Social Work Direct Practice
The Clinical Relationship
Chapter Six
Direct Practice and Indirect
Practice
• The concept of “direct practice” is used in contrast
to and in comparison with the concept of “indirect
practice”.
• These terms reflect deeply held, often opposing,
ideological convictions about the profession of
social work and its mission.
• They also reflect ideological assumptions about
the causality of personal problems and public
issues.
Terminological Turmoil
Within Direct Practice
• Ideological differences between direct and
indirect practice influence definitions of the
worker-client relationship in direct practice.
• Clinical social workers have been variously
described as (1) direct practitioners,(2) case
managers, (3) allocators of resources,
(4) psychotherapists/counselors, and (5)
traitors to the profession.
Differential Use of Self in Direct
and Indirect Practice
• Given this ideological disarray, it is important to
differentiate the practitioner’s use of self in direct
and indirect practice.
• In direct practice, the use of self (worker-client
relationship) is therapeutic. In policy, advocacy,
community and management practice, the
worker’s use of self (worker-others) is based on
leadership. (See chapter seven).
Direct Practice: Two Functions
• Direct practice is differentiated by its two
functions:
(1) the face-to-face delivery of concrete services
(case management) through a worker-client
relationship based on belief bonding
(2) the delivery of therapy through a worker-client
relationship based on a theory-guided
therapeutic alliance.
Core Values of the Helping
Relationship
According to Biestek (1957), a professional
social work relationship in direct practice is
purposeful and is characterized by the
values of:
(1) acceptance
(2) a non-judgmental attitude
(3) respect for client self-determination
The Helping Relationship
Belief Bonding
• The helping relationship in direct clinical
practice is based on belief bonding.
• The “bond” mirrors the facilitative
conditions of an effective relationshipempathy, warmth, acceptance, and actual
interest in the client.
• It is based on an emotional interaction
between the help seeker and help giver.
The Professional Clinical
Relationship
• The professional clinical relationship in direct
practice reflects: (1) the function of the agency,
(2) different stages of worker-client engagement
(beginnings, middles, ends), (3) different levels of
intensity (case management or therapy), and (4)
different roles and functions for the worker and
client.
• Not all worker-client interactions in direct practice
are considered therapy, however, all worker-client
interactions are intended to benefit the client and
are therefore therapeutic.
Working Relationship
• A working relationship is defined as the
observable ability of the worker and the client to
worker together in a realistic, collaborative
manner based on a mutually committed belief in
the helping relationship.
• Worker and client bond in the belief that mutually
agreed upon activities will bring about changes in
the client’s circumstances that will both benefit the
client and enhance the client’s self worth.
Characteristics of an Effective
Helping Relationship
• Efficacy in the worker-client relationship is based
on empathic understanding, non-possessive
warmth, unconditional positive regard,
congruence, genuineness and authenticity (Truax
and Carhuff, 1967).
• According to Kadushin these characteristics are
necessary conditions for effective interviewing.
• Not all helping interactions need the same level of
of relationship intensity.
Relationship: A Dynamic for
Change
• Many hold that relationship is, in and of itself, a
dynamic for change. Relationship, not theory,
matters (Effectiveness studies).
• Others hold that it is the theory that guides the
clinician and the therapeutic intervention that
accounts for change i.e. empirically supported
treatment (efficacy studies).
• The role of relationship to clinical outcome
success is controversial.
Therapy and the Therapeutic
Alliance
• In therapy, relationship depends on the formation
of a therapeutic alliance.
• Therapeutic alliance requires declarative
knowledge of specific theories which, through
their prescriptions, direct the enactment of a
therapeutic process. See chapters 12 and 13.
• The worker’s use of self in therapeutic alliance is
the art of healing.
Declarative Knowledge
• Generic descriptions of the social work
relationship cannot tell a clinician how to enact a
therapeutic process.
• Enactment competency relies on the linkage
between congruent theories of human behavior
(normal and abnormal) and the treatment process.
• How to do therapy (practice) is linked to content
on how humans behave and change (theory).
Procedural and Tacit Knowing
• Procedural knowing consists of declarative
knowledge (scientific knowing)
• Declarative knowledge consist of
(1) Theories of cause-effect (if this, then that;
explanation) that lead to….
(2)Theories of practice (prediction and
intervention (practice theories)
• Tacit knowing refers to the mastery of procedural
knowing in the art of relationship.
Does Therapy Work?
The Science of Relationship
• The trend toward evidence-based practice, has
renewed interest in therapy outcome and the
therapeutic process.
• Outcome studies (does it work?) benefit clients
when clinicians use best practices.
• Process studies (how it works) benefit educators
by driving curriculum and optimizing training.
• Comparative studies (which therapy works best)
legitimizes therapy choice, especially in a
managed care environment.
The Science of Therapy
Meta Analysis and Effect Sizes
• Early efforts to prove that psychotherapy worked
concluded that there was no evidence that
psychotherapy was more effective than no
treatment at all (Eysenck, 1952).
• Currently, meta analytic approaches, (based on
design rigor) are used to determine whether
therapy works.
• As a research statistical technique, meta-analysis
pools results from multiple studies and calculates
an effect size across studies.
Meta Analysis –Continued
Systematic Reviews
• Meta analyses may include efficacy studies only
or both efficacy and effectiveness studies.
• Meta analyses requires skill in conducting a
systematic review of the literature i.e. rigorous,
well-conducted studies on a focal topic must be
located. The researcher must document a study’s
inclusion or exclusion in the analysis.
• An effect size across studies is calculated.to create
a larger standardized statistical measure of change.
Efficacy Studies
• Promote scientific and design rigor
• Participants are randomly assigned to
different treatments and to control groups
• Treatment is standardized and clinicians are
trained to deliver the intervention according
to manual protocol.
• Standardized pre and post test measures are
administered by blind raters.
Efficacy Studies-Continued
• Measures are specific to the defined treatment
goals ( i.e. not generalized measures of overall
improvement).
• Efficacy-based outcome studies are concerned
with therapeutic process because replication
requires standardization of process.
• When clinician interaction is controlled by study
design (treatment protocol/manual), greater
confidence can be placed in the conclusion that the
outcome is attributable to a specific theory.
Effectiveness Studies
• In contrast, effectiveness studies allow for greater
clinician spontaneity and flexibility (less
standardization) in therapeutic process.
• Effectiveness studies allow a more expansive
definition of change and outcome success.
(generalized measures).
• Effectiveness studies are more aligned with the
complexities encountered in real practice and are
self-correcting
Does Therapy Work?
The Empirical Evidence
• According to numerous meta-analytic studies,
therapy does work better than no treatment.
• Therapy works for adults, adolescents, and
children.
• Studies have focused on anxiety and depression.
• Meta analyses continue to provide evidence about
what works, how it works, for whom, and at what
cost.
Is One Therapy Better Than
Another?
• Luborsky (1975;1997;2002) found that many
treatments work- therefore “other things” or
“common factors” must account for outcome
differences.
• Other factors that influence outcome are:
(1) chance, (2) expectancy, (3) placebo effect, (4)
variability in clinician expertise, (5) client factors,
(6) severity of the problem being treated.
• Few studies to date provide enduring evidence that
one therapy is better than another (Drisko, 2004).
Other Factors that Influence
Therapy Outcome
• Chance
Individuals get better just by chance.
• Expectancy
Individuals get better because they have sought
help and expect that the helping process will lead
to positive change.
• Placebo
Individuals get better no matter what treatment is
used as long as they perceive something is being
done that may help.
Evidence for Empirically
Supported Treatments
• Empirically supported treatments (manuals)
are supported both by the American Psychological
Association task force on the promotion and
dissemination of psychological procedures and by
the American Psychiatric Association.
• Research on the use of treatment manuals have
repeatedly concluded that their use leads to more
positive outcomes than does therapy without such
manuals.
• The science behind EST’s serves as an antidote to
ideological-based models and preferences.
Arguments Against Empirically
Supported Treatments
• Arguments against EST’s cluster around
practitioner variability as a dynamic, in and of
itself, in the art of healing i.e.the master clinician
versus the novice clinician.
• Clinicians fear that rigid protocols will
underutilize therapist expertise and oversimplify
the complexity with which clients present.
• Few EST protocols deal with V codes, personality
disorders, co-morbidity, and differences in
problem severity at the onset of treatment.
Clinical Social Work
Statistics
Federal statistics indicate that clinical social
workers provide more mental health
services (a large proportion of which is
psychotherapy) than do professionals from
other disciplines combined (Drisko, 2004).
Summary
• Clinical social workers do not reject social
causality. They recognize that the day-to-day
survival of individuals often cannot wait for social
change to occur; therefore they deliver concrete
services and assure client safety according to
existing policies and programs.
• They recognize that sometimes more than a timely
injection of resources is needed and they combine
material resources with supportive counseling.
Summary-Continued
• They recognize that external events and
interpersonal relationships can traumatize,
therefore they offer individual, couple, family and
group therapy through a theory-guided therapeutic
alliance.
• Committed to open assessment, multi-causality,
and evidence-based decision making, social work
promotes best practices by allowing the
practitioner flexibility and competency in theory
and method choice.