing the client’s perspective on the issue. For example, a client in a maternity ward was referred to the social worker because the nurses observed that the client and her boyfriend argued loudly on all their visits. The social worker introduced herself and said that the nurses had requested she visit the client. She conveyed the nurses’ concern about the client, especially regarding the tension they observed when her boyfriend visited. The social worker wanted to know how the client felt it was going for herself as a new mother and whether she had a concern about her relationship with her boyfriend. In health and mental health settings, interprofessional teamwork is increasingly emphasized as a way to improve patient care and achieve positive outcomes. Social workers in such teams are expected to communicate in a collaborative manner with other professionals, and hence would be expected to gain the perspectives of team members with respect to their reasons for referral. This information may be shared in regular team meetings, in informal interchanges on the ser vice, or through notes in the chart. Social workers think about the information they have about the client before the first meeting, regardless of how minimal or extensive it is. They try to begin to get a sense of what the individual may be feeling in relation to the situation and to seeking help from a professional. Preparatory empathy through “tuning in” has been discussed by Shulman (2016) and refers to the

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process of trying to get in touch, on an emotional level, with the possible feelings and concerns of the perspective client. As discussed in the chapters on the working relationship, when the social worker demonstrates empathy he draws on universal dimensions of the human condition. In this respect, empathy enables the practitioner to try to feel as another feels and anticipate possible reactions to a challenging situation. The limitation of the concept lies in the recognition that the affective and cognitive meaning of events is not only individual but also informed by a range of cultural and social identity factors. Differences in a range of characteristics such as age, class, ethnicity, gender, sexual orientation, ability, and so forth, may make it unlikely that one can fully identify with another who is significantly different from oneself. When social workers recognize these limits of empathy, however, while they can try to bridge the emotional space between the worker and client, they recognize any hunches about how clients may be thinking and feeling as purely tentative. When the worker offers empathic comments, it is the client’s reaction that can lead to a mutual dialogue that will assist the worker to better understand the client’s subjective experience. Empathy can be useful when it increases understanding and compassion; it is not useful if it leads to premature assumptions, judgments, and closure. Social workers who specialize in practice with a particular population or problem begin to discern a general range of reactions to particular situations based on research or on their experiences. For example, social workers who work with couples in which one partner has discovered that the other has been having an emotional and sexual relationship outside of the couple relationship may find that the betrayed partner usually reports experiencing great emotional pain that includes feeling enormous hurt and anger. Betrayed partners often find themselves ruminating about details of the affair, have difficulty sleeping and eating, and may experience depression. Indeed, theorists and researchers have noted the presence of behaviors similar to post-traumatic stress in betrayed partners ( Johnson, Makinen, and Millikin 2001). Knowing that these behaviors are likely and typical, the social worker can link this information to a cognitive type of preparatory empathy. That is, she may anticipate that the client will experience some or all of the reactions reported in the literature. When the practitioner actually meets the client, her tentative expectation may be confirmed or disconfirmed. She may find that the client describes her experience of these reactions, or

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that the client refers to some of them in an indirect way, or that these reactions are not present. There may be other reactions that were not anticipated. Used flexibly, this type of knowledge can provide a guide, a point for connection, and a direction for exploration. If used inflexibly, however, the social worker is likely to ignore or minimize the client’s unique reactions, which can interfere with the alliance building that is so crucial during this initial stage. Reflecting on One’s Own Thoughts and Feelings

Just as the social worker tunes into the client, he also tunes into himself. In the discussion of holistic competence in chapter 2, it was highlighted that social work practice is affected by practitioners’ emotional reactions to information from and interactions with clients, reactions that may be operating at various levels of awareness. And in turn, these responses affect practitioners’ critical thinking, judgment, and decision making regarding clients and their situations. Throughout this text, the importance of selfawareness has been underscored. Social workers need to be attentive to their own self-states and aware of triggers that can lead to feeling off balance in practice. Since social workers need to be calm, centered, and grounded when performing practice roles, emotional self-regulation has been identified in a number of studies as being central to achieving this stance (Bogo et al. 2013; Bogo, Regehr, et al. 2017). In chapter 3, strategies for practitioners to raise consciousness about their internal states (including physical sensations in the body, specific emotions, and states of mind) (Katz, personal communication, 2016) that can help them reduce anxiety and associated negative emotions were suggested such as mindfulness and deep breathing. Each social worker develops her own set of self-care methods to provide a strong foundation for this more focused attention. In anticipation of meeting the client, it is useful to have a sense of whether there are any particular issues presented by the client that have a special meaning for the social worker. As a preliminary step, thinking about similarities and differences between the client’s and the worker’s circumstances can be useful. The necessity of differentiating the worker’s experience from the client’s is underscored, while recognizing that the practitioner’s familiarity with issues provides another resource for relationship building—one that moves from the “inside out.”

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Based on a range of personal factors, the events presented by clients will have a different impact for each practitioner. For example, a young social worker who enjoyed riding a bicycle in an urban setting found her sense of safety challenged when preparing to work with a young male who was left paraplegic as a result of a motorcycle accident. For others who would not find themselves in such a situation, this particular situation would not trigger any sensitive or anxiety producing associations. Some reflection on potential issues can help the social worker sensitize herself to her concerns, anxieties, and internal reactions. This process can help practitioners be mindful of their internal thoughts and feelings, centered in their professional role, and client focused. It is useful to take some time to consider the following: What kinds of client situations will be challenging for the practitioner and what kinds of situations will the practitioner be drawn toward? How might the practitioner handle challenges, concerns, and triggers in both situations? i n i t i a l s ta g e : e n g a g i n g t h e c l i e n t

As noted, beginnings are a crucial part of any interpersonal relationship and encounter with a ser vice program. Impressions are formed in the first contact that can have a lasting effect on the way the client perceives the practitioner and the ser vice setting, and will determine whether or not the client will continue to work with the practitioner. In light of the common factors, some objectives of this phase are to develop enough understanding that the practitioner and client can formulate a preliminary joint assessment and determine some preliminary goals and tasks. As noted throughout the discussion of relationship and alliance dynamics, cultivation of a positive rapport, or the beginning of an affective bond, is crucial. With these objectives in mind, the practitioner works on two levels simultaneously, that of the process and that of the task. Process refers to all the ways the client and social worker interact with each other and the task refers to the content and substance of the work, which in turn is related to the goals. Previously, the point was made that these two aspects are interwoven and build on each other. For example, it is important to understand what the client wants to achieve in coming to the agency—the goals. This information may be gathered by the client’s direct response to the worker’s question, it may emerge in the discussion, or the client may not be able to answer the question directly. In the latter case, the client may not be able

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the i ni ti al s tag e • Engaging the client 

Discussing confidentiality



Establishing that a ser vice is requested



Relationship building



Information gathering by helping clients tell their story



Integrating a diversity perspective

• Toward developing shared understanding/an assessment 

Gathering relevant data



Analyzing the data: Toward formulation



Preliminary joint goal setting and planning

to put her goals into specific terms; she may simply be feeling upset and want some emotional relief from a troubling situation. The way the social worker asks for information, responds to the client’s description of her situation and her feelings about it, and how this helps or hinders the client to proceed in the interview constitute elements of the process. This interaction, both the verbal and subtle nonverbal aspects of the process, will be perceived by the client to some degree as helpful or not helpful. In turn, it will affect the client’s ability to gain greater clarity about what she wants to achieve (the goal dimension) and how this helping process will unfold (the task dimension). The various aspects of the initial stage are presented in the text box above. These activities incorporate both the task and process dimension in the helping process. This chapter reviews processes for engaging the client. The following chapter focuses on developing shared understanding so that an assessment of the client and situation emerges. From the first telephone call or face-to-face meeting with the potential client, the worker is concerned about conveying respect, interest, and a commitment to understanding the client’s situation and determining whether the agency can provide a ser vice. This stance is conveyed in verbal and nonverbal ways. Practitioners can use their own natural warmth, friendliness, and a low-key caring and concerned attitude to begin connecting with the person who may become a client. The aim at this point is to clearly communicate the role of the social worker and the purpose for meeting. A warm-up stage can help to put the client at ease and can include some social

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conversation along with a brief introduction of the worker and her role. The degree of formality or informality in these initial interchanges is based on factors such as the nature of the problem, what is appropriate for the age of the client, and whether the meeting is client initiated or court ordered. For example, a different stance is appropriate when initially meeting an individual who is referred for help with a life-threatening illness as compared to a family in which there is disagreement between parents and children about an appropriate curfew. When working with children and adolescents, there may be a preference for the use of first names and some informal discussion about how they reached the setting, what they usually do at this time of the day, and their hobbies or favorite activities. In meeting an elderly client, the worker should be sensitive to their age difference and inquire whether the person prefers to be addressed by their surname. Discussing Confidentiality

The profession’s code of ethics and value base honor the principle of confidentiality. This means that information that the client shares will be held private by the social worker and not shared. This principle enables clients to develop comfort in disclosing sensitive personal material that may reflect poorly on clients or on others in their lives. Therefore, practitioners should only share information with the client’s consent. In a child custody struggle, for example, a client may desire that the social worker convey to the mediator the efforts her client engaged in to ensure that her children were well taken care of after her partner left the home. Practitioners need to convey their commitment to confidentiality when they see their clients in the first meeting. Technology and electronic records have made it imperative that agencies develop secure systems so that client information cannot be accessed by unauthorized individuals. If workers are taking written or electronic notes during the interview, they must ensure that these are stored in safe locations and not removed from the setting. Understandably, clients will be concerned about where these notes are located and who may have access to them. The agency’s policy and systems should briefly be explained to the client in the first session. There are limits to safeguarding confidentiality, however, and these limits should also be made clear to the client in the first meeting. There are circum-

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stances that require the practitioner to disclose confidential client information. Social work students as well as practitioners share client information with their field instructor or supervisor, and when practicing in a team situation, with other professionals. Clients should know of these exceptions to confidentiality. When the practitioner explains this honestly and points out that this is done with the goal of improving client services, clients usually accept and even value this. Consent forms for audio or video recording are also imperative. The best way for students to learn practice, and for practitioners to improve their practice, is through reviewing such recordings (Chow et al. 2015). Hence, it is important to provide this rationale when asking for consent to record and also to convey agency policy about where recordings are stored, for what period of time, and how they are deleted or destroyed. Another exception to disclosure of confidential information occurs when the social worker is concerned that the client presents a danger to self or others. Hepworth et al. (2010) state: “If the client plans to commit kidnapping, injury, or murder, the practitioner is obligated to disclose these intentions to the intended victim and to law enforcement officials so that timely preventive action can be taken” (69). When the social worker is concerned that the client presents a suicide risk, she must intervene. Again, agencies have policies and procedures so that concerned workers can consult with supervisors to obtain a referral for psychiatric assessment. All jurisdictions have laws regarding the responsibility of a range of health and human ser vices professionals to report suspected child abuse or neglect, and this duty is being extended in many locales in the case of elder abuse and abuse of other vulnerable adults. As discussed in the previous chapter, when social workers learn of child abuse in the context of a helping relationship they are faced with the tension of, on the one hand, maintaining a relationship with the family and providing ongoing care and psychosocial support to address conditions contributing to maltreatment, and on the other hand, reporting the family to the authorities. Specialized techniques for addressing this challenge are grounded in clearly explaining the limits of confidentiality in the first meeting and revisiting these parameters in ongoing work (Tufford 2012). Finally, social workers and clients must be aware that in most jurisdictions they are not protected by privileged communication as in the case of clients’ lawyers. Hence, they can be ordered to disclose confidential information and also subpoenaed to appear in a court.

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In many agencies, the client is informed of the setting’s policies and procedures regarding confidentiality during the intake phase. Clients must sign a consent form indicating that they have been apprised of this information and voluntarily agree to meeting within the parameters set out before having access to ser vice and a first meeting with a social worker. Nevertheless, it is useful for the social worker to review the issues pertaining to confidentiality. In the previous chapter, the dynamics of working with clients who are mandated by the criminal justice system to attend a program were presented. Accordingly, at the beginning of the first meeting, the practitioner and client must discuss the mandate explicitly and fully. In some instances, clients do not fully understand why they were referred for counseling. For example, an adolescent girl was ordered by the court to see a counselor after she was charged with shoplifting. The client could not easily understand the link between the two events. For the social worker to engage in an effective working relationship with the client, it was necessary to address two issues: the client’s perceptions and the court order. In this example, it was more useful to first examine the client’s perspective and validate her confusion. Then it was timely for the worker to clearly communicate her understanding of why the court order was made. In this instance, the judge assumed that this usually high-performing adolescent was troubled in some way that became evident in the shoplifting incident and decided that rather than a punishment, a helping process would be more effective. The social worker should also convey what the court order consists of, what is expected of the client, and the consequences of noncompliance. Both the practitioner and the client should be clearly aware of the requirements of reporting to the court, and hence the limits of confidentiality. This situation requires workers to be able to manage the tension inherent in working toward the best interests of the client while also adhering to the expectations of the context in which the ser vice is provided. The more direct and clear the worker is in clarifying these parameters, the more likely he will gain credibility in the client’s eyes. Establishing That a Ser vice Is Requested

As mentioned previously, frequently clients are referred to social workers and social agencies by other professionals or institutions. For example, in

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school settings the teacher usually refers a student and the child’s family, in medical settings members of the team may refer the client to a social worker, and mandated ser vices such as probation and child protection are almost always initiated through a referral. Hence, it is of the utmost importance that the practitioner begin by clarifying the potential client’s understanding of the referral, the nature of the agency, and the ser vice that can be provided. The social worker shares with the client information that she already knows about the client’s situation and discusses the ser vices that the agency and worker can offer. In this way, the principle of collaboration is put into practice early in the helping process. The two participants explore whether the client’s needs and issues can be addressed by the program and the social worker’s role and function. Relationship Building

A central theme throughout this text is the importance of a trusting working relationship as the crucial foundation of the helping process. To briefly review the key characteristics presented in chapters 4 through 7, the social worker aims to offer warmth and caring concern, acceptance, positive regard, respect, and a nonjudgmental attitude. Genuineness, empathy, and a commitment to understanding and working with diversity refer to facilitative attitudes. These conditions improve the likelihood that the practitioner and client will forge an effective alliance based on agreements on goals and tasks, and the client’s sense of emotional bonding with the worker. Specific attitudes, behaviors, and skills include active attending and listening, offering support and validation, communicating developing understanding of the situation, and seeking feedback from clients to learn whether these initial impressions are capturing the client’s experience. Relationship building and maintenance continues over each interview and throughout the therapeutic process. Competent social workers stay attuned to overt and covert indications about the client’s degree of engagement and connection, and the client’s increased understanding of the issues they confront. When ruptures occur in the working relationship, they need to be attended to directly or through some change in what the social worker offers, the way she interacts with the client, the methods used, or the goals that are addressed.

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Information Gathering by Helping Clients Tell Their Story

This text advocates for a working relationship approach that is collaborative as opposed to a hierarchical one in which the expert professional proffers advice. From the beginning, the social worker should invite the client to tell his story in his own words. Competent practitioners listen carefully and help clients elaborate on and explore problems by using open- and close-ended questions, clarifying and asking for more specific details, reflecting thoughts and feelings, paraphrasing, and summarizing. These skills are fully discussed in the final chapter of this text. Individuals can benefit simply by expressing inner concerns to another person. By talking out loud, individuals can experience some sense of relief and somewhat better understanding of what is troublesome to them. This observation is consistent with insights from neuroscience research; just naming uncomfortable and distressing emotions can help people feel calm, especially when done in the context of an attuned, connected, and empathic relationship (Goleman 2006; Siegel 2010). Such a process can then proceed to exploration, developing better understanding of oneself and his situation, and ultimately enable the individual to make choices about how to react and proceed. These dynamics are discussed in greater detail as middle-stage interventions in the next chapters. What is notable in relation to the beginning stage is that the very process of information gathering, when done skillfully, can immediately offer the client some relief, and in so doing, fosters the positive impact of the developing working relationship. There are many ways of gathering information, from highly structured interviews to those that are unstructured. For example, a social worker can administer a checklist or a set of specific questions in an orderly fashion. Or, she can begin in an open-ended way, asking the client, “What has brought you here?” or “Could you tell me about your situation?” As the session proceeds, the social worker asks the client for specific relevant information that has not yet emerged. The social work practice principle of “start where the client is” puts into practice many of the values discussed regarding collaboration and giving the client’s view central focus. This principle gives the client’s agenda or immediate issue top priority. It guides the worker to follow the client’s lead and to respond to what she is introducing. Social workers are continually balancing the issue of when to guide the client to focus in greater depth and when to encourage him to develop

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more breadth. At what point does the worker need to help the client expand her story to obtain a fuller picture of her life and its important contributing factors? To what extent does the dialogue need to proceed into more depth about the client’s thoughts, feelings, motivations, and wishes about a particular matter? Although definitive answers are not available, the following factors can be considered: client interest, urgency of the situation and available time, and agency mandate. Especially at the beginning of the process, prior to the development of a strong working relationship, the topic that the client considers of greatest interest and concern provides a focus for the interview. Urgency and time available for the helping process also play a part. If the situation is a crisis and the individual’s health and safety are at risk, these matters become the focus of attention. When the issue is longstanding, it can be examined at a slower pace. Finally, the agency mandate and role of the social worker frame the issues that will be addressed. Following are two examples that illustrate how these different factors are used in guiding the interviewer’s behavior. The first example takes place in a hospital setting. A single mother has been diagnosed with ovarian cancer and has been told that she will need an operation immediately. She is referred to the social worker as she has stated that it is impossible to leave her two children for this procedure. This dilemma provides the focus for the meeting. The hospital social worker begins discussion by focusing on the mother’s concerns about her children’s reactions to a separation from her and listens to her describe the individual personalities and needs of each child at some length. The social worker responds supportively to the mother’s concerns about her children; however, given the quasi-emergency nature of the illness, the worker tells the client that they will need to change the focus of their discussion. She clarifies that she is involved to help her develop a plan that will take into account both the children’s care and the mother’s medical needs. She asks the client if they can move on to examine whether there are family members, friends, or neighbors that could help her with her children as she attends to this medical problem or whether they will need to explore using community ser vices. The second example takes place in a community-based senior center where the social worker is involved with an elderly widow who inquires whether the worker can give her information about applying for assisted living. This request provides the focus for the meeting. The client explains that she has been self-sufficient and living comfortably in her own apartment

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for many years. Over a harsh winter, she found it more difficult to get out, as her arthritis was exacerbated by the weather, leaving her isolated and somewhat depressed. Currently, she is feeling better but wonders about the future. During the initial interview, the client shows great pleasure when telling the worker about how well she manages living on her own in the community. The worker listens and provides feedback that reflects her understanding that the client is both satisfied with her current arrangement, but also concerned about the future. With a focus on these two themes, the interviewer can balance the interview to include hearing about the present and gaining a fuller picture of strengths, needs, and supports, while clarifying what future issues might arise and what assistance may be needed and available to help this woman continue to live in the community. Integrating a Diversity Perspective

Chapter 5 in this text discusses issues related to Competency 2, “Engage Diversity and Difference in Practice.” That chapter pointed out that individuals’ attitudes, thoughts, feelings, and behaviors reflect their own unique identification with and internalization of aspects of their original culture and the other cultures they reference. Furthermore, this dynamic applies to all participants in the helping process, the social worker, and the client (Dyche and Zayas 1995, 2001). Similar concepts and practices are offered by Ortega and Faller (2011) with the notion of cultural humility, and by Edwards (2016), who proposes cultural intelligence. In common across these viewpoints is the recommendation that the practitioner listen to and learn from the client about factors that will impinge on the helping process, such as (1) relevant aspects of the client’s culture in relation to the way she perceives the presenting problem, her current relationships, and life experiences; (2) internalized cultural expectations about seeking help from a professional; and (3) potential ways of dealing with issues. This is not an intrusive, unstructured attempt to learn about another’s cultural background. Rather, it is an intentional activity aimed at linking cultural information and meanings to the situation that is the focus of the professional meeting. These authors recommend that during the interview practitioners adopt a stance that conveys that the client is the expert about herself and that the social worker needs to understand the client’s views to be helpful. Through a back-and-forth interchange or dialogue, the worker uses skills of active

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listening and exploration, and attempts to convey what has been heard and understood, offers tentative hunches, requests feedback, and continuously offers reformulations and modifications based on the client’s responses and reactions to the worker’s comments. Findings from Clark’s (2003) study of experienced social work practitioners identified by peers as committed to working effectively with clients from diverse backgrounds was discussed in chapter  5. From the first encounter, these social workers demonstrated a collaborative stance and emphasized the importance of honoring and respecting their clients. They saw the challenge not as one of difference but rather as one in which workers lacked information and knowledge. They asked themselves and their clients, “What do I need to know to understand?” They stated that they may not understand what the client tells them and asked the client to work with them to let them know about their mistakes. They used questions such as, “What have I not asked you that is important? What am I getting wrong?” (Clark 2003, 111) In contrast are findings from research conducted by Lee and colleagues who used discourse analysis methodologies to examine exchanges between clients and social workers focusing on culturally relevant content (Lee and Horvath 2014; Lee et al. 2017). Applied to both a one-to-one dialogue and an interview with a family, where there is difference between clients and workers, these analyses illuminate the way social workers’ responses facilitate or limit relationship building and offering culturally effective ser vice. Specifically, this research found instances when the worker actively confirmed the client’s subjective experiences about culturally related material such as being an immigrant and the meaning of family (Lee et al. 2017). Other instances were found when the use of North American views of functioning dismissed the client’s culturally based values. An example is provided of a first session family therapy interview in which the mother discusses her view of the importance for an adolescent to privilege and respect the view of her elders regarding behavior that reflects on the family. The social worker responds by normalizing this adolescent’s noncompliant attitude and behavior as typical of normal development. This latter view is characteristic of a North American perspective of individuals’ needs to differentiate from their family-of-origin. In this instance, the worker privileges her norms and interpretation of adolescent behavior and misses the opportunity to explore in depth the client’s underlying feelings and culturally-based meanings associated with the presenting concern.

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Another important pattern was found in which a generally engaged and responsive practitioner provides minimal responses such as “umh, yeah, right” (Lee and Horvath 2014, 207) with no guidance for exploration or expansion when clients raised culturally based content. Lack of response and attunement will affect the client’s impression of the worker’s understanding and can impede bonding during this early stage of relationship development. There are some specific issues that practitioners need to attend to during the beginning phase when practicing with clients whose country of origin is different from the worker. These issues are the meaning of help seeking from strangers, the way language is used to convey problems, how acculturation manifests itself in the client’s attitudes and behaviors, and the client’s history of oppression. Practitioners need to be attentive to the meanings associated with requesting assistance from strangers and from professionals. Help-seeking behavior and the pathways used to gain help vary across cultures; in some cultures, extended families are expected to solve problems and approaching professional helpers is the last resort. In other cultures, the family doctor or the religious leader is respected and consulted when the family cannot deal with a difficulty on their own. Providing personal information to outsiders may be acceptable only in desperate situations. Problems may be minimized, based on a cultural belief that problems reflect poorly on the family or the community. Others may be reluctant to ask for help directly. The ways problems are identified and described varies across cultures as well. In many cultures, for example, the symptoms of depression are described in physical rather than emotional and social terms. Clients personal experiences are given meaning and transformed into stories which may be expressed in many different ways. Practitioners need to be open-minded and flexible as they gather information and try to make meaning of these client narratives. After reviewing research on crosscultural counseling, Tsang and Bogo (1997) concluded that clients who are not acculturated to Euro-North American cultures may present problems to professionals in ways that are unfamiliar to the practitioner. The practitioner will need to listen carefully and inquire at length to better understand the client’s experience and the meanings they attribute to the presenting problem. As noted earlier, behaviors with professionals and strangers may be influenced by cultural norms that are unfamiliar to the social worker. The potential client may also be influenced by racist or prejudicial attitudes

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toward her community held by the dominant group and hence may interact with the practitioner in a guarded manner, not spontaneously sharing information until the worker has demonstrated enough genuine interest and respect that the client deems engaging with the worker as potentially worthwhile. Clients who have immigrated from societies vastly different from North America may be living in two worlds simultaneously. Questions aimed at comparing the differences and similarities between those two cultures can be helpful if linked directly to the issues under discussion (Waldman 1999). For example, when child-rearing and discipline practices differ, clients who become involved with child protection authorities often report considerable confusion about the values, norms, and laws in the new community as compared with their country of origin. Social workers can help clients learn about the current expectations and guide them to consider how they can respond to them in a way that prevents further involvement with the authorities while also experiencing continuity with their own culture and life history. Younger clients who have been exposed to global popular culture through the Internet, movies, television, and music may not have the same sense of dislocation or confusion as their older relatives. A multicultural perspective also pays attention to and incorporates an understanding of “invisible wounds of oppression” (Hardy and Laszloffy 2002, 577). The aim is to take into account how structural issues of power, marginalization, and oppression operate in an individual’s internal functioning, in interpersonal relationships, and in the way problems are addressed. Four types of oppression are identified that are important to understand in relation to both the specific presenting problem and behavior with the worker. First, when others have persistently defined an individual’s problems, one can learn to be voiceless or silent and have difficulty advocating for oneself, being self-assertive, or being able to define what one needs. A second feature may be a sense of psychological, social, or community homelessness in which one feels alienated and experiences a sense of not belonging anywhere. Rage and an overwhelming sense of pain is another reaction to pervasive experiences of social injustice. Conversely, societal messages about lack of worth can be internalized as self-hate toward oneself, toward others who represent aspects of self, or toward both. In summary, this chapter introduced the notion of stages in the helping process, demonstrating that there is a structure to the way social workers

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view their work. That said, effective practitioners also demonstrate flexibility and recognize that activities in the beginning stage will be revisited as the work continues. The focus in this chapter has been on preparing for the first interview and engaging the client. Since client engagement is crucial for continuance with the therapeutic work, emphasis has been placed on processes that have been shown to facilitate relationship building. As these crucial activities progress, information about the client and her situation is forthcoming, leading to the practitioner and client developing an expanded joint understanding of the issues, identifying the goals that will provide a focus for the meetings, and arriving at an assessment and formulation. This, in turn, leads to planning and intervention.

9

Toward Developing Shared Understanding: Assessment and Formulation and it is difficult to clearly tell another about one’s challenges, strug gles, and current concerns. Clients often begin with comments such as, “I don’t know where to begin. . . .” It is also a challenge in both social and professional contexts to truly comprehend what another is trying to convey and grasp her intended meaning and perception of her situation. Given these natural tendencies in human experience, how can social workers adopt a position that recognizes the advantages of active listening and empathic understanding as well as the human limits of ever truly knowing another? At least some amount of time is needed to have an appreciation of another’s life. Premature problem solving and advice giving can work against developing an approximation of understanding. Instead, what is recommended is the opportunity for clients to discuss their narrative, issues, and concerns in some depth. Prolonged engagement is more likely to lead to shared understandings and goal setting will more closely reflect the client’s concerns and wishes. This principle is also consistent with the recommendations of Prochaska and colleagues, presented in chapter 7, who have pointed out that individuals may be experiencing a precontemplation stage and therefore not at all ready to engage in goal setting, planning, or taking action for changes in their lives (Prochaska 1999; Prochaska and Norcross 2002). Prematurely introducing an intervention plan is likely to be ineffective or result in the client not returning. Instead, a prolonged period of exploration with the client that focuses on the benefits and costs of change can be more productive. l i f e s i t u at i o n s a r e c o m p l e x

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Although a professional stance respects the fact that our knowledge of another will always be partial, it also recognizes that help can be offered and received, even under these conditions. Practice research has demonstrated that via a working relationship in which there is a sense of hope and an expectation that the work will be useful, positive outcomes are achievable (Duncan et al. 2010; Hubble, Duncan, and Miller 1999). Perhaps it is more accurate to state that the social worker strives for sufficient or enough understanding of the client’s subjective experience, wishes, and goals so that they can begin to work together (Tsang and Bogo 1997). Assessment is a continuous process that unfolds throughout the time that the social worker and client are working together. All assessments are incomplete; hence, the phrase “toward developing shared understanding” is meant to capture the fluid and partial nature of the engagement of the worker and client in a process of clarifying issues and expanding explanations for why a problem exists and what should be done. To provide structure, focus, and direction, most generic and specialized models include a defined stage during which information is collected, examined, and reviewed to answer key questions and provide a direction for goal setting and planning. In chapter 1, in the discussion of the knowledge base, it was noted that social workers use a range of perspectives and concepts to answer the questions, Why does this problem exist? and What needs to change for alleviation of the problem? “Guided by a person-in-environment framework” (CSWE 2015, 5), the profession has a long-standing commitment to understanding the reciprocal impact between the context and individuals’ lives, and to intervening accordingly. To review, an ecosystemic perspective directs attention to understanding these two dimensions when conducting an assessment (Germain and Gitterman 2008). A bio-psychosocial framework complements this perspective and adds depth and richness, integrating the past and present. This perspective also includes attention to the biological, psychological, and social basis of experience and the interrelationships among all three to explain situations related to human behavior and social functioning, specifically to health, well-being, and dysfunction (Berzoff and Drisko 2015; Simpson, Williams, and Segall 2007). Social workers use these perspectives to guide the information they seek and the way they think about assessment. Specialized models offer particular concepts to enable greater focus for our explorations. The following text box presents three activities that are undertaken to arrive at an assessment, goals, and an intervention plan:

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f rom as s es s men t to pla n n i n g • Relevant data is gathered from the client in the interview and from other relevant sources, with the client’s consent.

• Data is analyzed with reference to explanatory concepts, leading to an understanding or formulation made with the client.

• Formulation logically leads to preliminary joint goal setting and planning.

This perspective on assessment is consistent with Competency 7 in EPAS (CSWE 2015), “Assess Individuals, Families, Groups, Organizations, and Communities,” which recognizes that assessment is “ongoing . . . dynamic and interactive” (9), that data is analyzed and critically appraised using “theories of human behavior and the social environment” (9), and that assessment is affected by social workers’ personal, cognitive, and affective reactions. This competency emphasizes collaboration with respect to arriving at goals and selecting interventions based on clients’ values and preferences. A central theme in contemporary practice—identifying strengths, as well as needs and challenges—is again noted in this competency. g at h e r i n g r e l e va n t d ata

The data practitioners gather should ultimately provide them with information to answer the key questions that emanate from their explanatory frameworks about why a problem exists. The following template includes questions that flow from a contemporary understanding of the person-inenvironment or ecosystemic perspective and take societal and cultural experiences of marginalization and oppression into account. The questions also flow from a bio-psychosocial perspective, including social and contextual as well as biological and psychological issues. In addition, information related to key past developmental events that are salient in the present is gained. The questions in the following text box build on questions presented in the earlier edition of this text, with additional questions used by Hepworth et al. (2010). Obviously, all of these issues will not be covered in great detail in a first session. They guide the type of information to ultimately obtain and provide the social worker with a way of thinking about important factors that could be considered. Ideally, this information is gathered following the principle of “start where the client is,” giving priority

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to the way the client tells her story, while balancing the need to collect specific information for agency purposes and to provide an intervention direction. assessment guide Identifying Data

This section includes demographic information that describes relevant client characteristics such as age, gender, sexual orientation, occupation, current employment, socioeconomic status, religion, ethnicity, family status, and health status. Information about the client’s physical environment and living circumstances such as housing and neighborhood is also included. The type of information gathered is based on its relevance to the setting. In a health facility, for example, a medical diagnosis is included, and where there is managed care funding, a psychiatric diagnosis based on the current Diagnostic and Statistical Manual of Mental Disorders (DSM) classification may be required. Presenting Prob lem

This section includes relevant information about the presenting problem and how the client came to the agency. It provides data to answer the following questions: • •

•

•

•

•

•

What is the problem, who is involved, and where does it occur? What precipitated the current difficulty? What thoughts and feelings have been aroused? What is the duration and severity of the problem? Is it pervasive in the client’s life? How has the client coped with the problem? Why is the client coming for help now? Who else is involved in the problem? How are they involved? How do they view the problem, react to it, and contribute to its maintenance or solution? If this is a referral, who is the referral source and what is the reason for referral? Have there been previous agency contacts or is there any relevant history of professional help?

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The Individual

To understand the client’s needs, strengths, and resources, as well as her obstacles and challenges, the following information is useful to collect. The purpose of the work, the time frame available, and the nature of the presenting issue will affect how comprehensive the practitioner’s assessment will be and how much information he will initially gather. •

•

•

• • •

•

•

• •

•

What is the nature of the client’s functioning in the past and currently in key roles, in relation to his developmental stage, to work, or school, and in the context of cultural expectations? Does the client have adequate housing, income, employment, transportation, nutrition, clothing, and recreation? What is the client’s health status? Are there any significant health issues and does she take medication regularly? What is the client’s mental health status? Is there a psychiatric diagnosis? What is the nature of the client’s alcohol or substance use? What is the nature of the individual’s cognitive functioning, judgment, and intellectual and problem-solving capacity? What is the client’s view of reality, attitudes, assumptions, and core beliefs about self and others in the context of his cultural and life experiences? What is the nature of the individual’s emotional expressions about the problem, about significant relationships, and toward the worker? What is the nature of the client’s interpersonal functioning with family members, in intimate relationships, and with friends? Does he seek to understand others’ needs and engage in give-and-take? Is he confident about self and others in relationships? How does the individual cope with stress and deal with conflict? Does the client experience violence or the threat of violence in daily life in his relationships with family, peers, and neighbors? Are there significant life experiences, such as abuse, trauma, forced relocation, refugee status or imprisonment, that currently affect the client?

Environment (also Referred to as Social Situation)

The following information is useful to collect to understand the client’s environment; the expectations it places on the client; the strengths, supports,

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and resources it provides; and the obstacles and challenges it presents. The agency mandate, the time frame available, and the nature of the presenting issue will affect how much information will be sought. • •

•

•

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•

What is the client’s environment like? Who are the key participants (nuclear and extended family, intimate relationships, friends, work colleagues, neighbors) and what are the key systems (community, religious, or spiritual organizations; other social networks; relevant institutions related to health, education, the criminal justice system, and the social ser vice system) in the client’s environment? What is the nature of the client’s relevant and key interpersonal relationships along dimensions such as important dynamics, patterns, alliances, conflict and conflict resolution styles, decision-making patterns, and support? What cultural and societal factors affect the problem and the individual’s experience? What experiences of discrimination and marginalization affect the client and the situation? What have the client’s experiences been like with key societal institutions and ser vice programs? Are needed resources available? If not, what advocacy initiatives are needed? Do agency or program policies facilitate or hinder access to needed programs?

About Change and the Helping Pro cess •

•

•

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• •

What is the client’s explanation of why there is a problem and what are her beliefs about how to bring about change? What does the client think are possible solutions? What are the client’s goals for change? What individual and environmental strengths and resources can be brought to bear on the problem and issues? What individual and environmental obstacles and constraints need to be addressed? What does the client want and expect to gain from the helping process? What does the client expect the worker to do, what does she expect that she will have to do, and what does she expect they will do together to work on the presenting and agreed-on issues?

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p u t t i n g t h e i n f o r m at i o n t o g e t h e r

The worker seeks to understand the needs, problems, challenges, and barriers that the individual is facing as well as the personal and situational resources, strengths, opportunities, and supports available. With regard to the individual, it is important to understand how he responds to stress and to what extent reactions are internal and to what extent they are externally directed. For example, some individuals will adapt to environmental demands and change attitudes, feelings, or behavior when confronted with challenges. Others may feel overwhelmed, experience a flood of negative emotions, and retreat from the situation. And others may focus more on changing their physical, relational, and social environment so that it may more likely meet their needs. An individual’s unique style of coping can make the initial situation better or worse. Stress typically leads to a range of subjective emotional reactions—including anxiety, a desire to fight, or a desire to flee. Based on the situation, some reactions can promote problem solving and well-being, and others can further exacerbate the precipitating issue. For example, when the primary bread winner in a family loses his job, he likely will experience considerable stress. He may react to that stress with anxiety and energy that propels him to work tirelessly on finding another place of employment. Or, he may respond to the stress of the loss with great anxiety and profound feelings of demoralization. If he uses alcohol to manage these feelings to the point that he becomes immobilized, a downward cycle creating more stress begins. The dysfunctional reaction to the initial precipitant becomes a secondary and confounding problem. With regard to the client’s environment, the social worker seeks to learn about the obstacles and potential strengths that exist at micro-, mezzo, and macro levels. The micro level refers to the client’s significant relationships such as with intimate partners, family members, friends in social networks and activities, and people in work settings. The mezzo level refers to the nature of the neighborhood and community, the atmosphere and expectations in the work setting, and the programs and ser vices available through relevant social and health delivery systems. The macro level refers to the significant societal and structural forces that affect the client, such as health, education, or social ser vice programs and policies. Social workers are concerned about the clients’ life histories and whether they have experienced

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racism and marginalization in their interactions in their communities and with significant institutions by virtue of a range of individual diverse social identity characteristics. The social work profession is greatly concerned about the deleterious impact of racist and discriminatory attitudes on individuals and communities and is committed to promoting social justice. This committment calls for these societal contextual factors to be considered and addressed, even when the social worker’s agency role is focused on individual intervention. Social work practice theory embraces a strengths focus in addition to a realistic view of problems and obstacles to enhanced social functioning. This focus leads the social worker to inquire about clients’ past and current achievements and capacities. Cowger (1994) offered some useful guidelines: elicit and give priority to the client’s interpretation of the situation, ask about the client’s goals and expectations, explicitly inquire about personal and interpersonal issues, and environmental strengths and resources. In a study of child protection, social workers Oliver and Charles (2015a) sought to identify the social workers’ perceptions about how and why strengths-based ideas were applied. They found a range of definitions of strengths-based practice that focused on attitudes about the relationship, client self-determination, and the importance of linking internal and external resources. Of interest to this discussion were workers who were committed to consistently find, acknowledge, and build on client strengths, while taking challenges into account, “always seeking the bigger picture with the goal being a broad, balanced, and fair understanding that attended to both risks and strengths” (139). The information gathered in this assessment phase will provide a focus for intervention by separating out environmental and individual issues. The worker and client will consider the following questions in this regard: To what extent does the environment need to be changed to be more supportive and nurturing to the client? To what extent does the client need to change to adapt to environmental demands? To what extent does the client need to try to change external factors and relationships, or leave situations that are emotionally and physically damaging to the client? Given the focus on transactions, systemic interventions that aim to change interaction patterns between clients and significant others in their environment are also included in change efforts. Family therapists have also used an ecological model to assess the various systems that adolescents and their families

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are involved with: families, peers, school, and neighborhood (Nichols 2010). They examine risk factors, protective factors, and strengths to pinpoint where interventions need to be directed. In many presenting situations of child and family problems, family dynamics and interactions are the focus of change and the family is conceived of as the client. Hartman (1978, 1994) described an eco-map to provide a picture of the client and his significant relationships and context. It is a useful tool to ground the person-in-environment/ecosystemic perspective and to help worker and client collaborate when gathering information. Clients can see themselves and the key relationships, systems, pressures, and supports in their lives. The client and social worker draw a map and place the client at the center in a circle. Squares or circles are drawn to represent relationships with partners, family, friends, neighbors, and relevant systems such as neighborhood, work setting, religious organizations, clubs, and so forth. Lines are drawn between the client and each system with symbols to indicate whether the relationship is strong (______), tenuous (- - - - -), or conflictual (+++++). Arrows are used to indicate whether the relationship involves the client giving to the other, the other giving to the client, or both giving to each other. This tool elucidates the client’s world and can be used to explore the sources and nature of nurturance, support, stress, and difficulty. A genogram is another useful tool for collecting data for the assessment (McGoldrick, Gerson, and Petry 2008). It can be used to describe past as well as current family relationships and the culture of the family. Data can be collected and depicted using symbols to represent various members in the family and their relationships. A genogram has the appearance of a family tree or genealogy map. Lines between individuals are drawn to depict relationships such as marriage, children, and informal kinship networks. Originally a square was used to represent a male, and a circle, a female. Current depictions of genograms include symbols to depict gay, lesbian, bi, trans, and two-spirit persons. Diagrams of genograms and related information are readily available on the Internet. If using a genogram to collect information, the social worker and client will jointly produce a graphic representation of the individuals, their connections, and their personalities over the generations. Starting with the present, the client identifies the composition of the current family or kinship network. This helps to establish the nature of those relationships and whether they are a source of strength and support or of stress and difficulty.

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As the discussion unfolds, important information about the past can be gathered in relation to where key family members are living, and moves they have made within the country and from the country of origin. Family therapists developed the genogram to illuminate themes over time, patterns of family behavior, important values and norms, alliances and cutoffs between family members, and affiliations with key religious and ethnic communities (McGoldrick, Gerson, and Petry 2008). When conducting an assessment, it is useful to make a distinction between issues that arise from a crisis, a transitional stage, or from an ongoing situation. Crises and traumatic events can incapacitate individuals who were previously functioning well. Short-term intervention can be effective when aimed at helping the individual regain his previous equilibrium and deal with the impact of the crisis. Stress can arise when trying to cope with the effects of transitions. For example, issues can arise from the demands of new developmental stages and roles such as having a baby or leaving home for work or college. Transitions may also come about due to moving to a new community, city, or region; due to a change of employment; from voluntary immigration to a new country; or from gaining refugee status due to war or other traumatic events. The challenges of some of these transitions may be so great that short-term intervention is insufficient. Interventions may need to be prolonged as individuals are supported to deal with these new circumstances. Ongoing problematic environmental pressures, long-standing difficulty in a significant interpersonal relationship, selfdestructive behavioral patterns, or addictions may also require an extended intervention. How much historical data should a social worker collect? Given the time constraints of most settings, many contemporary models focus on the present and collect historical data when the client or the presenting problem deems it to be relevant. Clients who have chosen or were forced to leave their countries of origin may define current issues in relation to past experiences and make comparisons between what it is like coping in a new country with their earlier life experiences. When clients define problems in current functioning in relation to trauma as a result of having been abused as children or to difficulties they experienced in adolescence, the worker needs to be responsive and listen carefully to what the client chooses to reveal about these past significant events in his life.

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Using Multiple Perspectives to Guide Data Gathering

A study conducted in the late 1990s found that clinical social workers keep, on average, eight conceptual templates in mind as they listen to the client tell her story and link practice phenomena to explanatory frameworks (Timberlake, Sabatino, and Martin 1997). Since that time, the professional knowledge base has expanded even further and practitioners are faced with an ever-growing number of new concepts and research findings about human behavior and the social environment. Using more than one conceptual framework helps the practitioner identify aspects of the client’s situation that are missing from the client’s spontaneous narrative. A popular model used in social work and mental health professions is colloquially referred to as the 4 Ps (Henderson and Martin 2015). In this model, data is collected about biological, psychological, and social dimensions organized into four factors: predisposing, precipitating, perpetuating, and protective. These four factors are seen as impinging on the presenting problem and can be a potential focus in intervention. The biological dimension includes genetic, health and mental health history, and current status. Although social work practice theory has embraced a bio-psychosocial paradigm (Turner 2002), there has been less attention in the field to biological factors. With recent highly relevant research findings from the fields of neuroscience and neurobiology, a greater appreciation of the interrelationships between mind, body, and behavior is imperative for social workers (Shapiro and Applegate 2000). The psychological dimension consists of affective and cognitive components such as an individual’s thoughts and feelings about key relationships in the past and present, ways of handling conflict, his experience of self, and conscious and unconscious motivations. Cognitive factors also include the individual’s judgment, view of reality, worldview, and internal working models or schemas that include attitudes, assumptions, and core beliefs about self and others. Specific psychodynamic or cognitive theories can be used if the practitioner wishes to develop greater depth in understanding any of these factors. It is likely that the client and practitioner will require a longer period of exploration and discussion to learn about and understand these elements. Consistent with social work theorizing, other dimensions important to consider and include are the individual’s or family’s stage of development, and history of trauma or addiction.

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The social dimension consists of systemic factors and social determinants of health, including the nature of the individual’s central interpersonal relationships and networks, such as intimate adult relationships, current nuclear family, family of origin, extended family, friendships and social networks, and school or employment relationships. The many contributions from family systems theory and models provide a wealth of concepts and interventions that are part of most clinical social workers’ knowledge base (Nichols 2010). Structural factors relate to income; access to quality food, education, and health care; employment conditions and job security; availability of safe housing; and experiences with adversity, marginalization, and oppression. This dimension has been well articulated by social work and is part of the discussion throughout this text. Predisposing or risk factors are features that lead to vulnerability and include personal, biological, familial, and community experiences, as well as chronic stressors from any of these sources. Precipitating factors that resulted in help seeking or referral are one or more events that triggered and led to the presenting issue. Perpetuating factors are those that maintain the situation and contribute to the presenting difficulty. They may include unresolved predisposing and precipitating factors as well. Protective factors are those features that social workers would label as strengths, resilience, supports, and resources. Depending on the presenting situation, the orga nizational mandate, and the time available, all or only selected dimensions can be addressed. Specialized models can also be used to develop greater depth in assessing any of the dimensions. Each agency, based on its mandate and particular circumstances, provides assessment formats to guide practitioners in gathering the most relevant data. The assessment format presented in this text is one example of the information that can be collected when working from a stance that integrates the person-in-environment/ecosystemic framework and a bio-psychosocial multiperspective. The guide can also serve to organize the presentation of written information in an agency recording or in a verbal presentation to colleagues and team members. For additional guides, see Jordan and Franklin (2011) for a thorough review of quantitative and qualitative methods of assessment in social work. In most cases, the interview does not rigidly follow any particular guide; rather, the worker helps the client to tell his story, probes for more information in key areas, and over the course of the meeting(s), aims to gather most of the information.

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a n a ly z i n g t h e d ata : t o wa r d f o r m u l at i o n

Analysis takes place in the session with the client as an active participant and is ongoing and cumulative. As the working relationship develops, new information emerges that provides additional insights and a more complex understanding of the client and his situation. Analysis also takes place after the session as the social worker reflects on the interview or discusses it in supervision or consultation In chapter 3, the integration of theory and practice loop was introduced as a vehicle to assist social workers and social work students to reflect on their practice. The loop guides the practitioner to examine subjective reactions and objective facts, to analyze these observations through the lenses of one or more set of concepts, to identify potential goals, and to plan interventions. The aim of the activity is to construct a theory or formulation about the client and her situation. A person-in-environment/ecosystemic and bio-psychosocial approach has framed the discussion of assessment and served as the framework for guiding the social worker in initially seeking specific types of data (presented earlier in this chapter) and in subjecting that data to analysis. The questions on the following page, which are adapted from Goldstein (1995), serve to link the worker’s analysis of the data collected to the concepts associated with these approaches. When issues are the result of external and environmental situations, analysis points to the importance of intervention in those domains. This may involve the worker in advocacy on behalf of the particular client or in policy practice involving coalitions and alliances with other social workers and human ser vice professionals. Such networks would strategize and develop approaches to bring about change in programs, client entitlements, or social and health policy. This perspective is consistent with Competency 5, “Engage in Policy Practice.” In other situations, there may be a lack of information about available resources or a lack of skills in accessing entitlements. Social workers can assist their clients in acquiring these needed and helpful benefits. There are, however, situations in which it becomes apparent that the issue results from the client’s personality style and how the individual functions and copes across situations in his life. Searching for themes and patterns that cross systems can be very useful. For example, asking how

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ques ti ons to gu i d e data a n a ly si s • What are the links between the individual–internal issues, interpersonal issues, and the environmental situation?

• To what extent is the current situation a result of the lack of environmental resources or supports?

• To what extent is the current situation and difficulty a result of stress from current life roles, developmental tasks, situational stress, traumatic events, or experiences of marginalization or discrimination?

• To what extent is the current situation a result of the lack of fit between the client’s needs or aspirations and the client’s environment?

• What strengths, competencies, aspirations, and resources of the client and the environment are pres ent to address the situation?

• What obstacles, challenges, and constraints exist in the client and the environment that will affect efforts to change the situation?

• What are the client’s significant cognitive, emotional, and behavioral responses to issues in his life? How do these factors affect the current problem and the client’s efforts in dealing with the problem?

• To what extent are these thoughts, feelings, and reactions useful in the client’s life and to what extent do they limit or interfere with the client’s achievement of life goals?

• To what extent are significant interpersonal relationships (such as intimate, familial, social, and work- related relationships) and informal networks available and amenable to change so that a better fit between the client’s needs and the social environment can result?

• To what extent are there repetitious interaction patterns between the client and significant others that maintain the problem?

individuals specifically cope with issues in their intimate, family, work, and social networks will provide important information. This information may reveal styles that range from use of denial and distortion, to avoidance, repression, or acting out, to externalizing and blaming others, to excessively accommodating others’ wishes, leaving the individual angry or depleted, to suppression, anticipation, and planning. These styles may be an expression of core dynamic ways individuals learned to cope in childhood that may have served them well during those earlier stages but are not satisfying or

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ques ti ons to gu i d e d e v e lopi n g a for m u lat i o n • What is the key issue or problem from the client’s perspective? From the social worker’s perspective?

• How effectively is the client functioning? • What factors, including thoughts, feelings, be haviors, personality issues, past trauma, stressors, vulnerabilities, needs, and environmental circumstances seem to be contributing to the problem(s)?

• Identify the strengths, sources of meaning, coping ability, and resources that can be mobilized to help the client.

helpful in dealing with the challenges in their current adult life. In the formulation, it is important to define these themes and the repetitive nature of these core dynamics and patterns so that intervention can focus on helping the client recognize and understand these patterns. Such a focus can empower clients to break old patterns and develop more useful and gratifying ways of dealing with the complexities they face and achieving their own goals rather than reacting to others’ wishes. Analysis of information leads to a formulation: the development of a focused, concise, conceptualization of the person-in-environment. It is not a summary of the case but rather a creative synthesis based on the assessment. It must be succinct, and hence social workers will use their professional judgment to highlight the important people, events, and dynamics that contribute to the present situation. Formulations offer a tentative understanding of the central presenting issues and underlying contributing factors, what precipitated or triggered the issue, what predisposing factors led to it, what perpetuates it, and what protective factors or strengths can be marshalled. This 4 P framework is a device to organize reams of data, and if viewed at a higher conceptual level, provides information on which a formulation is constructed. The questions in the text box above, which are based on using person-in-environment/ecosystemic and biopsychosocial frameworks, can guide formulation development. Formulation also involves the social worker in examining and analyzing the information collected and the reactions he had to the client during the interview in light of explanatory concepts. These concepts are derived from formal models as well as from those ideas that constitute the worker’s

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implicit opinions derived from experience. The worker weighs the respective influence of relevant factors and seeks general themes that occur across areas of social functioning and over the life course. A search for connections between factors helps explain the links among the problem, the person, and the situation. The aim is to arrive at a working summary that explains why the client has the particular problem presented, given the client’s biological, psychological, familial, and social circumstances. This explanation should then logically lead to the identification of goals and a preliminary intervention plan. Since the summary only represents what is known at a particular time, it is seen as tentative. preliminary joint goal set ting and pl anning

The preceding activities of gathering information guided by a conceptual framework, reflecting on this information, and developing enough shared understanding with the client will culminate in some form of agreement about the goals to be achieved and how the social worker and client might achieve them. In formulating goals, two key questions are addressed: First, what are the practitioner and client trying to achieve in this work, that is, what outcomes should result from meeting together? Second, with respect to how to do this, the questions are, how will they work together, what are the client expectations about the process, and how will the worker provide input and use his expertise? Throughout this text, the concept of therapeutic alliance, developed by Bordin (1979, 1994) and discussed in chapter 4, establishes the importance of the client and social worker achieving agreement on the general objectives or goals as well as the tasks of the work. Goals serve to provide focus for the meetings; hence, collaboratively developing goals means that the client is actively involved in articulating her vision of what they wish to achieve. This provides direction for the discussions and solidifies the working relationship. This view is consistent with the principle of “starting where the client is” and gives primacy to the client’s choice of the issues to work on. Goal setting should always begin with what the client hoped to achieve in approaching the social worker. Goals are often expressed in vague or general terms, especially in initial meetings, such as “to feel better,” “to be accepted by peers,” or “to better handle the stress in my life as a single parent of two teenagers.” Helping clients express statements such as these in spe-

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cific and concrete terms may make goal setting and achievement more possible. It is useful to ask what would be different as a result of meeting with the social worker: what would the client be thinking, feeling, doing; what would be happening in his life; what would key relationships look like if the client was able to state, “my life is better”? A range of strategies that involve clients have been presented in the literature. One such strategy involves the creation and use of self-anchored scales. Such scales are developed by using the client’s own definitions of various points they may reach in relation to a specific goal. Using the frameworks discussed in this chapter, goals might include bringing about change in the individual, in the environment, or in the interactions between the two. Referring to change in the individual, change can occur with respect to thoughts and meanings, feelings and reactions, and behaviors. For example, a school social worker is working with an adolescent girl who has recently moved to her current high school from another part of the country. She has not covered the same curriculum as that offered in this high school and feels that she is falling behind in some of her subjects. The adolescent explains that she is so preoccupied with her concerns about her lack of friends that she is feeling too depressed to focus on her schoolwork. Previously an excellent student and also popular with peers, she feels lonely, ill at ease in school, and unhappy. The social worker can set up a self-anchored scale to identify and monitor progress toward goal achievement. Using the client’s words, the worker can develop a scale that defines the key goals—in this instance, making friends and improving her grades. Through discussion, the key issues that are affecting the client can be identified and concretized as goals expressed as gradations along a scale. In this example, it becomes apparent that the client is feeling self-conscious and awkward, and hence not reaching out or responding positively when others reach out to her. The client and worker could define points along a scale beginning with her current state as 1—feeling self-conscious and avoiding or not responding to others, 2—containing her anxiety and responding with a smile or interest when others approach her, 3—feeling relaxed and responding positively to others, 4—feeling relaxed and reaching out to others. The plan would involve a range of interventions to help this adolescent reach her goal of making friends, such as any of the following: individual sessions to examine her own perceptions of the values in the school, the various types of student groups and different norms they ascribe to, validating the

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teenager’s strengths and struggles in moving to a new school and new community, teaching basic relaxation techniques, and role playing and debriefing possible encounters. In a supportive relationship, this adolescent can examine possible changes in her behaviors that she may want to make regarding potential relationships with peers in the school. Social workers also contribute their expertise to goals and tasks to achieve them. In this example, the social worker recognizes the importance of the goodness of fit between the individual and the environment. Understanding the importance of friends and a peer group at this stage of development, she can help connect the adolescent to peers that share her academic interests and values. Working to improve relationships with key systems may include meeting with the family or developing and offering a group for other students who are new to the school due to relocation. Goals can also address helping improve her grades with referral and attendance at an extracurricular tutoring program. Such goals and tasks could also be converted into behaviors and included in a self-anchored scale detailing attendance and participation in such groups and programs. Literature from the field of rehabilitation, mental health, and gerontology present useful approaches to setting goals that meet the criteria of relevance and are emotionally meaningful to the client, realistic and achievable, and specific enough to be measurable (Bovend’Eerdt, Botell, and Wade 2009). Methods such as goal attainment scaling could be useful for social workers. This is a quantitative method for evaluating the attainment of goals that identifies the expected goal and two states above and two below that level. The method has been found to be a useful tool in case management and as a process intervention (Yip et al. 1998). Burnes and Lachs (2016) note that social workers can use goal attainment scaling to assess client progress as well as agency effectiveness. They describe its application in elder abuse programs in which unique goals are defined in relation to the client’s individualized expectations and circumstances. Assessing progress by using the scale at defined points in time throughout the intervention provides important feedback to the social worker. In addition, the agency can collate information about a wide range of clients to compare the effectiveness of different program models. Developed in related fields of education and business (Ruffolo, Perron, and Voshel 2016), the acronym SMART is used to refer to goals that are specific, measurable, achievable, realistic and relevant, and timely (http://

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topachievement.com/smart.html). Specific goals need to be concretely stated and should clearly identify factors such as what is to be accomplished, where, when, and why. An example of such a goal involves a divorced father with limited custody of his child who has been inconsistent in staying connected. He wishes to strengthen his relationship with his son and the specific goal selected with his social worker is to visit every Saturday morning to take his son to the park or to swim at the local community center. Goals should be measurable and answer questions such as how much and how many, and how will the client know when it is accomplished. In this example, the goal is to make this behavior a constant feature of this father’s relationship with his child. Keeping track of his ability to be consistent provides the information to assess whether the goal is being attained. Ultimately, the goal is to strengthen the relationship; however, this is a more difficult goal to measure. Hence, breaking up the overriding goal into achievable components may make it easier to eventually realize. Goals should be attainable, given the capacity of the person. In this respect, it is important to also identify obstacles to achieving the goal. For example, if this father has regularly ended his work week by socializing with fellow workers that involves excessive drinking and staying out late, these behaviors may have to change so that he can follow through on his commitment to visit his son the next morning. In this respect, goals must be realistic and something that the person is ready to work toward. In this example, the stages of change framework is also useful. If the father is in the action stage, then it is possible that he will forego his social evening on Friday so that he is able to fully engage with his son on Saturday morning. If, however, he is still contemplating the benefits and challenges of maintaining his current inconsistent visitation pattern, then the goal selected is not realistic. The final dimension in SMART goal setting is that of constructing a time frame. Again, this is reminiscent of the stages of change framework. When an individual is in the action stage, then a meaningful time frame can be set. While the first dimension in joint planning addresses outcomes, the second dimension is about how to achieve this and what tasks should be undertaken. Some tasks are easily identified and can be described to the client. For example, a family member with primary responsibility for care of her elderly widowed father approaches a long-term care facility to inquire about placement of her father. Through the assessment, the worker and client identify that she would prefer to continue to keep her father at home with her and

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this becomes a goal. The assessment also reveals that she will need some relief for this plan to succeed. The plan developed included ways to access home ser vices and a referral for periodic respite care. To proceed with the plan, however, the client’s mixed feelings about being solely responsible for her father and attitudes about herself as a caregiver need to be discussed and modified so that she can use the ser vices without feeling guilty or that she was letting him down. The social worker can explain the tasks and concrete details regarding referrals to respite ser vices. It is more difficult to convey the tasks involved in helping the client deal with her ambivalence and guilt, other than to explain that the client will need to receive counseling to address such issues. Another example is provided by a social worker in a mental health clinic who receives a referral for counseling for a young adult, a male in his midthirties. A psychiatric assessment for depression has concluded that he is not clinically depressed but rather needs the opportunity to consider why he feels “bored with his life and unmotivated to do anything to make it better.” In this situation, the social worker describes the counseling process as consisting of “meeting together, trying to figure out what the important issues in your life are, what we both think needs to change, and how I [the worker] can help.” Goal setting and examining whether the tasks and activity chosen is meeting the client’s needs is best seen as an evolving process with frequent, periodic points at which progress is reviewed and new objectives are made explicit. Some social workers include this activity in every session; others structure it at defined points. For example, one approach is to take stock every few weeks to evaluate whether the worker and client remain in agreement that the original goals are relevant. As new information, insights, and understanding is gained, goals may change and become more specific. Throughout the work, it is vital to remain client focused, to continuously attend to how the client is experiencing the meetings, to determine what the client finds helpful, and if there is little progress, to identify possible interfering factors in the client’s life or in the help offered. A collaborative stance involves actively soliciting the client’s participation. This can be accomplished by initially defining the work as collaborative, stating that the client’s input is crucial, and then regularly seeking and using the information provided. Asking the client, “What else do I need to know to help you,” is a useful strategy. Referring to the practice of psychotherapy, Hub-

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ble, Duncan, and Miller (1999) provide a viewpoint that is equally applicable to social work practice. They urge the practitioner to carefully monitor clients’ reactions to comments, explanations, interpretations, questions, and suggestions. As noted in chapter 6, these clinician-researchers recommend the use of two brief easily administered measures, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS) to gain information about the client’s experience of progress toward the goals and the nature of the relationship (Duncan et al. 2010). Clients indicate on a continuum their perception of specific and overall progress on outcomes on four items about their personal well-being, interpersonal issues, and social relationships. With respect to the session process, four items are about the client’s sense of the relationship with the worker, the focus on goals and topics the client wished to address, and the goodness of fit with the practitioner’s approach. Such information allows the worker to discuss and examine factors that are facilitating progress and those that are impeding it. Seeking and using client feedback demands a measure of flexibility on the part of the practitioner and a willingness to change one’s relational stance to fit with the client’s perceptions of what is most helpful (Hubble, Duncan, and Miller 1999). If social workers respect clients’ diverse preferences, they must be prepared to substitute their preferred intervention approach with that of the client’s. For example, they will be open to switch from a casual and informal position to one that is more formal if that is the client’s preferred personal or cultural expectation. Or, a preference to work primarily with behavior, with meanings and motivations, or with feelings will become secondary to providing what the client believes is necessary for change to happen. Currently, many mental health practitioners and agencies prefer short-term, present and future focused change interventions. However, the practitioner may encounter a client who believes that traumatic events in her family when she was growing up have a crucial influence on her current reactions and that she must understand the past to deal with present dilemmas. Other factors that can be modified are the degree of directiveness; who should participate in the session; whether individual or family therapy should be offered; and the location, timing, and duration of meetings. Although it is recommended that practitioners be willing to bend and flex to meet clients’ preferred styles of working, this does not imply that the social worker’s knowledge and expertise should be negated. Workers can

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share their power to direct the work with their clients as part of a collaborative and unfolding process. Especially during the beginning stage, when the relationship is not yet well established, workers can use the principle “start where the client is” and forge a partnership in a manner that is more, rather than less, comfortable for the client. An important question to address at this point is whether the practitioner’s current assessment and plan can benefit from a review of the research literature. Two types of studies may be of use: (1) studies about the population and problem, and (2) studies about empirically validated approaches for situations similar to that presented by the client. Studies about the population and problem can provide valuable missing information to the worker and can also guide him to address important gaps in his knowledge about a particular client. Studies about empirically supported interventions can provide a good beginning point to consider whether the client would be receptive to such an approach. If so, the worker must evaluate whether he has enough knowledge and competence to provide those interventions or whether the client should be referred to another worker, program, or agency that specializes in that approach. In assessment, goal setting, and planning, one should also consider whether interventions should occur with the individual alone or with intimate relationship partners or family members. Social workers have embraced family systems thinking from its inception and many describe either their primary affiliation, or at least some aspects of their practice, as offering couple and family therapy. If using a couple or family orientation, many practitioners begin the helping process by meeting with all significant and involved persons. For those practitioners who begin by seeing the primary individual, relationship partners will be involved to the extent that a family systems orientation pervades the way the social worker conceptualizes the presenting problem and perpetuating factors. If it is decided that others need to be included, they should be invited to attend as early as possible so that an alliance with all members of the system is forged. If others are invited to participate after a more prolonged period of engagement with the primary client, then the other(s) may feel that the worker is already allied with the primary client and cannot understand others’ perspectives. Similarly, the primary client may have difficulty when others are included later on, feeling that the relationship with the worker has changed and that their bond has been compromised or lost, and the client may even experience a sense of betrayal. A referral to another practitioner for couples or family therapy can provide a needed

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new start for work that focuses primarily on the couple or family. The initial client may still choose to continue with individual work. When the assessment reveals that necessary resources are lacking in the client’s life, the social worker will include plans to address these needs. Social workers are distinguished on multidisciplinary teams by their knowledge of ser vices and their ability to help clients gain access. The plan must consider whether it is sufficient to provide the client with referral information or whether the worker will need to actively assist the client in receiving the ser vice. Clients may require help to determine whether they meet eligibility requirements, to deal proactively and effectively with intake or bureaucratic procedures, and to present needs and requests in a way that will elicit a positive response. Entitlements are not always easily accessible and social workers who know how to “work the system” can provide invaluable information and coaching to clients. In some instances, social workers will have to make the links for the client, coordinate the ser vice requests, and advocate for particu lar clients. The case management model, described in the following chapter, presents aspects of working with these external systems on behalf of clients who are not able to do so entirely on their own. After the session, social workers reflect on their personal-professional reactions to the client and incorporate their insights into the emerging assessment. Reflection also entails a consideration of potential countertransference reactions. Recall the earlier discussions of workers’ cognitive and affective processes in chapter 2. Are there possible blind spots, that is, areas of identification or issues that will trigger and provoke uncomfortable personal feelings for the worker, or make an easy connection possible? Planning can include arranging for supervision or consultation that attends to examining the worker’s responses with the goal of gaining insights into pursuing alternative ways of interacting in the interviews. Finally, practitioners will confront a wide range of client expectations about seeking help from professionals. These expectations may be based on cultural values that define what constitutes a problem, how and where to seek help, and whether sharing personal or family problems with strangers is appropriate. Clients’ personal beliefs about change will affect what is seen as important, with some expecting an expert who will offer solutions to their problems whereas others may expect more collaboration. Past experiences with social workers and mental health professionals will also have a significant bearing on clients’ expectations.

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expectati ons ab ou t pr ofe ssi on a l he lpi n g • What does the individual hope to achieve? What goals are impor tant? • What tasks or activities does the client expect to engage in with the social worker and by herself between meetings?

• What importance is given to emotional support, increased self- understanding, practical skills, and resources and information for receiving help?

• What is the individual’s expectation and preference regarding the degree of direction from the worker and the client’s degree of participation?

• What is the expected time frame that the individual envisions will be needed to gain help?

• How will the individual and the social worker know whether pro gress is being made?

When clients’ hopes and expectations are not likely to be met by the service the social worker is able to provide, it is important during the initial stage to spell out what can and cannot be offered. Clients may attribute greater power and influence to social workers than they actually have. For example, social workers who screen applicants for admission to a long-term care facility often help family members develop interim community support strategies when there is a waiting list. The family may expect that if they cooperate with the social worker, she will be able to have their elderly relative admitted earlier. Clients in child protective services who are ordered by the court for therapy may expect that if they attend their sessions regularly, their children will be returned to them. That they must change certain aspects of their lives to be reunited with their children may not have been clearly communicated. The questions presented in the text box above can be used to discuss and clarify expectations about help seeking early in the contact. Thus far, the principles and practices of the initial stage of the social work helping process have been discussed. A wide range of interviewing skills provides the techniques and behaviors to put these principles into practice. The following skills are used throughout the stages of helping and are especially useful during the beginning stage. These skills are posing open- and closeended questions, seeking concreteness, attending and active listening, restatement and paraphrase, reflection, summarization, and seeking feedback. They will be discussed at length, with practice examples, in the final chapter.

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The Social Worker as Process Expert

social work practice has been described in a variety of ways: as treatment (Berzoff and Drisko 2015; Goldstein 2001), intervention, or implementation (Compton, Galaway, and Cournoyer 2005; Hepworth et al. 2010). Competency 8 states, “Intervene with Individuals, Families, Groups, Organizations, and Communities” (CSWE 2015, 8). These terms may be misleading, as they conjure up an image of a practitioner “doing something” to a client, that is, treating, intervening, or implementing an action plan. There can be an implication that the professional “has answers” and it is simply a matter of helping the client learn those answers. Clearly, this is not the view of professional practice that has characterized social work. Rather, social workers are seen as process experts, working collaboratively with clients, guiding and facilitating the client to become more self-aware and open to self-initiated change. This view of the social worker as a process expert is discussed throughout this text. The social worker knows how to engage people in a particular type of collaborative relationship and a process that entails joint discussion and reflection. Together, the client and social worker participate in a continuous dialogue, or therapeutic conversation, in which they examine the salient aspects of the client’s situation. Consistent with contemporary social work practice theory, clients’ strengths and their capacity for a collaborative effort are recognized (Saleebey 2013). The social worker’s knowledge and competence in interpersonal relationships creates a supportive “space and place” for this dialogue. Murphy and Dillon (2015) portray the social worker as providing steadiness and thoughtfulness, and “surround each t h e m i d d l e s ta g e i n d i r e c t

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unique situation with an invisible bubble of calm and focused attention” (60). Chapter 4 on relationship presented neuroscience research supporting the notion that relationships are crucial to neurobiological functioning, and hence to individual well-being and social functioning over the life cycle. This means that social workers can help clients develop new ways of feeling, thinking, and responding so that they can deal constructively with challenging issues they face, especially in managing emotional regulation (Siegel 2012). As stated earlier, highly attuned social workers can attend to clients’ feelings and use them as an entry into meaningful conversations. Reflective dialogues involve clients in meaningful, focused, conversations that can lead to insights, promote clients’ self-awareness, and enhance emotional regulation. As noted frequently in this text, unlike relationships in everyday life, the professional helping relationship exists solely for the client’s benefit. It provides the focused attention of another person who listens, explores, and aims to increase understanding of the client’s issues so that potential goals can be identified, change can occur, or a particular kind of support or concrete assistance can be offered. Providing premature advice, giving unrealistic reassurance, minimizing situations, and “swapping stories” can be typical reactions when one hears about family members’ and friends’ problems. Such reactions are not offered in professional work; instead, the social worker’s spontaneous internal reactions are reflected upon and processed to determine their meaning and whether they may be used intentionally in the interests of the client or held back. In this text, the term intervention will be used to maintain consistency with the professional literature, despite the earlier caveats noted above. Taking into account the collaborative stance presented earlier, intervention is defined as social workers’ actions that aim to prevent, support, or change something with the goal of improved individual and social functioning for the client. The term also includes the methods and techniques used to bring about desired outcomes. Competency 8, “Intervention” (CSWE 2015), recognizes that social workers use a range of methods, including those that are evidence informed, to achieve client goals and enhance clients’ capacities. Moreover, interventions may also be directed to the environment when social workers “negotiate, mediate, and advocate with and on behalf of diverse clients and constituencies” (CSWE 2015, 9). In this and the following chapter, a range of interventions are presented, drawing on supporting evidence when available.

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ongoing support and case management

The goal of direct practice in social work is to provide a ser vice that promotes an individual’s social functioning. This can occur through efforts that are mainly focused on support, on change efforts, or on some combination of the two. Since a person-in-environment/ecosystemic approach is used as the primary framework in social work practice, practitioners are always cognizant of the extent to which structural, systemic, and interpersonal factors play a significant role in the client’s current and past concerns, and the extent to which they must be changed to enhance well-being. Change efforts can therefore involve many external and internal aspects of an individual’s life. Any social work practice intervention addresses basic needs. When lack of resources or ser vices are part of the problem, the social worker directs her attention to helping the client access those resources. Activities may include referral and ensuring that the ser vice is offered successfully, liaising between different agencies, coordinating ser vices, obtaining entitlements for clients, and advocating on the client’s behalf. Based on the agency’s mission and resources, what has been called case management, may be the preferred approach. Case management refers to a ser vice originally developed for highly vulnerable client populations to ensure that they receive the help they need so that they can live in the community rather than in institutions (Rothman 2002). It was designed in the mental health field for those with severe mental illness and as a response to the fragmented ser vice delivery system. The term case management is used by a number of health and human ser vice professionals, often with different definitions and processes. In social work, it is similar in many ways to earlier conceptualizations of social casework, given its focus on obtaining needed environmental resources while also working with clients’ psychosocial issues that impact their ability to use these resources (Kanter 2011). Social workers often support clients with conditions and situations that are likely to be long term and affect their social functioning and well-being. For example, case management is used with children, adults, and families where there is a chronic physical illness; with elderly people living in the community where multiple health and social ser vices are required; with people with substance use issues; and with homeless people wishing to find stable housing.

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The basic premise of the approach stems from an ecological systemic perspective that recognizes that individuals can benefit from access to a wide range of social, emotional, and physical ser vices. Since ser vices are increasingly fragmented, many programs are difficult to access, and more so for those with limited interpersonal and organizational skills. Practitioners address clients’ concrete needs by acting as referral agent, advocate, educator, and coordinator. The relationship with the practitioner is also used in a supportive and therapeutic manner so that the client develops enough of a bond to follow through on referrals and sustains involvement with the services. The supportive nature of the working relationship provides a context that enables the client to experience structure and learn that help is available, promotes cognitive and experiential learning, and enhances selfesteem through successful experiences (Kanter 2011; Walsh 2002). In a meta-analysis of studies involving social workers’ use of case management, Reid and Fortune (2003) found that in a number of studies of people with severe mental illness the approach yielded positive outcomes in enhancing work and quality of life, promoting the ability to live independently in the community and avoid hospitalization, and increasing competence in the activities of daily living. Other meta-analyses of clinical case management offered by mental health professionals found similar positive outcomes. Positive outcomes were clients’ improved levels of social functioning, symptom reduction, client and family satisfaction, and reduced family burden (Ziguras and Stuart 2000). Practice principles in the case management model are presented here, as they emphasize work with the environment. Many of the interpersonal processes used with the client are similar to the generic principles offered in this text. The following discussion is based on Kanter (2011), Rothman (2002), and Walsh (2002). The initial stage in case management includes engagement and uses the processes discussed in chapter 8, the beginning stage, to arrive at a comprehensive assessment and a plan. The specific focus is on immediate problems, client needs, and ser vices required. A case management approach is appropriate when the assessment reveals multiple issues requiring ser vices from a variety of agencies. The problems presented by the client are such that the emphasis will be less on the work between the professional and the client in the interview and more on locating and coordinating external, environmental resources. The social worker adopts a supportive and collab-

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orative stance that aims for maximum client participation and choice in setting goals, reviewing and assessing the programs available, and, when choice exists, encouraging the client to decide what ser vices to use. During the course of this early stage of work, the practitioner may accompany the client to apply for ser vices, such as a special work training program, or to visit potential residential facilities. Case managers aim to understand clients’ internal dynamics and how they affect their ability to gain and use needed ser vices. The client’s personality style and consistent ways of dealing with stress, challenge, or threats in daily living will significantly impact his ability to use the resources located. Although the counseling aspect of case management does not aim to change persistent personality styles, without some modification of styles that are problematic, the best external resources may not be used successfully by a client. For example, if a client persistently responds to requests to follow guidelines with resistance, anger, and verbal abuse, that client will not be readily accommodated in community-based programs, group homes, or shelters. Skilled social workers develop and use a trusting and supportive relationship to help such a client learn alternative ways of understanding and responding to requests for compliance from the programs he wishes to access. Interventions may include psychoeducation about health and mental health issues, teaching life skills, and counseling aimed at self-management and modifying emotional reactivity. Effective case management also requires skill in information gathering, analysis of the goodness of fit between the client’s needs and the ser vice available, and referral and linkage so that the client and program staff engage successfully with each other. Professionals need to know the relevant information about programs, eligibility requirements, application procedures, changing practices, and exceptions to regulations. Collaboration with health, mental health, and social ser vice providers in a range of settings is key in learning how to navigate a complicated bureaucracy, realistically appraise potential resources and barriers, and gain little-known entitlements for their clients. Such information is often gained through informal professional relationships with employees in these ser vices. Such relationships include being respectful of staff at all levels and understanding their roles and functions, as well as the organizational contexts and pressures under which they operate. Emphasizing collaboration, joint efforts at problem solving and providing

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positive feedback about the effects of their efforts are likely to produce lasting informal networks that ultimately serve clients. Case management may be short term, intensive, or crisis oriented when the need is to locate, coordinate, and make successful referrals to numerous ser vices. Or, it may be long term, to organize a number of ser vices to enable an individual to live in the community with ongoing monitoring provided. After the initial phase, regular contact over a long period of time may support a plan that enables an individual to remain in the community while also providing for changing needs. For example, an isolated individual with chronic mental health problems recently discharged from an inpatient unit is helped to find housing, apply for a disability pension, arrange attendance at a community mental health clinic for medication and follow-up, and is linked to a drop-in center in the neighborhood where there are social activities. Periodic follow-up by the case manager reveals that this individual has poor self-care skills. A more intensive period of contact follows that focuses on linking him to a life skills program. Through a constant, respectful, and caring relationship with the case manager, the client accepts this referral, and with her encouragement, regularly attends the program and benefits from it. Other examples of interventions primarily aimed at support are found in health care settings such as palliative care units where social workers often meet with family members to provide support through the final stages of a terminal illness, or for newly diagnosed individuals to learn more about their health condition and management strategies. In child protection ser vices for foster children, the social worker’s focus may be to assist foster families to provide an emotionally supportive and stable home to meet children’s developmental needs. Although referring to a middle “stage” may imply a finite period of time, many practitioners work with populations with ongoing situations or conditions that cause this stage to proceed over a period of time, even though it may be divided into segments of ser vice. Programs are designed to meet a range of physical, medical, and psychosocial needs over the life cycle. For example, families with children born with visual, auditory, or physical disabilities, children who become wards of the state, and adults with chronic illnesses that interfere with their ability to live independently may require social work interventions on a continuous basis, or at significant times of transition. For instance, families with a child with significant physical

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disabilities may initially need information to understand the medical condition, information about available ser vices and government entitlements, and help to deal with their emotional reactions. At a later stage, the family may call the social worker for help in decision making about the benefits of the child attending a neighborhood school or a special school. At a yet later stage, vocational preparation and decisions about autonomous living arrangements may be the focus. Hence, the middle stage is continuous, but divided into segments of ser vice at particular points. A supportive, attuned, and empathic working relationship knits these phases together. The client returns to the social worker at crucial times based on the connection built and understanding established previously. The therapeutic relationship has provided a secure base that provides the client with the opportunity to share strong or troubling and negative feelings in a nonjudgmental space, to name these feelings and receive acknowledgment of and validation about them from the practitioner, and to gain insight. Through talking things out and thinking through issues, clients gain better mastery of a situation or arrive at a decision. Therefore, although the middle phase is presented as if it is discrete, time limited, and focused, in actual practice it can be fluid and continuous, and even have interruptions and be less action oriented than the technical language implies. Since working with a case management model brings social workers into intense and prolonged contact with vulnerable and marginalized clients, they are likely in the best positon to identify the impact of policies on populations at risk. Their experiences, insights, and recommendations can contribute to meaningful policy change. It is important that all social workers are committed to ensuring that this knowledge is used to advance human rights and social justice. This form of policy practice can be achieved through involvement in activism via the employing agency, interorganizational networks, special interest groups, and professional organizations. processes for bringing about change

The key concern of practitioners is how change can be brought about and what principles and processes are available to the social worker to achieve positive outcomes. In the following chapter, research on models and techniques, as well as process research, is discussed. In this chapter, change processes extracted from social work practice and specialized models are

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change pro cesse s • Developing an expanded understanding of the presenting problem and relevant issues and themes.

• Working in depth with links among emotion, cognition, and be hav ior. • Identifying strengths and addressing obstacles. • Developing new perspectives. • Taking action. • Attending to pro cess and content 

Attending to pro cess: Maintaining the working relationship



Attending to content: Monitoring and supporting goal achievement

integrated and presented, as they are deemed useful in generic practice. There are likely many other processes that can also be included in any practitioners’ repertoire. Although processes are presented in a linear order, in actual practice they unfold in a cyclical or looping manner. Conversations are repeated, key themes and insights are revisited and revised, and new behaviors and related changes are attempted more than once. It is important for both clients and practitioners to remember that change usually does not come easily or quickly. The text box above presents a list of the key types of change processes. The first two, expanded understanding and working in depth, will be discussed in this chapter; the remaining processes are discussed in chapter 11. d e v e l o p i n g a n e x pa n d e d u n d e r s ta n d i n g

Although substantial information is collected during the beginning stage and enough joint understanding occurs to develop goals, the middle stage involves developing an expanded understanding. During this stage, a more in-depth and integrated understanding of the client and presenting situation develops. The client’s internal dynamics regarding his thoughts, feelings, and behaviors in relation to the situation, is sought as well as the specific nature of interpersonal and systemic factors. As in everyday life, we share narratives or tell stories about what has recently happened. In interviews, clients frequently begin in this manner and tell the social worker what has happened to them since their last meeting in relation to

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important issues. Clients need to have this opportunity to expand on details they deem important. The practitioner listens attentively and links what the client is presenting to the primary clinical focus, listening for themes that recur in the individual’s reactions across systems and relationships, and through the life cycle. This type of intentional approach enables social workers to help clients identify reoccurring issues that have affected their social functioning and well-being. Especially when practicing in contexts of diversity, important information emerges in dialogue about the key events and experiences that the client introduces, as well as through seeking more information in a number of domains. For example, a female lesbian client was extremely distraught during her session with a male heterosexual social worker. She discussed her dread that she would be alone on the day of the gay pride parade in her city. The social worker inquired whether she had made any plans to attend the parade with friends and learned of her many unsuccessful attempts to find friends or even distant acquaintances to spend the day with. As the social worker explored this presenting issue, he heard about how important the sense of belonging to the lesbian, gay, bisexual, and transgendered community was to the client, and how attending the parade had always been a celebration for her. Having recently ended a three-year intimate relationship, the client was now alone and feeling rejected and disappointed with the total cutoff from her former partner. The process of choosing to live in a loving lesbian relationship and of coming out to family and work colleagues had been a difficult one for this client, but one that she felt she had ultimately handled successfully. Anticipating the impending community celebration, however, and that she would not be in a relationship when she attended it, stirred up painful recollections and feelings about previous experiences of feeling alone. It led her to reflect with sadness on the many family gatherings and work-related social events that she had attended alone prior to introducing her partner into these important circles. Fearful of being rejected, she had not come out to her family or at work for many years. The meaning of the presenting problem in that session, attending the parade alone, was expanded to a more complex understanding of the feelings engendered in the client—being alone and marginalized. Societal attitudes, as perceived in family relationships and in the workplace, had limited this client’s participation in meaningful events in the past. In the present, it was her single status that was interfering with her participation in a celebration

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she valued. This expanded understanding helped her recognize that it was important for her to attend and she left the session determined to find a way to do so. Practitioners balance clients’ needs for expression with a focused dialogue. Providing direction and structure is linked to positive outcomes and helps to contain clients’ concerns. One can invite the client to begin each session by asking what is most important to discuss. It is likely that the particular issue introduced is connected to the overall themes and goals that are the focal point of the work. Without some attention to what is important to the client in the moment, the meeting can become social worker directed, and when reviewing progress at the end of the session, it is disheartening for the worker to learn that the client’s main concerns were not addressed. The practitioner, however, has the responsibility to keep the overall goals set at the beginning (as discussed in chapter  9) in mind to provide some general direction for the work. Identifying Themes

By developing an expanded understanding of the client and his situation, the social worker and client can begin to identify recurrent themes, patterns, or behaviors in the client’s life. This also broadens the definition of the presenting problem. “A series of difficulties often represents a repeating theme in which the details may vary but the core event is the same” (Fusko 1999, 49). Fusko (1999) provides the example of helping a client identify a longstanding pattern of difficulty in getting along with authority figures and notes that helping the client with this theme will build his capacity to deal more effectively with authority figures in general and get along better with a current employer. Although it can be an oversimplification to reduce an individual’s life to a smattering of recurring patterns, these patterns frequently capture some essential themes that operate in a number of domains and over time. It can be liberating for an individual to identify, define, and label these continuing themes. Furthermore, while there are themes that are connected to pain and suffering, there are also themes about strength and resilience that the practitioner and client can call on to address current presenting issues. Themes may be individual, interpersonal, or developmental in nature.

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Themes Relating to the Individual

These themes refer to the response patterns that reflect the individual’s dynamics, that is, how various aspects of the personality work in somewhat characteristic ways. These dynamics may be sensed by the client, but have not yet been put into words. Through discussion, for example, an individual comes to recognize that when she is feeling anxious about a new project or responsibility at work, she will devote all her time to the task at hand. This may entail spending long hours at work, searching for information and new skills to help with the particular project, and doing whatever it takes to master the demands of a new position. This makes her a valuable employee and she is satisfied with her promotions. On the other hand, she recognizes that her life is not well balanced to meet other needs for relationships and recreation. Or, an individual may recognize that when faced with stress and anxiety about his work performance, his characteristic response has been to avoid dealing with the situation. Withdrawal may take the form of leaving the job or numbing his feelings through the overuse of alcohol or drugs. Disappointed with the lack of progress and advancement in his work, he comes to recognize how his characteristic pattern of dealing with anxiety has not served him well in the long run. Themes Relating to Interpersonal Relationships

Themes in interpersonal relationships are about the way an individual interacts with significant others, the way expectations and demands of others are dealt with, and how he perceives and manages conflict. These themes represent the individual’s view of self, other, and interpersonal relationships. For example, an individual may recognize that in her significant roles as worker, friend, family member, and relationship partner, she assumes responsibility for the well-being of others. This way of handling relationships has resulted in others valuing and cherishing her, viewing her as a person who can always be counted on. It has, however, often left her emotionally depleted and with little energy left over to meet her own needs. A frequent response to conflict in interpersonal relationships is to feel flooded with negative emotions and to believe that the conflict is of such a magnitude that the relationship is doomed. This feeling of being overwhelmed and having a pessimistic view of the future has been associated with emotional

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withdrawal from one’s partner and emotional distance and alienation ensues (Gottman 2014). Or, an individual complains that he can never please his partner—that the partner has always been too demanding and selfish in the end. Through further discussion and reflection, he recognizes that although he feels respected and understood at the beginning of a new intimate relationship, when his partner disagrees with him he reacts with anger that frequently escalates to physical threats. Reviewing his failed relationships, he begins to see that when he feels threatened and insecure, he lashes out aggressively. He therefore comes to recognize his contribution to broken relationships. Themes Relating to Developmental Issues

Developmental themes refer to patterns that were established early in an individual’s life and are repeated in the present even in the face of different external circumstances. In the long-standing social work model, psychosocial therapy, attention to these past dynamics is “usually undertaken in an episodic way . . . certain themes being explored as it becomes apparent that factors in the client’s development are blocking improvement in current social adjustment” (Woods and Hollis 2000, 141). Relevant aspects of the client’s past are looked at as they are raised in relation to the present focus. A wide range of past experiences at societal, familial, and personal levels can be important for understanding the meaning of current issues in a person’s life. It can be helpful to identify how societal and cultural values and messages have been transmitted through the client’s family-of-origin and through the generations. Also useful is gaining a more acute awareness of the way these messages have been internalized and how they operate in the present. Where experiences of marginalization, discrimination, and oppression have had an impact on the individual, these past and current episodes should be discussed. These dynamics can be seen to be operating in the example presented earlier in the discussion of the first process of change. In this example, the client is able to explore how in past situations, meanings and attitudes about her sexual orientation led to positions and associated feelings that still carry an emotional impact as she faces her current dilemmas. When clients are helped to reflect on earlier examples of repetitive patterns in their lives, it is helpful to distinguish between periods when these patterns helped the client manage in conflict situations and periods when

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these patterns limited the client’s capacity to grow and develop fully. For example, an adult who was the eldest child in a family with an alcoholic parent recognizes that ever since he can remember, he adopted a position of vigilance with respect to his father’s drinking behavior and accompanying anger and verbal abuse. This client felt responsible for his younger brothers and sisters, and tried to minimize the impact of their father’s anger on them by keeping the children out of the way when his father was drinking heavily, trying to anticipate his father’s requests and meeting them. This externally focused and highly responsible way of behaving protected his younger siblings and enabled him to feel positively about his ability to help others. Only in adult life, by reflecting on his overly responsible manner in the workplace and in relationships, has he become aware that overly focusing on the needs of others has left him less aware of his own feelings, unable to identify his own needs and pursue ways of having them met. A longstanding pattern that was highly functional during his earlier years is interfering with his ability to find fulfillment as an adult. Qualitative research on clients’ subjective experience of psychotherapy supports many of the processes discussed thus far (Watson and Rennie 1994). Former clients reported that ongoing dialogue with the practitioner helped them put into words their feelings, perceptions, beliefs, values, and needs in relation to their inner and external world. They came to understand themselves better and the strong reactions they had toward events and interactions in their external world. By telling stories about these significant events, some clients visualized themselves in the episode and reexperienced the feelings. The process of discussion with another person was deemed helpful. “In the act of sharing their experience and confessing their difficulties and disturbing material to another person, their problems became more concrete and real, so that their problems had to be confronted and given attention” (Watson and Rennie 1994, 503). The respondents further noted that finding the words to describe and convey their experiences was not easy; they had to make a number of attempts to put their inner experiences into words. Furthermore, they believed that through this process of finding the words to capture their feelings and thoughts, they were helped to distill the essence of what they were struggling with; they valued moving from a vague and amorphous sense of disquiet to having a handle on significant issues. Practitioners assisted them by guiding reflection, probing, and providing words or phrases to name and label their feelings.

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By developing expanded understanding, clients appear to become more aware of issues in their life, a greater sense of the relationship between internal and external factors, and the way the past operates in the present. Contributions from neuroscience research will be discussed below and provide insights into the ways these processes can bring about change. working in depth with links among emotion, c o g n i t i o n , a n d b e h av i o r Focusing on Emotion

Throughout this text, the contributions of neuroscience research are discussed and in this section links are made to contributions in the middle stage of change. To reiterate, social work theory increasingly draws on the extensive body of neuroscience research that shows how brain-based mechanisms affect feelings, cognition, and behavior, and are shaped and influenced by developmental, interpersonal, and contextual factors (Cozolino 2002; Damasio 2005; Miehls and Applegate 2014). This phenomena was discussed at length in chapters 2 and 3 with respect to holistic competence, pointing out how a social worker’s emotional reactions affect her cognitions, judgments, and the decisions taken with respect to each practice situation. This perspective about the human condition therefore applies to all of us—social workers and clients—and hence is foundational knowledge for practice. The recognition that neurobiological and brain-based mechanisms can change over the life course provides a compelling rationale for providing intensive interpersonal ser vices. Interpersonal practice has the ability to change the neuronal connections that underlie the links between emotional reactions, cognitions, and behavior (Fosha, Siegel, and Solomon 2009; Siegel 2012). Furthermore, similar to tenets in psychodynamic and attachment theory, neuroscience research shows how our present experiences and responses are shaped and influenced by previous internalized experiences as well as present interpersonal and contextual factors (Cortina 2010; Cozolino 2002; Damasio 2005). Neuroscience research also supports social work’s dominant focus on interventions aimed at internal and external dimensions and working with the links between emotions, cognitions, and behaviors. Neuroscience research highlights that “one of the most basic human challenges is integrating and coordinating the complex and very different

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systems that make up our brains” (Cozolino and Santos 2014, 158). These systems include a fast and a slow response system. The fast system involves the out-of-awareness, unconscious, quick behavioral reactions that respond to sensory and emotional data, and attend to nonverbal and verbal behaviors on the part of those we encounter in our environment. This system has been referred to as the low road (LeDoux 2002) in contrast to the high road, which provides slower highly processed information. These unexamined and unprocessed reactions can lead us to a range of emotional and behavioral responses from fight to flight, or freeze. There is also a slower system that involves conscious thought, reflection, and the potential for selfawareness (Kahneman 2011). This system, called the high road (LeDoux 2002), allows for cognitive processing to understand the quick reactions of the low road and to thoughtfully consider potential responses. Such considerations can lead us to intentional responses rather than unprocessed reactions. This requires developing emotional regulation (what some have termed integration), that is, examining emotional information and reflecting on what to do with such information (Fishbane 2007; Siegel 2006, 2012). A major focus of work in the middle stage of practice involves social workers helping clients to achieve this type of self-observation. This perspective recognizes that early social and emotional experiences are internalized and exert a powerful influence over the present. These early experiences are largely unconscious, so there is an inability to consciously connect current reactions with internalized feelings and thoughts about our sense of self, internal working models of relationships, and our ability to regulate our emotions. In this way, the past exerts itself in the present, but does not necessarily determine the present (Sroufe et al. 2005). The adage, known as Hebb’s law (Hebb 1949)—neurons that fire together wire together—purports the notion of stability: established brain networks determine our personalities and ways of coping. Neurogenesis and neuroplasticity is the brain’s ability to create new neurons and connections between them; establishing that change is possible throughout the life cycle. Change comes about through the experiences we have, especially in socially connected relationships in which there is emotional connection. The power of clinical social work lies in practitioners’ ability to engage individuals in exploring the links between these past experiences and the present. The specific focus is to recognize that memories (many of which are inaccessible to conscious consideration) serve as programs that operate

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in the present (Cozolino and Santos 2014). In the context of a supportive and empathic relationship (extensively discussed in chapter  4), interpersonal practice involves attending to these emotional states to understand these dynamics and ultimately create more positive experiences, meanings, and behaviors. This enables individuals to reexamine their expectations of self and other so that responses in the present can be freed from old patterns that may no longer be useful, necessary, or fulfilling for the individual. Entry into such work occurs by eliciting individuals’ emotions and associated feelings about present situations, often picked up by attending to bodily sensations. Although there is no agreed-on definition of the differences between the terms emotions and feelings, Damasio, a leading neuroscientist, states, “emotions are a set of programmed physiological actions triggered by a stimulus” (Damasio and Carvalho 2013, 144), and feelings are conscious experiences of those body states. For the practitioner, helping clients attend to their bodily sensations as they arise in the moment can provide a pathway to examining one’s emotions, to consciously name these feelings, and to gain some sense of mastery over them. The act of becoming aware of one’s emotions increases the possibilities of emotional choice and flexibility (Siegel 2006). When clients are overwhelmed by their strong emotional reactions, including fight-or-flight responses, Siegel (2006) recommends using psychoeducation to explain the way the brain works, and thus to normalize clients’ strong emotional and behavioral reactions. In a similar vein, Fishbane (2007) discusses with clients insights from neuroscience and explains how fight and flight are normal reactions to feeling attacked or overwhelmed. Links are made between old experiences, patterns, and reactions that appear to be operating in the present. Using these concepts, practitioners can help clients examine and better understand how these learned patterns are hardwired, even though they might not be appropriate or useful in the present. Siegel has developed what he calls the “handy brain puppet” to use in psychoeducation; demonstrations of this technique can be found on the Internet. Long before neuroscience research influenced practice, social workers and psychologists working in experiential and humanistic traditions recognized the importance of attending to emotions as crucial in organizing our perceptions, the meaning attributed to events, and how emotions influence our behaviors (Greenberg 2010). Clinical theorists note the usefulness of

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helping clients to become aware of these powerful emotions and learn how to talk about and reflect on them. By the very nature of emotions—that they are immediate and entail feeling something—individuals are often not able to spontaneously identify, label, or reflect on them. Rather, we are often vaguely aware of a sense of turmoil or the sensation that we are “caught up in our emotions,” feeling something in an intense way with little understanding or insight about what has triggered this state. Similarly, Fishbane (2007) notes that many people have not grown up in environments that focused on awareness of one’s feelings. Fishbane (2007) recommends a technique that begins with a focus on the body and asks clients to observe and name the sensations they are experiencing in their body. An example provided is one of learning to recognize the first signs of an emotion, such as the tenseness and sensation of fast heartbeats, shallow breathing, or sweaty palms, which might lead to blowing up in anger. Similarly, emotion-focused practitioners guide their clients to express, think about, and experience feelings deeply. This activity may elicit a range of emotions from anger to sadness, and might also include confusion, ambivalence, and general distress. As the social worker and client explore strong emotional states, they can illuminate associated thoughts and meanings, and the interrelationships among thoughts, feelings, and behaviors become more apparent. Mindfulness and meditation activities are also widely recommended as ways to increase somatic attunement and assist awareness of emotional states. An impressive body of evidence supports the positive impact of mindfulness on relieving stress (Kabat-Zinn 2003). Mindfulness entails attending to the moment-to-moment flow of experience with a receptive and nonjudgmental awareness, “cultivating and refining our innate capacity for paying attention and for a deep, penetrative seeing/sensing of the interconnectedness of apparently separate aspects of experience, many of which tend to hover beneath our ordinary level of awareness regarding both inner and outer experience” (Kabat-Zinn 1990, 15). Siegel (2007) proposes that mindful awareness contributes to building connections and integration between mind and body, thus facilitating a type of consciousness that leads individuals to more intentionally choose and change the ways they interact with their environments. Many social workers now include mindfulness and meditation in their work with clients; it is important to receive training in these approaches if one intends to incorporate these practices.

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These change processes must be grounded in the type of relationship discussed in chapters 4 through 7. Neuroscience concepts provide more data to support this contention and, when coupled with insights from attachment theory, explain the importance of helping relationships as secure attachments that provide comfort and stability when individuals are in states of emotional distress and dysregulation. Optimal functioning for adults involves a balance between independent self-regulation and having others in one’s life who can provide soothing (Johnson 2004). When individuals are aiming for change, an attuned and empathic helper can provide the calming and soothing presence needed to engage in explorations that can be painful, thus helping them to work through challenges and move forward. Neuroscience concepts provide explanations of how, through the mechanism of mirror neurons, emotional resonance between two people can occur and explains how practitioners can begin to understand the experience of the client on an emotional level. The term mirror neurons refers to the process in which we “reflect back an action we observe in someone else, making us mimic that action or have the impulse to do so” (Goleman 2006, 41). This process leads social workers to feel that they can sense the experience of the client. Cozolino (2006) characterizes it as the ability “to know another from the inside out” (202). Social workers describe this type of emotional resonance in reaction to another’s feelings as empathy and traditionally accord this quality great importance in promoting connection and bonding. This occurs by attending to the client’s emotional experience; using active listening and calm, focused attention; and maintaining an open, curious, and nonjudgmental stance. Of interest is that the same conditions described as social work practice wisdom and empirical findings on the power of the therapeutic alliance (reviewed at length in chapters 4 through 7) are now supported with data from neuroscience. To provide these qualities, practitioners in turn need to be self-aware regarding their own reactivity and must be able to remain calm and emotionally regulated in the face of information they hear from the client. When a social worker is accurately sensing and naming another’s feeling, the client will “feel felt” (Siegel 2010). Social workers’ feelings about the other should always be accompanied by collaboration by the client, however. Given social workers’ own internalized personal experiences— what psychodynamic theorists refer to as countertransference—they must

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remain alert to the possibility of misinterpreting the feelings the client is experiencing. Ruptures will inevitably occur in maintaining this type of relationship and repairs that acknowledge and apologies for them are necessary. Further discussion of maintaining the relationship is found in the following chapter. The role of language to achieve change is explained cogently by Cozolino and Santos (2014), who note that brain areas connected to speech become inhibited when we are highly anxious. And yet language is crucial for humans to organize their conscious experience: “language serves the integration of neural networks of emotion and cognition, which supports emotional regulation and attachment” (Cozolino and Santos 2014, 164). As noted in the previous chapter, others have used the phrase “to name it is to tame it” (Siegel 2010) to capture the essence of this idea. In the type of attuned, connected, and empathic relationship described throughout this text, naming uncomfortable and distressing emotions can help individuals use their cognitive capacities to understand their reactions. Similarly, emotionally focused clinicians have noted that one purpose of focusing on emotions is to symbolize the experience in words. They conceptualize this as enabling individuals to gain self-awareness and selfunderstanding so that they are better able to increase their sense of control over those feelings that previously exerted a powerful influence over them; these feelings affected their beliefs about what they could or could not tolerate or do (Greenberg and Bolger 2001). Emotional processing empowers individuals to no longer believe that they are a prisoner of their feelings. Awareness and understanding provide the tools to deal differently with one’s internal experience and subsequently to act differently in one’s external life (Greenberg 2002). A useful distinction is made between primary and secondary emotions (Greenberg 2002). “Primary emotions are the person’s most fundamental direct initial reactions to a situation. Secondary emotions are those responses that are secondary to other more primary internal processes and may be defenses against these (Fosha 2000; McCullough, Worthington Jr., and Rachal 1997). Secondary emotions are responses to prior thoughts or feelings, or to complex sequences of these—sequences such as feeling angry in response to feeling hurt, feeling afraid about feeling angry, feeling guilty about a traumatic event by attributing responsibility to oneself for the event, or feeling afraid by generating catastrophic expectations.

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Secondary emotions need to be explored to get at their more primary generators. Thus, accessing the healthy anger at unfairness that underlies the powerlessness of some depressions promotes adaptation, whereas accessing the shame and/or sadness at loss of esteem that underlies rage can promote attachment in place of destructiveness” (Greenberg 2002, 171). Neuroimaging studies identify the calming effect of what is also called affect labeling as it diminishes emotional reactivity and minimizes the impact of negative emotions on current experience (Lieberman et al. 2007). Helping clients learn to self-soothe must begin with helping them to first recognize their own emotions and how these are experienced in bodily sensations. Strategies for self-soothing can include working with the body through deep breathing and mindfulness practices. In addition, the social worker and client can search together for other effective strategies. When clients are in a calmer state, both in the session and in their everyday life, they are more able to use cognition to reflect on situations and to make more thoughtful choices. As the client comes to feel trust that the therapeutic relationship is safe, secure, and one in which the social worker accepts him, previously withheld or unexamined experiences and the bad feelings associated with them are more likely to be shared. Such narratives can involve painful or confusing memories. By reflecting on these experiences and feelings in the safe context of the social worker–client relationship, these memories and the negative parts of the feelings can be transformed; they become less toxic and are reintegrated back into memory in a less destructive way. This means that new neuronal connections can be made, and through repetition, new behaviors can occur. This is an example of Hebb’s law: newly created neurons will fire together and become part of the individual’s neuronal circuitry (Fishbane 2007). It therefore becomes apparent that talking about one’s issues and using language to identify and articulate one’s feelings serves many functions. It provides emotional regulation of painful memories associated with lived experience. It also launches the arduous but empowering task of understanding the way we function and how and why these habits and responses may have developed, ultimately enabling us to construct more positive narratives about our experiences and ourselves. Clinical practice involves reexamining themes, patterns, and meanings in individuals’ lives and providing alternative perspectives based on new ways of interpreting the information

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in a client’s life. This form of practice “leverages the ability of brains to connect, attune, join together, and trigger neuroplasticity in the ser vice of positive change” (Cozolino and Santos 2014, 66). In summary, neuroscience concepts provide understanding of how emotions permeate all aspects of human life and the way empathic responsiveness from the social worker provides resonance, clients “feeling felt,” and a safe space for change to occur. This, in turn, allows openness to new learning as the relationship emulates secure attachment, can provide safety to explore, and ultimately promotes the client’s capacity to self-regulate. When sessions include work on recognizing bodily sensations as messages about emotions, they can be named, labeled, explored, and tamed. Bringing our cognitive capacities to bear on unpacking emotional and behavioral experiences results in integration of one’s emotional and cognitive systems. Focusing on Cognition

Thus far, change interventions in the middle phase have focused on bodily sensations, emotions and feelings, and the ways these dimensions affect our thinking and behavior. There is a substantial evidence base supporting the use of cognitively focused interventions for a wide variety of disorders, including anxiety and depression (Clark and Beck 2010). Cognitive therapists have identified a number of tenets that can be integrated into any approach to gaining understanding about distress and to guide interventions. A selected number of principles and techniques follow. In Aaron Beck’s seminal work on cognitive therapy for depression and in subsequent writings, he proposed that cognitive processes lead to mental disorders (Beck 1976, 2011). These maladaptive cognitions include modes of organizing reality through faulty information processing, core beliefs, and automatic thoughts. These ways of thinking can become habitual responses to most aspects of one’s life and influence feelings and behaviors. In this regard, cognition, emotion, and behavior operate in a cyclical fashion, interacting with each other. As a result, behavioral interventions are often incorporated in cognitive behavioral therapy, although numerous approaches exist with varying emphasis on cognitive or behavioral interventions (Granvold 2011). While Beck articulated cognitive therapy for people presenting with depression, cognitively oriented approaches can be applied to habitual thinking

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in general. Observations from neuroscience support this conclusion. Cozolino and Santos (2014) point out that the human tendency to distort experiences, believing that our perceptions accurately interpret external events, likely “have evolved as part of our brains because they have had survival value” (166). Such distortions can lead to similar repetitious appraisals of events and subsequent repetitive behaviors that were previously useful at one point in an individual’s life but now cause distress. Change processes that provide clients with alternative perspectives can improve the “ability to test the real ity of their experience beyond the habitual, self-serving distortions created by their brains” (Cozolino and Santos 2014, 166). The following faulty cognitive processing styles are based on Beck’s work (Beck et al. 1979), supplemented by categories of automatic thoughts described by Leahy, Tirch, and Napolitano (2011). These styles provide useful concepts for understanding the way a client goes about making sense of his world. Arbitrary inference refers to drawing a specific conclusion in the absence of supporting evidence or when the evidence is contrary to the conclusion. It can involve emotional reasoning, a conviction that if one feels a certain way, then it must be true. For example, an individual feels that his presentation in class was poor and that he is stupid. This feeling overrides the positive responses of classmates and his instructor. Selective abstraction refers to focusing on a detail taken out of context, ignoring other more salient features of the situation and conceptualizing the whole experience on the basis of this fragment. Information is filtered, usually in a negative way, and positives are ignored. This pattern is also referred to as discounting positives (seeing positives as trivial) or negative filtering (seeing negatives and seldom acknowledging positives). In the preceding example, for instance, when reviewing anonymous written feedback about the presentation, the client remembers and focuses on the few critical comments and skims over the many positive ones. For him, the critical comments confirm how poorly he performed. Overgeneralization refers to drawing a general rule or conclusion on the basis of one or more isolated incidents and applying the concept across the board to related and unrelated situations. This tendency is seen when an individual frequently uses the terms “never” and “always” to describe another’s behavior in a relationship, such as “he never says a kind word to me” or “she is always critical of everything I do with the children.”

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Magnification refers to seeing small things as the beginning of a major problem and is an error in evaluating the significance or magnitude of an event. For example, an employee who receives excellent yearly written job appraisals fears that she will be fired on the rare occasions that her employer gives her mild negative feedback. Minimization operates in a similar manner, but in the opposite direction. An example of minimization would be when a family does not regard a child’s lack of interest in eating and lack of weight gain as an indication of a possible need for a medical checkup. Personalization refers to relating external events to self when there is little or no basis for making such a connection. An example of personalization would be when one partner in a couple assumes that the other’s silence at breakfast means she is angry despite her having frequently stated that she is not a morning person. Blaming oneself and taking responsibility for things that are not the individual’s responsibility are other examples of personalization. Polarizing or dichotomous thinking refers to thinking in extremes, with all experiences evaluated in one of two opposite categories—smart or stupid, good or bad—with no shades of gray. Mind reading occurs when individuals assume they know what other people think without having sufficient evidence to support this belief. This style is often seen in problematic intimate relationships in which one party incorrectly interprets the other’s thoughts or feelings based on subtle, often inaccurate, cues. Catastrophizing involves believing that something is far worse than it actually is, that is, predicting a negative outcome, and believing that if that were to occur, assuming an extremely far-reaching negative result. An example of catastrophizing would be a student believing that if he receives a poor grade on one essay, it will end his attendance at his college. Inability to disconfirm refers to rejecting any evidence that contradicts negative thoughts and appraisals. For example, a negative thought about oneself is held onto tenaciously despite being presented with examples that challenge the negativity with positive information. In addition to habitual styles of information processing, cognitive therapists aim to understand individuals’ underlying core belief systems. Cognitive theorists posit that from previous experience, individuals develop beliefs about themselves, about others and relationships, and about the human condition and the social world. These beliefs, also referred to as schemas,

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serve as filters in subsequent life experiences and influence an individual’s perceptions, meanings, and interpretations of internal experience and external events. These cognitions influence one’s feelings and behaviors, which in turn produce experiences that may reinforce and confirm these cognitions or challenge and modify them. This formulation is another way of understanding the cyclical and interacting nature of these processes. The goal in working with clients’ cognitions is to help individuals identify and understand these underlying belief systems, and modify those that are selfdefeating, thus leading to new behaviors. With awareness of these universal cognitive processing errors, practitioners can focus on eliciting client’s perceptions, thoughts, and attitudes. This focus will provide important insights for both the client and social worker, and can also serve as an entry into revealing associated feelings and behaviors. When addressing thoughts and meanings, the worker and client also examine the ways an individual processes information and makes meaning of his world. For example, a middle-aged man, James, was fearful that his gay relationship partner, Frank, was unhappy in their relationship and likely to leave. James reported numerous fights and disagreements that left him feeling demoralized. Although Frank reassured him that he was quite satisfied in their two-year relationship and that conflict and anger were “normal,” James remained fearful that the relationship would dissolve. Further exploration revealed that James’s family-of-origin frowned on displays of emotion and were described as “cerebral.” James expected positive relationships to be calm, with reasoned discussion of any differences. He believed that strong displays of emotion, especially negative feelings, indicated great conflict that would inevitably lead to the disintegration of the relationship. He interpreted Frank’s behavior through this schema, and when processing their disagreements, used emotional reasoning, convinced that his reaction of fear when Frank expressed himself in strong language was a true predictor of things to come. James’s overgeneralization and catastrophizing caused him to believe that a few disagreements would lead to the end of the relationship and he would never find another partner as suitable for him. This cognitive style interfered with his ability to see that their relationship held many positives or to believe Frank’s viewpoint that angry disagreements reflected a difference of opinion, not an end to the relationship. James’s magnification of the negatives led to pervasive anxiety and to the beginning of emotional withdrawal on his part. Frank experi-

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enced James’s withdrawing behavior as rejection, which fueled a cycle of greater distance between the two. This example shows how cognitive styles in information processing can produce feelings and behaviors that can make a situation more problematic and unfulfilling. Since James was uncomfortable with emotional expression, he found that a focus on his emotional experience was simply more anxiety producing. As a result, the practitioner began their work by helping James identify the thoughts and cognitive styles that led to his feelings and behaviors, challenged those conceptions, examined alternative interpretations, and ultimately helped him think, feel, and behave differently in the relationship. Automatic thoughts are another way of thinking about cognitive processing. These are thoughts that come to mind in response to a trigger: a particular type of event, action, or situation. A typical example is that of anticipating the need to speak in a large group and immediately believing that one’s comments will appear stupid. Such a thought is not the result of a conscious reasoning process but rather is automatic and may occur in words, images, or memories of similar situations. Practitioners attempt to help clients identify automatic thoughts by encouraging them to notice what goes through their mind when they have a strong feeling or reaction to something. Mindfulness and meditation especially focus on quietening the mind and taking an observing stance to process which thoughts come and go. Emotional regulation has been discussed in depth throughout this chapter. Writing from the standpoint of cognitive therapy, Leahy et  al. (2011) make the point that emotion and cognition are interdependent and influence each other in a feedback loop. They state that useful techniques for assisting clients can begin with either emotion-focused or cognitivefocused approaches. A synthesis of some key techniques for cognitive restructuring is presented here. Additional specialized techniques are found in numerous texts on this approach (for example, Beck, 2011; Burns, 1980; Leahy et al., 2011. Using a cognitive perspective, practitioners help clients identify recurring thought processes and core beliefs associated with the problems they are presenting. If these beliefs can be viewed as possible explanations for the client’s concerns or distress, then the client and social worker can examine the evidence that supports or disconfirms these conclusions. If there is scant evidence or experiences to support these conclusions, new meanings can be generated, with associated positive feelings and view of self for the client.

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Thought Rec ord Activity

When using the thought record activity technique, the client and practitioner work on a written record that is divided into three columns. In the first column, the client identifies the situation in some detail, describing who was involved, where it occurred, and what transpired. An example is the one mentioned above about reluctance to speak in a large class. In the second column, the client’s feelings or mood in relation to the occurrence is noted. An example would be anxiety and fear. In the third column, the client’s automatic thoughts are noted. In this example, the client believes he will say something stupid and others will think poorly of him. Using the examples of faulty cognitive processing styles described above, the practitioner can help the client see patterns in his automatic thinking process. Based on the information the client has shared to this point, the practitioner can inquire about evidence that challenges and disconfirms these thoughts or that supports them. It can also help clients distinguish the difference between their thoughts and feelings, heightening the way one influences the other. Together, client and social worker may develop alternative thoughts that are more positive. Finally, the client can reflect on their feelings after the discussion. The discussion aims to change the client’s automatic and negative thoughts, triggers, and accompanying feelings. This thought record activity can also be assigned as homework and stimulate clients’ awareness of their cognitive and affective reactions. Working with Negative Thoughts

It is possible to ascertain whether there is a pattern to clients’ thinking, especially with respect to negative thoughts. This involves identifying themes as the client and social worker review the situations that are upsetting to the client and brought up for discussion. Using psychoeducation, the practitioner might point out the links between these negative thoughts and their impact on feelings and behavior. Leahy et al. (2011), however, note that some clients believe that negative thinking protects them from disappointment, motivates them to reach their goals, or is simply a reflection of their reality. These therapists (Leahy et al. 2011) make the important point that encouraging clients to engage in positive thinking is not helpful. Instead, they recommend discussing the

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benefits, as well as the negative consequences, of their cognitive patterns. Similarly, Granvold (2011) notes that positively reframing a specific cognition may be resisted by the client and proposes using cognitive elaboration to focus on generating alternative thoughts, views, or meanings rather than challenging or trying to change the negative pattern. Specific behavioral training techniques are also used that require specialized training for the practitioner. Some examples of such techniques include desensitization and flooding, rewards and penalties, relaxation and deep breathing methods, skill training, and problem solving (Granvold 2011). This chapter has presented some central concepts and principles for social work practice in the middle stage where support, change, or both are the focus of the work. Two themes are evident in this discussion. One theme is that social workers use a range of competencies and skills to work collaboratively with clients to reach agreed-on goals. The social worker is a process expert and engages in a particular type of relationship that enhances clients’ capacity to improve their social functioning and well-being. The second theme relates to social work’s long-standing focus on the personin-environment context. Always thinking systemically about the interaction of internal and external factors on the key issues, the middle phase activity gives consideration to interventions in the environment, the individual, or both. Processes in the case management model were discussed in this regard. The majority of this chapter addresses processes for bringing about change. Developing expanded understanding of the presenting issue involves identifying internal, interpersonal, and developmental themes and patterns in individuals’ lives. Change processes are discussed that draw on new insights from neuroscience research and emphasize the links among emotion, cognition, and behavior. Based on such understanding, it becomes evident that assisting clients in developing emotional regulation enables self-reflection and cognitive processing, ultimately leading to greater intentional choice to improve the client’s experience. Neuroscience research provides data to support theorizing and the related interventions in a number of long-standing approaches in social work and related psychotherapeutic fields. The next chapter continues the focus on processes for bringing about change.

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of change processes related to Competency 8, “Intervene with Individuals, Families, Groups, Organizations, and Communities” (CSWE 2015, 8), with the continuing focus throughout the text on practice with individuals. The following text box was introduced in chapter 10 accompanying the discussion of the first two processes, expanded understanding and working in depth with links between emotion, cognition, and behavior. In this chapter, the remaining processes are considered.

this chap ter continues the discussion

i d e n t i f y i n g s t r e n g t h s a n d a d d r e s s i n g o b s ta c l e s Focusing on Strengths

Social work practice has traditionally been concerned with both the problematic issues and strengths that exist in individuals and their environment. In chapter  3, enduring knowledge-based themes were reviewed, drawing attention to Saleebey’s (2013) influential strengths-based approach. Chapter  9 focused on assessment and joint understanding, and emphasized finding, acknowledging, and building on client strengths, while taking challenges into account, that is, “ always seeking the bigger picture with the goal being a broad, balanced, and fair understanding that attended to both risks and strengths” (Oliver and Charles 2015b, 139). To reiterate, this focus is included in EPAS as a feature of generalist practice and as a core value, “recognize, support, and build on the strengths and resiliency of all human beings” (CSWE 2015, 11), as well as in the assessment competency,

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pro ces s es of c ha n ge • Developing an expanded understanding of the presenting prob lem, relevant issues, and themes.

• Working in depth with links among emotion, cognition, and be hav ior. • Identifying strengths and addressing obstacles. • Developing new perspectives. • Taking action. • Attending to pro cess and content 

Attending to pro cess: Maintaining the working relationship



Attending to content: Monitoring and supporting goal achievement

“assessment of strengths, needs, and challenges within clients and constituencies” (CSWE 2015, 9). Social workers seek to capture and use examples of the client’s successful past coping and mastery. By examining areas of the client’s life that are conflict-free and satisfying, client attributes and skills are identified. These examples provide a rich reservoir of information that helps social workers understand clients’ internal strengths and resources. When individuals turn to others for help, they may be feeling overwhelmed and demoralized, and thus lose touch with their strengths. By commenting on and highlighting these examples, the social worker can help the client become aware of and appreciate these instances of success, resilience, and effective coping. There are many instances when the client does not see or does not perceive such experiences as positive or exceptional. When the social worker seeks to emphasize these positive instances, it can begin to promote a more satisfying and empowering self-image for the client. With greater self-esteem, the social worker can help the client to draw on her resources and capacities to address the issues at hand. Furthermore, when previous coping styles are not being used in the present, Goldstein (1995) recommends discussing this with the client and exploring what is currently interfering with the client’s ability to use those personal resources and what they would need to recapture them. Clients come for help because something is troubling to them and they are likely to initially present difficulties, problems, pain, and deficits to the professional. The principle of “starting where the client is” directs the social

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worker to begin at this point and respond to the client’s lead. The strengths perspective, however, takes the dialogue away from this singular focus on problems, dysfunction, and pathology. Some clients will welcome and feel invigorated by reclaiming their own power. Others will feel that the practitioner is not giving enough credence to the pain and discomfort they face or will view the practitioner as superficial and not having an accurate understanding of the situation. Using empathy in the relationship, social workers will sensitively balance recognizing and responding to clients’ distressed feelings while also realistically offering expanded views of their capacities. Social workers think systemically and identify strengths in the client’s social environment. Significant environmental factors that affect an individual’s well-being are the presence of supportive people such as families, friends, employers, spiritual advisors, community members, and teachers. The availability of resources and institutions that provide not only for basic human needs but also reinforce and celebrate accomplishments, and provide a sense of connection and belonging, merits attention. Schools, work organizations, community centers, religious and spiritual communities, and neighborhood organizations can enable people to learn, grow, and develop their strengths. While the case management model focuses especially on helping clients locate and use environmental resources such as ser vices and programs, all direct social work practice interventions should be carried out with the aim of helping clients to find, connect with, and make use of potential naturally occurring nurturing systems. Social workers acknowledge that the client’s abilities and resilience are at the core of practice; they attend to evidence of client interests, talents, and competencies whenever and wherever they meet with them (Saleebey 2013). The following five types of questions are designed to focus on positives, coping, and possibilities, rather than on problems and deficits. First are questions that take into account the challenges clients have faced and inquire about how they have managed to survive: What have they learned about themselves and their external world from those experiences? These survival sorts of questions are followed by elaborations and summaries about special strengths, insights, qualities, or skills the client has developed while dealing with adversity. Second are questions related to identifying the sources of support in the client’s life. The social worker asks about individuals, groups, and organizations the client can depend on and what specifically each of these individuals or systems can provide to the client. Additional questions inquire about how the client connected with these supports and what posi-

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tive characteristics in the client may have led others to want to be supportive. The third set of questions is related to the future and asks about the client’s possibilities, hopes, and visions, and how the social worker can help the client achieve those aspirations or draw on his special abilities and talents to make those dreams a reality. The fourth set of questions is about esteem and draws attention to what others would say about the client’s positive qualities, what gives the client self-pride, and what circumstances lead the client to feel positively about himself. The final set of questions is about exceptions and is similar to those discussed below. Solution-focused therapy was developed by social workers at the Brief Family Therapy Centre in Wisconsin and has influenced family ser vices and mental health ser vices. This approach is generally short term and seeks to identify and amplify strengths in the interests of assisting clients to meet their goals (DeJong and Berg 1998; de Shezar 1985). The unique focus is on finding solutions rather than exploring problems. Recognizing that much interview time consists of discussion of problems and difficulties, these clinicians used exception-oriented questions to ask about recent instances when the problem might have occurred but somehow did not. DeJong and Berg (1998) propose the following steps and questions to elicit exceptions to the client’s problems: The practitioner begins by trying to establish concrete details about the exceptions. “We’ve been talking at length about the situations that lead you and your partner to argue. Can you tell me what it’s like when you are not disagreeing?” When the client provides an exception, the practitioner then asks for details about it, “the who, what, when, and where of exception times” (DeJong and Berg 1998, 95). They recommend that practitioners listen for and respond to what is different in the exception as compared with the problem time. These details can then be used to expand positive experiences. The practitioner then uses paraphrase and summary to clarify what the client has said about the times that were not problematic. “When the two of you are doing something you like together, like bowling or taking a walk, you aren’t arguing.” When the exception has been described, the practitioner inquires about how the exception occurred—who did what so that it happened. Clients may or may not be able to identify what circumstances or actions led to a change. A distinction is made between deliberate exceptions, such as “my partner asked me to go for a walk and even though I was exhausted from a long day of work and taking care of the kids, I agreed,” and random exceptions when the client is not able to distinguish any

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precipitating events. By encouraging the client to elaborate on the circumstances around a deliberate exception, the client can become more aware of recent successes in relation to the concern presented and the desired goals. Successes are highlighted and used to engender hope for future positive changes. Client strengths are also uncovered when a client is able to illustrate what he did differently. DeJong and Berg (1998) recommend that practitioners always attend to strengths and compliment the client for any successes. In the above example, the social worker might offer statements such as, “You seem to have anticipated that going for a walk would be good for the two of you. Even though you were tired, you went along with his suggestion for the sake of the relationship.” Narrative therapy, developed by Australian social worker and family therapist Michael White, provides a philosophy and model that emphasizes strengths and resilience as being at the heart of practice (White 2007, 2011). The goal is to free clients from oppressive cultural assumptions and empower them to become active agents in charge of bringing about change. Change occurs by coauthoring with clients new stories about themselves that emphasize their preferred ways of relating to themselves and to the larger culture. In this way, the practitioner facilitates a transformation in an individual’s or family’s set of dominant stories from ones that are flawed and subjugated to those that are heroic. Drawing on social constructivism, this approach views individuals and families as separate from the problems that happen to them. The strengths focus rests on the recognition that individuals possess many skills, competencies, beliefs, values, commitments, and abilities that can be used to change their relationship with problems in their lives. The practitioner works with the multiple stories in peoples’ lives, cognizant of both the dominant, problem-saturated stories and those that are alternate, subordinate, or subjugated. These latter stories are located outside the problem and contain individuals’ and families’ strengths and abilities to change. The practitioner seeks rich descriptions of these stories, drawing out strengths. Through par ticu lar tellings and retellings of these subordinate stories, clients can be helped to develop preferred ways of being. The power of the intervention is conceptualized as based on externalizing the problem, locating the alternate story, and retelling it in the presence of witnesses, the social worker and the reflecting team. Since narrative therapy is highly specialized, social workers who aim to use this approach will need to have advanced training. For a generic practi-

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tioner, it provides an interesting value-based way of thinking about the ways we construct and express our views of self and others through the use of language. The discussion of language and neuroscience was discussed in the previous chapter. Focusing on Both Strengths and Obstacles

A focus on strengths does not avoid a realistic appraisal of existing barriers or obstacles to change. The approach presented in this text gives primacy to the nature of the relationship and the ways the two participants are able to develop a helping system. Individual client factors, however, can assist or impede the formation of a working alliance. The nature of the two individuals, the worker and the client, are active ingredients in determining the nature of an alliance. Earlier, we discussed the contributions of practitioners and the way ongoing self-awareness and reflection assist us in being client centered and intentional rather than reactive in our work. Similarly, the client’s stance influences both the relationship created and the ability to extract something of use from the meetings. For example, individual change can be assisted or compromised by people’s willingness to risk engagement. When mistrust, skepticism, and hostility toward professional help are predominant, it may compromise the client’s ability to take an active and collaborative position. Two extensive reviews of client involvement in the related field of psychotherapy found the following client factors highly predictive of positive results: cooperation, personal investment, openness, and collaboration, rather than a dependent or controlling posture (Garfield 1994; Orlinsky, Grawe, and Parks 1994). Some clients may demonstrate these attitudes in the beginning stage as a by-product of their personal style. For clients who are ordered to see a social worker for counseling or therapy, it is understandable that they may initially present with hostility or guardedness. The challenge for social workers is to help clients arrive at a position that is more likely to help them benefit from the meetings they must attend. Social workers performing mandated roles, as in child protection, for example, are uniquely challenged to balance strengths-based approaches with their duty to protect children from maltreatment; they invite collaboration and also are obligated to assert their authority when necessary. An extensive study of this type of practice reveals tensions in enacting what Oliver terms firm, fair, and friendly practice (Oliver 2017; Oliver and

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Charles 2015a, 2015b). The social worker invites maximum collaboration by asking for the client’s input on all matters, remaining open to criticisms, and seeking strengths to use in constructing safety plans. Social workers also acknowledge their authority and work to reduce the power differential based on their perception of the client’s abilities and the degree to which the client can engage with the worker. Workers maintain clear boundaries and aim to be transparent, especially about their mandate and authority. Studies discussed in chapter  6 underscore the importance of humanistic qualities when working in mandated settings (de Boer and Coady 2007; Ribner and Knei-Paz 2002). Oliver (2017) studied social workers who used a strengths approach in child protection and found the “moral imperative to treat fellow humans well because they are human was the driving force in keeping the strengths-based relationship honest and authentic” (149). Barriers to change can come from significant intimate relationships or family and extended kin systems, especially when individual change will affect these relationships. Family systems theory highlights that change in an individual will have an impact on others in the person’s relational world (Nichols 2010). Parts of a system may react positively or negatively to change in one member’s behavior. This can occur in extended and nuclear families, in intimate couple relationships, between close friends, and in work groups. For example, a twenty-seven-year-old man has been working with a social worker to explore whether he is able to live on his own. He has lived with his parents, who have helped him with many of his physical needs since he became quadriplegic after a diving accident in late adolescence. His parents may react positively to this move, supporting his independence and autonomy. Or, they may perceive this move to be unrealistic and, fearful for their son’s safety, may discourage any further thought or discussion about it. Social workers often work directly with the significant relational systems in a person’s life, such as an intimate partner, sibling, nuclear family, or subsets of the family-of-origin. At times, this may not be possible, as the relevant family member is not willing to participate or is geographically unavailable. In other instances, the individual client may not wish to involve others in the interviews. When forced to work with an individual alone regarding relationship issues, it is important to “think systemically” and devote attention to the interactions and experiences of the primary client with the influential people in his life.

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Naturally occurring networks, such as neighbors, friends, teams in work organizations, and colleagues in faith-based organizations can be sources of great help or present barriers to change. If these associations are experienced by the client as exploitative, undermining, burdensome, or problematic, the focus may change to helping the client reevaluate membership in these systems. For example, youth members of violent gangs must go against the prevailing gang culture if they want to complete high school and obtain a legal form of employment. Not as clear-cut are those situations in which immigrant or undocumented women, especially those who do not speak English, are living with physically abusive husbands. These women may periodically seek shelter, but they report that they risk losing acceptance and their position in their ethnic communities if they choose to call the police or seek a legal separation from their spouse. Client strengths and goals are compromised not only by small systems but by larger systems as well. Social workers understand that structures in society can systematically create barriers for groups of people, such as women; people from visible minority populations; gay, lesbian, bisexual, and transgendered people; immigrants and refugees; the elderly; and people with visible and invisible disabilities. Barriers take many forms and include lack of access to or availability of needed resources. Useful programs and ser vices may not be present in an individual’s community, there may be long waiting lists, or the eligibility requirements may exclude the client. Furthermore, social ser vice, educational, and health policies and programs that are designed with the intention of helping people often include ideologies, regulations, and procedures that actually defeat their own goals of enhancing the social functioning of their clients. For example, application materials and processes for entitlements may be so difficult to understand and complete that individuals who attempt to do so, give up in frustration. In another example, individuals who complete retraining programs may not have needed resources to remove themselves from receiving welfare and support benefits. They need funds to purchase clothes appropriate for employment interviews. Also, if the individual has parenting responsibilities transportation is needed if the individual lives a distance from the employment site and cannot spend long periods of time on public transportation. Retraining programs need a broad perspective that considers such issues and goes beyond the aim to teach only new vocational skills.

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Trauma- Informed Practice

When examining strengths and obstacles, it is also important to understand and acknowledge the impact of past trauma on clients. Increasingly, social workers recognize that many clients have histories of great deprivation and negative life events, histories that will affect the way they present in an agency and how they engage with professional helpers. As a result, social work has embraced a trauma-informed perspective. The American Psychiatric Association (2013) defines trauma as “an exposure to an extraordinary experience that presents a physical or psychological threat to oneself or others and generates a reaction of helplessness and fear” (Levenson 2017, 105). The Adverse Childhood Experiences study examined the relationship between exposure to early adversity in a sample of Americans and found a strong relationship between early adversity and a wide range of health, mental health, and behavioral problems in adulthood (CDC 2013; Felitti et al. 1998). Trauma can also be experienced due to sudden and unpredictable events such as natural disasters and accidents. In the helping professions, attention is often directed to trauma in the family context in the form of single or repetitive threats. Clients attending social ser vice agencies and health care settings may have grown up in chaotic or toxic home environments and experienced early trauma. These extremely negative surroundings in early life can produce states of hyperarousal that activate fight-flight-freeze responses. Previous discussion in chapter 4 about attachment and in chapter 10 about neuroscience highlights how such early experiences can affect attachment patterns and contribute to the development of distorted cognitive processing and cognitive schemas as well as challenges in emotional regulation that produce difficult reactions and behaviors. Highly traumatic early experiences can profoundly affect one’s sense of identity, and expectations of others in intimate and family relationships; can cause difficulty in emotional self-regulation and impulse control; and can impede the ability to accept criticism (Anda et al. 2006; van der Kolk 2006). Psychodynamic and attachment theories have always emphasized how past experiences are internalized and inform present social functioning; empirical research further supports these conclusions (CDC 2013; Felitti et al. 1998). When social workers elicit histories of such difficult early experiences, or surmise their existence from limited information shared by clients, they

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can use a set of trauma-informed principles to think about the impact on the client’s current social functioning and also interpret the client’s behavior during sessions with the practitioner (Levenson 2017). An important distinction is made between trauma-informed care and trauma-focused therapy. The latter uses specialized approaches to directly treat trauma not only from childhood but also from, for example, experiences in battle conflict, natural disasters, car accidents, assaults, and terrorist attacks (van der Kolk 2015). In comparison, in a podcast Smyth (2013) points out that trauma-informed care is a perspective that provides a context for practice. Smyth notes that trauma-informed care started as a movement by survivors who observed that the way systems offer ser vices for victims of trauma can frequently become a retraumatizing experience due to procedures, expectations of client compliance, and attitudes of staff. Trauma-informed care is a philosophy that can be valuable when clients request help or are mandated to attend counseling for issues not directly related to trauma treatment. This perspective can be helpful in understanding clients presenting with serious concerns such as mental illness, substance abuse, homelessness, and child welfare. A wide range of current issues may be affected by their past victimization. The social worker “neither ignores nor dwells exclusively on the past trauma.” Rather, “practitioners are sensitive to the ways in which the client’s current difficulties can be understood in the context of the past trauma” (Knight 2015, 25). Consistent with a focus on understanding current behavior in relation to both past and current events, social workers are aware of how clients’ reactions, which may appear maladaptive, can be understood in relation to what has happened to them in the past and the coping strategies they used. For example, Burns (2017) describes a woman in her late fifties who had been the victim of decades of violent spousal abuse. Since her spouse threatened to kill her and her daughters if she left the relationship, she stayed and tried to protect her daughters; this left her fearful, demoralized, and depressed. Now abandoned by her husband, she experienced pervasive feelings of unworthiness and guilt for not being able to leave him, felt wary in the presence of men, and could not trust potential new partners. These dynamics were evident in her difficulty in engaging with members in her group for abused women or with her social worker. Smyth (2013) states that the core assumption in trauma-informed treatment is “what happened to you, not what’s wrong with you.” Practitioners

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are not expected to be experts in specialized trauma treatment, or even to explicitly ask the client about a trauma history. Rather, the recommendation is that they work with the understanding that trauma may be present. Past experiences can have a significant effect on the client’s current feelings, thoughts, and expectations. In turn, social functioning may be compromised and relationship building may be challenging (Greaves and Poole 2012). Smyth (2013) recommends using principles such as collaboration as opposed to compliance, understanding the need for safety, and supporting client choice and empowerment whenever possible. These principles are used in conjunction with generic practice approaches or with specialized models to enable rebuilding of healthy interpersonal skills and coping strategies. In addition, consistent with social work’s person-in-environment perspective, practitioners in many situations will need to work with systems to provide ser vice in a manner that is sensitive to the client’s particular needs. For example, a young male refugee approached the agency for newly arrived families for help with finding classes to learn English and to find employment. He had experienced early physical abuse in his own family and ran away in mid-adolescence, finding marginal employment to support him. Traveling with other young men, he had been able to leave his homeland, but the journey to North America had been fraught with tremendous hardship and he had survived by being persistent and demanding. Using a trauma-informed perspective, agency social workers understood his behavior, but frontline staff found his stance threatening and reacted in a punitive manner, focusing on bureaucratic procedures and often denying his requests, which further exacerbated his aggressive and demanding behaviors. The temptation in such a situation is to negatively label the client. A trauma-informed approach recognizes how past noxious experiences and the individual’s related coping mechanisms have become internalized. These dynamics are played out when similar current situations are felt as triggers that produce reactions which are nonproductive in the current environment. Agencies working with clients who are likely to have had trauma in their past need to pay attention to the organization’s culture and the way they provide support for their staff. As reviewed in chapter 3, well-being and self-care approaches are effective when organizations and social workers mutually address important issues.

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developing new perspectives

As noted in the previous chapter, the social worker brings her expertise in understanding and working with the process when meeting with clients. In the context of a supportive, empathetic relationship and through exploration, both problematic and positive elements in the client’s life are examined in depth. The focus is on identifying surface and obvious factors as well as illuminating internal and underlying dimensions of which the client may not be fully aware. Through conversation with the worker, clients can begin to gain some expanded understanding of the links between the current situation, relevant past and current dynamics, and themes that cross various aspects of their lives. The social worker’s focus, the questions posed, the validations of strengths, and exploration of barriers all provide external feedback so that another perspective of self and the world may emerge. Listening to the social worker’s viewpoint, the client can begin to gain some distance from the immediate situation, which in turn enables development of new perspectives. This is akin to psychodynamic practice, which is supported by neuroscience and attachment concepts discussed throughout this text and in the previous chapter. Specifically, this reflective, affective, and supportive discussion engages what LeDoux (2002) refers to as the high road bringing to bear cognitive processing of previously out-of-awareness, unconscious, and often painful emotional reactions. Through mutual attention to and discussion of emotions, associated experiences, and meanings, together the client and social worker can work toward the development of emotional regulation, expanded cognitive understandings, and more positive perspectives of self, other, and relationships. Similar change processes can be found in a number of specialized approaches, but different terms are used. For example, psychoeducational approaches can be used to explain the interaction among biological, psychological, and social phenomena, and provide information to develop new perspectives. Cognitive behavioral approaches (briefly summarized in the previous chapter) use a range of interventions to challenge and modify maladaptive cognitions that result from faulty information processing. These interventions challenge automatic thoughts and core beliefs, replacing them with more positive perspectives. Narrative- and solution-based approaches, discussed above, focus on client’s strengths; exceptions to problematic experiences; and locating, telling, and retelling stories that provide alternate

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perspectives. Alternate perspectives are found that illuminate resilience when the social worker and team reflect viewpoints that are different from the one presented by the client. As noted earlier, former clients report that putting words to their experiences in the sort of therapeutic relationship presented in this text stimulates what Tallman and Bohart (1999) refer to as “generative thinking” (112): the human capacity for thinking about issues, figuring out what is happening and what is important, considering alternatives, reviewing one’s experience, and generating possible solutions and outcomes for each way of responding. They note that when in a helping context, the practitioner’s role is to elicit and support these naturally occurring processes. Since the development of new perspectives is the goal of many change models, a range of techniques can be used to reach this goal. Social workers vary along a continuum in being more or less direct in going beyond providing focus and using gentle questioning to providing active feedback and their interpretations of dynamics that perpetuate key issues. Questions can be used to help the client examine assumptions that were previously seen as fixed and rigid. Social workers’ explanations or interpretations, offered tentatively as hunches, can help clients understand how their recurrent reactions are indications of unacknowledged thoughts, feelings, and expectations of self or others. A social worker’s use of gentle challenge or confrontation and reframing are also ways of helping the client to unfreeze rigid perceptions and consider alternative possibilities. Finally, another way for social workers to help clients gain new perspectives is by offering information about resources, psychological and social phenomena, and relevant medical or mental health issues. These techniques are discussed in the final chapter on interviewing skills. Since all of these techniques are provided within the context of an accepting relationship, the client is likely to feel supported rather than judged. Clients are helped to see that what they do, how they feel, or how they interact with others makes sense, given unique personal and family histories, as well as the cultural values and sociopolitical forces, they have experienced. With better understanding of their motivations and reactions, clients can more meaningfully begin to consider whether their typical ways of dealing with situations in their life are likely to meet their needs in a way that is consistent with their self-image and goals. When clients reflect on current and past factors that impact their behavior, they can be helped to separate out what was appropriate in earlier and different interpersonal

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relationships from what they can choose to do and who they wish to be in the present. For example, a client reflected on how homophobia in his workplace had led him to take a distant and isolated position with colleagues. He wondered whether with changed societal attitudes toward gay and lesbian people and a diverse workforce, in his current job he might be able to be less vigilant about discrimination and allow himself to be known and to know others with whom he worked in a more authentic way. By developing new perspectives, individuals can come to feel differently, and more positively, about themselves. Attributes that might previously have been experienced as negatives about the self may now be understood as contributing to personal resilience and a reasonable or effective response to a difficult external situation. Areas of strength that an individual previously took for granted may now be perceived as evidence of abilities. Realizing that these qualities or attributes can be applied in other situations can build self-confidence and self-esteem. Such feelings about oneself can positively impact an individual’s deliberate attempts to make behavioral changes. As reiterated throughout this text, social workers draw from the personin-environment and ecosystemic perspective to help clients sort out the contributions of individual, relational, and societal or structural issues to experiences in daily life. They balance the identification of what needs to change in the environment, in the client, and in the interaction between the two. It is extremely helpful for clients to take responsibility for what they bring to difficult situations and also to recognize what is not their responsibility and what are burdens they experience from factors beyond their individual control. Providing information and education about issues that clients might not usually have knowledge about can be useful in this regard. When clients recognize the impact of external forces, social workers can discuss with their clients whether they wish to involve themselves in community or social action. ta k i n g a c t i o n

Recall the discussion at the end of chapter 7 regarding the stages of change formulation developed by Prochaska and colleagues (Prochaska, DiClemente, and Norcross 1992; Prochaska and Norcross 2002), and the identification of the following stages: precontemplation, contemplation, preparation, action, maintenance, and termination. This work helps the practitioner recognize how much readiness to change the client is experiencing

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and importantly when it is appropriate to engage in action planning. Individuals do not progress in a linear fashion through these stages; back-andforth efforts are to be expected. It can be assumed, however, that as the processes discussed in this and the previous chapter unfold, the client is moving through the contemplation and preparation stages, and is now more ready than initially to take some action toward change. An important question is, what should the focus be for change efforts? Initial assessment, formulation, and goal setting occur during the beginning phase, and likely have been deepened through the processes discussed in the middle phase thus far. The initial goals may change, but likely focus on the individual, the environment, or the interaction between them. Individually focused change may begin in any aspect of feeling, thinking, and behaving about specific or general dynamics. Since these dimensions are interrelated, change in one aspect will probably cause a reverberating effect in the other factors. Clients have reported a “surge of energy and an elevation in their mood” (Watson and Rennie 1994, 504) with new emotional and cognitive insights. This, in turn, seems to provide the impetus for making behavioral changes. When aiming to replace old patterns in the client’s life, there are two dimensions to consider. First are the client’s new adaptive responses in interactions with others. Second is to anticipate and manage others’ potential responses to these changes. Thinking systemically, a change in one part of the system will have repercussions, not always in the hoped-for direction. For example, a man in his early sixties, who typically adopted a distant position in family, social, and work relationships, came to recognize how that pattern conveyed a message to others that he was not interested in them, leaving him feeling isolated and disengaged from others. As he tried to change this behavior with more proactive interpersonal initiatives, he observed that his efforts were not always well received. His children did not immediately respond to his overtures, perceiving them as out of character and “too late.” His spouse resented his intrusion into areas of their life that had previously been her domain. Coworkers were suspicious of his motives to extend their relationships beyond fixed and familiar parameters. When clients experience reactions such as these in relation to their change efforts, constancy and encouragement to persist is crucial. The social worker not only provides support to the client to continue making efforts but also helps the client consider others’ reactions and their possible thoughts and

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feelings in relation to these new behaviors. Reviewing a number of studies on what clients say was helpful in counseling, Bohart and Tallman (2010) highlight “support for trying out new behaviors” (93). When contemplating taking action, it is important for the social worker to convey a realistic and positive vision of what the future might consist of for the client. The social worker should also offer hope; this has been identified as one of the common factors across models and is associated with individuals’ thoughts about their ability to move toward their goals (Snyder, Michael, and Cheavens 1999). These researchers identify two components of change. First is pathways thinking, one’s ability to think about various ways out of a situation, and second is agency thinking, one’s appraisal of his ability to actually take action and proceed on a selected path. If an individual cannot see potential ways out of a situation or feels he does not have the ability or resources to move along in such a direction, then he is likely to become immobilized and cannot easily bring about any change. Through conversations together, the client and social worker consider alternatives and the client can examine potential directions. In such a dialogue, the practitioner may offer information, suggestions, and questions that begin with “what if . . .”; brainstorm with the client; encourage the client to imagine possible future scenarios; and use stories illustratively. When offered within a collaborative relationship, this type of dialogue stimulates the client to develop his own ideas about what he wants to do differently. With a clearer sense of the goal, the focus then shifts to what initial steps are needed, that is, determining the pathway along which the client can begin to reach that goal. In addition, consideration needs to be given to what conditions are needed for the client to take those steps, that is, agency thinking needs to be taken into account and efforts should be made to identify and then support what the client believes he needs to increase his ability to take that action. Returning to the case example above, the social worker inquired, “What do you need to happen in order for you to continue to reach out to your adult children even though they are resentful that you were not there for them when they were younger?” Through exploration and discussion, the client, with the social worker’s help, recognized that to demonstrate to his children his sincerity and commitment to forging a better relationship with them, he needed to be persistent and reliable. In turn, he believed that he needed the social worker’s support at this

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point to help him maintain his hope that with his best efforts, his children would ultimately believe him and allow more connection with him. Change does not usually occur easily and progressively. There are many instances of a process more akin to “one step forward and two steps backward.” Individuals can momentarily loose hope when their new efforts do not elicit a favorable response from others. Similarly, there can be unanticipated challenging consequences of taking new initiatives. For example, a single mother with two children had invested great time, energy, and hope in upgrading her employment situation only to encounter new stresses with full-time employment, restrictions on day care availability, and her children’s distress about her increased absence. When clients recognize that there are societal or organizational situations that are beyond their power to change, social workers may wish to point out opportunities in the community for clients to join with others to work for social change that increases ser vices or changes in relevant governmental policies. Some clients choose not to identify themselves with social causes that have an impact on their lives, whereas others gain a great sense of empowerment and relief from working with others in similar situations. For example, a young mother of an autistic child was reluctant to join a parent group that was lobbying the school board to provide special classes for children with autism. She felt that all of her energy was devoted to caring for her daughter and providing extra stimulation for her. She was still struggling with the emotional and practical implications of the diagnosis and fears about her child’s future. She stated that becoming part of a group of parents in a similar situation “only makes me feel worse about the diagnosis.” Contrast this with a young woman who had two bouts of cancer and became a community advocate for special ser vices for women with cancer. She states, “working together with others with this terrible condition gives me energy and hope for my future.” The interview can provide the chance for clients to try out and rehearse new behaviors. Social workers can discuss potential scenarios from the point of view of each participant and offer coaching or role play. Possible future conversations can be enacted, with the social worker making comments that help the client consider and rehearse alternative behavioral responses, such as, “What might you say if your daughter tells you she is not interested in your feelings?” or “How could you respond to her so that your anger and hurt don’t push her further away?” The social worker might also provide

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suggestions through coaching, such as, “Have you thought about telling her that you can understand her feelings?” It is usually worthwhile for practitioners to draw links between the client’s insights and emotions, and how new intentions take shape in everyday life. Unless the internal gains made in the interview are carried into clients’ significant experiences and relationships out of the interview, change will not happen where it is most meaningful—in the client’s life. Planning next steps and conveying realistic confidence in the client’s ability to take those steps can facilitate mastery experiences for the client. When a new course of action is discussed in a session or homework tasks are agreed to, it is crucial that the worker follow up in the next meeting with inquiries about what transpired and the results of what was done differently. When clients report successes, these should be explored and reinforced with inquiries about how it was accomplished and the client’s subjective experience of doing, thinking, and feeling differently. Frequently, clients and practitioners will gloss over successes and return to a focus on problems. Solution-focused therapy has provided useful insights and techniques for amplifying those client actions that are exceptions to the problem, that yield success, and that can be usefully generalized to other aspects of a client’s life (de Shazer 1985). While the relationship provides the emotional support for risk taking and new learning to occur, it is crucial that the client recognize what he did to bring about that change and reflect on the new healthy interpersonal skills and coping strategies used. Furthermore, in the interests of the client’s self-development, the client identifies the impact of this new behavior on his sense of self. at t e n d i n g t o p r o c e s s a n d c o n t e n t

Throughout the middle phase, the worker is attending to two dimensions: (1) the interpersonal work with the client, and (2) the progress toward goal achievement. While these dimensions are intertwined, they can be conceived as consisting of a process component and a task component. The first component focuses on the processes of change discussed in this and the previous chapter and the social worker’s behaviors or interventions that facilitate changes. This component includes attention to the alliance: the client should continue to feel understood and accepted by the social worker, there should be collaboration, and the social worker and the client should

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be focusing on issues that the client deems relevant. The second component focuses on working toward achieving the goals and requires attention to outcome. One aspect of the Integration of Theory and Practice Loop, discussed in chapter 3, is the importance of evaluating progress. An ongoing reflective stance is recommended, one that considers the impact of the social worker’s interventions on progress toward achieving the client’s goals both within and after sessions. Attending to Pro cess: Maintaining the Working Relationship

It is important to remember that the work with the practitioner in the interview is always in the interests of providing a context, experience, and activities that will prompt, support, and facilitate the client’s active engagement in change efforts. As noted throughout this text, when individuals’ external environments do not provide nourishing well-functioning interpersonal relationships that could help them solve problems in everyday living and provide support and assistance, professional helpers can offer a safe “place and space” where the self-healing processes of thinking-feelingbehaving can occur (Tallman and Bohart 1999). Recall the extensive discussion of the helping relationship in chapters 4 through 7 and the well-supported finding from extensive empirical research that the helping relationship is a potent factor in bringing about positive change for the client, far more so than the techniques of particu lar models (Norcross 2011; Wampold and Budge 2012; Wampold and Imel 2015). Furthermore, a recurring finding from studies of effectiveness is that it is the client’s experience of the relationship that is associated with outcome, more so than the ratings of the social worker or observers (Duncan and Miller 2000). The practice principle emanating from this research is that practitioners need to stay highly attuned to clients’ perceptions about the working relationship and actively inquire whether it is offering the components that each client believes are important. Such feedback empowers clients, makes explicit that the process is a collaborative one, and provides information to allow for change in the middle of the work rather than after the fact. Two brief, easily administered measures to monitor the alliance and the outcome were discussed in chapter  4: the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS) (Duncan et al. 2010). With respect to the relationship, there are four items that clients respond to by indicating

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on a continuum their experience of the working relationship, the goals and topics they wished to address, and the goodness of fit with the practitioner’s approach. Campbell and Hemsley (2009) found that both scales demonstrate good reliability and concurrent validity when compared with more complicated and longer scales. Most social workers do not use scales to monitor relationship connection, however. Rather, they are attuned to both nonverbal and verbal behavior that indicates that certain elements are either missing or helpful. Practitioners strive to incorporate information from such feedback into meetings with the client if it can reasonably be included. Working relationship elements may be about bonding and a sense of being listened to and understood, or about pace, style, frequency and duration of sessions, topics for discussion, tasks undertaken, and attention to the clients’ goals. These elements reflect a range of client characteristics, from individual attachment and personality styles, current needs, and motivation, to sociocultural norms and conventions, to the client’s readiness for change. The preferred style for practitioners is one that is professionally appropriate, flexible, and accommodates the client’s wishes when possible. Across studies, practitioner characteristics that clients universally describe as helpful are warmth and caring concern, acceptance, genuineness, understanding, and empathy. Studies also show that practitioner negative behaviors such as blaming, ignoring, rejecting, and being judgmental are destructive to working relationship maintenance (Lambert and Barley 2002). Social workers can be faced with challenging clients, such as clients mandated to attend sessions. Consequently, clients may behave in a negative, attacking, or hostile manner. Practitioners work hard at understanding the underlying dynamics and issues that may produce this behavior, avoid critical or defensive responses, and maintain an engaged client-centered stance. This requires practitioners’ heightened awareness of their cognitive and affective processes and active reflection to manage understandable, but potentially negative, reactions to and behaviors with clients. Throughout this text, the collaborative nature of the working relationship and the usefulness of a stance that promotes client collaboration have been emphasized. To accomplish this, in the beginning stage the social worker presents the work as collaborative. This principle is demonstrated in the many comments social workers make that seek feedback, such as asking directly whether they have understood clients and asking clients for their ideas about topics under discussion. Explicit statements about working as a

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team (“putting two heads together”) and brainstorming about ideas and possible solutions reinforce this notion. Reinforcing the concept that clients are the experts on their own lives, their culture, and any relevant social identity characteristics is consistent with this approach. In the middle stage, the social worker can enhance the working relationship by referring to positive experiences that the client and social worker have had together, especially when they find themselves at a difficult point in their work. For example, a woman in her early sixties who had immigrated from India twenty years earlier observed that as she got older, she missed her extended family network back home. She found herself feeling lonely, especially at times of family celebrations that she was not able to attend. She expressed regret that she had agreed with her husband to leave her home country for the benefit of their own children. When there were family events back home, she felt depressed and resentful. The social worker had initially seen the client at such a time and could draw on these earlier experiences together to remind her that she had faced such feelings before and that they had spent time discussing her situation and reactions, out of which emerged a number of insights and decisions. She had recognized that her feelings were normal and expected, a product of having been raised in a close and supportive extended family. She also recognized that it was at these times, when she acutely felt the physical distance from her relatives, that the client needed to be actively involved with friends in her local community who could be supportive and understanding. She saw that her depressed feelings led her instead to withdraw, further exacerbating her depression. Together, the client and social worker had come to appreciate that while difficult to do, the client’s initiative to seek support from these friends had ultimately been very helpful to her. Such recall of joint work helps the client acknowledge and draw on her own previously successful coping strategies. It also strengthens the working relationship bond, which in turn helps the client move beyond the demoralization that accompanies her depressed feelings and experience some hope that she will get some relief through both discussion of the issues in the sessions and taking actions that helped in the past. Even when a positive working relationship has developed in the beginning stage, it too can wax and wane during the more challenging phases when change efforts are actively pursued. Practitioners need to remain sensitive to strains and tensions, and take the initiative to explore what feelings might be operating but unexpressed by the client. Studies have found

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that clients will continue to attend sessions even when they report that they did not feel the worker really understood them or they did not find the meetings helpful (Hill et al. 1993). Given this finding, it is useful for practitioners to make explicit not only in the beginning stage but also throughout the meetings that discussion of the relationship, including negative feelings, is expected and important. Safran and Muran (2000; Safran et al. 2002) provide an extensive discussion of ruptures in relationships, defined as a negative shift in the alliance that can be experienced as a tension or breakdown in the relationship. Ruptures vary from minor tensions to major issues that can threaten the continuity and progress of the work. To deal effectively with ruptures, they recommend that the social worker first identify where the difficulty lies: Is there disagreement about the goals or tasks, or are their strains in the nature of the bond? If there is obvious disagreement about the tasks, for example, when an adolescent female client maintains that she wants individual sessions and will not attend if the social worker pursues involving the rest of her family, the worker may agree to this in a direct manner. If there is disagreement in the goals, such as the client wanting to focus on peer relationship difficulties while the presenting problem and referral was to increase her school attendance, the social worker will need to find a way to accommodate both goals. The client may indicate a problem with the bond. This may occur nonverbally or verbally. For example, the client may appear annoyed when she notices the social worker subtly checking her screen or device for texts or e-mails during the session, even though the client does this herself. This annoyance may be demonstrated by the client providing fewer and fewer responses to the social worker’s comments. If the worker recognizes these dynamics, she may respond indirectly by putting her device away and positioning herself away from her screen, thus adopting a more attentive stance. Experienced workers continuously and intuitively respond in indirect ways when they sense that the client is feeling misunderstood or uncomfortable in some way. If the client verbally tells the worker that she feels the worker does not understand what her concerns or struggles are, the worker would need to more actively pursue information about these concerns and listen more carefully to what the client is expressing. Repairs to disjuncture in relationships can be addressed at a surface or underlying level of meaning. In the previous example, the client is an adolescent in her late teenage years. Her mother and stepfather have expected

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her to provide extensive caretaking of her younger step siblings. Her adamant refusal to have family sessions could be addressed at the surface level by providing a rationale for family work since the issues are about her perception of the unfair division of chores in the home now that the younger children are also teenagers. If her refusal were addressed on an underlying level, the social worker would explore an important theme for the client— her perception that she must always share with her siblings. Her anger at the social worker would be linked to her disappointment that the counselor would no longer be there exclusively for her. Although social work practice theory encourages direct expression of clients’ negative or critical comments, it is human nature that practitioners may experience such comments as personally distressing. They may feel these comments indicate something about their personality or their competence and suitability for this type of work. It is natural to respond to criticism with fight-or-flight responses. Subtle and covert negative reactions can also occur, such as withdrawing emotionally and becoming guarded, passive, or relatively silent during the sessions. These sorts of reactions between the client and the social worker, with each contributing negative communication behaviors, can create a nonproductive interaction cycle. When confronted with negative feedback from clients, it is more useful for social workers to listen carefully and clarify the client’s concerns, including the client’s perception and interpretation of the worker’s behavior. Although it may feel uncomfortable, it is important for workers to take responsibility for their contribution, acknowledge this with the client, and apologize for a mistake or hurtful comment. Although practitioners may be surprised by clients’ views about the interaction and perceptions of the social worker’s interest, workers can recover from these disjunctions in the relationship and manage their own feelings effectively. Through both exploration with the client and reflection and debriefing after the session, on their own or in supervision, they are likely to learn something of value about clients and about themselves. Attending to Content: Monitoring and Supporting Goal Achievement

Goal setting, which is an integral part of the social work process, was discussed in chapter 4 in relation to developing the therapeutic alliance and again in chapter 9 in relation to developing an assessment based on joint

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understanding. Social workers keep focused on the goals of the work and attend to indications of progress or lack of movement toward achieving positive outcomes. A number of methods presented in those chapters include self-anchored scales, goal attainment scaling, or use of standardized measures such as the ORS about the client’s experience of progress toward the goals and the SRS about the client’s experience of the alliance (Duncan et al. 2010). Outcomes from social work intervention can be a change in the presenting problem; a change in the client’s ability to to understand the situation and circumstances that led to seeking help; a change in significant interpersonal relationships, such as those with intimate partners and family members, and in social and work relationships. Clients involved in mandated ser vices may meet the conditions of the court or the agency while also gaining personally from the required involvement with the practitioner. For example, in child protection interventions, the client may learn new parenting skills and how to effectively work with the agency social worker so that the client can request support and resources if difficulties arise in the future. When the presenting problem is due to a lack of resources, a crucial outcome is that the client experiences a significant improvement in basic human requirements such as food, shelter, and housing. This may be as a result of the client’s efforts, such as successfully completing a training course and finding employment, or as a result of successfully linking with a ser vice that provides the resource that was absent. The social worker continuously reviews process and outcome to determine whether progress is being made. When there is less than optimal movement, as suggested by Safran and Muran (2000), it is useful to consider whether the goals, methods, or tasks are appropriate for the particular client and situation. Was the client in a stage in the change process that was matched by the worker’s interventions? Or did the social worker assume that the client was more ready to take action then he actually was? When the goals are not being achieved, it may be timely to reconsider the original goals. Were they realistic, was the client a full participant in defining the goals, and were they truly agreed-on? Did the goals sufficiently capture the client’s underlying feelings that may have affected whether or not they could be achieved? For example, a gay male client requested help to leave a relationship that he felt was no longer meeting his needs. After a number of sessions, it became evident that he had very mixed feelings about his partner

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and was confused about whether or not the best course was to work to improve the relationship or to leave it. In the initial sessions, these feelings had not been explored, and when they surfaced, it became clear that the client was still in a contemplation phase, not an action phase. The client and social worker reconsidered the goal and decided that resolving his mixed feelings was the necessary first step. Conjoint couple therapy was agreed on as a method to help the client determine whether the blend of independence and interdependence he wanted was possible in this relationship. It was only after a few months of conjoint therapy with his partner that he came to the conclusion that the relationship dynamics were too rigid to allow for the kind of changes he wanted. Through the conjoint work, he achieved the clarity and conviction he needed to work on the initial goal of leaving the relationship. In this example, the goal was redefined and the intervention methods were expanded to include couples counseling. As the nature of the presenting issues and goals were better understood by both client and social worker, another intervention approach was used, one more appropriate for the concern. In other instances, the initial assessment needs to be revisited and examined to determine whether the approaches and resources introduced are sufficient to meet the presenting needs. For example, when peer tutorial help did not assist a shy and isolated adolescent boy to improve his scholastic performance, the social worker considered consultation with the school psychologist to determine further the nature of the student’s performance problems. This assessment revealed that the student needed professional tutoring for assistance in reviewing the material systematically. Although the peer tutor had helped the student develop social skills that caused him to feel more comfortable in the school environment and happier, it was not sufficient to address his educational needs. By adding a different type of resource, the adolescent was able to meet his goals. In the interests of goal achievement, practitioners are responsible for ensuring that the interviews and the overall helping process is focused and structured. Social workers are expected to make effective and efficient use of time and resources regardless of whether the practice is carried out in an agency, a managed care environment, or in private practice. Maintaining both focus and a supportive working relationship are characteristic of skilled practitioners and are associated with positive outcomes for clients.

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Despite the use of appropriate helping principles, change may not be forthcoming; experienced social workers recognize that facilitating change is not a straightforward matter. Shulman (2016) offers a useful perspective. He recognizes that in the helping process, clients are likely to have mixed feelings about both change and working with social workers. He attributes this to the nature of the process: stressful issues are discussed and associated painful feelings are stirred up; individuals must confront their own contributions to problems, including their long-held beliefs that might be impeding their own progress, and take responsibility for their actions. Clients show mixed feelings about change in direct and indirect ways. Some clients directly tell the social worker that they do not understand what the issues are, or that the topic under discussion is too difficult. More indirect ways of expressing ambivalence are by changing the topic under discussion, going off on tangents, silence, agreeing in a halfhearted way with the social worker’s conclusions while giving nonverbal signals of disagreeing, missing sessions, reluctance to book more meetings, coming late, not initiating topics for discussion, and appearing bored and distracted. It is important for practitioners to be sensitive to the many ways clients can express their ambivalence and recognize that this may be intentional, or more likely is a result of struggling with a difficult issue. Drawing on Schwartz’s (1961) principle of the “demand for work,” Shulman (2016) notes the important role and responsibility of the social worker to keep the interview structured and focused on “what we are here for” (Schwartz 1961, 23) and how the worker and client will work together. The worker does not demand specific changes in attitudes, skills, or behaviors. The only expectation is that there will be mutual contracting and ongoing engagement with the topics agreed-on and their associated feelings. While the term “demand” may conjure up a confrontational and challenging stance, this is not the intent. A social worker’s demand for work, when offered in a supportive manner within a caring working relationship, can be experienced as a powerful motivator. For example, whenever the topic of complying with a restrictive diet is raised, the client, a severely diabetic young woman, adopts an oppositional stance and declares that the topic is boring. The worker acknowledges with the client how tedious the subject is and some of the painful feelings they have already discussed about her eating behavior, and refocuses on their agreement to work to develop ways to help

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the client maintain better health. Shulman (2016) makes the point that the social worker’s expression of empathy and genuine concern for the client must accompany a demand for work. A working relationship that is characterized as accepting and nonjudgmental provides the context within which a practitioner can make demands, use confrontation skillfully, and maintain focus in the work. This chapter continues the discussion of some central concepts and principles for social work practice in the middle stage, where support, change, or both are the focus of the work. Change processes in this chapter built on those presented in chapter 10—developing an expanded understanding and working in depth with links among emotion, cognition, and behavior. This chapter began the discussion of change processes with a consideration of the importance of a strengths focus while also addressing obstacles, and taking past trauma into account. The next change processes discussed were developing new perspectives and taking action. Continuing to build on recurrent themes throughout this text, discussion of change processes related to both attending to process and content completed the chapter. A wide range of specialized models that include particular helping processes beyond those presented in this chapter are found in social work literature and the literature of related human ser vice fields. As a result, social workers today are confronted with a multitude of approaches and techniques, with varying empirical support for the claims made about achieving goals. In chapters 10 and 11, a selection of change processes was gleaned from a review of contemporary approaches. Social workers also select and choose the theoretical concepts, intervention approaches, techniques, and skills that resonate with their own personal styles. In this way, they build their own professional practice model as discussed in chapter 1, integrating the professional knowledge base with the way the social worker uses the self in practice. Moreover, committed to collaborative and empowering relationships, social workers practice in a reflective and iterative manner, drawing on their successes and failures to find and fashion unique helping pathways for each client.

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As the middle stage is coming to a close, social workers “facilitate effective transitions and endings that advance mutually agreed-on goals,” as noted in Competency 8 (CSWE 2015, 9). Practice wisdom has led social workers to value the importance of a “good” ending. A good ending provides the opportunity to review progress the client has made since the initial meeting with the social worker and helps him integrate changes made into his life and take ownership of them, anticipate the future, and bring closure to an important working relationship. The terminology of ending suggests that there has been a beginning, a protracted middle phase, and now the work is finished. This reflects social work practice in counseling situations in which the worker and client have met within a time frame agreed on by both of them or set by the agency, often dictated by funding arrangements. There are other practice situations in which the phases are not clearly demarcated. In the health field, for example, social work intervention frequently occurs in response to a crisis or transition and practitioners may go through all phases during one short contact event or period. In part due to the intensity of a crisis, a helpful and engaged social worker can have a profound effect at such a time, and although there is not a formal ending stage, termination processes presented in the following discussion can be thought of as general principles that can be adapted based on the particular context.

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Many final stage processes are similar to those used earlier in the working relationship. Throughout the middle stage, for example, the social worker and the client regularly review the progress being made toward achieving goals, the tasks and processes that are helpful, and the nature of the working relationship. This type of review is repeated during the termination stage and encompasses reflection on all of the sessions. The difference is that these processes are now used in the interests of ending the work. t h e t i m i n g o f t e r m i n at i o n

Ideally, termination occurs when the client and the social worker believe that the goals they identified are met, enough progress has been achieved, or the client has experienced alleviation of the presenting situation or problem. This can arise during the middle stage as the social worker and client, during review or spontaneously during sessions, observe that changes the client has made to reach the goals have occurred. In this context, the social worker may ask the client whether it is timely to space their meetings further apart with the intention of moving toward ending the work. Consistent with the stance of collaboration, there should be an opportunity for the client to take an equal part in the decision about when to end the work. Clients who have had a positive working relationship with the social worker and who have made progress may feel strengthened and energized by their experience. At the same time, they may also be concerned about losing the involvement with the worker. Some clients are concerned about becoming overly dependent on the social worker and view termination as an indication of their ability to function independently. Managed care policies and agency approaches may also prescribe the number of sessions a client may expect at the organization. When this is the predominant practice, the social worker informs the client that they will be able to meet for the set number of times—often approximately six meetings. A termination time frame is therefore present from the beginning, requiring social workers to help clients set specific goals and maintain a focus on achieving the desired outcomes from the beginning of their contact and throughout every session. Termination may also occur when there has been an agreed-on period of ser vice and the client has made little progress. The practitioner has the responsibility to point this out in an empathic and nonjudgmental

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manner, and to engage the client in exploring reasons for this, including taking into consideration the social worker’s behavior and the approaches taken. A change in approach may be advisable, a transfer to another social worker or ser vice might be needed, or a planned termination with the offer for ser vice at another time might be warranted. As discussed throughout this text, social work effectiveness is dependent on a range of factors, including the nature of the problem, client characteristics, environmental demands and supports, and the working relationship between the social worker and client. There are situations in which, despite the best efforts of all involved, change does not come about. Work by Prochaska and colleagues, reviewed in chapter 7 (Prochaska and Norcross 2002; Prochaska, DiClemente, and Norcross 1992), illuminates this phenomenon to some extent. They identified stages of change, noting that the first three— precontemplation, contemplation, and preparation—can exist for a considerable time. When individuals are experiencing these stages, action-oriented change strategies would be premature and hence unsuccessful. Therefore, in agency settings in which the number of meetings is mandated, it may be useful to frame the work as “episodes of ser vice.” The client may benefit from taking a period of time to contemplate the many pros and cons surrounding change; this may be all he can do at a particu lar time. At a later time, another series of sessions may help him move into an action stage. Many terminations between clients and social work students occur when the student’s practicum period ends. Students may feel guilty and disappointed that they have not provided enough help to the client, and recognize that termination is premature and not in the best interests of the client. In consultation with the field instructor, a transfer to another social worker may be recommended. Transfers can make the termination phase more complex for the client because he is leaving a helpful working relationship at the same time that he must develop a new one with somebody he does not know. In such situations, it is helpful for the worker to review and discuss with the client his perception of his progress, needs, and preferences. Depending on the extent to which the initial goals have been achieved, the client may prefer to terminate the work and reapply to the agency at a later time if necessary. When a client prefers to transfer to another social worker, the student should arrange a meeting between the client and the new worker to facilitate the transition.

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Finally, there are situations in which endings are unplanned, as, for example, when clients announce that they will not return or they simply stop attending sessions. It is important for the social worker to try to explore the client’s reasons for ending the work while respecting her right to do so. When the client does not inform the social worker of termination, the worker should reach out through an e-mail, telephone call, or letter to arrange a conversation in which he may be able to assess what accounts for the client’s decision to stop attending sessions. An unplanned termination may reflect the client’s sense that the working relationship with the social worker is strained or that attending the interviews is unhelpful or too difficult. Given the opportunity to discuss reasons for dropout with the client, the feedback received may assist the social worker to repair the alliance and the sessions can continue. In some instances, attempts at repair are not successful and the practitioner needs to respect the client’s decision, highlighting any gains that the client might have been made. Client-initiated termination can also reflect factors not related to the sessions. For example, if the location and time of the sessions presents too great a burden for the client, an unplanned dropout might simply signal that fact. Client termination can also reflect positive client perceptions. Many practitioners are troubled when clients do not terminate in a planned manner and may feel they have failed the client. Studies show, however, that as many as twothirds of clients who drop out report they have made considerable progress (Fortune 2002). Cultural conventions may also affect the termination phase. Once the social worker has become part of the client’s network of support contacts and is perceived as a helpful and caring person, some clients may expect that the social worker will be a permanent person in their lives. The client might view a formal termination phase as perplexing and feel rejected by it. It is important for practitioners to understand the cultural norms surrounding endings, gift giving, and invitations to significant family events. In many instances, practitioners accept that they will continue to occupy a place of importance in the client’s life, even if they no longer continue to meet within the context of the working relationship. When small gifts, cards, and occasional telephone calls from the client to the social worker are indications of appropriate cultural behaviors associated with transitions, practitioners should graciously accept them and not offer psychological interpretations about their meaning.

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Pro cesses of Termination

• Review pro gress • Consolidate gains • Plan for next steps • Pro cess the emotional bond

p r o c e s s e s o f t e r m i n at i o n

As with processes in the beginning and middle stage, in the termination stage the following processes do not unfold sequentially but are intertwined and repeated: Review Pro gress

Competency 9, “Evaluate Practice” (CSWE 2015), highlights the importance of social workers taking a critical look at their practice to identify the processes that lead to positive outcomes. Social workers should choose the most appropriate methods to discuss progress with clients, to build knowledge for the future, and, an important task, to help clients integrate the gains they have made into their lives. A useful way to introduce the termination stage is to engage the client in a discussion reflecting on the period of time the social worker and client have met. Together, they can recall the presenting situation that brought them together and their initial meetings. They can review the way they initially understood the issues that needed to be addressed and how they approached working on them. Different or expanded understandings and key themes they discovered should be highlighted. Consideration should be given to the progress that the client has made, what has changed in his life, and why it has changed. An observation about themes and topics that are still challenging, difficult, or problematic should also be offered to indicate that individuals are in a constant process of dealing with life’s events and this work of improved social functioning is a lifetime project, whether or not the individual is receiving professional help. Hence, it is extremely helpful when the review includes the client’s and the worker’s perceptions

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of issues that may reoccur or are ongoing. Furthermore, a discussion about what the client and worker have learned should include a realistic evaluation of the strengths and vulnerabilities of the client and her environment. An important aspect of this review is a joint consideration of how the goals were achieved, with particular attention to what the client brought to the effort. With a focus on strengths and collaboration, it is important to help the client identify his attitudes, competencies, and resources that affected the change. The best termination gift the social worker can offer the client is helping her recognize the internal strengths and capacities she can use on her own to change current and future situations in her life. It is also useful for the social worker to hear from the client what he experienced as helpful inputs from the practitioner. Clinical research studies that identify the processes associated with positive outcomes have been discussed throughout this text. The case-by-case feedback that clients give to individual social workers is also invaluable, as it helps practitioners develop specific knowledge about their own practice; indeed, it serves as the most useful “supervision” and continuing education one can receive. Seeking regular client feedback is consistent with processes discussed throughout this text and supports the notions of deliberate practice discussed in chapter 3. Through extensive studies in social psychology (Ericsson 2004) and emerging studies in psychotherapy (Chow et  al. 2015), researchers have found that better per formance is achieved when practitioners focus in a deliberate way on improving their performance. Recall that a range of activities were identified by helping professionals, including social workers, such as supervision with and without review of session recordings, live supervision, reviewing recordings of sessions on their own and with peers, discussing sessions and therapy in general with peers, thinking about sessions, writing notes about sessions, reading journals and therapeutic materials, attending workshops, and participating in self-care activities. Chow et al. (2015) found that social workers who spent more time on their own on activities that focused on reviewing their practice had better client outcomes. Consolidate Gains

During the termination phase, while reviewing clients’ progress social workers focus on helping clients identify and take ownership for what they

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did to bring about change. An important goal of social work practice is to build client capacity for independent functioning. Hence, it is useful to bring attention to the client’s strengths and new ways of thinking, feeling, and behaving that have developed. This type of feedback and resulting client ownership increases a sense of mastery and recognition of capacities that she can use in future situations. Through exploration guided by the social worker, clients can be assisted to distinguish between individual and environmental factors. Social workers should examine which changes result from the client’s new thinking, feeling, or behavior and which changes result from contributions from significant social relationships and environments that include interactions with family members, friends, and work colleagues. Clients can then extrapolate and generalize to consider what factors and circumstances will be important for them to have to maintain their achievements. For example, a young man who had been a member of neighborhood street gangs was able to break out of what he identified as “bad, old habits” through his sessions with the social worker and during addiction treatment. He was aware that loneliness could lead him back to his former peers, and during the termination phase he discussed many strategies he had developed to avoid being lonely, including returning to see the social worker if he felt he was slipping. The social worker and this client also considered whether he was interested in participating in a new peer modeling program run by a neighborhood agency. For many clients, the stage of maintaining and consolidating gains will proceed over an indeterminate time long after they have discontinued meeting with the worker. For example, many intervention models for addictive behaviors state that attention to relapse prevention is a lifetime concern (Prochaska and Norcross 2002). It is useful for social workers and clients to explicitly clarify the general lessons the client has learned that he can take from the intervention and use in a range of situations and problems in his natural environment. For example, emotional regulation and cognitive and behavioral strategies for managing anger in an intimate relationship can be transferred to parenting skills and interactions at work. Through his work with the practitioner, a client who recognized that he has a “short fuse” and expresses anger too quickly and inappropriately in a range of interpersonal and work-related situations developed a range of strategies to calm himself down, listen carefully, and think before responding. Along with this insight, the client had learned a number of useful

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strategies for anger management, such as attending to the feelings in his body, noticing physical sensations connected with angry outbursts, practicing deep breathing or counting to ten, taking a break, and in general limiting alcohol consumption and ensuring adequate sleep and exercise. These strategies that the client learned in counseling served as useful activities to manager anger in his everyday life. The person-in-environment perspective draws attention to significant factors and relationships in the client’s environment that can support new behaviors or undermine them. During the middle stage, these factors will have been identified and changed if possible to support the client’s goals. When significant systems cannot be changed, the client may have been helped to protect himself from their effect or deal with them differently. During the termination stage, it is especially important to review these environmental conditions and how the client has learned to elicit support from or respond to them in a different way (Fortune 2002). To some extent, the work with the professional can be seen as an episode in a client’s life that facilitated some movement forward. It is hoped that the resulting changes will continue over time, becoming increasingly integrated into the person’s usual social functioning without the presence and involvement of the social worker. Change entails struggle, progress, and backward slips, and is a natural part of the human condition. It is helpful to discuss this notion with the client and to reinforce this view of growth and change. Plan for Next Steps

In many practice situations, termination includes discharge planning or transfer to another agency that can provide the resources or programs the client needs. Social workers need to determine whether the client can easily access those resources on her own or whether unforeseen requirements and waiting lists will present overwhelming obstacles to her. For example, after a period of individual meetings to help a young family from Columbia that was new to the United States with parenting issues, the social worker and couple decide that although they will terminate their meetings, the couple will join the local community center and enroll in an eight-session parenting group. If there is some concern that the plan, though agreed to by all, may face obstacles to implementation, the social worker should anticipate

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them and assist if necessary. The center may charge a membership fee that the couple cannot afford and they may not be aware that they can ask for a lower fee, the classes may have a waiting list, or they may need help in accessing child care so that they can attend together. When clients are confronted with the regulations for eligibility for government retraining programs, financial assistance, home care, and a host of such ser vices, they may feel overwhelmed and defeated by the red tape associated with applications, long waiting lists, and less-than-welcoming staff. Social workers should be able to work with these systems, advocate for clients, facilitate referrals and transfers, and obtain resources and entitlements for clients. Although the principles of self-determination and building client capacity guide practitioners to encourage individuals to take these steps on their own, the reality of government bureaucracies and their programs is such that a social worker may need to intervene to ensure that a plan or referral is actually carried out. When the social worker persists in dealing with large systems, clients can learn useful attitudes and strategies through the model the worker provides. In addition, small encouragements from the worker can offer the client a boost to reinforce his desire and capacity to act. Practitioner followup with clients is important. Social workers will learn whether the referral was successful and whether prolonged social worker involvement is still necessary to ensure follow-through. When follow-up reveals that the resource is not available or not adequate to meet the client’s needs, the social worker may need to become reengaged to develop alternate plans. When the client’s working relationship with the social worker was key in providing a degree of social support and interpersonal connection that was previously missing in the client’s life, termination should occur only when alternative supports are present in the client’s life. Through counseling, the client may have changed his behavior in social situations and developed the skills and ability to initiate and maintain relationships. When working with individuals who are isolated as a result of chronic mental illness, multiple losses as they age, or relocation and immigration, termination planning should include some form of volunteer or informal social support through home visits, accompanied recreational activities, or connection to social and community centers. When the social worker has become an important part of the client’s network, thought should be given to the impact on the client of losing that connection when termination occurs.

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An important goal in such situations is to assist the client in connecting to naturally occurring supportive social relationships and networks. When there is a planned termination and the social worker remains with the agency or is still available in the community, the model of “the family doctor” has merit. Individuals see their family doctors for specific concerns and for regular checkups. Similarly, it is reassuring for many clients who have worked productively with a practitioner over a period of time and perceive that they are ready to terminate to know they can return if needed for a “booster session” or a checkup. Indeed, when the helping relationship has been positive and the client believes the social worker understands her, the ongoing availability of the worker and the agency can reinforce the client’s sense of having a secure base. Pro cess the Emotional Bond

The emotional connection between the social worker and client in the helping relationship has been emphasized throughout this text. Although many clients can accept that endings are inevitable, it is not unusual for both the client and the social worker to have a range of feelings and thoughts about ending the work and saying good-bye. It is helpful when practitioners encourage clients to express these feelings and recognize that they are normal, healthy expressions of pleasure, relief, ambivalence, or sadness about ending the work (Fortune 2002). For the client, the social worker has become a person of greater or lesser importance in her life, someone she can rely on to provide a constant and available presence. Since the working relationship may have provided a secure attachment base for the client to explore and change, endings may stir up feelings associated with a range of personal relationships, such as earlier significant relationships with caretakers in which the client experienced feelings of abandonment and loss, or current relationships with intimate partners and family members in which the clients feels frustrated and unsupported. A client’s feelings of loss and abandonment at termination of the working relationship can be expressed directly or presented in a range of indirect ways. Clients may present new problems that will warrant continuing the meetings, miss or forget appointments, or appear to feel indifferent about ending the working relationship. Any of these behaviors provides another opportunity for the client to explore thoughts and feeling about central

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relationship themes in her life. If concerns are handled in a way that is different from previous important endings in the client’s life, new learning can ensue. The immediacy and emotional meaning of termination of work with the social worker can offer the client a corrective experience of working through an ending in a way that leads to new internal working models of self, other, and relationships, and ultimately to increased self-esteem. Practitioners also experience a range of feelings during the ending stage of a working relationship with a client. Depending on the way the work with the client affected the practitioner’s experience of his personal and professional self, ending a working relationship may be experienced in a positive manner and cause the social worker to feel that his work is effective. The client’s progress may increase the worker’s positive feelings about his abilities and career. Ambivalent feelings are also normal, however, and the practitioner may feel that he will miss the client at the same time that he gains personal and professional satisfaction from the client’s ability to carry on independently. In some situations, the social worker may experience feelings of relief that the work with a particular client is ending. This may result from the client’s behavior or issues that have triggered anxiety, negativity, or painful countertransference in the worker. Some social workers may become anxious and preoccupied when working with suicidal clients; others will experience distress while working with clients who are verbally aggressive and hostile or passive and dependent. Recognizing one’s feelings and discussing them during supervision or peer consultation can be meaningful for the social worker and lead to new insights, and ultimately to more effective termination strategies with the client. While the professional role requires social workers to be aware of and manage their feelings, it would be normal to view a termination in such situations with some measure of relief. The social worker’s relief might also be accompanied by feelings of guilt about recognizing one’s own difficulty in being fully present for the client or in not being able to offer an ideal working relationship. Again, the social worker’s reflective discussions with peers and clinical supervisors can be extremely helpful ways of coming to terms with these sorts of interpersonal challenges during termination of a working relationship. For a variety of reasons, clients may suggest that now that the work is ending they would like to have a personal relationship or friendship with the social worker. The necessity of maintaining boundaries between confidential

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and structured professional relationships and fluid social relationships is clearly stated in the code of ethics of all the helping professions. It is the practitioner’s responsibility to avoid dual relationships, and hence he cannot gratify the client’s wishes for such a personal relationship. It is important, however, for the practitioner to discuss the client’s request in an empathetic and nonjudgmental manner, and to share the reasons for this professional standard. The unequal relationship, wherein the social worker knows a great deal about the client and the client knows little about the worker, would create a set of power dynamics in which clients can be exploited. Furthermore, if the client would benefit from follow-up meetings or wish to return for counseling later, the social worker could no longer provide the necessary help. It is important for the social worker to convey that this professional policy is not designed to reject clients, but rather to protect them and ensure that access to their professional helper remains intact. When social workers find they would like to continue the relationship with the client, they are advised to pay attention to these feelings and understand what they reveal about themselves and their work. For example, is the worker concerned that despite progress, the client still does not have enough positive relationships in his life? Is termination premature in this case? Should more effort be directed to helping the client develop such relationships? Does the worker feel regretful that more was not accomplished? Is he second-guessing his initial decision to go along with the regulations about insurance coverage in the client’s plan and offer a limited number of sessions? Has he done all he can to apply to the funding authority for increased sessions? Or, is the worker feeling a sense of attachment to the client beyond the working relationship? For example, does the client represent the “good daughter” that the social worker never had? When the responses to these questions reveal that the worker is struggling with personal issues elicited by the termination, supervision or peer consultation provides a venue to discuss the matter and develop strategies to contain personal reactions so that the worker can respond to the client in a professional and ethical manner. Ethical issues about continuing the helping relationship arise regularly for social work students when a client’s termination or transfer is caused by the practicum ending rather than being based on client need. In a discussion of students’ contact with clients after termination, Ringel and Mishna (2007) conclude that instructors in practice courses and in the field need to navigate a delicate balance. On the one hand, they need to provide a space

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where students can express their views and explore their feelings about such terminations. On the other hand, they need to be clear about ethical obligations to maintain appropriate boundaries that, if violated or crossed, put both the client and the student at risk. Based on students’ anecdotes offered to these instructors in advanced practice courses, it appeared that students had approached field instructors about clients’ desire to stay involved with the students and the students’ desire to do so as well. Students reported that their field instructors reiterated ethical principles about boundaries in professional relationships, stated that continued involvement with the client would be inappropriate, and directed students to terminate it. In retrospect, these students recognized that they needed to better understand their feelings about termination, which ranged from feeling that their special understanding of the client would be of benefit, to feeling guilty about leaving prematurely. Some students secretly continued to meet their clients after the practicum. They talked about feeling unsettled and confused even though they did not consider their meetings to be crossing a boundary, but rather deemed them part of continuing to help the client. Most students reported that these relationships became problematic due to the clients’ demands or needs. Ringel and Mishna (2007) recommend that instructors familiarize students with termination issues and provide practice guidelines such as informing clients about ending the working relationship in the initial meeting. Students also need to be able to discuss their mixed feelings about leaving the client in light of these guidelines so that they can develop a better understanding of the rationale for ethical standards regarding termination. Such open discussion stands in contrast to instructors simply stating the relevant ethical standard of practice without guidance about potential issues associated with termination of the working relationship. Clients’ social identity characteristics, which can enhance practice relationships or make them more difficult, may or may not be significant in endings of the working relationship. Working in a way that is sensitive to clients’ diversity in ethnicity, race, religion, and sexual orientation can be experienced as energizing by some practitioners and challenging by others. The social worker may feel she has benefited tremendously from learning about the client’s cultural group in a way that is different from reading or attending workshops. During the termination phase, she is likely to thank the client for enriching her knowledge. Or the worker may feel she was never able to sufficiently and usefully address the way racism or issues

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associated with sexual orientation had an impact on the client’s life, including in their working relationship. The worker may feel a lingering confusion and regret about whether she should have initiated more or different discussions about such themes with the client. Similarly, working with clients who are from similar reference groups as the social worker can create comfort or discomfort, depending on the degree to which they share similar values and how their personalities fit together. During termination with a client who shares many similarities, the worker may anticipate missing the easy connection afforded to him because of their many subtle shared understandings. Or the worker may have felt uncomfortable with the client’s assumption that since they shared significant social identity characteristics, they also shared specific attitudes and beliefs. A good ending can be internalized by the client, along with memories of the work with the practitioner and new insights and behaviors acquired. Hence, clients and practitioners can review the elements in the working relationship that made it special, and clients can learn that important aspects of this relationship can be stored in their “hearts and minds” (Murphy and Dillon 2003, 281). Murphy and Dillon (2003) recommend that during termination the worker and client discuss the working relationship itself and what it has meant to both parties. The worker can also give the client feedback about how the worker experienced and valued the collaboration and partnership. This chapter focused on the various inherent facets of ending the social worker–client partnership. The discussion continued the text’s focus on two intertwined themes: content and process. Content focuses on a review and evaluation of the issues that were presented, goals that were identified, and the degree to which these goals were met. Process focuses on the salient dynamics that helped the client make progress and achieve goals. Endings also entail attention to the emotional bond between the social worker and client with the hope that helpful aspects of the working relationship have become incorporated and form part of the client’s positive attachment schemas. The ending phase is guided by reviewing the key dimensions of the therapeutic alliance: emotional bonding and agreement on goals and tasks.

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Interviewing in Social Work Practice

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Communication and Interviewing Skills

are the nonverbal and verbal behaviors the social worker uses in the helping process When one watches a social worker interacting with a client, we see the practitioner uses a wide range of skills to carry out the therapeutic or change processes described throughout this book. Previous chapters discussed the processes and tasks associated with the helping process stages. These processes and the communication and interviewing skills that will be presented in this chapter are interrelated with processes described at a higher level of abstraction and skills described in a concrete and behavioral manner. These behaviors and skills reflect the holistic practice competence dimensions discussed throughout this book and highlighted in EPAS 2015: “The demonstration of competence is informed by knowledge, values, skills, and cognitive and affective processes that include the social worker’s critical thinking, affective reactions, and exercise of judgment in regard to unique practice situations” (CSWE 2015, 6). Hence, all of the competencies always include the use of skills. Chapters 1 and 2 discussed the interrelatedness of these components as the social worker strives to achieve specific goals. The challenge for practitioners is how to navigate the distance between values and abstract concepts, and specific actions to respond to each client’s distinctiveness. That is, since the components underlying interview behavior are generally expressed on an abstract level, each practitioner must develop her own way of transforming these principles into concrete behaviors in actual interviews. These behaviors must also be responsive to clients so that they experience social workers’ comments as helpful. As a result, the particu lar constellation of interviewing skills used in any session varies c o m m u n i c at i o n a n d i n t e r v i e w i n g s k i l l s

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according to the topics under discussion, the client’s comfort level, the purpose of the interview, and whether a particular practice model is guiding intervention. The primary factor that influences the selection of interviewing skills is the social worker’s endeavor to identify which skills are more likely to bring about some positive change for or offer some relief to the client for a troubling situation at a particular time. In texts on social work practice skills are presented in written form as if they are separate and discrete, similar to the way one might think about learning or rehearsing skills to play a musical instrument or a sport. Yet this does not reflect the reality of actually carrying out practice skills, or for that matter the way a piano is played, or a sport is learned. Although groups of skills provide a foundation or set of building blocks, they must be drawn together into a smooth, flowing, and natural performance (Ivey, Ivey, and Zalaquett 2018). When carrying out the tasks and processes of the various stages, social workers draw on combinations of various skills. Change processes and skills overlap and circle back on themselves as themes and issues are revisited and reexamined. This reflects the nature of actual professional practice, which requires judgment in the selection and application of skills. Recall the challenges of learning to practice presented in chapter 3. Engaging in repetitive practice of a single skill at a time, one after the other, or of a limited group of skills, with the sole intention of gaining some mastery, has been found to be useful. Using simulation to develop skills provides a foundation that can be transferred into field learning with actual clients (Bogo, Lee, et al. 2017). A final word about interviewing skills is needed. Through intensive analysis of audiotapes of workers and clients in our project on cross-cultural counseling, our team found frequent examples of interviewing behavior that was technically very effective (Tsang, Bogo, and Lee 2011). The practitioners used the skills that will be presented here and the clients responded in a way that led to furthering their mutual understanding of the issues to be addressed. As a result, engagement was successful and clients evidenced positive outcomes from the counseling. There were, however, many instances when the social workers’ use of skills was awkward or not well timed to respond to the immediacy of the client’s presentation of a problem. Further examination of these instances demonstrated the importance of understanding the processes in and progress of an interview by analyzing it in its entirety. For example, there were instances when the client tried

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intervi ewi ng ski lls • Starting the interview • Using questions to gather information • Seeking concreteness and asking for clarification • Attending and active listening • Responding • Setting goals • Providing information • Providing suggestions • In- depth exploration • Reframing • Offering interpretations and explanations • Challenge • Putting it together

to introduce topics for discussion in a subtle or vague way. The practitioner missed these cues, did not respond to or explore them, and continued with the worker’s own agenda. It is interesting to note that the client followed the worker’s lead, but from time to time would again introduce the topic. When the worker finally heard what the client was trying to convey and responded to that theme, the engagement process was ultimately successful. In a number of interviews, the worker picked up on the salient theme only during the last ten minutes of a one-hour interview. Analyses of many instances of these sorts of interview sequences reinforced the importance of practitioners maintaining a focus on the processes that lead to successful engagement. Despite episodes of awkward communication and lack of understanding, a joining process can occur when the social worker continuously tries to attend to, listen to, and understand what the client is trying to articulate, and then responds in a way that conveys that she has sufficient understanding to proceed. This analysis demonstrates that interviewing skills are merely the tools used to carry out the helping processes and practice principles. Conversely, without some mastery of the interviewing skills, the practitioner would not have the benefit of tools or techniques to ground or enact these general principles.

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s ta r t i n g t h e i n t e r v i e w

Many clients spontaneously enter into conversation with the social worker and talk about why they are seeking professional help, what their issues of concern are, and what they hope to gain from work with the practitioner. Personal experiences are given meaning, help shape a person’s identity, and are transformed and expressed as narratives or stories. It is preferable therefore to encourage clients to tell these stories in their own way. This approach provides the client with some sense of leadership and control in the professional encounter. It also provides the worker with insight into how the client organizes his experiences, how he defines the issue, and what is most important for him. During the beginning stage, the social worker approaches interviews open to hearing about and understanding the client’s perceptions about his problems. Some clients are less verbal and do not spontaneously offer full descriptions of the issues that have brought them to the social worker. They look to the worker to provide direction in the interview. Questions can help clients to begin this process, focus and elaborate on their situation, move beyond details, and explore many aspects of their lives that were previously unexamined. The long-standing social work principle of partializing the problem guides the practitioner to ask about one aspect of the situation at a time and delve into relevant facets. Less pressing concerns can be returned to at a later time. The social worker is engaged in two processes simultaneously: (1) using interviewing skills to gather information with the aim of building a joint understanding with the client; and (2) building the working relationship through nonverbal behaviors that indicate the social worker is focused on the client, and listening carefully, and through verbal behaviors that include responding with empathy. u s i n g q u e s t i o n s t o g at h e r i n f o r m at i o n

Person-in-environment/ecosystemic and bio-psychosocial perspectives are used in this book to guide information collection, as presented in the assessment guide in chapter 9. While listening to the client, the practitioner keeps these frameworks in mind to identify gaps in information. Hence, questions are used for a reason—to pursue areas of interest that are impor-

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ques ti ons that c a n be u se d a s pr ompts • “Can you tell me more about this?” • “How was that for you?” • “What were you feeling about this situation while it was was occurring?” • “What sense were you making of this situation while it was occurring?”” • “What is the reaction of  ____ (any significant person in the client’s life) to this situation?”

• “What is the reaction of ____ (any significant person in the client’s life) to the way you are responding to this situation?”

tant for achieving joint understanding. Open-ended questions can be used as prompts to help clients expand in a general way on information they are offering or to help them discuss specific topics. Open- ended Questions

Two types of questions are identified in the literature on interviewing skills: open-ended and close-ended questions (Hepworth et  al. 2010; Kadushin and Kadushin 2013). Similar to the prompts described above, open-ended questions are phrased to encourage the respondent to communicate information and focus on issues that he perceives as essential. With their unstructured nature, open-ended questions help clients take more of a lead in the interview and provide possible directions for them to explore and elaborate on thoughts or feelings that are expressed in a limited way, that they are only vaguely aware of, or that are hinted at or implied in their presentation of an issue. These questions thus assist in providing additional information and elucidating the depth and complexity that surround human situations. The importance of emotional or feeling states has been highlighted throughout this book. Emotions contribute to attributing meaning to events and organizing our perceptions, and affect our behaviors. Contemporary practice approaches aim to help clients process emotions and emotional reactions. Social workers endeavor to help clients recognize their emotions, understand and clarify what triggers or stimulates specific emotions and what specific emotional states may convey. The aim is to ultimately help clients learn how to deal productively with emotions. Rather than simply

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examples of ope n - e n d e d q u e st i on s t hat c a n b e us e d at s p e c i f i c ti mes i n the i nt e rv i e w i n a n i n t e n t i on a l way • “What brings you here?” (Used at the very beginning of the contact.) • “What would you like us to discuss today? What is most pressing?” (Used to begin interviews, especially in the beginning stage.)

• “What are some of the things about this new job [or any area the client identifies as a problem] that is troubling you?” (Used to help the client expand on the presenting problem.)

• “How is it for you now?” (Used to explore the problem in relation to both the past and the pres ent.)

• “How have you reacted to new situations in the past?” (Used to elicit information about characteristic response patterns and potential strengths.)

• “What else do you think I need to know about you to help me understand what you are experiencing and your situation?” (Used to elicit impor tant information, especially toward the end of a first interview.)

• “Do you have any further thoughts about our discussions last week?” (Used to draw links between sessions.)

encouraging clients to vent, which has not been found to be effective in reducing distress (Greenberg 2002), practitioners aim to help clients access the emotions connected to significant events. Direct questions about feelings, such as “how did you feel when that happened?” or “how do you feel about that?” can sound hackneyed, especially if they are used too often. Below are some examples of questions that can help clients elaborate on and experience feelings in greater depth. Another form of open-ended question that is useful to elicit clients’ feelings is an incomplete phrase that ends with a question mark, such as in the following interchange: The client lives in an assisted living apartment building and is discussing her difficulties with her apartment mate. She tells the social worker about her efforts to help her roommate, whose mobility is more limited than the client’s. When the client asks in turn for some assistance that she believes the roommate is able to provide, her roommate is usually not responsive. The social worker comments: “You’ve tried to be a helpful roommate . . . when it’s not returned you feel . . . ?”

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examples of que st i on s fr om st u d i e s of e m ot i o na l ly f o c us e d change pro cesse s c on d u c t e d by gr e e n b e rg e t   a l . ( 1 9 9 3 ) • “What are you experiencing right now?” • “What were you aware of right then?” • “What does that feel like?” (127)

examples of que st i on s t hat fac i li tat e t h e e x p lo rat i o n o f f eeli ngs (adap t e d fr om hi ll a n d o’br i e n 1 9 9 9 , 1 1 2 ) . • “What else have you been feeling?” • “Can you tell me more about how you felt about that?” • “How did that make you feel about her?”

Another form of open-ended question occurs when the social worker picks up on a feeling the client expresses and repeats part of the client’s phrase. By using a questioning tone at the end of the comment, the worker encourages the client to elaborate. Continuing with the previous example, the client relates that on the preceding day she asked her roommate to pick up her mail when she went to the mailboxes for her own mail, as she did every day. Her roommate did not respond to her and the client states that she felt angry and stupid for asking. The social worker comments, “You felt stupid. . . . ?” Open-ended questions are extremely useful for helping clients identify and reflect on the perceptions, thoughts, and expectations they use to interpret and make meaning of the situations in their lives and the feelings they experience. Similar to open-ended questions for exploring feelings discussed above, practitioners can use the technique of offering an incomplete phrase that ends with a question mark or repeating part of a client’s phrase that includes a thought. Close- ended Questions

Close-ended questions are primarily used to elicit factual information. They are especially useful during intake and the beginning stage of the working

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examples of que st i on s t hat e n c ou r age cl i e nts to ta l k a b o ut thei r i nternal t hou ght pr o c e sse s • “What do you make of that?” • “How does that make sense to you?” • “What was going through your mind when your friend said that she didn’t think you could succeed in that course?”

• “What were you thinking when your partner said he would try to control his anger next time?”

• “What are you hoping for?” “What would that mean for you?”

relationship to obtain the most pertinent facts about the client and the situation. They can be used throughout the helping process to clarify details and expand on missing information. When using close-ended direct questions, practitioners need to pose queries in a manner and tone that conveys respect, a nonjudgmental stance, and a genuine desire to understand the client and his circumstances. The direct question needs to be posed in a way that leaves the client comfortable to elaborate on the substance of the response. Social work students observe that when they ask a number of closeended questions, they can fall into a pattern of “question from the worker/ response from the client” that is more analogous to a ping-pong game than a collaborative dialogue. If social workers use a series of closed questions to obtain a substantial amount of information, they can inadvertently cause the helping process to seem expert oriented. This leaves the client with the impression that once the worker has amassed “the facts,” she will provide “the answers.” Furthermore, such a worker-directed stance reinforces the power differential between the worker and client; it may leave the client feeling he has little control over the direction of the session or the process and can encourage him to be passive. The helping model discussed in this book emphasizes a collaborative working relationship in which the worker and client proceed, as much as possible, in a joint effort to understand the client’s situation and facilitate change for her. This approach has been associated with positive outcomes and empowerment for clients. Closeended questions therefore can most productively be used judiciously and as one skill among others, such as open-ended questions, restatement, and reflections, that help clients provide information and elaborate on key topics.

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Close-ended questions are also used when social workers are following a structured interview questionnaire that is required by the agency to determine such matters as eligibility for ser vice, diagnosis, or types of intervention needed. To establish eligibility for home care ser vices, for example, there are a number of questions about the client’s physical functioning, medical status, and her ability to carry out activities of daily living that must be asked during intake. In crisis situations, social workers need specific information to evaluate the severity of the crisis and the social and environmental supports available to the client. In mental health settings, social workers may administer standardized symptom checklists to determine appropriate referral and treatment procedures for the client. When there is a perceived risk of suicidal behavior, helping professionals ask the client directly about the presence of suicidal thoughts and whether there is a plan to do so. Similarly, when assessing for the client’s alcohol or drug use, it is important to ask directly about the amount of the substance the individual uses on a daily and weekly basis. Topics such as suicidal ideation, substance abuse, violence in the home, and sexual abuse are emotionally laden topics, and both clients and social workers may feel uncomfortable raising these subjects for discussion. Assumptions may be made or the discussion may be vague, resulting in confusion for both the social worker and the client. A series of close-ended questions posed by the worker are useful to clarify the problem and the frequency and duration of any number of client behaviors. This information is necessary to assess the type and severity of a range of mental health and social problems, and to determine what type of intervention may be needed. Close-ended questions can also provide useful direction when clients feel overwhelmed by and anxious about their situations, and state that they “don’t know where to start.” A structured and focused set of questions can help clients contain a sense that they have lost control of their lives and conveys that help will be offered. Such structure is also useful when the interview appears to wander or when the client’s discussion veers into tangential topics that, while related, are less pertinent to the main problematic issue or issues at hand. In this instance, when the social worker uses questions in a gentle manner, she can steer the conversation back to the central issue or issues. The social worker may sometimes need to offer a rationale for changing the topic. For example, a mother who is exasperated and exhausted by the demands of her adolescent daughter tells the worker about

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her own adolescence and her fear about disobeying her parents. She then begins to reminisce at length about more general aspects of growing up, commenting about tastes in music, clothes, and movies. The worker redirects the interview by drawing a link between what the client is discussing and the presenting issue—her relationship with her daughter. The worker then uses a question to refocus the interview: “It sounds as if your experiences growing up and your daughter’s experiences growing up were very different, both in your family and in what was going on in the community and in the world around you. Are there any similarities between what you both experienced?” Kourgiantakis et al. (Kourgiantakis, Bogo, and Katz 2016) offers comments that social workers can use to bring clients back to focus on the main topic at hand, such as, “I would like us to go back to . . .”; “Earlier we were discussing . . .”; “That sounds important, can we come back to that after we discuss . . . ?” Considerations in the Use of Questions

It is important to keep in mind that overusing questions can detract from developing a collaborative working relationship and an interview that serves as a therapeutic conversation. As a general guide, one should try to use questions that are simple, clear, and fairly short. Practitioners are advised to refrain from stacking questions, that is, asking a number of questions before the client has the opportunity to answer the first one posed, such as “How many children do you have, and are they in school and living with you?” Asking a question and providing a number of possible responses in a way that is akin to a multiple-choice question is not a useful way to gather information. Take, for example, a question such as, “When your partner threatened to leave, did you feel angry, or relieved, or did you worry about how you would manage?” Although asking questions that begin with “why” may help the client respond with information about his own or others’ motivations, or his explanation for why a situation has occurred, researchers have found that these sorts of questions may make clients feel challenged and put on the defensive (Collins 1990; Hill and O’Brien 1999). Instead, questions that begin with “how” or “what” are recommended. For example, “Can you tell me what was going on for you that led to leaving the house after that argument?” has a softer ring than “Why did you leave after

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that argument?” Social work students are often reluctant to appear intrusive and therefore avoid asking questions about topics that appear to be overly personal. This can inadvertently send a message to the client that certain subjects are to be avoided, which can limit the potential for comprehensive understanding. We observe that it is a social convention to use close-ended questions as a manner of speech to express a preference or to lead the person with whom one is speaking in a par ticu lar direction. Based on the tone used, for example, a question such as “Do you want to come with me to a movie?” can convey that the listener wants the responder to answer in the affirmative. This type of leading question can also be used in a professional interview. For example, when the social worker asks, “Shall we talk about the trouble you are having at work?” she may be asking the client to set the agenda or she may be directing the conversation. An open-ended question such as “What aspects of your situation do you feel we should pursue right now?” would help the client take the lead. Effective pacing is important in interviewing because it helps guide information gathering. Pacing refers to the rate and manner in which we conduct the interview and use a range of skills to elicit information. Social workers are aware that asking too many close-ended questions can create a pace that is inconsistent with providing enough time and emotional space for clients to express themselves. Pacing also refers to timing; when the social worker introduces particular topics within an interview and during the overall intervention process. The concept of the client’s readiness with respect to change (Prochaska 1999), as discussed in chapter 7, provides useful information about how to assess clients’ readiness to focus on thinking about change as distinct from planning for change or taking specific actions. The social worker should attune pacing the exploration of topics that might be difficult for the client to her level of comfort with the social worker and readiness to discuss material that might lead to feelings of vulnerability or shame, or both. Tracking the client through open-ended questions or prompts is an important skill in conducting interviews. Tracking includes responding in a way that conveys that the social worker is following the narrative offered, is striving to understand it, and is communicating to the client the worker’s developing grasp of the situation. Questions that are relevant to the client’s concerns signal to the client that the worker is actively listening and involved

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in learning more about the client’s central issues. Questions that are tangential or abruptly or prematurely change the subject under discussion can break the flow of the client’s narrative and distract from clarifying the information the client is trying to share. seeking concreteness and asking for c l a r i f i c at i o n

In social conversation, we often express ourselves in general terms that can be vague or unclear. In contrast, in the social work interview we are aiming to achieve an understanding of another’s internal states and external circumstances that requires a level of precision in communication that is not commonly used in everyday conversation. Individuals vary in their ability to recall and report details of a situation. Furthermore, when people must communicate in a language other than their primary one, it is even more difficult to understand and convey ideas about emotional nuances and the worldview, values, and working models that affect perceptions; the meanings they attribute to others’ behavior; and the feelings that are aroused when discussing significant experiences. The concept of concreteness refers to communicating in a specific manner by using words that explicitly describe events, experiences, behaviors, perceptions, and feelings (Hepworth, Rooney, and Larsen 2002). The related skill is seeking concreteness by asking for clarification of material that is presented in a vague, confusing, or abstract manner, thus bringing it into sharper focus. The social worker’s ability to develop sufficient joint understanding of the client’s situation to enable meaningful goal setting is crucial to providing direction in the working relationship. In the absence of clear information, such shared understanding may be hampered and the work may proceed based on false assumptions because of the social worker’s poor comprehension of the client’s viewpoints and her situation and because the client does not have a sufficient grasp of how the helping process works. Simple open-ended questions can be used to encourage clients to offer more concrete information, to clarify what they have presented, or to explore a given issue further. Some additional techniques that can assist clients to provide a more textured and complex description of important issues are (1) obtaining specific,

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examples of que st i on s t hat se e k c on c r e t e n e s s or reques t clar i fi c at i on • “Can you tell me what you mean when you talk about re spect?” • “Can you tell me exactly what happens when you say that you feel threatened in your relationship?”

• “You said that you feel uncomfortable with your roommate...uncomfortable, in what way?”

• “I am not sure I understand....can you go over that again?”

detailed examples of sequences of events that provide a broader context for understanding, and (2) linking these examples to thoughts and feelings. Clients frequently share examples of situations that are representative of key themes or issues in their lives. It is worthwhile for the social worker to inquire in some detail about these examples, specifically asking the client to describe the sequence of events, including what was happening before the incident occurred, the incident itself, and various participants’ reactions in the situation. In this way, the worker can begin to identify a pattern of reactions and counterreactions in the client’s life. Descriptions of behaviors that refer to the issues under discussion can help concretize the meaning of emotionally meaningful terms found in such statements as “my teenagers don’t show me any respect,” “my life is a struggle,” “my partner and I are not close,” “I am alone in my pain,” or “ I have a real problem with my temper.” Another way for the worker to gain a sense of what the issues are is to ask the client to help her get a picture of what has happened with questions such as, “If I were watching you and your sisters having a fight, what would I see?” or “If I were doing a home video of what happens when you open the door to your house when you come home from school, what would be on the video?” Second, when gaining a picture of significant events and behaviors, it is useful for the social worker to ask the client to describe and clarify the way she was feeling in the example under discussion, the perceptions she had of the situation, and what information she used to draw those conclusions. This line of exploration will clarify the interrelationships between internal and external dynamics, and can assist the client in developing better selfunderstanding. For example, the client tells the social worker, “I feel like a failure as a mother—my daughter has no respect for me.” The worker uses

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open- and close-ended questions to gain more concrete information by guiding the client through a description of a sequence of events that demonstrate “no respect” and by clarifying the perceptions and feelings associated with these presenting statements of concerns. By helping the client clarify these details, it became clear that the client expects her adolescent daughter to respond positively to her requests for help in the home, especially since the client is recovering from a recent operation. The client interprets her daughter’s reluctance to help as disrespect for her mother’s wishes. In this example, respect would be evidenced by the daughter’s compliance with her mother’s wishes. Furthermore, the mother associates lack of respect with evidence that she has not been a good mother and has been remiss in teaching her daughter “good” values. Her expressed feeling of being disheartened about her mothering skills are connected to her perceptions and appraisals of the current interactions between herself and her daughter. As clients describe the concrete details of a situation, they often disclose accompanying feelings and begin the reflective work that leads to gaining a better understanding of their perceptions, feelings, and reactions. For example, an adolescent client reveals that when she loses her temper with her younger siblings, she threatens them with things she doesn’t mean, and cries afterward and feels badly for doing it. When describing her high school as tough and one where there are a lot of people who pick fights, she volunteers that she feels scared and is very careful to avoid people who might start a fight with her. She describes feeling “all stopped up inside” when she leaves school, and while talking about her angry outbursts at home after school, the client draws the link between her aggressive behavior at home and her avoidant response to potential aggression at school. at t e n d i n g a n d a c t i v e l i s t e n i n g

Asking questions is only one part of the social worker’s activity. At the same time, she is engaging with the client in a nonverbal manner through a range of behaviors, gestures, and expressions. Furthermore, the worker is listening carefully to what the client is saying and how he is conveying information. An important step in moving toward understanding another is the ability to listen in an active and open manner that conveys interest, attention, and engagement with the person and the material being shared. Listening relies on social workers’ ability to “quiet . . . [their] own frame of

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reference and listen more carefully to who and what are important to . . . [their] clients” (deJong and Berg 1998, 23). Attending and active listening are two terms that are used in the literature on interviewing in helping professions (Hill and O’Brien 1999; Murphy and Dillon 2015). The term attending refers to the nonverbal stance that practitioners use to orient themselves to their clients (Hill and O’Brien 1999). The term active listening refers to a reflective type of listening and hearing that is attuned to the totality of the client and her experience. That is, the practitioner is listening for more than the facts that the client is presenting. With active listening, the social worker strives to understand the verbal and nonverbal substance of the client’s messages. The practitioner attempts to grasp both the specific and more general essence of what the client is trying to communicate by integrating the client’s feelings, meanings, and the context in which the situation occurred. The worker pays attention to what the client says and how it is said, as well as what feelings are expressed, directly or indirectly, in relation to whatever is shared. Through this type of listening, the worker is able to begin identifying themes and patterns. Attending and active listening are used throughout the helping process and are especially important during the early phase as the worker aims to build an effective working relationship with the client. Recall the qualities that characterize helping relationships discussed in chapters 5 and 6: warmth and caring concern; acceptance, positive regard, respect, and a nonjudgmental attitude; empathy and genuineness; and respect for diversity. If the worker’s stance does not align with these attitudes and values, attempts to engage in active listening may appear stiff and inauthentic. Attending and conveying that one is listening begin with nonverbal actions and refer to a range of behaviors. Body posture in the way we sit can convey openness and interest or lack thereof depending on whether we lean toward or away from the client; whether our body position is relaxed and open; whether our arm and leg movements are distracting; and whether the distance between ourselves and the client is comfortable, that is, whether it is too close and potentially experienced by the client as intrusive, or too distant and potentially experienced as uninterested. Facial expressions such as occasional smiling can be interpreted as encouraging, whereas frowning may be interpreted as passing a negative judgment. Generally, eye contact should be a natural gaze; a prolonged stare that engenders discomfort should be avoided. Head nods are also a natural way

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to indicate acknowledgment of what the client is saying. The social worker’s tone of voice can convey meanings such as concern or surprise and judgment, or aloofness and lack of interest. Some nonverbal behaviors that impede building a working relationship are looking away from the client, scowling, a tight mouth, yawning, a speech rate that is too slow or too fast, distracting behaviors, and acting rushed. Social workers need to be aware that nonverbal behaviors can also reflect social and cultural norms and avoid misinterpreting a client’s behavior due to their own lack of knowledge of such norms. Nonverbal social conventions and expected behaviors are learned during childhood through socialization in the family to the norms of the culture. These early lessons are incorporated into our personal styles and will be apparent during the interview, both on the part of the client and the worker. There is an abundant literature that presents rules of nonverbal behavior in a number of countries and cultures. This literature may describe dominant trends that can usefully serve as a backdrop or reference point for the practitioner. In some cultures and languages, for example, the word yes does not signal agreement but rather indicates that the listener has heard and is following the speaker. Misunderstanding can occur if this simple attending behavior is not understood accurately when speaking with clients who use this social convention differently than the worker. Since practitioners cannot be conversant with the multitude of nonverbal conventions that exist, it is useful to be aware that there may be such differences and learn whether different social conventions and norms are at play with each client by observing nonverbal interactions. For example, if the worker observes that the client averts her gaze when he tries to make prolonged eye contact, this may indicate a cultural or an individual preferred style of interacting. Clients should have the opportunity to choose how close or how distant they would like to be from the worker. Clients’ special needs must also be taken into account. Clients with visual impairments may be able to see and “read” the worker if he sits at an angle to the worker rather than in a face-to-face configuration. Clients who are totally blind will likely depend on their hearing acuity to determine whether the worker is speaking directly to them. When working with clients who use a hearing aid, practitioners should ensure that they face the client and speak directly to him, rather than raise their voice. Many social workers encounter elderly people who have some degree of hearing loss, vision loss, or both. It is

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useful to ask clients about these conditions and for suggestions to help the worker find the best positions and ways to converse with them. This general category of attending behaviors includes simple verbal acknowledgments such as “I see,” or utterances such as “uh-huh” or “mmhm.” Generally, such comments indicate that one is listening to, following, or tracking the speaker, and encourage the client to continue talking about a particular topic. They serve as a facilitating response in place of a comment that addresses the issue directly. These comments and accompanying nonverbal gestures such as head nods serve as furthering comments; they encourage the client to continue to disclose aspects of the situation under consideration. Voice tone (whether it conveys warmth and interest) and speech rate and volume also communicate attending and interest. For example, if the client struggles with understanding English or has difficulty hearing, a worker who adjusts the speed of her speech and enunciates clearly indicates her desire to have a meaningful interchange with the client. To maximize attending to the client, social workers should also be aware of what might be distracting during sessions. There are divided opinions among practitioners about taking notes during a session. Note taking can distract from attending to the client and can communicate that the worker is focusing more attention on writing a record than listening to the client. As a general guideline, it is preferable that the worker record information after a session, thus allowing her to devote full concentration on the client during the interview. In many settings, the pressures of workload require that social workers write notes as the client speaks. When this is the case, it is helpful for the worker to explain to the client why she is doing this. For example, an intake worker in an assisted living residence for seniors stated: “The team at the home will want to know about you as we help you to settle in when you move here. I’m going to take some notes as we talk so that I don’t forget some of the important information.” When taking notes, the worker can still maintain a stance of active listening by offering frequent nonverbal indications of her interest and involvement, such as head nodding and eye contact. Eco-maps and genograms (Hartman 1994), discussed in chapter 9, are useful devices to organize information as it is being collected during the session. These tools engage the client and the social worker in a joint effort to describe and document the important systems in the client’s life, the history of his family relationships, and the characteristics of his relationships in general.

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Developing an Attending Stance

Perhaps the greatest challenge when learning to develop an attending stance is to find behaviors that are personally authentic, comfortable, and relaxed while at the same time respectful of clients. For example, a relaxed, somewhat slouched posture that is in tune with that of an adolescent client may convey interest to the client. If the social worker finds this posture uncomfortable or it feels contrived, however, it will diminish his natural demeanor. Similarly, the worker may be comfortable with a relaxed posture, but it may convey a lack of respect to a client who is older than the worker, or from a culture that expects a more formal posture from professional practitioners. Workers need to be flexible in finding a balance between the client’s preferences and the worker’s natural style. The importance of social workers’ awareness of their cognitive and affective processes and use of self was discussed at length in the first part of this text in relation to holistic competence. Social workers embrace a selfreflective attitude that causes them to be mindful of and attuned to their own feelings, perceptions, and reactions. Reflection is recommended as it can lead to increased understanding of the social worker’s thoughts and feelings in reaction to her interactions with the client. This understanding in turn can promote intentional and purposeful interactions with clients rather than ones that are reactive, and potentially destructive, or at the very least, unhelpful to clients. Self-awareness and self-understanding are a work in progress as social workers develop and change through new experiences in their professional and personal lives. Many factors can diminish the social worker’s ability to be attentive, including idiosyncratic personal issues unconnected to the practice issue presented, such as a worker’s preoccupation with her sick child at home, or countertransference reactions triggered by similarities between the client’s situation and issues in the worker’s personal life. Contextual organizational factors can also have an impact on the social worker’s attentiveness. These include the presence of a comfortable and safe surrounding, a private space with minimal distractions and interruptions, and an environment in which clients’ cultural norms and linguistic needs are anticipated and accommodated. Tuning in to the possible feelings of the client were discussed earlier in this text as potential aids to being fully present and receptive to whatever the client may present. Preparatory

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empathy may provide a useful starting point for the worker, but hunches should always be subject to confirmation by the actual experience of the client. In an attending stance, the practitioner is open to learning about each client’s uniqueness. In the contemporary work environment, many organizations have been affected by downsizing or managed care and have diminished or insufficient human resources to meet clients’ needs. Still, expectations about the quantity of work produced continue to grow, which exerts pressure on workers to handle cases quickly and efficiently. These demands can distract practitioners from therapeutic processes and produce a greater focus on meeting administrative needs rather than working through a collaborative and empowering client relationship. Video recording actual or simulated client interviews and reviewing them was discussed in chapter 3. This is an effective way to raise the social worker’s awareness about her nonverbal styles and behaviors and whether they provide congruence with her verbal messages. Students can review these recordings and examine their own behavior in light of the elements Egan (2002) discusses: posture and gestures; eye contact, gaze, and movement; facial expressions such as frowns, twitching, smiling, rolling one’s eyes; voice-related characteristics such as speaking speed, tone, volume, silences, stumbling, and repeated use of hackneyed phrases such as “okay,” “I see,” and “wow”; and the physical distance or space between the student and client. Students can also examine the effect of these behaviors on the client. Obtaining feedback from a colleague or the person who plays the role of a simulated client is important given the human tendency to evaluate negatively a behavior that may be viewed positively by the other. responding

As noted, intertwined tasks in the interview include gathering information for assessment, providing interventions, and building and maintaining a working relationship. The latter requires the social worker to connect with the client’s emotions in a way that leads the client to view the social worker as empathetic. When this occurs, the client is more likely to return for subsequent sessions. Interviewing skills ground these processes, but they are powerful only when they are used in conjunction with the more nebulous qualities that promote bonding in the helping relationship. These

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s ki lls and be h av i or s for r e spon d i n g to c l i e nts • Restatement or paraphrase of client’s narrative • Reflection of feelings • Silence • Offering summaries of client’s narrative • Eliciting and responding to feedback • Offering support and validation • Sharing impressions

qualities, discussed in chapter 6, include warmth and caring concern, acceptance, genuineness, and empathy. Pacing and tracking the client to proceed at the client’s pace was briefly discussed earlier with respect to the use of questions. Similarly, when offering any of the responses that follow, the practice principle of “going at the client’s pace” is demonstrated when the client perceives that her message was understood and that the social worker’s comments are relevant to her substantive concerns (Hepworth, Rooney, and Larsen 2002). Clients are likely to provide some sort of feedback that indicates whether they believe the worker is in tune with or is missing some important aspect of the client’s story. Client feedback may be verbal and direct or indicated by nonverbal gestures. The importance of client feedback has been stressed throughout this book; it can be used to refocus attention so that discussions are client centered. Restatement or Paraphrase

Restating or paraphrasing the client’s comments refers to converting the original content expressed by the client into words that are expressed in a succinct and clear manner, with the aim of trying to understand the client better. Typically, the social worker offers a restatement after the client has presented a significant amount of information. The terms restatement and paraphrase refer to the content or meaning of what the client has said. The term reflection refers to the same process when it is directed at the feeling the client has conveyed. To paraphrase, the practitioner uses active listening, tries to understand what the speaker is conveying, and then formulates

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comments according to the practitioner’s version of what was said. The worker offers this version to the client in a tentative manner, inviting his response and feedback. Through many series of such interactions, the dialogue progresses to a point where the worker may offer a summary of issues and point out connections among aspects of the situation, relevant dynamics, and pertinent themes. Paraphrasing and restatements serve a number of purposes in the interview. They are a simple and nonintrusive way of keeping the focus on a relevant topic and serve the same purpose as questions or comments that seek concreteness. That is, they encourage the client to provide more information, elaborate on the message, or explore the particular subject further. When the client believes that the social worker’s paraphrase indicates that he is understood, he may also feel supported and connected to the social worker. Furthermore, as has been noted in discussing middle phase interventions, the process of “talking out loud” can be helpful by itself; when one hears himself repeating stories and talking about issues, he can obtain some clarification. When another person also responds, the experience is similar to what has been called “having a sounding board.” Simple and clear feedback can further assist in clarifying and making further sense of our experiences, feelings, and responses. When the helper’s paraphrases do not fully and accurately grasp what the client is trying to convey, the client has the opportunity to further clarify his message as he offers feedback to the worker (Hill and O’Brien 1999). Social work students often comment that when using paraphrasing, they feel as if they are simply parroting what the client has told them, which leads to a sense of “going around in circles.” Since the goal is to elicit information about the various aspects of the client’s problematic situation such as the facts, the context, and the relevant thoughts, feelings, and behaviors associated with it, paraphrase used alone is not sufficient. Paraphrasing needs to be used in conjunction with posing questions, seeking concreteness, and engaging in reflection of feelings. For example, working with a social worker, a young man recognizes that his characteristic reaction to criticism in interpersonal relationships is aggression, which in turn leads to more difficulty in those relationships that he values and wants to keep. He wonders why people have to question what he is saying. The worker paraphrases, “You think the other person does not believe what you’re saying.” The client then goes on to discuss how angry he gets, introducing the feeling

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example of a di a logu e i n w hi c h t he c li n i ca l i s s ue i s c l a ri f i e d by paraphras i n g

Client: I really think that it is useless for me to continue in high school— what good is it for me to learn all this stuff that I’ll never use later on? Anyhow, it’s just so hard for me to get up and drag myself into school each day. I’d like to just lie in bed and never get up. But then I get a decent mark on a test and I won der if I should stick it out. Worker: You’re wondering if the effort involved in school is worth it? Client: I guess..., but I can’t find the energy to get interested in my work, I just want to sleep or space out. And then for no reason, I feel all upset— like crying. I think maybe it’s like what happened to me last year...sort of depressed feeling. Worker: You think that feeling low is affecting your interest in continuing in school? Client: Yeah, that’s more like it. I can get into school, it’s just that this upand- down feeling takes over the way I feel about every thing. And I can’t figure out why I get this way...what brings it on.

dimension of these interactions. The worker might then probe and use an open-ended question to further understand those feelings, saying, “What is it about another person questioning you that leads you to feel angry?” or the worker might seek concreteness, “Could you describe a recent example of someone questioning you and you feeling angry in response?” A rich repertoire of interviewing skills used interchangeably leads to a flow in the interview that more closely resembles a dialogue than a stilted set of responses. Reflection of Feelings

The important processes in focusing on emotion and working in depth with links among emotion, cognition, and behavior were discussed in detail in chapter 10. Theorists from various perspectives acknowledge the crucial role of emotion in organizing our perceptions, attributing meaning to events, and affecting our behaviors (Cozolino 2002; Damasio 2005; Greenberg 2010; Miehls and Applegate 2014; Siegel 2006, 2012).

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Following the literature, a distinction is made between interviewing skills used to address content and cognitive aspects of the client’s message, such as the skill of paraphrasing and restatement, and interviewing skills used to address feelings, such as the skill of reflection (Hill and O’Brien 1999; Poorman 2003). This is an academic point, and while useful for presentation in a text, in actual practice the social worker’s responses when addressing content, cognition, or feelings may appear the same regardless if it is called paraphrasing or reflecting. The important feature in using these interviewing skills is the worker’s intention and her purpose in offering a particular comment. That is, is the purpose to clarify the events and to paraphrase and explore the thoughts, perceptions, and meanings the client draws on, or to elicit and identify the client’s feelings? The literature defines reflection of feelings as the social worker repeating or rephrasing the client’s communications about her feelings, or putting into words feelings that are implied by the client’s nonverbal behavior or by the content of the material under discussion (Hill and O’Brien 1999). Reflection is used to help clients verbally describe the feelings they are experiencing, to focus on a specific feeling, and begin to explore it in greater depth. When practitioners use the skill of reflecting feelings, they are specifically directing clients to attend to the range of emotions that are stirred up in relation to an event or situation and to become aware of those feelings that likely act as a powerful influence on the client’s thoughts and subsequent actions. To offer reflections, practitioners use attending and active listening. By observing the way the client displays feelings or strug gles to control the overt expression of feelings, the worker gains insights that can be captured in his reflection of the feelings. Directing attention to feelings, which are often sore spots or sources of pain for an individual, requires sensitivity, support, and empathy. Once again, the importance of the developing working relationship cannot be underscored enough. During the early stages of working relationship development, reflection of feelings needs to be offered tentatively, as the bond between client and worker is only beginning to grow. On the other hand, when the worker does not connect with the client’s emotions, the client may not feel heard or understood, and might decide not to return. In our analysis of the engagement processes during first sessions, we found that clients continued in counseling when social workers connected to their feelings by furthering comments that encouraged discussion of feelings and by reflecting feelings that were conveyed directly or implied

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(Tsang et al. 2011). In comparison, when the worker did not respond to the client’s feeling comments and instead changed the topic or offered a cognitive response, the client did not continue in counseling. Skills such as use of questions and seeking concreteness can also be used to assist clients to recognize their emotions and the role they play in their life. Practitioners often talk about the importance of helping clients “get in touch with their feelings.” This refers to the notion that individuals often talk at length about the details of a situation and demonstrate emotions in nonverbal ways, such as through an agitated presentation, blushing, crying, discomfort, and so on. When asked directly about the feelings connected to the topic, individuals may or may not be able to label their emotions. In some instances, the individual is aware of general feelings of confusion, being overwhelmed, or being distressed, but has difficulty being specific about these feelings, the situations that elicit them, and the accompanying perceptions and meanings attributed to them. In other situations, an individual may respond to a query about his emotions by talking about what he thinks about a situation and giving a cognitive or intellectual response rather than an affective one. Or clients sometimes intellectualize feelingoriented material by talking about feelings rather than actually experiencing them and examining associations. When practitioners use the skill of reflection of feelings, it is crucial to remember the distinctions drawn between primary emotions, which are found on the surface and readily accessible, and secondary emotions, which are less obvious but perhaps more painful and important. This draws our attention to the need to reflect not only the feelings that are on the surface, such as anger, but also the underlying feelings that may fuel them, such as hurt or vulnerability. As the work progresses, the social worker and client likely will have gained more knowledge and understanding of the client’s characteristic emotional responses to particular situations. Reflection of feelings remains an important entry point into greater in-depth exploration of any issue. Note in the following example that the reflections the social worker offered have three characteristics: (1) they stay close to the client’s original expression and incorporate the client’s language; (2) they link the feeling to the context, in this instance the client’s relationships; and (3) they are succinct and the recording of this interview reveals that they are offered in a gentle tone and with a questioning manner at the end of the reflection. The

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The following example illustrates how the practitioner used reflection of feelings to help the client identify the various feelings causing her confusion about whether to remain in a relationship with a partner. The client is discussing her annoyance with her partner’s reluctance to be spontaneous. The social worker listens to and acknowledges the client’s expression of anger, leading the client to elaborate: “I feel controlled by him, I have to do what we plan to do...if something in teresting comes up that I’d like to do, I have to do it alone.” The worker builds on the term “alone” and says, “What is that like for you?” The client becomes tearful and speaks at length about her years as a single parent and remarks on how busy and involved she was with her children. Now that they are young adults and occupied with their own lives, she has the time to spend with her new partner. The worker reflects, “ You’re aware of feeling lonely, missing the close connection with people in your life.” The client then elaborates on how much she misses her children and her strug gle to recapture some of that closeness. The worker reflects, “You feel a void when Jim (new partner) can’t provide the closeness you want...?”

latter conveys the worker’s tentative impression and provides the emotional space for the client to disagree. These guidelines can be used when students are first learning to offer reflections. Social characteristics have a profound impact on an individual’s comfort in expressing and sharing feelings in general and with a stranger in particular. In some cultures, negative feelings are to be endured and the expression of feelings suggests immaturity and brings embarrassment to the individual, their family, and the person who witnesses the emotional display. In other cultures, emotions and private information are readily shared. For example, North American popular television programs provide a model in which the most intimate details of people’s lives are disclosed and displayed. Age and generation also impact internalized norms about expressing feelings. Many older individuals subscribe to a value on privacy and suppression of feelings. As noted earlier, generalizations about people

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on the basis of variables such as ethnicity, gender, and age can only serve as broad themes and possibilities. Social workers must assess the uniqueness of each individual client and the degree to which these cultural norms apply. When a client does not readily respond to reflection and discussion of feelings, practitioners need to give thought to whether this reflects a personality dynamic, such as being reserved, frightened, or uncomfortable with feelings, or whether this reflects an internalized social norm. Silence

Social workers must consider when to allow silence and when to use questions or responding skills to further the interview. Beginning practitioners often comment that since silence feels uncomfortable, there is a tendency to fill it up by talking. As the practitioner’s comfort level with sitting in silence develops, she can give thought to instances when allowing the silence to progress will be a helpful interviewing strategy. Silence can be helpful when it is apparent that the client is thinking about the topic under discussion. Individuals vary with respect to how much time they need to form responses, continue a line of discussion, or manage the strong feelings that have been elicited. When the social worker responds too quickly, he may subvert the client’s desire to think something through. On the other hand, some people find prolonged silence uncomfortable, anxiety provoking, and immobilizing. They benefit from the structure and focus the worker provides by guiding the session verbally. In other situations, the practitioner may become aware that she is taking too much of a leading role in the session and therefore decides to provide more emotional space for the client to express herself. When a silence arises in this context, the worker may wish to sit it out and nonverbally or with minimal prompts encourage the client to take the initiative. Finally, patterns of silence can vary based on different cultural meanings ascribed, such as respect for the other person, or a signal that the topic is too private and the client does not feel comfortable to discuss it further. As in the use of all interviewing behaviors, practitioners develop and use their clinical judgment to decide when to allow silence to proceed and when to replace it with verbal guidance. The skill of “reaching inside of silences” has been described by Shulman (2016, 72). This occurs when the social worker is attuned to the client’s emotional state and tentatively suggests possible feelings that the client

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may be experiencing that contribute to the silence. Along with related feeling-oriented comments that display an understanding of the client’s feelings, this skill contributes to conveying to the client a sense of the worker’s caring. This skill can help the client provide a more direct expression of her feelings. Offering Summaries

Throughout the interview, the practitioner offers paraphrases, restatements, and reflections that can be thought of as testing out whether the worker has grasped the salient components of the presenting problem and the client’s situation as well as the essence of the client’s relevant perceptions, thoughts, meanings, and feelings. During the next step, the social worker and client link these separate components together and identify themes. Summary statements provide structure to the interview, as they integrate many aspects of the clients’ story. Summaries can also refocus the discussion and prompt the client to elaborate on specific ideas. Social workers generally offer summary statements in a tentative manner that invites the client to provide feedback, additional information, and qualifying comments. Through this type of dialogue, the worker will revise her summaries so that a joint understanding with the client emerges. Summary statements provide the client with information about the degree to which the worker has connected with him and understood his circumstances and concerns. To the extent that the client ends the interview with a sense that the worker has this type of understanding, or at least is committed to developing it, the client and worker have likely achieved enough of an engagement that the client will return. There are two types of summaries: (1) those that take place periodically throughout an interview, and (2) those that are used toward the end of a session. Periodic summaries link a number of factors, such as information given earlier with new information; connections among the client’s concerns, feelings, perceptions, and behaviors, or connections between any two of these; interrelationships between significant persons in the client’s life and the presenting problem; and key external and internal factors. The following example of a periodic summary comes halfway through the first interview. The client, an eighteen-year-old female, is attending a mental health clinic. The client and social worker have traced the client’s reoccurring

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experiences of feeling depressed in relation to her presenting concern that she is once again feeling low. The worker offers the following summary: “It sounds as if when we look back over the past few years, when you were depressed before you always had reasons for it, like fights with your friends, or your mom’s illness, or worrying about failing in school. Now you don’t really feel there is any reason for it and that’s confusing for you.” Summaries offered at the end of the interview aim to be comprehensive and provide an entry into goal setting and planning. They aim to highlight the key issues to be addressed. In this respect, they provide focus and direction for the interventions in the next phase. These summaries can also be used at the beginning of the next session to provide continuity over time and structure to the beginning of each subsequent interview. As the work progresses, the concluding summary in each session will change to reflect new information and perhaps new directions. Continuing with the above example, in the last quarter of the interview the client revealed limited information about an experience when she was harshly scolded for childhood sexual play. The client believed this event was contributing to her current feelings of being stuck, trapped, and uncomfortable when she starts to get close to a potential boyfriend. The social worker states: It sounds as if you’re saying that while you feel confused about why you are feeling depressed, you wonder if there might be some connection with your being uncomfortable as you get close to a new boyfriend, and this experience when you were much younger. These are all really important things to explore and this counseling process will give you the chance to do that. You started to talk about that experience with a counselor last year, but you felt too scared about it and stopped. You think that it’s something you want to try to look at again now and we’ll have to talk about what we need to do in this counseling so that you can continue with it.

The client responds with relief, saying, “That’s the main reason I came here in the first place, I think I need to figure everything out.” Eliciting and Responding to Feedback

The importance of working in an interactive and collaborative way has been underscored throughout this text. The process of helping unfolds largely through dialogue; therefore, practitioners should be attentive to the

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client’s response to their comments. All of the client’s comments can be conceived of as including an element of response to the worker. When the client responds with further elaboration, or indicates that the dialogue is helpful, the topic is relevant, new ideas are gained, or new actions are planned, the worker can probably assume that the interview is progressing well for the client. Feedback that indicates that the client is not being helped can arise in a variety of ways. The client may simply correct the worker’s impression with a direct clarification, disagreement, or refocusing statement. For example, when interviewing a mother who was distraught about her adolescent daughter who was skipping classes, the social worker drew attention on a few occasions to positive similarities between the mother’s descriptions about herself and about her daughter. The mother gently refocused the worker saying, “that may be so, we are alike in many ways, but I am very frustrated about how different we are in our ideas about her future, and that’s what I need help with—how to get her to attend her classes.” This information helped the worker attend to the problems, as well as the strengths, that the client wanted to discuss. Clients can also provide feedback in subtle or indirect ways. For example, in a second session the worker inquired whether the client had any further thoughts about their discussion in the first meeting. The client said that she actually could not remember what they discussed. Further clarification revealed that this client had a learning disability when she stated, “If I just talk about something, it doesn’t sink in.” By discussing this comment, the worker and client decided to end each meeting with brief written notes summarizing what the client would do or think about between meetings. Missed appointments and hesitancy in arranging subsequent meetings may also suggest that the client is not finding the sessions useful. Another example of the importance of directly seeking feedback occurs when there is a discrepancy between behavior and internal appraisals. For example, after a prolonged discussion about a particular topic in which the client appeared to be fully engaged, the social worker asked whether the conversation was helpful. The client responded, “The discussion was helpful, [but] it wasn’t about what I really wanted to talk about.” This example reveals how complex it is to assess another’s experience. Despite the appearance in the session that the client was actively participating and seemed to be receiving something of value, in fact the client would have preferred

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to be discussing another issue. The client did not give feedback at the time, which could have allowed for the agenda to be changed. In this example, when the worker requested feedback, the client did provide the worker with useful information. Together they then considered ways the client could more actively set the agenda. The worker suggested that each meeting begin with some thought given to what the client considered most pressing to discuss. Offering Support and Validation

Social workers provide support to clients in many different ways. Support is provided through the working relationship when the client views the social worker as available, attentive, respectful, and committed to understanding and helping. As noted throughout the text, this stance is, in and of itself, nurturing and reassuring; it is also a crucial foundation from which change may occur. Practitioners offer this working relationship by displaying a set of values, attitudes, and behaviors in nonverbal, subtle, and verbal ways. The client is more likely to reveal and discuss a wide range of feelings, wishes, and thoughts when she feels it is likely that she will not be humiliated, misunderstood, or judged negatively. When these conditions are present, the client perceives the helping relationship as safe and trust and confidence in the potential usefulness of this process may develop. To reiterate, practitioners use the interviewing skills presented thus far to demonstrate their warmth, genuineness, and empathy. Questions, paraphrases, reflection of feelings, summarizing, and sensitive responses to client feedback can be experienced by clients as supportive when used in the context of building a beneficial working relationship. Support is also experienced when workers provide validation. Validation can be extremely powerful as it occurs when the practitioner confirms the client’s subjective experience of the situation he is describing. It is akin to “bearing witness,” conveying that the story shared is difficult, challenging, or painful and that the client’s feelings and reactions are understandable. Validation creates a feeling that someone appreciates the impact of a situation. The actual feeling that the client describes may be very painful and validation will not diminish that discomfort. Rather, it can offer enough support that the client can tolerate the pain and explore in more depth or elaborate on the feeling and the situation.

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Recall the case example presented to illustrate the skill of summarizing. The client had struggled on and off over many years with a vague feeling of being low or depressed. She had a sense that in some way it was connected to a childhood experience of sexual play and a harsh parental response that had left her feeling shamed and guilty. When in an earlier attempt at counseling the previous worker had prematurely suggested that her parent’s response was the issue, the client felt uncomfortable and stated, “I don’t want to blame my mother for my feelings”; she then discontinued sessions. Still troubled and preoccupied seven months later, she initiated a request for counseling at another agency. She waited until more than half the session had transpired before disclosing these issues and the discomfort she experienced when thinking and talking about them. The following worker response demonstrates the skill of validation through her understanding the client’s struggle with competing feelings. It also conveys that the worker and client will work together in this counseling experience: “I think it’s courageous of you to want to look into these things. On the one hand, it is scary and it’s understandable that you feel hesitant. When you tried it before, it didn’t feel okay. On the other hand, you feel that it’s going to be in your best interest to sort out all these feelings. I think that it will help you, and we both have to figure out how we can talk about this in a way that makes it not so hard for you.” Support and validation also can be experienced by clients when practitioners use a strengths-based approach. This focus was discussed extensively in chapter  11. Interviewing skills discussed in this chapter can be used in the ser vice of drawing out, reflecting, highlighting, and validating clients’ past successful approaches and current strengths and resources. At the same time, workers should not minimize clients’ concerns by providing positive reflections that clients view as unrealistic and not in accord with their lived experience. Social workers also provide support to clients with their knowledge of resources, which enables them to quickly assess the gaps in resources in a client’s life and, using communication and advocacy skills, work with a range of agencies to secure them. For example, social workers in medical settings develop a network of relationships with community agencies that provide ser vices in the home, including nursing, occupational therapy, and basic personal care. When a client is facing discharge from a hospital and needs assistance to return to independent living in the community, the social worker’s ability to organize these ser vices provides a level of fundamental

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support that is invaluable. Moreover, social workers are skilled at dealing with complicated eligibility requirements that can be overwhelming when clients feel desperate and overwhelmed. Sharing Impressions

The social worker is guided by the tasks of the beginning stage to arrive at sufficient joint understanding with the client that they can productively agree to meet again and work on some topics or goals. In chapter 9, frameworks for assessment are presented. As noted, developing an understanding takes place when the client is an active participant in the interview and the worker reflects on the situation both during and after the interview. The worker shares her impressions about factors internal to the client and those in the environment that contribute to his situation, and encourages feedback about those impressions so that some agreement about what needs to be addressed and how that can be achieved is reached. Practitioners share these impressions through restatement, paraphrasing, reflecting feelings, and offering periodic summaries. At the end of the first interview, impressions are shared as summaries that suggest potential intervention plans. When the organizational context requires a plan that adheres to a limited number of sessions and involves a definite time frame, impressions form part of a more formal summary. In turn, this summary is used to assess progress and determine next steps. For example, a family has met with the worker as agreed on for six sessions to develop more effective approaches to helping their ten-yearold son with school adjustment issues. The worker observes that the family has started to make good use of the meetings and have followed up on suggestions. They have not yet held a meeting with their son’s teacher. The worker summarizes: “It seems that you are saying that you’re able to use the techniques we’ve discussed with positive effect. I’m wondering, though, about the meeting with the teacher . . . we’ve discussed it but it hasn’t come about. . . . I think that’s an important thing to do.” set ting goals

Goal setting was discussed in chapter 9. Goals provide focus and direction for the meetings. Moreover, clients may feel overwhelmed by issues they

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examples of que st i on s t hat a ssi st i n se t t i ng g oa l s • “What do you hope will be happening in your life when we finish our meetings?” • “What will your relationship look like when you can say it is better?” • “How will we know that our meetings are successful? What will be happening? How will you be feeling?”

encounter and unsure where to begin to bring about change or resolution. The social work principles of partializing the problem and setting priorities involve breaking down a large issue into its component parts and determining which goal needs most attention at the outset. These practice principles have proven useful over time. From the conversation between the social worker and client and the worker’s initial impressions, preliminary goals emerge that may be expressed in general terms, such as, “I’m trying to understand what these feelings of depression, which come and go, are about,” to very specific terms, “I want to get and keep a job.” Guiding clients toward concreteness helps them define their goals in clear, behavioral terms and can be used to focus on the future, much in the same way that the strengths-oriented questions presented in chapter 11 do. There are many situations in which clear goals will only emerge through exploration and discussion over time. When the agency provides opportunities for more prolonged work, there is less pressure to define goals specifically, but it is nevertheless a useful process and should be kept in mind. It helps clients clarify vague and abstract feelings and thoughts in terms that may make them more accessible to discussion, reflection, and progress. Partializing the problem can be seen in the following example. A client comes to the agency for help in getting and keeping a job as his employment history has been unstable. Goals are broken down into filling out the forms for entry into a vocational rehabilitation program, attending the retraining program regularly and punctually, and working with the job placement officer. The client may feel that these goals are likely to be unachievable until he feels more confident that his medication will help him maintain stability in his mood and behavior. This goal may take priority

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over the others or the client and social worker may decide to focus on it in addition to beginning the vocational program. When clear goals are present, it is easier to identify the tasks or steps that the worker and client need to take to ultimately reach those goals. To enact a successful referral, for example, the worker may need to obtain the necessary forms that the client must complete and the client may need to sign an agreement with the agency to attend a program regularly. When the goals are about internal or interpersonal dynamics, the only tasks at the beginning phase that may be identifiable are to attend sessions and to give some thought to the matters discussed. At a later point, the tasks may include the client putting some insights derived from the interview into action in her life. p r o v i d i n g i n f o r m at i o n s ki lls f or prov i d i n g i n for mat i on • Offering comments • Information about the ser vice • Psychoeducation • Normalization

Offering Comments

Information, in the broadest sense of the term, is offered in many ways. Active listening and the process of eliciting and responding to feedback were discussed earlier. During the interview, the social worker and client are continuously involved in this cyclical interchange of listening, commenting, listening, and so on. The worker’s comments can be conceived of as providing information in subtle ways. When highlighting strengths, for example, the worker is “providing information”—he is saying in effect, “Even though you are telling me about the difficulties in your life, I see that you also have many positives and the ability to cope with tough situations.” Social workers also provide information about the client’s situation in a direct manner. Although the helping process has been discussed as a collaborative one, clients expect that social workers will offer something to

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them that they could not acquire on their own. Expectations will vary and are affected by factors such as the ser vices the agency offers, how clear the client was about her goals when initiating the process, or whether the service request was a result of an agreed-on or mandated referral. If the client was self-referred for counseling, she may be more or less clear about what the problem is and what type of help she wants. During the beginning stage, therefore, the social worker offers his impressions in a tentative manner that invites comments. The practitioner’s impressions may expand the definition of the issues to be addressed or may focus more specifically on a particular topic. For example, a single mother approached an agency serving adolescents for help with her daughter’s poor school attendance and failing performance. An interview with the daughter and mother revealed that their tense relationship interfered with their ability to deal with the school issue. The social worker speculated on and shared her impression that it seemed that their relationship was a source of strain and disappointment for both. This led to an open discussion in which both recognized that their recent immigration from their home country left them feeling lonely. Both mother and daughter wanted a closer relationship and were disappointed with their estrangement. Throughout the interview, the worker used the preceding interview skills and introduced her impressions through reflecting feelings and by offering summaries in a manner that invited reflection and dialogue. This process led to an expansion of the issues to be addressed. Information About the Ser vice

Since most social workers offer ser vice within an agency context, they must be clear about what the agency can provide, what the duration of ser vice is, what problems they can address, and what is expected of the client. Some clients will also want to know about the professional qualifications of the social worker and something about his role or function in the setting. Shulman (2016) recommends that the session begin with the worker describing in simple language the purpose of their meetings and the role that the worker plays, especially when clients are mandated by the court to attend. In our analysis of first sessions in a wide range of settings, we found that the social workers did not begin the first interview giving this type of information (Tsang, Bogo, and Lee 2011). Rather, they asked open-ended questions about the client’s decision to attend the agency, such as “What

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brings you here?” or “What prompted you to contact the agency?” Some workers began with some preliminary comments about their understanding of what led to the meeting with the social worker. Examples of such comments included: “I understand that the staff on the floor thought it would be a good idea for you to see a social worker since you were leaving the hospital. What do you think about that?” “I see on the intake form that you are concerned about feelings of depression, is that why you came in?” It was only at the end of the session that the workers in this study offered information about how they might be able to help the client. After workers had developed some grasp of the presenting situation, had conducted a preliminary assessment of the client’s significant relationships and issues, and had arrived at some joint agreement with the client about what needed attention, they proposed what they, as representatives of the agency, might be able to offer. All of their comments were related to the specific needs of the client. For example, a worker proposed joint counseling for an adolescent and her mother, and also informed them that she could facilitate a meeting with the school. In another case, a worker informed an adult female client who wanted counseling about relationship issues and was depressed and potentially suicidal that he would continue to meet with her and also refer her for a psychiatric assessment and provide her with information about the crisis team should she feel suicidal and unsafe. These interviewing behaviors in positive outcome cases lead to the recommendation that information is most useful when offered at a time that it will be meaningful for the client. This usually happens toward the end of the interview as part of a general wrap-up, summary, and plan about the next steps. Any policies about attendance, cancellation of meetings, fees, and limits to confidentiality can also be explained at that time. Psychoeducation

Social workers serve an educational role when they link clients with environmental resources. Educating clients about a range of issues and expectations related to individual and social functioning can be incorporated in the helping process and is referred to as psychoeducation. This approach is frequently used in groups when information is presented in a formal manner, group discussion and exercises take place, and individual members share their own thoughts and experiences regarding the topic. Psychoedu-

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cation can also be integrated into the individual counseling process, although it should be offered in a way that does not cause the client to feel that there is a power imbalance between the social worker and the client. For example, social workers working with children and their families know about milestones in child development and can share this information in an appropriate way with parents whose expectations may be unrealistic. Social workers practicing with the elderly and their families also know about the components of healthy aging, indicators for community-based supports, and the range of typical reactions on the part of the elder adult and their family members to decision making about moving to a care facility. When an elderly person decides to enter a residential setting and then expresses highly ambivalent feelings about having moved, social workers can help family members by providing information about reactions to relocation and suggestions about how to best respond to this. Social workers in the health and mental health field know a considerable amount about their clients’ conditions and can provide invaluable psychoeducational information about such issues as when an individual might reach a point when they can resume normal activities of daily living, feel less tired, have more motivation, and whether these are realistic expectations and goals. As social workers are learning from neuroscience research that explains human behavior and emotional reactions, practitioners are including simple education about the way brain functioning influences feelings and behavior in their practice with clients to facilitate clients’ self-understanding. Findings from neuroscience research and associated process principles were discussed in chapter 10. Normalization

Related to imparting information is the process of normalization or universalization. This occurs when the social worker uses data from research studies or numerous practice experiences to convey to the client that a particular reaction he is having is one shared by many others. For example, a woman had been receiving an experimental medical intervention for infertility and was informed by the physician in the clinic that the program was terminated, as it was not producing the desired outcomes. The social worker on the ser vice met with the client and listened empathically to her feelings of disappointment, discouragement, and anger. The client told the worker that even though she had agreed to the protocol, actually hearing

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that the interventions were not working was devastating. The social worker had met and worked with many women in such situations and could honestly convey that the client’s reaction was similar to that of other women who had heard this information. For many people, learning that others have had similar reactions and feelings is validating and helpful. Other clients, however, may feel that hearing about someone else’s reaction trivializes their own, or that there is nothing in common with these other women and such information is burdensome, tangential to their current needs, and not useful. When using normalization, the practitioner needs to be sensitive that her comments do not cause the client to feel that the uniqueness of her situation is being minimized or diminished. providing suggestions

The approach presented in this text continues the social work tradition of building the client’s capacity to think through issues, make her own decisions about what to change and how to go about finding solutions, and take action. Reflecting on this stance, Woods and Hollis (2000) observed that this tradition of reluctance to tell clients what to do has probably been more extreme than what actually occurs in practice. They suggested that experienced social workers are likely to give some direct advice to clients. The degree of direction in workers’ suggestions falls along a continuum ranging from indirect to direct depending on the client’s situation. Especially when there are situations of urgency or where safety is an issue, the social worker might adopt a more active position regarding recommendations on particular actions. For example, if the client tells the worker of a suicide plan, the worker might insist that the client go to an emergency department and the worker will accompany the client. If the client remains unwilling to do this, the worker might contact the relevant authorities. When the situation poses less risk but appears inadvisable, the worker might strongly urge the client to take a particular course of action. For example, a young adolescent girl tells her social worker that she has becomes sexually active with her boyfriend. The worker learns that this client has little knowledge of or interest in birth control. The educational information that she provides the client about getting an appointment at a Planned Parenthood clinic and choosing a method of birth control is not given in a neutral manner; she urges the client to do so.

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There are many situations in which social workers provide clients with suggestions or encourage them to consider alternatives when deciding on a course of action where the risk is not as blatant as in the above examples but where the client may benefit from the worker’s advice. For example, a teenaged boy was concerned that his poor attendance record at school had left him so far behind in his studies that there was no hope of catching up. He sought out the school social worker and found support and understanding. He felt that his only option was to drop out of school. In response to the worker’s questions, it emerged that he had not considered other options. The worker suggested a meeting with his teachers to work out a plan and to arrange a volunteer tutor. They also discussed switching to an alternative school that would provide some credit for work he had already completed. In this instance, the worker provided a number of suggestions the client had not known existed. Since a positive alliance had been established, together they proceeded to consider the advantages and disadvantages of these options. When offering suggestions, it is generally advisable to first ensure that there has been some exploration of the issue with the client and that he is truly “stuck.” Too often practitioners find it too uncomfortable to tolerate the difficulty that the client is experiencing and therefore rush in prematurely to offer suggestions, only to find that the client has a reason each one would not work. If enough time and emotional space for exploration and reflection have not transpired, the client may not yet be ready to fully consider what the worker is proposing. The social worker’s manner, tone, and stance are additional elements that impact how the client views the worker’s advice. Within the context of a strong working relationship and when offered in a manner that invites dialogue and consideration, many clients will be open to the suggestion and view it as new information. Recall that in a study on helpful aspects of psychotherapy, clients noted that they almost never followed practitioners’ suggestions (Gehart-Brooks and Lyle 1998). Rather, clients reported that the give-and-take in the discussion stimulated them to come up with their own new perspectives and behavioral, emotional, and cognitive changes. Relationship issues and tone are important to keep in mind when offering suggestions. An authoritarian and opinionated manner on the part of the worker may divert the client from considering the issue under discussion. Rather, the client may become preoccupied with the dynamics between herself and the worker, and wonder about the impact on their relationship

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if she disagrees with the worker. The working alliance may be ruptured and a hierarchical power dynamic reinforced. i n - d e p t h e x p l o r at i o n

The goal of in-depth exploration is to expand the client’s awareness and understanding of phenomena that have a significant impact on their thoughts, feelings, and behaviors. While specific models emphasize different components, promoting emotional experiencing and developing cognitive understanding or insight are effective helping processes across models. Contemporary change theory recognizes the interrelatedness of these domains and encourages practitioners to adopt integrative approaches (Duncan et al. 2010; Greenberg 2002; Siegel 2010). As noted in the preceding discussion of reflection of feelings, chapter 10 provides conceptual frameworks to guide our understanding and processing of the links among emotion, cognition, and behavior. In- Depth Exploration of Feelings and Promoting Emotional Experiencing

Working with feelings and emotional reactions requires attention to levels that proceed from the surface to greater depth. Hence, attention to feelings at a deeper level entails the social worker proceeding in a sensitive and gentle manner. It would be unusual to expect anyone to share her deepest feelings about an issue in a first encounter. Exceptions to this occur when an individual’s sense of self and integration is threatened, such as in situations of trauma or crisis, or as indications of forms of mental illness. The skills of reflecting feelings and reaching inside of silences, presented earlier in this chapter, provides a good beginning point from which to proceed to more in-depth exploration. As the social worker considers further probing, the following factors are relevant. Since depth exploration can produce painful feelings, the worker should give thought to the strength of the working relationship and the degree of bonding between client and worker. Has the alliance developed to the point where the client views the worker as empathic, supportive, and nonjudgmental, and he may expect that sharing difficult feelings will lead to a validating or encouraging response? If the sense of attachment in the working relationship is a positive

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one, the experience of exploring and expressing difficult or previously unacknowledged feelings and being understood and accepted can have extremely positive effects. When clients acknowledge, identify, and experience feelings, workers can express acceptance and provide permission to “allow them to come to full expression” (Cormier and Hackney 1999, 135). Phrases such as “it’s OK to feel what you are struggling with” and “it’s important for you to let yourself cry” can provide the client with enough support to explore and tolerate the discomfort associated with the topic. A working relationship where there is emotional bonding can provide a holding environment that provides nurturance and helps clients contain a sense of being overwhelmed. For example, a father who had left his son when the boy was two years old is currently seeking a closer relationship with the now twelveyear-old boy. In early sessions, he became tearful when discussing his reasons for leaving and would attempt to contain his tears by changing the subject. The worker consistently offered nonjudgmental responses to his disclosing what he termed as his “selfishness,” thus strengthening the therapeutic relationship. This ultimately enabled in-depth exploration of the client’s feelings of sadness about what he had missed in his son’s life, and his guilt and self-loathing about abandoning the boy and his mother to seek a more exciting love relationship with a new partner. The social worker should also give thought to the individual, familial, and cultural meanings attached to expressing feelings. If in all these domains the client has learned that this is not valued, or if it is seen negatively as a self-indulgent process, the client may experience this type of expression as one that stirs up anxiety and is not initially helpful. In such cases, beginning with exploration of cognitions or external norms may be a more productive direction. Or, practitioners may want to make the discussion of feelings an explicit topic and ask clients what they have learned about talking about feelings. They can discuss what the client thinks about these norms and expectations and whether these cultural or familial values currently fit for the client. The client may perceive prevailing cultural mores as helpful and reasonable or as oppressive and constraining. A social worker who both respects the impact of culture and can be nonjudgmental when raising these issues provides a rare opportunity for the client to explore various aspects of her feelings. For example, a middle-aged woman from a Middle Eastern country was referred to the social worker in a family health clinic when her moderate depression was not relieved with medication.

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Through exploration, this client was able to express her unhappiness in her long-standing arranged marriage and her sense of being trapped in it with no alternatives. When exploring the topic of cultural norms, she stated that her parents and husband would not approve of her talking in this open way to a stranger. She continued by saying, however, that she had felt enormous pressure from keeping these feelings locked up inside her and discussions with the worker were providing her with a great deal of relief, helping her to think more clearly about her situation. Depth exploration of feelings is accomplished by using a variety of basic interviewing skills while maintaining a continuing focus on feelings. Probes and open-ended questions are useful to elicit feelings that may be relevant to the situation but are implied, hinted at, or expressed in a nonverbal way. A universalizing comment can be a helpful preface to such probes. For example, a client is discussing her instrumental needs if she plans to leave an abusive spouse and appears distraught. The social worker says: “Many women who have left abusive men feel scared and uncertain when they are thinking about such a big move. What are you feeling about it?” Seeking concreteness can be used in exploring feelings that the client expresses in vague and general ways. Asking for specific nuances of feelings helps the client further express dimensions of the feelings. Some people find it useful to use metaphors to describe their feelings. A client contemplating the power imbalance in her spousal relationship frequently stated she felt small. The social worker asked, “What does this feeling look like to you?” The client thought for a while and then responded, “I feel like a little mini-person with him, that when I am standing next to him my eyes come up to his belt buckle.” This graphic description vividly conveyed to both the client and the worker how diminished, insignificant, and powerless this client felt. Emotionally focused therapist Sue Johnson describes evocative responding as a way of illuminating and heightening the client’s emotional experience: “The therapist attempts to vividly capture the quality and the implicit elements of this experience, tentatively expanding such experience, often by the use of evocative imagery. This then helps the client to construct this experience in a more differentiated way” (Johnson 1996, 45). The purpose is to prompt clients to be more deeply in touch with their emotions, and by using a rich vocabulary, highlight the most poignant aspects of an emotional or physical response, desires, longings, and conflicts. Rather than

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offering an expert summary, the aim is to use powerful and vivid language to guide clients to the “leading edge of their experience and [invite] . . . them to take another step in formulating and symbolizing the experience” (Johnson 1996, 46). Johnson offers the following examples of evocative responding: “When you say that there is a catch in your voice, like it hurts so badly to even have to put that into words, that you may not be the person she wants in her life.” “You’re trying so hard to get on with your life and you feel a heavy weight pressing down on you . . . the gloominess when you realize that she may not come back to your relationship.” That an individual may experience opposing emotions toward the same situation or person is well recognized. Hence, practitioners expect to hear about the client’s ambivalent or mixed feelings and it is helpful to normalize that conflicting emotions are often a corollary of human relationships. For example, a teenaged boy attending an inner-city school has been accepted in an enriched program based on his aptitude, motivation, and achievements in courses and extracurricular activities. The program is in a high school in another part of the city where he knows no one. On the one hand, he is excited by the chance to pursue studies that may lead to a scholarship at a desired college. On the other hand, he is afraid of being lonely, feels anxious about whether he will be accepted in the new school, wonders how his current friends will view him, and is concerned that he might not succeed. These mixed feelings are paramount in affecting his decision about whether or not to accept the admission offer. Through exploring these seemingly contradictory feelings, he was able to recognize how important a sense of belonging with friends had been to him throughout his life. During highly conflictual times in his family life, his friends had provided a stability he valued. By recognizing the issue at the core of his ambivalence, he could consider ways he could attend the new program and still maintain his close connections to particular friends. In- Depth Exploration of Thoughts and Beliefs

When considering the skills of in-depth exploration of thoughts and beliefs, it is useful to refer to the discussion about working with cognitions presented in chapter 10. To review briefly, cognitive theorists provide concepts that help practitioners and their clients identify and understand how ways of processing information affect the meanings that clients give to and

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the feelings they associate with personal events in their lives. Concepts also provide explanations for how current experiences, feelings, and perceptions are filtered and interpreted through cognitive schemas. When preparing to explore thoughts and beliefs, practitioners recognize that many factors will affect the client’s ability to engage in reflective discussion, including the client’s intellectual functioning and the degree to which he can engage in formal-operational thinking and use logic, abstractions, flexibility, and reasoning (Brems 2001). To work with cognitions, the client needs to be able to reflect on and talk about events, relationships, and situations, even when they are not currently occurring. Based on a client’s ability to engage on this cognitive level and think about alternative explanations, interpretations, meanings of a situation, and cognitive interventions can be useful. This requires some ability to symbolize one’s experience by using language and a degree of openness and flexibility while considering different ways of viewing and appraising events. Rather than rigidly interpreting most events in a fixed manner, the client needs to have some willingness to consider whether one could interpret events in another way. The more flexible and open the client is, the more likely it is that he will be able to use new information gained through the helping process. Intelligence, educational level, and age do not predict the ability to be reflective, to think abstractly rather than concretely, or to be flexible rather than rigid in one’s beliefs. When considering cognitive patterns and beliefs, it is always necessary to understand the degree to which they reflect sociocultural mores and values. As noted throughout the text, the meanings given to a range of personal and interpersonal events is highly influenced by cultural belief systems. Social workers need to actively listen for and inquire about the links between individual schemas and these larger belief systems. As stated throughout this text, families interpret these beliefs in their own ways when bringing up their children; individuals also have unique individual interpretations of and affiliations with these systems. In-depth exploration of thoughts and beliefs aims at helping the client elaborate on these various aspects of their meaning systems to discover whether there is dissonance and contradictions in particular areas. In the interest of empowering clients to make decisions in their best interests, such critically reflective discussions can raise clients’ consciousness about belief systems that may be oppressive. The basic interviewing skills of asking open- and close-ended questions, seeking concreteness, paraphrasing and restatement, and offering summaries

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provide the beginning point for more in-depth exploration and elaboration of clients’ cognitions. The aim is to elicit the underlying thoughts, schemas, and beliefs that affect the clients’ feelings and behaviors. This process leads to summarizing themes or patterns that reflect a deeper and more textured and comprehensive understanding of two interrelated dimensions in the client’s life: (1) significant internal factors and external systems, and (2) the ways his feelings, thoughts, and behaviors affect his relationships with external systems and are, in turn, affected by them. Throughout this process, the worker maintains the focus of the sessions and ensures that the client is fully involved in the identification and exploration of themes and patterns, and that a joint understanding between the client and worker evolves. refr aming

Family therapists introduced the concept of reframing into the helping literature as a technique that offered a different way of thinking about a situation or story that the client has shared (Watzlawick, Beavin, and Jackson 1974). Thinking systemically, their aim was to identify contextual factors that were influencing the way the presenting problem was attributed by family members to one individual in the family. These theorists proposed that by providing a different viewpoint, perspective, or meaning to a problem, new attitudes and options emerge. For example, a family sought help for their ten-year-old son whom they described as aggressive with his younger siblings. As the therapist gained more information about the family dynamics, she relabeled this child as the peacekeeper because his challenging behavior brought his parents together to develop ways of handling him and diverted them from the marital conflict that threatened the family’s stability. With this new view of his behavior, the parents could consider ways they could manage their relationship and contain the acrimony between them. The practitioner might support their desire to protect their son from such a heavy responsibility as taking care of the family and reframe their efforts to interact more positively with each other as an example of their concern for their child. Although social workers developed the technique of reframing in work with families as it reflects a belief in a systemic understanding of individual difficulties, it can be used effectively when working with individuals. Reframing, or relabeling, generally challenges individuals’ perceptions, and if

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effective, facilitates a shift in characteristic and patterned ways of appraising behavior. Again, with expanded meanings given to an event, there are more potential opportunities for action. For example, whereas an eightyear-old boy’s mother describes him as wild and oppositional after the school day, the social worker characterizes him as bright and active, thriving on stimulation and activity. Rather than focus on strategies to discipline and contain the child, the focus moves to ways to provide activities that allow him to be physically active in a structured and safe environment. To some extent, reframing has similarities to the concept introduced earlier of working with underlying emotions that fuel surface affect and behavior. Recall the discussion based on Greenberg’s work on primary and secondary emotions (Greenberg 2002). This perspective highlights the importance of helping clients recognize, relate to, and express the softer emotions underlying aggressive or hostile stances, such as the pain that underlies anger or the hurt that underlies hostility and withdrawal. Especially in work with couples, practitioners use reframing to help clients recognize that one partner’s aggressive attack on the other may reflect the individual’s feeling of being abandoned and unsupported by that partner (Johnson 2004). When partners can recognize the underlying feelings of need for connection and fear of rejection, they can soften their reactions, become more empathetic to the other, and respond differently to an angry attack. In these instances, reframing helps clients interpret others’ feelings and behaviors in more benign ways. Working within an emotionally focused approach, the practitioner uses attachment theory and a conceptual understanding of emotions and emotional experience to formulate the reframes. Reframing can be used not only in relation to specific problem behaviors but also more generally in relation to clients’ experiences. As discussed in chapter  11, social workers use a strengths-based approach to reframe clients’ problem-saturated stories, drawing on examples of clients’ coping and survival as stories of courage, determination, and persistence in the face of great odds emerge (Saleebey 2013). When narratives are given a different form, new ways of experiencing past and present events are created. Positive reframing redefines negative or hopeless situations in an affirmative manner that may identify overlooked aspects of the self and hence enhance self-esteem or create potential for change. It is also used liberally in solutionfocused work that changes the emphasis from the problem to the solution (deJong and Berg 1998).

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Formulating reframes hinges on the ability to understand that many meanings can be attributed to a situation or set of behaviors. Where a problem or pattern has persisted over time, it is likely that individuals will develop fixed and rigid interpretations of particular behaviors. As one develops an appreciation for the complexity of human functioning and the recognition that there can be multiple meanings for events, practitioners find different ways to perceive and use new terms to describe the problem that clients are presenting or the relevant behaviors and feelings. Practitioners who use this skill note that there must be a ring of truth to the relabeling. It must make sense to the social worker for her to have some conviction when offering it; it must also make sense to the client and reflect in some way a part of his experience that he can relate to if it is to have some impact. When reframing is used as a technique to highlight strengths or provide alternate explanations that have little or no basis in the client’s reality, he may perceive the practitioner as off-base, not empathetic, and misunderstanding the essence of the issue. In these cases, the client is likely to ignore or reject the reframe. o f f e r i n g i n t e r p r e tat i o n s a n d e x p l a n at i o n s

Interpretation is another technique that practitioners use to offer clients alternative ways of understanding their internal and external worlds. The term originated in psychoanalysis and psychodynamic therapy in the twentieth century, and referred to the practitioner’s use of this specific conceptual framework to explain or interpret aspects and themes in the client’s life. Interpretations originally focused on links to early experiences and transference to the therapist brought unconscious material into awareness (CritsChristoph and Gibbons 2002). In contemporary social ser vice and mental health practice, practitioners from most theoretical perspectives use a form of interpretation or explanation to assist clients in gaining insights and alternate perspectives. The practitioner goes beyond what the client has said or recognized; makes connections between aspects of the client’s internal world, such as between events, themes, patterns, and causal relationships; and gives alternative meanings or explanations for persistent issues, reactions, and feelings (Hill and O’Brien 2014). When interpretation brings about new understandings for clients, they can feel empowered, liberated, and energized.

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New ways of thinking and feeling can lead to more confidence and selfesteem, and to a readiness to try new behaviors. Similarly, theorists drawing on interpersonal neurobiology explain the way the brain works (Siegel 2006). Such explanations provide information and normalization for clients when they are overwhelmed with strong emotional and behavioral reactions. These explanations pave the way for interpreting links among current and former experiences, patterns, and reactions. Murphy and Dillon (2003) discuss this skill using less technical language, describing it as helping clients develop new perspectives by “sharing ideas or hunches about content, affect, themes and patterns, or relationship dynamics of which they may be unaware” (159). They note that these hunches are only guesses or working ideas and should be offered in an exploratory and provisional way, inviting response from the client. Within the stance of collaboration, the metaphor for offering interpretations is one of two people putting their heads together to come up with some useful ways of thinking about and acting on a challenging situation. Practitioners can use questions or statements to convey the interpretation. For example, the worker might say the following as a statement: “Your father wasn’t around when you were little, your partner didn’t help out much when you had your first child . . . with your second baby coming, you are feeling very anxious that you will be on your own again with no one to count on for help.” Or the practitioner might offer this interpretation as a question and begin with the phrase “Do you think that since . . .” Research evidence supports the positive impact of interpretations on outcome in short- and longer-term psychotherapy when they accurately address aspects of clients’ central interpersonal themes (Crits-Christoph and Gibbons 2002). High levels of transference interpretations can lead to poor outcomes, however. While these researchers emphasize that interpretations need to be “accurate,” a collaborative and interactive view of practice, as presented in this book, emphasizes the importance of a practitioner’s stance that invites discussion of the interpretations she offers. It is not “accuracy” but the practitioner’s commitment to arriving at joint understanding that appears to lead clients to experience the process as helpful. From their review of studies, Crits-Christoph and Gibbons (2002) note a number of factors that affect clients’ responses to interpretations. First is timing, which involves clients’ readiness to listen to and absorb the content of the message. Recall the discussion of a young woman in our study who told her current social worker that she had stopped attending counseling sessions

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when her previous social worker had linked her discomfort with sexual activity with a boyfriend to her parents’ reactions to discovery of her sexual play when she was a child (Tsang, Bogo, and Lee 2011). This interpretation was obviously not well timed; the client was not ready to consider this and reported that it increased her discomfort to suggest that her “parents were to blame.” A second factor involves the nature of the alliance and whether the client is able to provide feedback about an interpretation and disagree with its content or let the practitioner know that the ideas presented are too troublesome to consider further. It is important for practitioners to “tune into” their clients’ reactions during the sessions, tolerate clients’ discomfort, and if appropriate, retract the interpretation. They also will invite the client to offer her own interpretation, comment on the troubling emotion, or offer support. Even when interpretations are not well timed, when offered in an empathetic tone and manner in the context of a solid working relationship, the client and worker can discuss the disjunction and misunderstanding and repair the bond. If the social worker thinks that the content of the message has merit, she may reintroduce it at a later time, when she believes the client might be able to consider it. Cody (1991), a clinical scholar, notes that interpretations offered in a critical tone and experienced by clients as harsh and confrontational, can lead to poor outcomes. Practitioners encourage clients to develop self-reflective cognitive skills to promote their future ability to recognize, examine, and productively manage emotions that are stirred up, rather than impulsively react. Hence, workers might be more helpful when they refrain from offering their own interpretations and focus more effort on assisting clients to make their own observations and draw their own conclusions. Worker comments within the interview such as “What do you make of this?” and “What are your thoughts about the recurring theme in your life, ‘I can only depend on myself ’?” give clients the opportunity to develop their own insights. Practitioners can also end sessions with an explicit suggestion that the client give the matters under discussion some further thought and begin the next meeting with an inquiry about any insights the client may have since they last talked about an issue. challenge

For the majority of the interview, practitioners listen, focus, and structure the discussion on the client’s most pressing and relevant issues; provide support

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and encouragement; and help clients explore thoughts, feelings, and their reactions in significant relationships and to external events. When these processes take place within the context of a working relationship where bonding includes emotional connection and strong rapport, the client is assisted to develop greater clarity and understanding, arrive at new positions, and take new actions. This description of the process of helping sounds more fluid and straightforward than the process in everyday practice. It is not unusual for the client and worker to experience moments, and even periods, when this process does not flow naturally and the client feels “stuck.” Many reasons may account for a sense of repetitive discussions of reoccurring themes and patterns with little forward movement. The skill of challenge, also referred to as confrontation or pointing out discrepancies, is an additional helpful tool. Challenge refers to making a comment that aims to help the client develop greater awareness of her thoughts, feelings, or behaviors by addressing contradictions, discrepancies, fixed beliefs, or defenses (Hill and O’Brien 1999). They are used when it seems to the social worker that the client is unaware of aspects of her internal or external experiences that are perpetuating the problematic situation and maintaining the status quo. For example, an elderly spouse tells her family that she is getting more and more exhausted caring for her husband who has Alzheimer’s disease. After many home visits from the seniors agency social worker, however, she rejects all offers of in-home care, day programs he could attend, and respite care, saying that she would feel too guilty if someone else took care of him. The worker gently and supportively challenges her, saying, “I wonder how we can help you—you clearly need some help to care for your husband and yet feeling guilty about receiving it seems to leave you without help and more and more exhausted.” When offering challenging comments, social workers must be aware of their tone and give thought to how best to phrase their statements or questions. Following a review of studies of confrontation, Hill and O’Brien (2014) conclude that they are powerful interventions, but they frequently had a negative impact on the client, leading to interactions that interfered with the collaborative aspect of the working relationship. In the studies, practitioners pointed out discrepancies to clients, such as when a client tells the worker that he plans to do something about his procrastination about studying but does not demonstrate that he is taking responsibility for his behavior and changing his study habits. Clients tended to respond defen-

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sively, which in turn sometimes led to the practitioner responding with more confrontation, thus producing a downward cycle in their interaction and a rupture in the alliance. They therefore recommend that when workers use the interviewing skill of challenging client’s behavior, they should offer their comments with empathy and in a way that accords with a solid working relationship. It is human nature to react to information that may sound critical with increased anxiety and a reasonable response is to reject it. Hence, social workers give thought to how to offer a challenging comment in a way that keeps the client’s anxiety at a manageable level and enables the client to listen to and think about the comment, but is not so bland that it has no impact on the client. Too much support, an apology before offering a challenge, or couching the comment in mild and general terms can result in the client’s dismissal of the challenge. An example of an effective challenging dialogue follows. A middle-aged man lost his clerical job due to cutbacks in the public works department. He has undergone retraining and is now working in a manual job that he feels is beneath him. In his meetings with the employee assistance social worker, he has been critical of the other workers on his team and also has complained that they ignore him in their informal conversations. When it became apparent to the worker that he is unaware of how often he has told her anecdotes about his critical comments to his fellow workers, she feels that a gentle challenge is in order. Her comment begins by acknowledging his disappointment with his current position: “We’ve talked about how hard it has been for you at this stage of your life to move from an inside to an outside job, and that’s made you angry. You’ve also acknowledged that you prefer to have a job rather than be unemployed. Do you think there is some connection between the other men being unfriendly and the fact that you’ve been fairly critical of them?” In this example, the worker summarizes a theme they have covered and makes reference to their joint discussions. She then poses her challenge as a question, offered in a gentle and understanding tone. Since the client views the worker as having concern for him, he is able to respond, although somewhat defensively, that these men don’t work as hard as his previous coworkers. The worker returns to her challenge, “That may be so, but how do you think they might see you when you make these critical comments?” The client takes this comment to heart and together they begin to consider how he can find ways to connect with his current coworkers.

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Shulman (2016) identifies the importance of “challenging the illusion of work” (153), that is, when both the client and social worker avoid exploring difficult topics or deeper and painful feelings, it is the worker’s responsibility to change course and encourage “the client to work effectively on her or his tasks and to invest that work with energy and affect” (16). Using an empathic approach, practitioners should make “demands for work” (149) by encouraging clients to focus on key issues even though they may be painful, working with them to elicit and examine difficult feelings, and challenge cognitions that involve blaming others for problems rather than accepting one’s own contribution. Such an empathic approach can lower defenses and help clients examine their own roles in problematic interpersonal encounters. In general, a stance that encourages reflective discussion between client and worker can, to some extent, neutralize the inherent tension that one experiences when being challenged by or hearing a potentially critical comment from a valued and respected person. There are a number of phrases that might serve as useful prefaces to challenging comments, such as “Have you noticed that . . . ,” “It is interesting that . . . ,” “I’m curious/puzzled by the fact that on the one hand you say . . . and on the other hand,” “Can we take a moment to consider this . . . ,” “I’m trying to understand this . . .” When offering challenges, practitioners should draw from examples that are currently under discussion (Kourgiantakis, et  al. 2016). The worker might also return to anecdotes the client has offered in previous interviews. The potency of such anecdotes, however, derives from their proximity to issues that are currently under discussion and with which the client is emotionally engaged as he works to sort through a situation. Ambivalent or mixed feelings may account for some of the client’s contradictory thoughts or actions and it is useful to highlight that two different feelings can exist at the same time and may result in confusion for the client. Often individuals talk about two differing thoughts or feelings using the term “but,” such as when a client says, “I know this relationship is not good for me but I love her.” Such language implies that nothing can be done about resolving the situation—in this example, that the client’s love holds him in a particular position. It can be helpful for clients when the worker rephrases the presence of two discrepant positions by using the term “and” as a way of recognizing that two states are possible, that their presence makes a resolution more difficult, and that each needs to be ex-

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plored and considered in relation to each other. For example, the worker might comment: “You experience great pain in this relationship, you are uncertain about your partner’s continuing interest and reliability, and you still feel connected and attracted. Can we further examine both sides of this dilemma and see how you can deal with these two opposing feelings?” As with all of the middle phase processes such as resolving ambivalence, dealing with being “stuck,” and searching for alternatives, challenging issues are not simply clarified or addressed after one discussion in a session. Challenges may need to be repeated several times and in different ways (Hill and O’Brien 1999). Challenges, interpretations, and reframes all may stimulate the client to look at a situation differently. There is an intricate relationship among thoughts, feelings, behaviors, and our sense of self. Hence, it is understandable that information that seemingly threatens an integrated and cohesive view of self is likely to take time to examine, process, understand, and perhaps at some point, accept. When studying interviews in which these strategies are used, one is struck by the observation that clients frequently react to these worker interventions by initially refuting them, denying the essence of what is presented, or debating with the worker. In some instances, it is appropriate that the practitioner stop work on the particular theme. Professional helping is not about being “right” and the worker should not assume a position in which he is debating with the client the superiority of his insights over the client’s. A client’s strong rejection of a worker’s challenge, interpretation, or reframe can be considered useful information or data; it may indicate that the comment’s substance is not meaningful to the client or that the client is not able at that moment to examine a view that is contradictory to the one he currently holds. In contrast are those instances when the worker persists in a gentle fashion, or returns to the substance of the comment in another way and the client recognizes the issue and includes the new perspective in his thinking, feeling, and discussion. These later interactions can be thought of as the process of working through an issue. The difficulty for the worker is deciding when to stop pursuing a challenging comment and when to persist in offering it in a different manner. Client reaction is the primary source of data to guide the practitioner, along with reviewing session recordings on one’s own, or in clinical supervision or with peer consultation. By analyzing crucial moments in interviews with others, practitioners can gain insight into their own behavior, distinguish between issues relating to

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use of self or simply skill level, and obtain other perspectives on the client situation and ways of effectively intervening. putting it together

Interviewing skills have been discussed thus far in discrete terms. In our analysis of first sessions in positive outcome cases, we found that the social workers used four sets of skills in a conversational manner to achieve the tasks of the first stage: gaining sufficient understanding of the client’s situation to proceed and building a helping relationship by providing empathy and support (Tsang, Bogo, and Lee 2011). The first set of skills involved a considerable number of open-ended questions, requests for concreteness, and clarifications to encourage each client to elaborate on what he had initially offered. They also used these skills to obtain information from the client that described his ecological map. It was apparent that all of these social workers used an ecosystemic/person-in-environment perspective while working in different fields of ser vice, from an agency serving adolescents, to a community health center, to a mental health facility. The second set of skills involved the workers in offering periodic brief summaries throughout the interview that pulled together information the client had shared up to that point. These summaries were offered in a way that invited the client to confirm that the worker had understood the client’s message or to correct the worker’s impression of it. Third, these summaries went beyond factual information; the practitioners usually included some comments about the client’s thoughts and feelings. The social worker drew these comments directly from what the client had shared or had subtly alluded to. The practitioners seemed to also use these summary statements as empathetic responses that provided support to clients and led to further elaboration by them. These summaries and the clients’ responses can be seen as sequences of interactions that led toward affirming a joint understanding of the client’s experience of the presenting problem and related issues. In one client’s words, she felt that the worker “gets it.” It frequently took the better part of a one-hour interview for these experienced social workers to offer an elaborated summary that was inclusive enough to lead naturally into the client and worker setting up some preliminary goals or plans. The fourth set of skills includes those that offer support, encouragement, or hope to clients. Practitioners used a range of techniques to re-

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spond on an emotional level to the client’s confusion, distress, and pain. In some instances, they validated painful emotions, in others they pointed out the client’s strengths and courage in dealing with past difficult situations or feelings, and in others they identified any areas of positive and effective functioning on the part of the client. This review of the study’s first sessions reveals that the interviewing skills discussed in this chapter should not be used in a mechanistic or formulaic manner. They were integrated into each of these experienced workers’ personal styles and were used in a purposeful or intentional manner to achieve the beginning stage tasks in a way that was sensitive to the client’s presentation of self and situation, as well as his comfort with the pace and timing in the interview. From clinical observations, it is apparent that practitioners use an even wider range of skills to achieve the many processes of the middle phase. Hence, social workers are constantly traversing the arc of theories and concepts that help them understand the client, processes and principles that guide their interventions, and skills that actually put these ideas into practice. a final word

As discussed at length in chapter 3, there are many effective ways for social work students to develop holistic competence and learn to integrate theory and practice in a way that is congruent with their personal styles. Many hours of practice with simulated and actual clients appears to be the most useful way for students to develop their own way of executing the skills. Students’ words and stances need to feel natural and congruent with their personal style, not contrived or stiff. Practice alone is not sufficient, however; it must be followed by review of recorded interviews. Such reviews can focus on a number of dimensions. First, the student can devote attention to linking conceptual material with understanding the client situation. Second, the student can focus on the way she is putting selected concepts or interventions into practice. Such reflection appears useful in bridging abstract concepts with concrete actions. Third, observation of oneself provides the stimulus to examine professional use of self and to identify internal cognitive and affective processes that may have occurred during the interview. The closer in time this reflection occurs to the actual conduct of the interview, the closer one comes to reflection-in-action. Review and reflective

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discussion with peers and course and field instructors also appears to be beneficial. Social work practice frequently occurs in public places, that is, in front of other professionals, in teams, and with students in teaching settings. Accordingly, from the very beginning of their education, it is important for social workers to learn to overcome performance anxiety and develop the ability to demonstrate their competence in interpersonal processes. Classroom teaching that uses simulation with feedback has been shown to be extremely effective in linking theory and practice, and in developing students’ holistic competence (Bogo et  al. 2014; Kourgiantakis, Bogo, and Sewell, in press). Review of recordings can occur in a number of ways. For example, the student can view segments of the interview to consider the essence of what the client was trying to convey, themes that are reflected in the segment, and the student’s intentions that led them to make the comments they did. Since the recording captures what was actually said, it provides concrete data for students to assess whether their statements were clear, how they were received by the client, what impact they had on the client, and how they served to further the interview or to interfere with its progress. When observing the interview, the recording can be stopped and alternate ways of phrasing a particular comment can be formed and a role play or simulation can be conducted to reenact a particular segment. This type of deliberate practice, discussed at length in chapter 3, appears to be an especially useful way of developing a skillful interviewing style. For many students, reflecting feelings and in-depth exploration of them are the most challenging skills to use. The feelings associated with the issues that generally bring individuals to a social worker include anger, sadness or depression, fear and anxiety, shame, vulnerability, confusion, inadequacy, and discouragement. Social workers are also attuned to the positive emotions of happiness or joy, peace, love and caring, energy, and strength and mastery. It is useful for the worker to develop a language rich in expressive terms. For example, the feeling of being angry can be described in many different ways, including terms such as “annoyed,” “cranky,” “enraged,” “exasperated,” “frustrated,” “furious,” “hostile,” “mad,” “outraged,” “upset,” and so on. Each practitioner can develop a diverse repertoire of terms to help clients describe a particular aspect of these general emotions. The second issue many students identify is the need in the interview to develop a balance between

practi ti oner be hav i or s t hat c a n i m pe d e in f o rm at i o n gatheri ng and c li e n ts’ w i lli n gn e ss to d i s c us s p e rs o na l thoughts , f eel i n gs, or b e hav i or s • Offering strong judgmental comments or ignoring the client’s cultural and value system.

• Making inappropriate humorous comments or minimizing the situation. • Failing to track the client by not responding to his messages, abruptly changing the topic, or responding to emotionally laden messages with superficial or irrelevant comments.

• Interrupting the client. • Providing too much structure and talking too much. • Giving long explanations or “minilectures” about human be havior and social conditions.

• Providing too little structure and only minimal responses. • Displaying discomfort that conveys that the topic under discussion is threatening or uncomfortable in some way.

• Being overprotective of the client in a way that implies he is too fragile to discuss difficult matters beyond a surface level.

• Offering premature problem solving by giving advice and suggestions. • Excessively focusing on problems and weaknesses without attention to strengths.

• Excessively focusing on facts and external circumstances without enough attention to the client’s subjective experiences.

• Excessively focusing on irrelevant information and topics or persons other than the client, or becoming sidetracked in general.

• Providing false reassurance, that is, reassurance that is not based on solid data. For example, reassurance that the situation will work out or that the worker believes the client has the ability to handle the situation successfully when data indicates that would not be the case.

• Engaging in power strug gles with the client over what information is needed and to what extent.

• Arguing with the client and taking an authoritarian, dogmatic stance. • Criticizing or belittling clients, or demonstrating condescension to them.

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sensing when one is overly intrusive when reflecting feelings and when one is too distant and superficial. Timing and the development stage of the working relationship will have an impact on learning this skill. Specifically, as the working relationship between the student and client develops and the client recognizes that the student will respond empathetically rather than in a shaming, critical, or negative way to the client’s disclosure of and elaboration on information, it becomes easier for both the student and client to discuss emotional issues. If the dialogue is conducted on a superficial level, however, the client will not have the opportunity to experience what it is like to reveal emotions. There is a circular or interrelated nature to the client’s ability to disclose and the student’s ability to reflect feelings. With opportunities to practice these skills, especially with feedback from course and field instructors, students are able to improve their level of comfort and competence in executing them. From analyses and comparisons of student interviewing behaviors in class and in field practicums, researchers have identified a number of behaviors that interfere with effective interviewing (Collins 1990; Collins and Coleman 2000; Hepworth et al. 2002). When learning the interviewing skills presented in this chapter, it may also be useful for pracitioners to strive to diminish the frequency of the behaviors on page 367 that undermine their efforts to develop a productive partnership and to assist clients in presenting and elaborating on relevant aspects of their situations. The final section of this text reviewed a number of generic or core interviewing skills for use in social work practice. As noted throughout, these skills constitute the fundamental building blocks that practitioners use to transmit conceptual material, values, and practice principles to their actual work with clients. Skills are a central component of holistic competence. Social workers are faced with an ever-expanding knowledge base that offers them new and useful ideas to help those they serve. Of equal importance is the rich learning and professional development that results from self-reflection and review of one’s own practice. One of the rewards of social work practice is the opportunity for continuous personal and professional growth provided in this human ser vice vocation.

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index

Ability: evidence of, 281; and working relationship, 133 Abstract conceptualization, in learning theory, 50 Abuse, 207. See also Child abuse and neglect Acceptance: in helping relationship, 102, 131–138; open communication in, 94; in relationship building, 139 Accountability, and staff supervision, 13 Acculturation, 214 Action for change, 185 Active experimentation, in learning theory, 50, 51 Active listening, 112, 197, 277; to offer reflections, 333; and paraphrasing, 330–331; use of term, 325; when taking notes, 327 Adolescents, 292, 319–320; differences for, 152; disagreement with, 289–290; mother-daughter issues, 324; with school issues, 339, 349; sexual issues for, 328, 348 Adolescents, working with, 206; as clients, 30–31, 233–234; in helping relationship, 148; as involuntary clients, 172; North American perspective of, 213; in working relationship, 152, 166 Adverse Childhood Experiences study, 276 Affective processes: attention to, 133; emotional self-regulation, 44–46; in holistic competence, 47; in reflective practice, 46–47; self-awareness, 46–47; social identity, 42 Affective reactions, 311 Affect labeling, 260

Affirmative action, 42–43 African American experience, discrimination in, 106 African Americans, education and employment of, 43 Agencies: assessment formats provided by, 228; funding formula of, 187–188; issues addressed by, 211; number of meetings mandated by, 297; policies and programs of, 122; providing prolonged service, 31; secure systems developed by, 206; self-anchored scales used by, 234; and social work practice, 12–13; supervision provided by, 64; visiting schedules of, 166 Agency thinking, 283 Agreement, in therapeutic alliance, 151, 152, 153 Ahn, H., 102 Ainsworth, M. D. S., 90, 91 Alcoholism, programs for, 172 Alcohol use, assessing for client’s, 319 Alliance: concept of, 175, 176, 177; negative shift in, 289 Alliance building, 203; interviewing activities and behaviors, 157. See also Therapeutic alliance Allied health professionals, working relationships formed by, 142 Ambivalence, client, 185 American Association of Marital and Family Therapists, code of ethics of, 168 American Psychiatric Association (APA), 276 Anger, strategies for managing, 301–302 Anger management groups, 172, 176

400

Antidiscrimination policies, 123 Antioppressive models, 69 Apology, in helping relationship, 140 Applegate, J., 93, 95 Arbitrary inference, 262 Asakura, K., ix, 86 Assessment: avoiding premature conclusions from, 35; as continuous process, 218, 219; crisis in, 226; developing, 290–291; family participation in, 238; joint, 81; and planning, 219; research on, 238; social identity in, 43–44; strengths perspective in, 74; theoretical explanations in, 17; understanding in, 218 Assessment guide: change and helping process in, 222; environment in, 221–222; 4 Ps model, 227–228; identifying data, 220; individual in, 221; presenting problem in, 220; social situation in, 221–222 Association of Social Work Boards, 11, 171 Attachment, in professional helping relationships, 95 Attachment styles, 90; avoidant, 91; in children, 91 Attachment theory, 18, 88, 89, 135, 254, 276; and developing new perspectives, 279; with emotionally focused approach, 356; and neuroscience concepts, 258 Attending: to offer reflections, 333; use of term, 325 Attending behaviors, 327 Attending stance, developing, 328 Attitudes: community, 15; focus on eliciting client’s, 264; in helping relationship, 147; humanistic, 174; self-reflective, 328; of social work students, 116 Autonomy, in learning experience, 52 Bachelor, A., 149 Barley, D. E., 98 Beck, Aaron, 261 Behavioral theory, 19 Behavioral therapy, cognitive, 261

index

Beliefs, in-depth exploration of, 353–355 Berg, I. K., 272 Bess, J. M., 46–47 Biases, 77 Bio-psychosocial information, client’s, 68 Bio-psychosocial perspective, xii, 18, 227, 229 Birth control, choosing method of, 348 Blind spots, for practitioners, 77 Blythe, B. J., 172 Body posture, 325 Bogo, M., 34, 40, 67, 77, 111, 171, 214 Bohart, A. C., 280, 283 Bonding: and criticism, 135; and disagreement, 145–146; diverse experiences and, 115; impediments to, 214; self-disclosure and, 164 Bonovitz, J., 93 “Booster session,” 304 Borash, M., 175 Bordin, E., 151, 156, 232 Boundaries, with termination, 307 Boundary-crossing issues, 167, 168–169, 171 Bowlby, John, 88, 89 Brain-based mechanisms, 254–255. See also Neuroscience Brain development, 95 Brandell, J., 93, 179 Brief Family Therapy Centre, Wisconsin, 271 Brookfield, S., 39 Brown, L. S., 167 Buffalo University School of Social Work, 62 Burnes, D., 234 Burnout: practitioners experiences of, 60; prevention of, 60, 65; research on, 65, 67 Burns, D., 277 “But,” clients’ use of word, 362 Cameron, M., 103 Campbell, A., 156, 287 Canada: research on social workers in, 58; schools of social work in, 10 Canadian Association of Social Workers (CASW), code of ethics of, 10, 168

index

Cancer, women with, 284 Caregiving, in professional helping relationships, 95 Caretakers: early experiences with, 90; elderly as, 360 Caring concerns, 130–131 Caring profession, social work as, 85 Carkhuff, R., 140 Case management, 22, 243, 246–247; counseling aspect of, 245; ecological systemic perspective on, 244; effective, 245; examples of, 243; initial stage of, 244–245; middle stage of, 246–249; problem-solving in, 245–246; short term vs. long term, 246–247; use of term, 243 Catastrophizing, 263 Challenging: client’s rejection of, 363; interviewing skill of, 359–364; strategy of, 363 Change, 255; in assessment guide, 222; client’s perspective on, 181–182; client’s readiness for, 321; components of, 283; focus for, 282; in helping relationships, 83–84; internal vs. external factors affecting, 180–181; and persistence, 180–181; and power dynamics, 125; processes for bringing about, 247–248, 267; recognition of possibility of, 73; and relationships, 86; role of language in, 259; specialized models for, 179; theories of, 18; toward understanding, 178–179; transtheoretical model of, 181 Change, barriers to, 274; naturally occurring networks, 275; in traumainformed practice, 276–278 Change, stages of, 182, 191, 281–282, 297; action, 185; contemplation, 183–184; and joint planning, 194; maintenance, 186; practice principles based on, 187–188; precontemplation in, 182–183; preparation, 184–185; and skill sets, 194; and strengths perspective, 188; termination, 186 Change efforts, 243 Change processes, 247–248, 267, 268, 269; anticipation of clients’ response in, 282–283; characteristics of, 284;

401

collaboration in, 286; developing new perspectives, 279–281; emotionally focused, 317; focusing on strengths, 268–273; goals of, 75, 280, 290–294; and helping relationship, 286; maintaining working relationship in, 286–290; in middle stage, 294; monitoring progress in, 291–292; obstacles in, 273–275; outcomes in, 291; and revisiting initial assessment, 292; and skills, 312; taking action with, 281–285; types of, 248; in working relationship, 286–290 Charles, G., 224 Child abuse and neglect: assessment of, 35; reporting suspected, 13, 177, 207; and stages of change, 184–185; and therapeutic outcomes, 98; and trauma-informed care, 277 Child maltreatment, study of, 34–35 Child protection services, 153; clients in, 172, 240; for foster children, 246; managerial approach to, 40–41; strengths approach in, 274 Child protection workers, strengths-based approach of, 174 Child-rearing practices, clients’ confusion about, 215 Children, working with, 206 Child welfare services: clients of, 140; relationship with parents in, 172–174 Child welfare workers: burnout of, 65; study of, 34–35 Chow, D. L., 300 Clark, J. L., 110, 145, 213 Class, and working relationship, 133 Client capacity, building, 303 Client reaction, as source of data, 363 Clients, 130–131; in abusive relationships, 78; adaptive responses of, 282–283; adolescents as, 233–234 (see also Adolescents); in assessment guide, 221; challenging, 287; and change processes, 188, 293; constraints and challenges for, 83; constructing theory or formulation about, 229; and development of trust in treatment relationship, 96; from diverse backgrounds, 213; education

402

Clients (cont.) for, 75–76; effect of ethnicity on, 107; emotional attunement to, 111–112; empowerment of, 75; expectations of, 44, 115; and extratherapeutic factors, 98–99; family as, 225; first meeting with, 203–204; focus on needs of, 127; and give-and-take conversations, 84; goals of, 204–205; goodness of fit for, 83; harmful behavior of, 132; with hearing problems, 326–327; internal change for, 76; internalized culture of, 107; living in two worlds simultaneously, 215; in mandated services, 291; new perspectives for, 280–281; personal experiences of, 214; personality styles of, 245; perspective on change of, 181–182; preparing for first interview with, 195–200, 201; readiness for change of, 183; reasons for referral of, 201; resilience of, 74; and shared understanding, 217; social environment of, 98–99; social identity characteristics of, 307; in social work, 24–25; and social worker’s emerging understanding, 110; strengths and resources of, 269; subjective experience of, 143–144; suicidal, 305; and termination, 297–298; understanding key concerns of, 111; unexpressed feelings of, 288–289; with visual impairments, 326; and worker’s self-disclosure, 161; worker’s similarity with, 163; in working relationship, 25–26, 73 Clients, characteristics of: belief or hope in, 99; bio-psychosocial information, 68; elderly, 38; environmental factors in life of, 68; hopelessness of, 129; hostility of, 71; with marital problems, 135–136; stereotypical, 106–107 Clients, engaging, 205, 216; discussing confidentiality, 206–208; establishing requested service, 208–209; helping clients tell their story, 210–212; initial stage, 204–206; integrating diversity perspective in, 212–215; and relationship building, 209 Clients, involuntary, 132; effective relationships with, 174; emotional

index

reactions of, 173; nonjudgmental stance with, 173; past experiences of, 173; relationship building with, 172–177; working with, 176 Clients, questions for: about change, 283; discussion of problems and difficulties with, 271 Clients, simulated: and practitioners’ emotional self-regulation, 45–46; study assessing suicide risk in, 45 Client service, goal of, 129 Client-social worker relationship, 4, 102–103. See also Helping relationships; Working relationships Client strengths, uncovering, 272 Clinical practice: and positive change, 260–261; traditional base for, 18; understanding relationships in, 151, 166 Clinical Social Work Association, 171 Clinical supervisors, influence on practitioners of, 33 Coaching, in change processes, 284 Coady, N., 85, 174, 359 Code of ethics, 127; of professional associations, 167–168 Cognition: and change processes, 279–280; effect of emotions on, 8, 264; in neuroscience, 261–265 Cognitions, working with, 354 Cognitive behavioral approaches, and change processes, 279–280 Cognitive behavioral therapy, 19, 22 Cognitive meaning, 202 Cognitive processes: attention to, 133; critical thinking, 36–38; distorted, 276; and emotional regulation, 267; impact of context on, 40–41; implicit knowledge in, 38–39; influenced by emotions, 57; mindfulness, 39–40; use of knowledge, 30–36 Cognitive processing styles, 262–264 Cognitive skills, self-reflective, 359 Cognitive theory, 19 Collaboration, 24; in alliance building, 158; in case management, 245–246; with clients, 47, 273; in helping relationship, 154–158; promoting client, 287; seeking, 274; and termination,

index

296; in trauma-informed practice, 278; in working relationship, 124 Collaborative approach, 155; building and sustaining on, 193; in helping relationships, 84 Colleagues, and helping relationship, 141–142 Communication: body posture in, 325; empathic, 145–146, 150–151; eye contact in, 325–326; facial expressions in, 325; head nods in, 325–326; negative behaviors with, 290; privileged, 207; tone of voice in, 326 Communication behaviors, 7, 28 Communication skills, xii, 3, 311–312. See also Interviewing skills Communities: conflict in, 65; and practice context, 14–16; professional and collegial, 63; at risk, 122 Compassion fatigue, 59 Competence: defined, 5; demonstration of, xi; developing, 49; educating for, xi; in EPAS, 29, 48; influences on, 26–27; metacompetence, 5–6, 41; overall professional, 8; practicing, 55; procedural, 5; in strengths perspective, 73 Competence, holistic: affective processes in, 41–47; central premise of, 28; and complex practice behaviors, 6–8, 6f; dimensions of, 7, 29; interviewing skills in, 368; and learning styles, 51; metacompetencies, 28, 29; selfawareness of one’s self-state in, 46; and stages of change, 188; values associated with, 6, 6f Competence, procedural, 28–29 Compton, B. R., 178 Conceptual map: for collaborative relationship strengths, 17f, 21; example of, 17, 17f, 26. See also Genogram Concrete experience, in learning theory, 50, 51 Concreteness: concept of, 322; in exploring feelings, 352; requests for, 364; seeking, 323, 334 Confidence, in helping relationship, 146–147

403

Confidentiality: discussing with clients, 206–208; in helping relationship, 131–132; and ICT use, 170–171; with interpreters, 199; limits of, 177; safeguarding, 206–207 Conflict: in helping relationships, 83; intercultural, 120 Conflict of interest, and boundary violations, 167 Congruence, use of term, 141. See also Genuineness Consent forms, 208 Constructivism, 19 Contemplation stage, in change process, 183–184 Content, 308 Continuing education, 123 Cooperation, of clients, 273 Coping: individual’s unique style of, 223; providing information about, 230–231; questions for clients about, 270–271 Coping strategies: in change processes, 285; of immigrants, 288 Coping styles, examining, 269 Core foundation, for social work students, xii Council on Social Work Education (CSWE), 10, 14–15, 171, 172; EPAS of, xi, 172; on field education, 53. See also Educational Policy and Accreditation Standards Counseling, 176; cross-cultural, 148, 214; effectiveness of, 148–149 Counseling process, psychoeducation in, 347 Countertransference, 94–95, 128, 328; as enactment of internal working model, 89; in psychodynamic theory, 258–259; in therapeutic working relationship, 115; use of term, 86–87 Couples, reframing used with, 356 Couples therapy, 91, 136, 170, 182, 202; conjoint, 292 Cournoyer, B., 178 Court mandated services, 121 Court-ordered decisions, 138, 140 Cowger, C., 224 Cozolino, L. J., 258, 259, 262

404

Creativity, in strengths perspective, 73 Criminal justice system: clients in, 172; clients mandated by, 208 Crisis: assessment of, 226; social work intervention in, 295 Critical thinking, 5, 36–38, 311 Criticism, practitioner’s response to, 361 Crits-Christopher, P., 358 Cross-cultural practice, 112 Cultural competence, concept of, 106 Cultural complexity, 43 Cultural conventions, and termination phase, 298. See also Norms Cultural frames of reference, learning about clients’, 147 Cultural literacy approach, 106–108 Cultural norms: and nonverbal behaviors, 326; and patterns of silence, 336. See also Norms Culture: and cross-cultural practice, 112–113; cultural humility, 109, 124; developing internalized, 116, 117; and diversity, 106–114; and ethnicity, 106; and help-seeking behavior, 214; and institutionalized racism, 105–106; meaning of, 108; reflective exercises for, 118–119 Damasio, A., 256 Data analysis, questions guiding, 230 Data gathering, using multiple perspectives, 227–229 Davis, D. A., 131, 132 De Boer, C., 174 Decision-making processes, 13 Defensive styles, used by clients, 75 deJong, P., 272 Deliberate practice (DP), 300, 366; defined, 54; simulation in, 79 DeLois, K. A., 75 “Demand for work,” principle of, 293–294, 362 DePanfilis, D., 23 Depression, symptoms of, 214 Dewey, J., 50 Diagnostic and Statistical Manual of Mental Disorders (DSM), 220

index

Dialogue, 147; about change processes, 283; and empathy, 202; example of challenging, 361; focused, 250; in helping relationship, 145–146; important information in, 249; one-to-one, 213; supportive space and place for, 241–242 Dichotomous thinking, 263 Differences: for adolescents, 152; and controversy, 123; and demonstrating empathy, 202; dimensions of, 4–5; dynamics of practice across, 120; influence on assessment of, 35–36; self-disclosure in working with, 162–163; in social work practice, 10–11; working with, xiii. See also Diversity Dillon, C., 144, 166, 178, 241, 308, 358 Disabilities, and barriers to change, 275 Disadvantage, social dimensions of, 188 Discharge planning, 302. See also Termination Discipline practices, clients’ confusion about, 215 Disclosure, exceptions to, 207. See also Self-disclosure Discomfort, nonverbal expressions of, 146 Disconfirm, inability to, 263 Discourse analysis methodologies, 213 Discrimination, 120; in expanded understanding, 252. See also Marginalization Dislocation, 70 Diversity, 84; and affective processes, 44; and cross-cultural practice, 112–113; and cultural competence, 106–114; dimensions of, 42; and empathy, 147–148; for immigrant women, 105; influences on assessment of, 35–36; of social identity characteristics, 108; in social work practice, 10–11; valuing, 124; working with, xiii Downsizing, 329 Drake, B., 172–174 Drisko, J., 22, 102, 103 Drug addiction, programs for, 172 Drug use, assessing for client’s, 319

index

Dual relationships, 171; avoiding, 160; upon termination, 306 Dual roles, 176 Duncan, B. L., 19, 101, 156, 183, 237 Dunning, D., 55 Dyad, working relationship as, 137–138 Dyche, L., 108 Ecological maps, 364 Ecological theory systems, 17 Eco-maps, 327; for collecting data for assessment, 225 Ecosystems perspective, 67–68, 72–73, 229 Education: for clients, 75–76; professional, 49; psychoeducation, 171, 256, 346–347 Educational Policy and Accreditation Standards (EPAS), of CSWE, xi, 10; on collaborative relationships, 126; competence in, 29, 48; critical thinking in, 37; on diversity, 105, 108; person-inenvironment perspective in, 15; on relationship building, 81–82; social justice and equity in, 119 Educational programs, social work, xii Edwards, J. B., 212 Edwards, J. K., 46–47 Effectiveness studies, 23, 24 Egan, G., 329 Elder abuse, 207 Elderly: and barriers to change, 275; as caretakers, 360 Electronic devices, inappropriate behavior with, 198 Elliott, R., 144 E-mail, client contact using, 170. See also Internet Emotional attunement, to client, 111 Emotional bonding: creating, 175; and in-depth exploration of feelings, 351; and termination, 304–308; in therapeutic alliance, 151–152, 153 Emotional processing, 259 Emotional resonance, 258 Emotions: attending to, 256–257; becoming aware of, 256, 257; and change processes, 285; and cognition, 264–265; crucial role of, 332; vs.

405

feelings, 256; focusing on, 259; in interviews, 368; naming uncomfortable and distressing, 259; in neuroscience research, 254–261; positive, 366; primary vs. secondary, 259–260, 334; processing, 315–316; regulation of, 255, 264, 267; in relationship building, 139; of social work students, 57; in thinking and behavior, 41. See also Feelings Empathy, 258; clients’ experience of workers’, 149–150; defined, 144–145; demonstrating, 202; and diversity, 147–148; in helping relationship, 102, 143–147; and interviewing skills, 340; practitioners’s achievement of, 144; preparatory, 201–202; Carl Rogers on, 143; styles of, 149; in sustained mutual inquiry, 145; theoretical perspectives about, 145 Empirically supported models, 12 Employment, and illiteracy, 153–154 Empowerment, 120; in social work practice, 10–11, 75 Ending: use of term, 295. See Termination Engagement process, in interview, 313. See also Clients, engaging England, Hugh, 32 England, social work researchers and practitioners in, 40–41 Entitlements: accessing, 229; application materials and processes for, 275 Environments, deprived, 122 “Episodes of service,” 297 Equity: and diversity, 117–125; social worker’s commitment to, 132; use of term, 119 Eraut, M., 38 Ericsson, Anders, 54 Ethical dilemmas, 11, 25 Ethical issues: about continuing helping relationship, 306–307; in practice classes, 168 Ethics: and self-disclosure, 168; and social work relationships, 166–169 Ethnicity: culture associated with, 106; effect on clients of, 107; and working relationship, 133

406

Ethnospecific settings, preference for, 70 Evidence-based practice, 22, 24 Expectations, 106; about professional helping, 240; about quantity of work produced, 329; of clients’ behavior and attitudes, 44; and exploration of feelings, 351–352; of social work students, 116 Expectations, clients’, 99, 115; and goal setting, 239; meeting, 240 Expertise, professional, intuition in, 31–32 Exploration, in-depth: of feelings, 350–353; goal of, 350; of thoughts and beliefs, 353–355 Extratherapeutic factors, 19, 98–99 Eye contact, 325–326. See also Communication Facial expressions, 325. See also Communication Factor-Inwentash Faculty of Social Work, at Univ. of Toronto, 34 Fairbairn, W., 88 Faller, K. C., 212 Familiarity, and empathy, 150 Family: as client, 225; extended, 288; interview with, 213; in social work practice, 238 Family sessions, 153 Family systems theory, 68–69, 228, 274 Family therapists: ecological model of, 224–225; genogram developed by, 226 Family therapy, 19, 213 Fatigue, compassion, 59 Feedback, client: directly seeking, 339–340; eliciting and responding to, 338–340; goal of, 330; in goal setting, 237; positive outcomes, 300; required, 155; and working relationship, 287–288 Feedback, in social work practice, 20 Feelings: articulating one’s, 260; awareness of own, 253; clients’ awareness of, 334; depth exploration of, 352; vs. emotions, 256; expressing, 351; in-depth exploration of, 350–353; intellectualizing, 334; negative, 335; in psychodynamic theory, 87; reflection of, 332–336; social workers’, 258; of

index

social work students, 116. See also Emotions Feminist psychologists, 19 Fiduciary relationships, 167 Field education, 53; audio or video recordings in, 79; best practices for, 79; process recordings in, 69 Field instructors, xiii, 20; discussion and reflection with, 169; influence on practitioners of, 33; integrating theory and practice taught by, 32–33 Fight-flight-freeze responses, 276 Fight-or-flight responses, 256 Figley, C. R., 59 Fishbane, M. D., 256, 257 Formality, of interview, 205–206 Formulation: cognitive processes in, 264; constructing theory of, 229–230; data analysis for, 229; developing, 231; goal setting and planning, 232–240; and role of social worker, 231–232 Fortune, A. E., 22–23, 244 Foster, R. P., 116 Foundation core, of social work theoretical concepts and practice principles, xii, 72 Foundation core skills, 6f, 7 4 Ps model, 227, 231 Frank, J. B., 98 Frank, J. D., 98 Frank, Jerome, 101 Franklin, C., 228 Fredrickson, Barbara, 61 Fusko, L., 250 Galaway, B., 178 Gambrill, E., 23 Gangs, prevailing culture of, 275 Garland, E. L., 23 Gay affirmative practice, 110 Gender: and client experience, 121; in diverse practice, 42; and working relationship, 133 “Generative thinking,” 280 Genograms, 225–226, 327 Genuineness: in helping relationship, 138–142; and interviewing skills, 340; Carl Rogers on, 143; use of term, 138, 142

index

George, U., 111, 123 Gibbons M. B. C., 358 Gibbs, L., 23 Gibson, M., 160, 164 Gitterman, A, 24 GlenMaye, I., 75 Globalization, 107–108; and practice principles, 159 Goal achievement, 292–293 Goal attainment scaling, 291 Goals: agreement on, 308; arriving at, 219; criteria of relevance for, 234; examples of, 232–233, 235; in initial meetings, 158; question of, 176; SMART, 234–235; in therapeutic alliance, 151–153 Goal setting, 217; in change processes, 290–291; evaluation of, 236–237; family participation in, 238; in interview concept, 342–344; and interview summaries, 338; preliminary, 232–240, 343 Goldberg, J., 64 Goldstein, E. G., 88 Goldstein, H., 85, 269 Good enough mother, 93 Goodin, H. J., 57 Goodness of fit: for clients, 83; in effective case management, 245; between individual and environment, 234 Grady, M. D., 22, 25 Graham, J. R., 58, 61 Grant, 174 Granvold, D. K., 267 Green, J. W., 105, 120 Greenberg, L., 356 Greenberg, L. S., 144 Grencavage, L. M., 98 Group interventions, 22, 23 Gutierez, L. M., 75 Guttierez, L., 43, 109 “Handy brain puppet,” in psychoeducation, 256 Harder, N., 57 Hartman, A., 225 Head nods, 325–326. See also Communication

407

Health care settings, interventions aimed at support in, 246 Health field, social work intervention in, 295 Hearing loss, of client, 326–327 Hebb’s law, 255, 260 Helping process, 82–84; in assessment guide, 222; assessment of, 3; attending and active listening in, 325; beginning phase in, 195; communication and interviewing skills in, 311–312; empathy in, 144; engaging client in, 204–206; integrating diversity perspective in, 212–215; iterative, 194; neurobiology and, 95; preparatory stage, 195, 196; preparing setting for, 195–200, 196–200; specialized models for, 294; stages in, 191, 192; and stages of change, 182 Helping Relationship Inventory (HRI), 156 Helping relationships: acceptance in, 131–138; and change processes, 286; characteristics of, 100; client’s perspective of, 148–150; collaboration and partnership in, 154–158; conflict in, 83; context for, 80–82, 99–100; covert messages in, 82; cross-cultural engagement in, 84; defined, 85; emotions connection in, 304; empathy in, 143–147; forming, 130; genuineness in, 138–142; importance of process in, 82–84; key characteristics of, 85; key components of, 127–130; key words in, 147; lack of progress in, 154; metaphors in, 147; middle phase of, 261–265, 285, 288, 294; and neuroscience concepts, 258; procedures and techniques in, 100–103; professional, 127–128, 242; reevaluation in, 140; secure base provided by, 93; theory about, 85–86; therapeutic alliance in, 151–154; warmth and caring concern in, 130–131 Help seeking, meaning of, 214 Hemsley, S., 156, 287 Hepworth, D. H., 178, 219 Herman, D., 23 High road, in brain-based research, 255

408

Hill, C. E., 360 Historical data, in assessment, 226 Ho, D., 116 Hodges, B., 55 Holding environment, concept of, 93, 135 Holism, 26; in social work practice, 8 Holistic competence, see Competence, holistic Hollis, F., 348 Homelessness, and trauma-informed care, 277 Homophobia, client’s reflection on, 281 Horvath, A. O., 113 Hospitals, social workers in, 197, 211 Hostility, 273 Housing, unsafe, 122 Howard, M. O., 23 Hubble, M. A., 101, 183, 236–237 Humanism, 25 Humanistic approach, in psychology, 138 Humanistic theory, 19 Human service professions, 95 Human service work, 41 Hutchinson, T. L., 57 Idealizations, social workers’, 116 Identity: complexity of, 114; developing internalized, 116; in diverse society, 117; ethnic or cultural, 115; in interviews, 108, 314; professional, xiii; and traumatic early experiences, 276–277 Illiteracy, and employment, 153–154 Immigrants, 104–105; women, 288 Immigration, 70 Independent functioning, building client capacity for, 301 Independent living, client’s return to, 341–342 Individualization, 124 Informality, of interview, 205–206 Information: disclosing sensitive personal, 206–207; obtained from client, 114; seeking, 112; via interpreter, 200 Information, providing, 344; about service, 345–346; normalization, 347–348; offering comments, 344–345; psychoeducation, 346–347

index

Information and communication technology (ICT), 169; affecting working relationship, 170; handheld devices for, 170; and practice principles, 159 Information gathering, from interviews, 210 Information processing, in psychodynamic theory, 87 Information sharing, in working relationship, 81–82 Informed consent procedure, and ICT, 171 Initial stage, of engaging client, 205–206 Inquiry, in helping relationship, 147 Insights, client’s, and change processes, 285 Insurance coverage, regulations about, 306 Intake worker, 200–201 Integration of Theory and Practice (ITP) Loop Model, 67–79, 68f, 79, 229, 286; evaluation in, 77 Intentional approach, 249 Interest, and open communication, 94 Interferences, in working relationship, 193 Internal working model, 47, 88, 89, 90–92, 115, 227, 255, 305 Internationalization, 107–108 Internet, 169; and culture, 107; and self-disclosure, 159. See also Social media Interpersonal practice, of social work, 8 Interpersonal relationships, 4, 241; competence in, 366; cross-cultural engagement in, 84; in expanded understanding, 251–252 Interpersonal school, American, 88 Interpersonal skills, in change processes, 285 Interpretations, by practitioners, 357; client’s rejection of, 363; clients’ responses to, 358–359; positive impact of, 358 Interpreters: appropriate, 199; trained, 199; using, 199–200 Interrelationships, clarification of, 323–324. See also Relationships Intersubjectivity theory, 88 Interventions, 18, 20–21; addressing basic needs, 243; aimed at support in, 246;

index

defined, 242; empirically based, 102; formulating plan for, 72, 78; limitations of short-term, 226; in middle phase, 261–265; outcomes from, 291; task of, 153; use of simulation in, 53–54; use of term, 242 Intervention studies, 22, 27 Intervention techniques, xii Interviewing, effective, 368 Interviewing skills, xii, xiii, 3, 28, 197, 280, 311–312, 313; active listening, 324–328; to address feelings, 333; asking for clarification, 322–324; attending, 325, 328–329; balance in, 366, 368; basic, 354–355; challenging client, 359–364; core, 368; developing, 366; effective pacing, 321; eliciting and responding to feedback, 338–340; first interview, 342; in-depth exploration, 350–355; offering interpretations and explanations, 357–359; offering summaries, 337–338; offering support and validation, 340–342; paraphrasing as, 331–332; providing information, 344–348; providing suggestions, 348–350; putting it all together, 264–265; reflection in, 328, 332–336; reframing, 355–357; responding, 329–330; restatement, 330–332; seeking concreteness, 322, 323; selection of, 312; setting goals, 342–344; sharing impressions, 342; silence, 336–338; starting interview, 314; summarizing, 364; use of self, 328; using prompts, 321–322; using questions to gather information, 314–315; very effective, 312; video recording of, 329 Interviews: analysis of, 312–313; and change efforts, 286; diversities and differences in, 109, 212–215; engagement process in, 313; preparing setting for, 195–200; professional, 108; review of audio-recorded or videorecorded, 77, 365, 366; social work, 80 Interviews, simulated: observation of, 56–57; students’ reflections in, 38 Intuition, 31 Investigation, empirical, 19

409

Ireland, social work researchers and practitioners in, 40–41 Ivanoff, A., 172 Job retention, 63–64 Johnson, Sue, 91, 352 Joining process, in interviews, 313 Joint understanding, and interviewing skills, 314 Jordan, C., 228 Joy, nonverbal expressions of, 146 Judgment, exercise of, 311 Judgments: errors in, 77; in helping relationship, 147 Kabat-Zinn, J., 39, 40 Kanter, J., 244 Katz, Ellen, ix, 58, 146 Keenan, E. K., 25, 103, 112, 123 Knei-Paz, C., 174, 175 Knight, C., 24 Knowledge: cognitive processing of, 30–36, 55–56; in context of practice, 16–27; implicit, 38–39; levels of, 16; personal knowledge base, 7–8; practice, 25–26; tacit, 30, 38, 41. See also Information; Wisdom Kohut, Heinz, 87, 144 Kolb, D., 38, 50, 51 Kourgiantakis, T., ix, 320 Kruger, J., 55 Labeling, affect, 260 Lachs, M. S., 234 Lambert, M. J., 19, 98, 100 Language: and change, 259; using expressive terms in, 366 Leahy, R. I., 262, 264, 266 Learners, social workers as, 108 Learning: in change processes, 285; exercise for, 58; field education, 53, 312; life-long, 48; as ongoing process, 50; optimal professional, 51, 52; outcomes for, 53, 54; in social work education, 79; styles of, 51–52; and supervision, 64; systematic use of simulation in, 53–56; in working relationship, 101–102 Learning disability, 339

index

410

Learning environment, creation of safe, 123 Learning theory, experimental, 50–52 LeDoux, J. E., 279 Lee, E., 111, 113, 213 Leiter, M. P., 65 Lewin, K., 50 Licensing boards, 11 Life skills program, 246 Linguistic elements, in helping relationship, 147 Linkage: in ITP loop model, 72, 77, 78; use of term, 193–194 Listening, active, 112, 197, 217; in helping relationship, 147; in interviewing, 324–328 Listening, in relationship building, 139 Logie, C., ix, 56 Loop, in ITP loop model, 67 Low road, in brain-based research, 255 Macro, 6,9,14,68,119,223 Macro levels, client’s significant relationships at, 223 Magnification, in cognitive processing, 263 Main, M., 90, 91 Maintenance stage, for change, 186 Managed care, 329 Managed care organizations, 76 Managerial approach, to child protection, 40–41 Marginalization: in expanded understanding, 252; in individual’s internal functioning, 215; in shared understanding, 219, 224 Martin, D., 55 Maslach, C., 64, 65 Mastery experiences, for client, 285 Mathias, J., 37–38 Mattison, M., 171 Meaning making, in psychodynamic theory, 87 Medical settings, social workers in, 341 Meditation, 257 Memories, in interpersonal practice, 255–256 Mental health practice, 357

Mental health services: clients in, 172; goal setting in, 236 Mental health social workers, study of, 34–35 Mental illness: case management in, 243; and trauma-informed care, 277 Mezzo, 6, 14, 68, 223 Mezzo level, client’s significant relationships at, 223 Micro, 6, 9, 223 Microanalytic techniques, to track practitioner’s responses, 113 Middle phase, of helping relationship, 285, 288; interventions in, 261–265; social work practice in, 294 Miehls, D., 88, 95 Miller, S. D., 101, 183, 237 Mindfulness, 39, 257; aim of, 40; effectiveness of, 39–40 Mindfulness-based cognitive therapy, 19 Mindfulness-based reduction (MBSR), 39 Mind reading, 263 Mirror neurons, 258. See also Neuroscience Mishna, F., ix, 40, 86, 130, 164, 168, 169, 170, 171, 306, 307 Mistrust, 273. See also Trust Misunderstandings, 133, 326. See also Understanding Mitchell, S. A., 88 Model Regulatory Standards for Technology and Social Work Practice (ASWB), 171–172 Models: in context of practice, 21; as healing rituals, 101; limits of sole reliance on, 25 MorBarak, M. E., 64 Mother, single, and change, 284 Motivation, and learning, 51 Multicultural perspective, 215 Munro, E., 41 Muran, J. C., 289, 291 Murphy, B. C., 144, 166, 178, 241, 308, 358 Mutuality, in alliance building, 158 Nakanishi, M., 118 Napolitano, L. A., 262 Narrative approaches, 279–280

index

Narratives: clients’, 214; in interviews, 314; validation of, 113 Narrative space, creation of, 114 Narrative theory, 19 Narrative therapy, 272–273 National Association of Social Workers (NASW), 171; code of ethics of, 10, 168 Needs, basic: human, 89; in relationship building, 139 Negative thoughts, working with, 266–267 Networks, naturally occurring, 275 Neural functioning, and relationships, 95 Neurobiological mechanisms, 254–255 Neurobiology, interpersonal, 95, 96 Neuroimaging studies, 96, 260 Neuroscience, 16, 258; affective processes in, 42, 44–45; cognition in, 261–265; cognitive research in, 18, 45–46; and developing new perspectives, 279; emotions in, 261; social aspects of, 95; and social work, 95–97; thought record activity in, 266 Neuroscience research, 260, 267; contributions of, 254; emotions in, 254–261; on naming uncomfortable and distressing emotions, 210; on relationships, 242; social workers learning from, 347; and working with negative thoughts, 266–267 Nielsen, B., 57 Nomenclature, 22 Nonverbal behaviors, in relationship building, 139 Norcross, J. C., 98 Normalization, 347 Norms, 106; challenges to, 117; and client behavior, 214–215; and exploration of feelings, 351–352; for interacting with professionals, 198; and nonverbal behaviors, 326 North America: contemporary practice in, 126; diversity of, 104; social work in, 42 Notes, taking, 327 Objective Structured Clinical Examination (OSCE), use of simulation in, 56

411

Object relations theorists: American, 88; British, 88 O’Brien, K. M., 360 Observations: of client by social workers, 39; in field education, 79; of interviews conducted by students, 56–57; linking reflections to, 39; of social work students, 51 Obstacles to change, 273–275. See also Change processes Office: interviews in, 198; planning for, 197; waiting room for, 196 Oliver, C., 174, 224, 273, 274 Online profiles, 160 “On-the-spot inquiry,” 31 Openness, of clients, 273 Oppression: in cultural analysis, 124–125; in expanded understanding, 252; history of, 214; in individual’s internal functioning, 215; in shared understanding, 219; types of, 215 Orange, D. M., 88 Organizations: focus on individual in, 64–65; reflection in, 41; supportive, 63 Ortega, R. M., 43, 109, 212 Outcome Rating Scale (ORS), 156, 158, 291; in change processes, 286–287; in goal setting, 237 Outcome studies, 97 Overgeneralization, 262 Pacing, of interview response, 330. See also Timing Pain, nonverbal expressions of, 146 Palombo, J., 88 Paraphrase, use of term, 330 Paraphrasing, as interview skill, 331–332 Parenting group, 302 Parenting skills, 301 Parents: alcoholic, 253; sharing information with, 347 Participant-observer, view of oneself as, 40 Partnership: in alliance building, 158; in helping relationship, 154–158 Pathways thinking, in change process, 283 Pearlman, L. A., 59 Peer modeling program, 301

412

Peers: consultation with, 70; in students’ practice, 63 Perceptions, focus on eliciting client’s, 264 Performance anxiety, of social workers, 366; of students 57 Perpetuating factors, in data gathering, 228 Persistence, and change, 180–181 Personal investment, of clients, 273 Personalities: and brain networks, 255; practitioners’, 42; in psychodynamic theory, 87 Personality style, 180 Personality theory, 17 Personalization, 263 Personal-profession style, developing, 129 Personal self, social worker’s, 4. See also Self Person-in environment/ecosystemic approach, 243 Person-in-environment perspective, xii, 15, 18, 178, 218, 231, 278; to assessment, 229; change in, 75; social workers practice in, 14; and termination, 302; and trauma-informed approach, 278 Pinderhughes, E., 105, 134 Planned, 303–304 Planning: and assessment, 219; family participation in, 238; and interview summaries, 338; joint, 235–236; preliminary joint, 232–240; research on, 238. See also Assessment guide Polarizing, 263 Police practices, impact of, 78 Polyani, M., 38 Populations, in social work, 26 Populations at risk, impact of policies on, 247 Positivist perspective, 30 Positivity, importance of, 61 Postmodernism, 19, 37, 154 Post-traumatic stress, in betrayed partners, 202–203 Poulin, J., 156 Poverty, 122 Power: access to, 120; in cultural analysis, 124–125; defined, 120; dynamics and

index

diversity and, 117; in individual’s internal functioning, 215; reflective exercises for, 122 Powerlessness, 75, 120–121 Practice, context for: community in, 14–16; organizations, 12–14; profession in, 9–11 Practice, social work: art of, 27; deliberate, 54, 79, 300, 366; diversity in, 124; information and communication technologies in face-to-face, 169–172; integrated view of, 3–6, 6f; interpersonal interactions in, 4; knowledge building for, 34; middle stage of, 241, 246–247, 255, 285, 288, 294, 295, 302, 363, 365; processes of, 7, 137; reflective, 110; and theory, 54. See also Integration of theory and practice loop model Practice knowledge, 25–26 Practice principles, 103, 178; based on stages of change, 187–188; in case management, 244; concept of, 129; in cross-cultural practice, 112–113; general, 108; and globalization, 159; from process-outcome research, 111; putting feelings into words, 96; with respect to diversity, 124–125; “starting where the client is,” 152, 210, 219–220, 238, 269–270; in use of simulation, 53–54 Practice research, 218 Practice skills, 312 Practice theory, 18; helping relationship in, 85 Practice wisdom, 80, 110, 126, 158, 178, 298 Practitioners, 287; achievement of empathy of, 144; attraction to social work of, 69–70; challenge for, 311; characteristics of, 287; client expression elicited by, 280; clients’ relationships with, 244; cognitive processes of, 30; commitment to confidentiality of, 206; compassion fatigue of, 59–60; conscious cognitive reflection of, 71–72; emotion-focused, 257; ending stage for, 305; engaging clients, 204–206; experienced, xiii; facilitating

index

response of, 327; finding information about, 160; following up with clients of, 303; and goal achievement, 292–293; and goal setting, 250; holistic competence of, 3, 5; inappropriate behaviors of, 367; individualization by, 124; minimal responses of, 214; negative behaviors of, 287; openness of, 140–141; organizational contexts for, 62–63, 66; as participants and observers, 128, 143–144; performance of, 300; pressures on, 329; professionalism of, 127–128; providing suggestions, 348–350; questions for client used by, 270, 271–272; reflective evaluation by, 76–77; respect shown by, 132; responding to criticism of, 290; self-knowledge of, 128; supportive organizational contexts for, 63; supportive spaces for, 123; in working relationship, 25–26. See also Information, providing; Interviewing skills; Working relationships Precipitating factors, in data gathering, 228 Precontemplation, in change process, 182–183 Predisposing factors, in data gathering, 228 Preferences, in learning styles, 52 Prejudice, 70, 120; social workers’, 116 Preparation for change, 184–185 Principles, in context of practice, 20. See also Practice principles Privacy, in helping relationship, 131–132. See also Confidentiality Privilege, 120; in cultural analysis, 124–125; feelings about, 121; recognition of one’s own, 116–117; reflective exercises for, 122; and skin color, 121; social dimensions of, 188; of social workers, 133–134 Problem solving, in case management, 245–246 Problem-solving-oriented models, 19 Process, 308; defined, 204; use of term, 82, 193; verbal and nonverbal aspects of, 205

413

Process experts, social workers as, 241–242, 267 Prochaska, J. M., 184, 186, 187 Prochaska, J. O., 181, 183, 184, 187, 191, 217, 281, 297 Proctor, E. K., 131, 132 Profession: education for, 49; social work as, 9–11, 48 Professionalism, defined, 138 Professional practice, conducted in public spaces, 57 Professional practice model, 33 Professional relationships, 103; and change, 185; characteristics of, 134–135; empathy in, 149. See also Working relationships Professional response, 72, 76 Professional restraint, in helping relationship, 142 Progress, evaluating, 286 Prompts: in interviews, 321–322; questions used as, 315 Protective factors, in data gathering, 228. See also Confidentiality Psychodynamic practice, and developing new perspectives, 279 Psychodynamic theory, 17, 19, 86, 254, 276; and basic beliefs about relationships, 89–90; cocreation of working relationship in, 92; internal working model in, 90–92; transference and countertransference in, 86–88; working models developed in, 92–95 Psychoeducation, 171, 256, 346–347 Psychoeducational approaches, in change processes, 279 Psychological approach, to data gathering, 227 Psychology: experiential, 143; self, 144 Psychosocial developmental theories, 17 Psychosocial-oriented models, 19 Psychotherapy, 133, 300; clients’ subjective experience of, 253; effectiveness of, 148–149; helpful aspects of, 349 Psychotherapy research: on clients’ subjective experience, 253; on deliberate practice in, 54

414

Publications, social work, 23 Puppet, in psychoeducation, 256 Questionnaire, structured interview, 319 Questions, 334; about coping, 270–271; close-ended, 317–320; considerations in use of, 320–322; in developing formulation, 231; and feelings, 317; to gather information, 314–315; in helping relationship, 140; open-ended, 113, 264, 315–317, 332; overusing, 320; for setting goals, 343; stacking, 320; at start of interview, 314; structured and focused, 319 Race, and working relationship, 133. See also Ethnicity; Power; Privilege; Skin color Racism, 70; in shared understanding, 224; and societal institutionalized, 105–106; and working relationships, 307–308 Racker, H., 87 Randomized controlled studies, 23 Rapport, positive cultivation of, 204–206 Rasmussen, B. M., 164 Rationality, technical, 31 Reactivity: automatic nature of, 40; self-awareness of, 57; in working relationship, 96–97 Reality, modes of organizing, 261 Reamer, F., 16, 166, 167, 168, 170, 171 Reductionist conclusions, 109 Referrals: of clients, 208; client’s understanding of, 209 Reflection: example of, 334–335; of feelings, 332–336; goals of, 328; in ITP loop model, 69, 77; ongoing, 141, 273; on reactions to client, 239; in relationship building, 139 Reflection-in-action, 33, 40, 365 Reflection of feelings, defined, 333 Reflective discussions. in field education, 79 Reflective exercises: on culture, 118–119; forming helping relationship, 130; on learning style, 52; on power and privilege, 122; for self-awareness, 70; self-in-context, 66

index

Reflective observation, in learning theory, 50 Reflective practice paradigm, 31 Reframes: client’s rejection of, 363; formulating, 357 Refugees, 104–105 Regehr, C, ix, 34, 55 Regulatory bodies, 11 Rehabilitation programs, 172 Reid, W. J., 22–23, 244 Reisch, Michael, 117–118 Relational systems, working with, 274 Relational theory, 88–89 Relationship building, 158, 209; acceptance in, 139; activities and behaviors, 139; concerns in, 139; emotional bond in, 109; and engaging clients, 209 (see also Clients, engaging); with involuntary clients, 172–177; and maintenance, 209; social workers’ responses in, 213 Relationship dynamics, and joint understanding, 112 Relationship issues, and providing information, 349–350 Relationship maintenance, and duty to report, 177–178 Relationship models, 90 Relationships, 85; centrality of, 102; and change, 86; communication pathways for, 95–96; primary, 62, 66; repairs to disjuncture in, 289–290; role in helping of, 97; for self-in-context, 66 Religion, and working relationship, 133 Religiosity, 61–62 Report, duty to, and relationship maintenance, 177–178 Research, 22; on burnout, 65, 67; in cognitive neuroscience, 18; on field education, 53; in informing social work practice, 21–22; to inform practice, 21–22, 24; on interprofessional teams, 13; practice, 218. See also Neuroscience research Research studies, dropouts in, 25 Resentment, feeling of, 120–121 Resilience: and attachment styles, 90; in strengths perspective, 73

index

Resources, lack of information about, 76 Respect, in helping relationship, 131 Responding: evocative, 352; skill of, 329–330 Response, in ITP loop model, 77 Restatement, use of term, 330 Retraining programs: broad perspective needed for, 275; eligibility for, 303 Retrieval, in ITP loop model, 67–68, 68f, 77 Ribner, D. S., 174 Rice, L. N., 144 Ringel, S., 168, 169, 306, 307 Risk factors, in data gathering, 228 Risk taking, in change processes, 285 Ritter, B., 118 Rogers, Carl, 138, 143–144 Role play: in change processes, 284; with student peers, 56 Root, J., 171 Rosen, A., 22 Saakvitne, K. W., 59 Safety: constructing plans for, 274; development of, 137; in preparing interview setting, 200 Safran, J. D., 289, 291 Saleebey, D., 73, 268, 269 Santos, E. N., 259, 262 Scales, self-anchored, 233–234, 291 Schaufeli, W. B., 65 Schon, D., 30, 31, 32, 33, 39, 76, 110 Schwartz, W., 293 Self, 73; active involvement of, 30; cultural, 108–109, 118; differential use of, 150; in-cultural context, 118–119 Self, use of: in holistic competence, 97; in practice, 294; use of term, 46 Self-assessments, inaccuracy in, 55 Self-awareness, 5, 43, 115; affective processing in, 47; cultural, 124; developing, 134–135; and gift giving and receiving, 169; in holistic competence, 41–42, 97; ongoing process of, 141, 273; of practitioners, 46, 116; in professional practice, 8; for reflective exercises, 70; of social workers, 109, 203; of students, 57, 58–59; in working relationship, 93

415

Self-care: for nursing students, 57; of social work students, 59; strategies for, 60–61 Self-care skills, poor, 246 Self-confidence: and change processes, 281; poor, 75 Self-destructive behavior, 172 Self-determination, 303 Self-disclosure, 159–166; appropriateness of, 160; and boundary crossing, 168; in client-centered approaches, 162; client confused by, 165; and client’s expectations, 164–165; conditions for, 164; evaluating impact of, 165; goals of, 159; international, 162; negative effect of, 163; types of, 162; of workers, 150 Self-doubt, of social work students, 49 Self-esteem: and change processes, 281; low, 75 Self-healing processes, 286 Self-image, 90; promoting empowering, 269 Self-in-context, 66 Self-in-relation theory, 88 Self-knowledge: development of increasing, 46–47; and learning, 135; of practitioners, 47 Selfobject, use of term, 87 Self-observation, 255 Self psychology, 87, 88, 162 Self-reflection, 61; and emotional regulation, 267 Self-reflexivity, 43, 124 Self-regulation, 5, 44–46; in holistic competence, 41–42; in professional practice, 8 Self-reliance, in learning experience, 52 Self-soothing, 260 Session Rating Scale (SRS), 156, 158, 291; in change processes, 286–287; in goal setting, 237 Setting for practice, preparing: anticipating linguistic needs in, 199–200; and clients’ cultural norms, 198–199; creating private space and, 196–197; minimizing distractions and interruptions, 197–198; and safety issues, 200; welcome for, 195–200 Sexual abuse, close-ended questions in, 319

416

Sexual orientation, 42; and working relationship, 133 Shier, M. L., 58, 62 Shulman, L., 48–49, 293, 336, 362 Siegel, D. J., 96, 256, 257 Silence, as interviewing skill, 336–338 Simulation: to develop skills, 312; in OSCE, 56; systematic use of, 53–56 Skepticism, 273 Skills: in context of practice, 20; in cross-cultural practice, 113. See also Interviewing skills Skin color: in helping relationship, 131; interpretation of, 134; and privilege, 121, 164 SMART goals, 234–235 Smyth, N. J., 277 Social approach, to data gathering, 228 Social constructionism, and critical thinking, 37 Social constructivism, 272 Social identity, in individuals’ lives, 68 Socialization, of children, 107 Social justice: in context of practice, 17; and diversity, 117–125; and effective service, 121–122; social worker’s commitment to, 132; use of term, 119 Social media, 169; and culture, 107; online profiles on, 160; and self-disclosure, 159 Social networking sites, 160 Social psychology, 300 Social work: art of, 25; choosing profession of, 58; effectiveness of, 297; practice, 81; theoretical concepts in, 86; theory and practice in, 16 Social worker—client partnership, 308 Social workers: aspects of self in professional role for, 123; assessments of, 3; community-based, 13; concerns understood by, 111–112; continual reflexive process for, 123; cultural perspectives of, 109; at direct service level, 122; dual relationships of, 167; employee assistance, 361; frontline, 15; integration of theory and practice by, 32; as learners, 108; mandated roles performed by, 273; meaning of experiences of, 134; in medical settings,

index

166; mission of, 121; nonjudgmental stance of, 132–133; North American, 116; personal issues of, 71–72; personal self of, xi, 135; primary relationships of, 62, 66; as process experts, 241–242; qualitative exploratory research with, 110; regulation of, 11; role of, 127; school, 30–31; and self-disclosure, 160–161; specializations for, 202; teaching new, 32; use of self of, 25; valued characteristics of, 174–175 Social workers, preparation of: discussing confidentiality, 206–208; examining pertinent information, 200–204; integrating diversity perspective, 212–215; relationship building, 209 Social worker’s self, in learning and practice, 78–79 Social work practice: location of, 152; middle phase of, 267, 285, 288, 294, 295, 302, 363, 365. See also Practice Social work theory, neuroscience research in, 254. See also Neuroscience research Sociocultural mores,and cognitive patterns and beliefs, 354 Solomon, J., 90 Solution-based approach, 279–280 Solution-focused therapy, 19, 271, 285 Spousal abuse, 277 Stage theories, 185. See also Change, stages of Standards of practice, 127 State boards, 11 Stereotypes: of clients, 106–107; social workers’, 116; of white worker, 106–107 Stories, in interviews, 314 Strengths, in client’s social environment, 270 Strengths-based approach, 19, 180, 268–269, 272; in child protection, 274; and focusing on obstacles, 273–275; reframing in, 356; support and validation in, 341 Strengths-based practice theory, 224 Strengths perspective, 73–74; in assessment, 74; and stages of change, 188 Stress: mindfulness to relieve, 257; minimizing, 60; practitioners experiences of, 60; and transitions, 226

index

Strom-Gottfried, K., 168 Students, social work, xii, 44, 127; anxiety of, 56–57; competence developed by, 49; and ethical guidelines, 168; and group supervision, 63; in helping relationship interviews, 142; holistic competence developed by, 365; review of recordings by, 366; self-awareness of, 58–59; simulated interviews conducted by, 56–57; and termination, 297, 306–307; using questions, 318; well-being of, 59 Substance abuse: close-ended questions in, 319; and trauma-informed care, 277 Suggestions, providing, 348–350 Suicidal ideation, close-ended questions in, 319 Suicide risk, 34–35, 207 Summarizing, as interviewing skill, 337 Supervision: dimensions of, 64; effective, 63; and helping relationship, 141–142; of social workers, 13–14 Supervisors, qualified, 70 Support: offering, 340; ongoing, 243–247; questions for clients about, 270–271. See also Helping relationships Systemic thinking, 73 Tacit knowledge, 30, 38, 41 “Talking out loud,” 331 Tallman, K., 280, 283 Task-centered models, 19 Tasks: agreement on, 308; in context of practice, 20; defined, 204 Teams: importance of supportive, 63; interprofessional, 201; multidisciplinary, 239; and social work practice, 13 Temperament, and attachment styles, 90 Termination: client-initiated, 298; ethical issues related to, 169; introducing client to, 299–300; and maintaining boundaries, 305–306; planned, 303–304; premature, 306; strategies for, 305; timing of, 296–298; unplanned, 298 Termination gift, 300 Termination processes: consolidating gains, 300–302; emotional bond in,

417

304–308; planning for next steps, 302–304; reviewing progress, 299–300 Termination stage, for change, 186 Theories: in context of practice, 16–18, 21; limits of sole reliance on one, 25; and practice, 54. See also Integration of Theory and Practice Loop Model; specific theories Therapeutic alliance: concept of, 232; developing, 290–291; expanded, 155; in helping relationship, 151–154; key components of, 175; neuroscience support for, 258; three-part formulation of, 151, 153 Therapeutic factors, 19–20 Therapeutic relationship, cultural work in, 113–114 Therapist activities, and clinical outcomes, 54 Therapists, empathic failures of, 87 Third party, in interviews, 199 Third-party payment plans, 76 Thought record activity technique, 266 Thoughts, focus on eliciting client’s, 264 Thyer, Bruce, 22, 23–24 Timing: funding formula in, 187; in helping relationship, 146–147; in interviews, 368; for practitioners, 359 Tirch, D., 262 Tone of voice, 326, 327 Transference, 94–95, 128; as enactment of internal working model, 89; use of term, 86, 87 Transitions, effects of, 226 Transparency, 24 Trauma, defined by APA, 276 Trauma-focused therapy, 277 Trauma-informed approach, and person-in-environment perspectives, 278 Trauma-informed care, 277 Trauma-informed practice, 276–278 Traumatization, vicarious, 59 Treatment relationships. See Helping relationships; Relationships; Working relationships Tripodi, T., 172

418

Trust: development of, 137; in development of working relationship, 94; and empathy, 150; for involuntary clients, 175; in neuroscience study, 96; and self-disclosure, 159–160 Tsang, A. K. T., ix, 111, 123, 214, 312 Tufford, L., 177 Turnover, rates of, 63–64 Understanding: in assessment, 218; developing expanded, 248–250; and empathy, 145, 217; and joint dialogue, 147; misunderstanding, 326; searching for joint, 154–155 Understanding, expanded, 268, 269; developmental issues in, 252–254; discrimination in, 252; goals of, 254; identifying themes in, 250–252 Understanding, joint, 355; arriving at, 342; developing, 322 Understanding, shared, 217; analyzing data for, 229–232; gathering relevant data for, 219–220; putting information together for, 223–228 Unemployment, 70 Universalization, 347 University of Buffalo, School of Social Work at, 62 “Unskilled and unaware,” use of term, 55 Validation: in helping relationship, 102; provided by workers, 340–341; skill of, 341 Values: challenges to, 117; in helping relationship, 147; origins of, 115–116; social work, 131 van Wert, M., 86 Vayda, E., 67, 77 Verbal behaviors, in relationship building, 139 Video recording: of client interviews, 329; by students, 69 Violation in home, close-ended questions in, 319 Vision loss, of client, 326–327 Voice tone, worker’s, 326, 327 Vulnerability, connecting with others’, 60

index

Waiting room, 196 Waldman, F., 176 Walsh, J., 179, 244 Wampold, B. E., 101, 102 Warmth: in helping relationship, 102; and interviewing skills, 340; Carl Rogers on, 143; use of term, 130 Weick, A., 85 Weight, counseling for, 183 Well-being: effect of professional work on, 59, 66; emotional, 61, 66; physical, 61, 66; psychological, 61, 66; spiritual, 61–62 Western values, 116 White, Michael, 272 Williams, C. C., 123 Winnicott, D. W., 87, 93 Wisdom, practice, 80, 110, 126, 158, 178, 295 Women: with cancer, 284; diversity issues for, 105; immigrant, 288; immigrant or undocumented, 275; stages of change for, 184; in violent situations, 77–78 Women’s studies, 16 Woods, M. E., 348 Work environments, creating positive, 63 Worker, white, stereotype of, 106–107 Worker self-disclosure, and countertransference, 161–162. See also Self disclosure Working alliance, 69 Working relationship between practitioner and client, 73 Working relationships, 25–26, 80; accepting and nonjudgmental, 294; alternative internal, 92; beginning stage, 195; building, 110; building and maintaining, 129; building effective, 174; characteristics of, 137; client in, 137; clients in, 132–133; cocreation of, 92; collaborative, 114–115, 126, 180, 287, 318; developing, 333–334; development of, 81, 104; development of trust in, 94; as dyad, 137–138; elements of, 287; empathic communication in, 150–151; ending, 303–305; establishing practical, 175; exclusive purpose of, 127; formal vs. informal, 155; impact of reporting

index

on, 177–178; importance of trust in, 209; interferences in, 193; and interviewing skills, 314; issues affecting, 128; learning in, 101–102; narrative space in, 114–115; positive, 288; preparatory stage, 195, 196; preparing setting, 195–200; process in, 193; professional, 127; Carl Rogers on, 143–144; and social groups, 120; study

419

of role of, 97; supportive nature of, 244; termination of, 303; theory and, 85; as therapeutic alliance, 151 Worldviews: individual’s, 38; learning about clients’, 147; respect for different, 43 Young, T., 156 Zayas, L. H., 108