Introduction to the Text and the Decision Tree Navigating Direct and Indirect Practice Competency In Generalist Practice • To increase competency in generalist practice, this text provides a theory and evidence-based guide to decision-making. • Six scenarios, focused on client systems of different sizes, are presented to illustrate the decision-making process. See text. • The decision tree is used to prioritize assessment foci and guide consideration of more than one method or theory of intervention based on the complexity of the case at hand. Competency in Generalist Practice-Continued • Skill sets consistent with different sizes of client systems are necessary for competent practice; thus the text presents content on clinical social work and social work practice in policy, advocacy, management and community practice in alternating chapters. • All practice methods, empirical evidence, and competing theories must be assessed for cultural relevance. Overarching Cultural Principles The overarching cultural principles presented in this text are consistent with the Standards of Cultural Competence in Social Work (NASW, 2000). • All actions must conform to the NASW Code of Ethics. • Practitioners must be cognizant of the distinction between personal, professional, and client values. • Practitioners must be able to engage in ethical analysis and decision making. Cultural Principles Standard 1: Ethics and Values • Clinicians must be aware of the ideological and value premises of clinical theories. • Macro practitioners must be aware of competing ideological and value premises when determining the desired end-goals of policies, programs and reform efforts. • Tactical means to achieve desired-end goals must be ethical. Standard 1: Ethics and Values Continued • Clinicians must conform to licensing regulations and practice within the law. • Macro practitioners must (1) follow standard accounting procedures, (2) recruit, hire, and fire within the laws regulating employment, (3) refrain from malfeasance while in administrative office. • Community practitioners must practice within a fair and equitable democratic political process. Standards 2 & 8 Self Awareness- Professional Education • Professional education must include content that leads to practitioner self-awareness. • All social workers must develop an understanding of their own personal and cultural values and beliefs. • Each practitioner must recognize the relativity, rather than the universality of, his/her own cultural framework. Standards 2 & 8 Self Awareness- Professional Education • Everyone is exposed to different degrees of privilege and discrimination based on race, ethnicity, religion, gender, sexual orientation, and health status. • Clinical practice: cultural missteps in the helping process must be recognized and corrected. • Macro practice: practitioners must be cognizant of the toxic social forces that necessitate social policies and programs e.g. poverty, violence, inequality & political under-representation. Standards 3 & 8 Cross Cultural Knowledge • Professional education must provide the student with cross-cultural knowledge and skills. • Practitioners must possess descriptive knowledge (cultural sensitivity) of diverse client populations; especially those client groups with whom they work. • Within group differences as well as between group differences must be taken into account in order to counter the tendency to reduce cultural complexity to cultural stereotypes. Standards: 3 & 8 Cross Cultural Knowledge • Clinical practitioners must take into account how culture shapes family life, individual identity, priorities, and help seeking behavior. • Clinical practitioners must be cognizant of how diverse cultural groups conceptualize or construct health and illness. Practitioners must be alert to assessment bias –mistaking difference for pathology must be monitored. • Clinical practitioners must recognize & draw upon the cultural strengths of diverse client groups. Standards: 3 & 8 Cross Cultural Knowledge • All practitioners, clinical and macro, must examine their theories and the empirical evidence they cite for bias. • Macro practitioners must examine desired end goals for value and ideological assumptions. • Macro practitioners must be aware of and support the cultural relevance of an agency, policy, program, planning, or change effort. Standards: 4, 5, 10 Skills, Language, Leadership All students/practitioners should: Principle 4: possess skills in cross-cultural social work practice e.g.be able to work with diverse client groups. Principle 5: be cognizant of the importance of language when working with diverse client groups. Principle 10: exhibit tolerance for difference and dissent; all are required to engage in effective & ethical leadership. Standards: 4, 5, 10 Skills, Language, Leadership Clinicians: • should be skilled in ethnographic interviewing techniques and should acquire competency in the utilization of appropriate ethno-psychotherapies or refer clients to clinicians with such competency • should refer clients to same-language clinicians or used trained translators. • take into account cultural values and preferences when forming a collaborative worker-client partnership and treatment approach. Standards: 4, 5, 10 Skills, Language, Leadership Macro practitioners should: • Possess skills in group dynamics in order to manage competition and conflict within and between diverse racial and ethnic groups. • Possess skills that promote tolerance for difference and dissent. • Possess skills in ethical and effective leadership and follower-ship. Standards: 5 & 7 Service Delivery/Workforce Clinicians Must recognize & take into account issues of racism (and other isms) that may exist within the agency & between the agency, worker and client systems. Macro Practitioners Must take into account social work’s equity goal. Are policies, programs, and services reaching highly vulnerable client populations in need of services? Standards: 5 & 7 Service Delivery/Workforce • Management: Management practitioners must recruit and hire bi-lingual, bi-cultural and racially diverse personnel. Standard 6: Empowerment Practitioners need to assess power (who has it, who does not). • Practitioners need to assess how each theory, practice model, or method constructs power. • Practitioners must assess their own alliance with power. • Practitioners should possess skills in both case and class advocacy. • Practitioners should use their power to benefit clients Basic Premises of the Text • Scientific process (explanation-predictionprescription) is necessary for competent practice. • Explanation allows for prediction (cause-effect) and subsequently prescription (prevention or intervention). • Empirical evidence is critical in determining the efficacy of one intervention over another. • As part of cumulative knowledge, theory is critical to the enactment of treatment/intervention. Basic Premises Of the Text Continued • Logic and philosophical proof is valued in addition to empirical evidence. • Postmodern perspectives are included as part of open assessment and treatment choice. • All theories (scientific as well as philosophical theories of social justice) and all empirical evidence, requires screening for cultural relevance Basic Premises-Continued • Generalist practice, because of its commitment to open assessment and method and theory choice, promotes competent practice. • Normative policy and social goals advocacy need to be screened using comparative value analysis and overarching ethical principles. • In addition to scientific knowledge, social work practice requires knowledge of economics as well as knowledge of political & legislative processes. Aims of the Book • To teach students two skill sets; one for clinical social work (direct practice) and another for policy, advocacy, administrative and community practice (indirect practice) i.e. competency in diverse skills is needed for Generalist Practice. • To promote critical thinking through theory choice and evidence-based decision making • To enhance the teaching, learning, and practice application of complex and often polarizing social work content Book Format Direct and Indirect Practice • The book is formatted to teach clinical social work skills and skills in policy, advocacy, management, and community practice in alternating chapters. • The decision tree guides the practitioner in both direct practice and indirect practice. Competency in Generalist Practice • Requires open assessment of all system sizes • Requires selective use of one or more practice theories and methods for the same case • Requires evaluation of treatment/program options according to existing empirical evidence • Requires that theories and empirical evidence be screened for cultural relevance • Requires value (ethical) analysis of theories and evidence relevant to the case or situation at hand. Evidence-Based Practice Best Practices • • Evidence-based practice requires appraisal of the empirical literature to determine the efficacy of one treatment intervention over another. Best practices is defined as the conscientious, explicit, and judicious selection of an effective (evidence-based) and appropriate intervention strategy for a specific client or situation ( Sakett, Richardson, and Rosenberg, 1997). Two Tools to Teach Theory Application • The Case Scenario: Teaches students how to apply a major theory to selected facts of the case in order to guide intervention consistent with that theory. • Decision Tree: Teaches students how to ascertain a range of information relevant to the case at hand through open assessment and prompts the practitioner in the prioritized selection of one or more methods and theories (model building) based on open assessment of the case at hand. Decision Tree • The Decision Tree is a conceptual tool that uses a systematic and exhaustive process to organize thinking consistent with existing knowledge and empirical evidence in order to reach a treatment decision consistent with best practices. • The Decision Tree prioritizes and navigates existing knowledge and empirical evidence. What the Decision Tree Does • Helps the practitioner systematically and logically navigate what is known in order to produce prescriptions that are case or situation specific • Cues practitioners to ask all relevant questions, identify all relevant variables, consider all possibilities (theories) and evaluate all evidence (whether positive or negative) in a proper sequence before arriving at a treatment decision. • It provides proof of process in arriving at a treatment decision. It does not create new knowledge. How the Decision Tree Works Seven Steps • The Decision Tree prompts the practitioner to engage in open assessment (all seven steps) to ascertain the facts relevant to the case at hand. • It then orders (steps 1-7) the obtained information beginning with those facts of the case that have life-threatening and survival relevance. • The tree prompts practitioners to review all methods, theories, and empirical evidence at each decision point Step One:Assure Safety The Fiduciary Model • Step one guides the practitioner in the execution of his/her fiduciary duties in order to assure client safety and the safety of others. • Chapter two (The Legal Aspects of Social Work Practice) elaborates on the fiduciary model of practice for all social workers. Step Two- Crisis Intervention • Step two guides the practitioner in the application of crisis intervention or crisis management. • Chapter 8: three models of clinical crisis intervention: (1) basic on-site intervention, (2) advanced clinical crisis intervention, (3) domainspecific crisis intervention. • Chapter 9 crisis management: disaster preparedness & recovery in the disaster after-math. Policy, advocacy, management & community techniques are applied to domestic & international crises. Step Three: Urgent Need Clinical Case Management • Step three guides the practitioner in the direct face-to face provision of concrete services to individuals and families in need of immediate or timely resources. • Chapter 10: elaborates upon two direct practice models of clinical case management: (1) system driven (traditional) (2) consumer-driven (empowerment). • Chapter 3 : elaborates on indirect practice as the policy and program context of direct practice. Step Four Case Advocacy • Step four (chapter 11) guides the practitioner in the use of case and class advocacy skills. • Case advocacy: (advocacy to benefit individuals) (1) The Broker Model (2) The Adversarial Model • Class advocacy (advocacy to benefit populations). (1) Policy advocacy (2) Rights Advocacy. Step Five Social Work with Individuals Step five guides the practitioner in the selection of clinical methods, theories and skills needed to work with individuals. • Chapter 4: clinical interviewing skills • Chapter 6: use of self in a clinical therapeutic relationship. • Chapter 12: practice theories/individuals • Chapter 13: applies the decision tree to an individual case. Step Six: Work With Families • Step six guides the practitioner in work with families: • Chapter 14: Family therapy methods: (1) Family Life Cycle. (2) Systems Theory (3) Bowenian Therapy, (4) Structural-Strategic Therapy • Chapter 15: Family and child welfare (1) Work with impoverished families (2) Protective services Step Seven Use of Group Method Step seven of the decision tree has four branches: (1) the use of groups in clinical practice (2) the use of groups in administrative practice (3) the use of groups in advocacy practice to achieve social goals (4) the use of groups to build community Use of Groups in Clinical Practice Chapter 16: • Addresses group dynamics –curative and antigroup dynamics are discussed. • Clinical groups are categorized as: self-help, psycho-educational, recreational, normative (social conformity), skilled-based, analytic and the context of social milieu in day programs and residential living. • Therapeutic groups are distinguished from analytic therapy groups . Use of Groups in Administrative Practice Chapter 17: Group method informs the use of groups in administrative practice: (1) boards and councils, (2) committees, (3) task groups, (4) project teams, (5) deliberative meetings and (6) the organization as a whole. Includes presentation of social exchange theory and The Coverdale model for managing the dynamics of task groups. Use of Groups in Social Goals Advocacy • Step seven guides the practitioner in the use of groups for the purpose of social goals advocacy (structural change) and for the purpose of policy advocacy (legislative and regulatory change). • Chapter 17 elaborates on the theories, methods and skills needed for direct action organizing for large scale change (movements) and for local change (issue campaigns, election campaigns, and fund raising). Groups in Community Practice • Step Seven: Groups in Community Practice • Chapter 17: The macro branch of community practice attempts to balance the rights of the community as a whole with the rights of individuals and minorities while regulating inter(between) group tensions. • The clinical branch attempts to deliver face-toface mental health services to clients with chronic diminished capacities who reside in the community- Tertiary Community Mental Health Special Features of the Text • In addition to the features already described, the text offers non-clinical communication skills for practitioners in policy, advocacy, administration and community practice. See chapter five. • In contrast to the use of self in clinical practice, chapter seven focuses on the macro practitioner’s use of self in terms of leadership. The chapter includes theories, empirical evidence, and skills relevant to leadership. The Decision Tree • See exhibit 1.1 at the end of this chapter.