Supervision

Every Wednesday my mentor and I have supervision at my field placement. This time is – and I hesitate to use this word, but it’s the best one I have – a sacred time, and I truly treasure it.

The notion of supervision in Social Work can be confusing to those outside of our profession: it doesn’t mean that my supervisor is in my session watching me interact with client (that’s observation). Rather, supervision is where (at least in my current setting, because it varies by practice, agency, setting, and individuals involved) my mentor and I sit down for an uninterrupted hour, and get to share in each other’s presence, where we close out my case notes for the past week (since I am functioning under my supervisors clinical license, he must sign off on all of my work). It’s where we discuss case conceptualization, where we talk about struggles that I am having free from judgement. It is where new ideas and concepts are bounced around, and where I can ask for help that I wouldn’t necessarily interrupt his day for during the regular week. It’s for bi-directional feedback.

Generally my feedback is incredibly positive; two weeks ago I was given feedback by my mentor (after the staff meeting) on something I needed to improve on. However, I wasn’t left ‘high and dry’: my mentor reminded me that he was my greatest advocate, and that he was there to work with me on what it was that I needed to improve. He checked in with me all of this week, and during our weekly session he made sure to find out if this week was a better week than last (which it was). On top of that, we’ve been doing satisfaction surveys of our clients, which – while anonymous, are linked to clinician – and my clients are in the “extremely satisfied” or “very satisfied” categories, so I felt much more confident walking out of supervision this week, than I did last week…not only because I did better as a colleague and Social Worker, but because I knew my clients were doing better as well.

The important part, though, through all of this, was that when presented with negative criticism, I was willing to listen, and willing to change: because at the end of the day, the goal is being a better clinician, a better colleague, a better co-worker…and even if I didn’t agree with that negative criticism; I didn’t want others to have that perception of me (whatever it was) so I worked to change my behavior, so I could – in turn – change the behavior of others.

Supervision is important, it is ongoing, and it is important we pay attention to what we like in our supervisors, because at some point (very soon) we ourselves will be providing (and yet still receiving) supervision…and we want to be the supervisors that we have enjoyed and learned from most.

36 Steps in in 12 Hours: Meeting Our Clients Where They Are

While I am working to complete my Master’s of Social Work (MSW) I am also completing my CASAC (Credentialed Alcohol & Substance Abuse Counselor) credential alongside it as well.

For one of my classes, The Nature and Treatment of Alcohol and Other Drug Problems, we are required to go to three 12-step meetings. This is not the first time I’ve been required to go to 12-step meetings, and I always find them empowering, and interesting, and insightful (for a lot of reasons).

A few Thursdays ago I went to 3 twelve-step meetings in 12 hours…so I had 36 steps under my belt by the days end: I went to a morning AA meeting, an afternoon AA meeting, and an evening NA meeting (and truth be told, I always prefer the NA meetings to the AA meetings…I’m not sure why yet, something for me to meditate on and explore within myself).

We often say (or are often taught) that we have to “meet our clients where they are, not where we want them to be.” But how many of us actually follow that advice?

What I found so interesting is that at almost every 12-step meeting I’ve gone to there has been a similar theme, and one that I think is telling (or should be) to my fellow counselors:

“My counselor doesn’t get it,” “my counselor doesn’t listen to me,” “my counselor wants to talk about past issues…and all I want to do is move forward.”

This – to me – is a failure of meeting our clients where they are. When I have a session with a client, the questions I ask have to be carefully constructed…and I can’t ask them because they interest me…I have to ask questions because they’re beneficial to or are of interest to my client.

This justified negativity toward counselors doesn’t spring from the Big Book or Basic Text, it’s not endemic to AA or NA, or to 12-step programs or literature…so if you’re an addictions counselor and you’re looking for someone to blame, you’ll have to do some inner reflection.

While we (as counselors) can look at a client’s past and find useful threads, and meaningful connections to trauma, if our clients are looking forward to their bright future, we can’t allow ourselves to be anchors holding them back – or worse, dragging them back – to their past…instead, we have to be Solutions-Focused, allowing them to pragmatically reach the goals that they set for themselves, so we can remain helpful, and relevant to them…otherwise we just become a stumbling block on their path to recovery.

Always remember: Just for today!

This is your quick reminder…

This is your quick reminder that it’s okay to take some time for you. You’re doing the best you can, and that’s okay…in fact it’s great, and it’s awesome! I hope you’re having a great day, but if you aren’t, there are people who love and adore you…and work isn’t everything: it doesn’t define who you are as a person, it’s just one of many many many parts of who you are…and even if today was a bad day, you’ve survived every bad day until now, and you’ll get through this one too. Go have a cup of coffee or tea, sit for a few minutes, enjoy it…breathe in the aroma, and take some time for you. Take a couple of deep breathes, relax your shoulders, clear your mind…and when you’re ready, get back to work…the world needs you.

Adults Have Kids (or The Wisdom of Not Always Being Placed Where We Want)

I am not a kid person. I general I dislike having to deal with any children that are not my Godson, or any of my adopted nieces and nephews. In fact, when I adopted my cat they said “you need to be warned, she doesn’t like loud noises or children” and my response was “perfect, we’ll get along just fine!”

Entering the MSW program in my 30’s I had a relatively good idea of where and what I wanted my future Social Work practice to look like (or at least I thought I did: it’s expanded tremendously as I went through my program, though the general idea has largely stayed the same).

So last year, for my first field placement, I indicated on my placement request form that I was looking for an adult population, in a clinical setting…and my Field Placement office met me half way: I would have one day a week doing Solutions-Focused Brief Therapy at a Family Solutions Center (so adults would be involved…but so would their children…).

I said “Okay…”

Then the other shoe fell: I would be spending my other day a week doing School Social Work.

I was (initially) a little disappointed. I was super excited at having the opportunity to do some clinical work…but…School Social Work? Children? Teachers? Parents? PTA? Soccer Moms (and Dads)? Why would I – a soon to be Social Worker working with adult clients – need to do any of that? How was that at all relevant to my future practice!?

Because. Adults. Have. Children. You. Doorknob (I say to myself, now…older and wiser…)!

…and sometimes it is absolutely critical that we learn how to interact with populations that we are uncomfortable or dislike working with, because our clients (and our code of ethics) require us to do so…and it was one of the world’s most amazing experiences.

I learned Theraplay and I learned how to work with children and their families. I learned how to work with parents and guardians. I learned how to interact with CPS. I learned how to liaise between administrators, teachers, parents, and students. I learned about the incredible developing minds of Kindergartners, First, and Second Graders…and how they can explode cartons of chocolate milk with only their eyes (sort of like…Darth Vader). I learned how to elicit information (and the truth) from unwilling children, and how to play games while at the same time conducting counselling sessions. I learned how to effectively advocate for my students’ needs. I learned a lot about myself. I also learned about the incredibly important role of public schools within a community, and why I think they need to be protected and cherished at all costs.

Now, as I complete the last 8 months of my MSW program, and I am in the Field Placement of my dreams, and I interact and work with adults as a Domestic Violence Counselor as part of my day job, I am extraordinarily thankful that my first field placement forced me to grow and stretch my boundaries as a Social Worker…because while day-to-day I get to work with my “ideal” populations, I also know that if I need to work with children I can, and because I had this incredible experience, with incredible mentorship, guidance, and supervision, I know I can do so effectively. 

My first field placement gave me the gift of expanding my toolkit, which can only benefit my clients…so if I client tells me that they’re having concerns at home…and they’re an adult…and they have children, I can have them bring their kids into the office and I know that I have the training and the experience to work with that client and their family as a whole…and I would have never had that if I had my “ideal” field placement for my foundation year.

…I also wouldn’t be working as a Domestic Violence Counselor either with my incredible team at my incredible place of employment…so if you’re a student working your way through an MSW program, work with your Field Placement Office…and trust them (at least a little bit)…they may not give you what you want your first go round, but odds are they may give you what you need.

 

Permission to Nuke The Whales

One of the traps that I think some of my clients (and even myself, to be honest) can get caught up in is that generally we want to do the right thing, and that sometimes we want to do the right thing so much that it becomes deleterious to our overall well-being and daily functioning. I think this is especially true if one has a chronic disease, disability, condition, or illness.

For instance, if you have a disability that makes lifting and moving difficult, and you really want to recycle…but the act of recycling causes your kitchen to fill up with plastic bottles because you don’t have the physical strength or energy (or spoons) to bring the bags down on recycling day once a week (or once every other week)…and then you find yourself constantly falling over bags of recycling in your kitchen, then is recycling really your best option? In this case I advise my clients to give themselves permission to nuke the whales and throw the bottles out with their regular garbage.

Sometimes depression makes it hard to clean up the litter box. Who wants to use disposable litter trays? They’re bad for the Earth, it’s wasteful, you’re throwing out aluminum or plastic each week…all of that’s true. That said, a kitty litter box that’s overflowing is bad for a client’s health, can contribute to a greater feeling of depression (due to the smell/mess/’failure’ to take care of something), and the kitty won’t be happy either. So what’s better in this case? Personally, I think giving yourself permission to nuke the whales and go for the disposable kitty litter trays.

Reduce, Reuse, Recycle…always sound advice. Paper plates, plastic forks, spoons, and knives: who needs em? Just more petroleum based products in our landfills. However, if your chronic illness, disability, depression, mental illness has you living with a kitchen sink full of dishes all the time (which can bring with it bacteria, mold, or vermin)…and it’s easier to just throw out paper plates, plastic forks, spoons, and knives…and those disposable plates and utensils are what makes it possible for a client to have a clean living space (and feel better)…then it’s time to nuke the whales and stock up on disposable plastics.

There is a time and a place for environmental activism…there’s also a time and a place to remember that clients have every right to put themselves first, and it’s one of our goals – I believe – as Social Workers, to remind clients that they are allowed to take care of themselves first, that they are allowed to put their needs first, and that we can work together to help them find other ways of taking care of the environment (and even offsetting their adaptations/restrictions) so that nuking the whales can become a win-win situation…because our clients aren’t going to be healthy (or successful) if their own environments (remember PIE) aren’t inhabitable, let alone be able to worry or do anything about Mother Earth.

*Social Work Desk does not advocate nuking actual whales. Please do not do this. Looking at you, 45 & Kim Jong-un.

Sunday Paperwork Catchup & Doing The Best You Can

Today is a paperwork catch up day: lots of paperwork to scan in and shred, some assignments to get done or get started on, and lots of writing to do! There’s also a fair amount of home office clean up to get done as well (fortunately, the folks at UFYH have made that a bit easier for everyone).

I was also hoping to get some volunteer work in this weekend, but that’s just not going to be possible (since the laws of physics still apply to me) so I’m going to remind myself that the only thing I can expect from myself is to “do the best I can” and so long as that standard is met, I get to be cool with myself.

Now, time to get cracking on the home office clean up, so I have the space to actually get my paperwork done…and then I’ll probably order a pizza…because social work students survive on a healthy dosage of carbohydrates and cheese.

Boundaries, Scope, Diagnosis & Diagnosis Dilution

“No doctor should assume responsibility for the health of one he loves or one he hates” – Dr. Michaels, And Be a Villain, A Nero Wolfe Mystery by Rex Stout

These words were written by one of my favorite authors in 1974, as Dr. Michaels was being interviewed by Nero Wolfe and his sidekick, Archie Goodwin, as they worked to take down the nefarious Arnold Zek.

Boundaries
Boundaries are not only important, they are critical. They not only protect our clients, but they also protect us as workers. Dr. Michaels, in the Nero Wolfe Mystery And Be a Villain by Rex Stout makes an incredibly important point: boundaries are not just about the use of self in our individual practices, they’re also about whom we accept to take on as clients, and whom we recuse ourselves from working with.

While I have found that certain positions such as Community Health Workers (CHWs) and Patient Health Navigators (PHNs) can have a little leeway, since these positions are non-therapeutic in nature, and are about connecting clients to resources and brokering information between providers, I still think the best practice is that they don’t work with those with whom they have a personal relationship.

Some in the CHW community disagree, given their role as communal workers. I think this is also fair, and I again point to the work that they’re doing as non-therapeutic in nature, and therefore subject to some amount of leeway: they’re working as brokers and educators within their own communities. They know their communities (and themselves) best. So far it seems to be working quite well, in many different communities, around the world.

Then there are those positions such as Social Workers, Psychologists, Life Coaches, Psychiatrists, and all the branches of Medicine where there really is no leeway: we don’t take on family, friends, loved ones, or enemies as clients. Period.

We also don’t take on those cases where we’ve heard too much. For instance, if a case has been brought up over and over and over and over again in case conference, it’s better to refer the case to a clinician outside of the organization or agency: no matter how well trained the clinicians at an agency are, no matter how trained they are to be impartial, the client – ethically – deserves a real fresh start when they’re being transferred because the clinician and client have agreed that it isn’t working out. It is unfair to provide the client with a “fresh start” while the person that they’re having their “fresh start” with has heard a large portion of the background story, and the problems that the worker and client were having together.

Boundaries also mean staying within our professional scope and training.

Scope
Scope of practice is important, ethically and legally.

Few pediatricians are trained to accurately diagnose Fetal Alcohol Syndrome (a specialist must be called). Clinical Social Workers do not all work with the same populations (some specialize in grief and loss, some are generalists, others specialize in childhood and adolescent issues, others in addictions, etc.). Life Coaches may have some knowledge of psychology, yet it is against the law (and also ethically improper) for them to provide psychotherapy, counseling, or interventions in any way that are clinical in nature. Psychologists do not have the same psychopharmacological training as Psychiatrists do, etc. Each and every one of us have a defined scope of practice that we must work within.

When we respect our own educational boundaries, when we recognize and proudly proclaim that in certain situations “I don’t know” it frees us to work within the scope of our own knowledge (and removes from us the pressure of being an all knowing expert). It allows us to safely make referrals to colleagues (of which there is the side benefit of building our professional network). It protects the best interests and safety of our clients, and it protects ourselves.

It is impossible to know everything, and there is a great deal of danger in assuming because one has a little bit of knowledge in many subjects, that one is professionally able to work in all of them.

Unfortunately, not everyone stays within their scope of practice (and this is a serious problem). Also problematic is when those who do not stay within their scope of practice and training attempt to diagnose, or provide off the cuff diagnosis.

Diagnosis & Diagnosis Dilution

Unless someone is fully qualified, they should not attempt to assign diagnoses and labels to others, and never to themselves (there are a plethora of reasons why it is improper to self-diagnose).

No matter how much one thinks they’ve read, one is neither qualified nor ready until they’ve taken the very heavily supervised coursework and completed a heavily supervised process.

Just so one can understand what it takes for a Social Worker to eventually be clinically qualified in New York State: we must take Graduate level Psychopathology, have two field placements over two years with 1:1 supervision for one hour, once a week (minimum), and 9 other graduate credits in evidence based clinical course work. Then there’s the initial licensing exam (which *still* doesn’t make one qualified).

After initial licensure you get hired and work under another clinician’s license. At this point, after all this coursework and a master’s, the only expectation your supervisor generally has of you when you start is that you have a basic understanding of differential diagnosis. Then, with regular supervision, and after 3,000 hours of paid clinical work (where you hone your differential diagnosis and counseling skills daily, M-F, 9-5) you can sit for the clinical licensing part of the exam.

Assuming you pass, you then earn your clinical designation. But guess what? New York State views that as a learner’s permit because it will still be about another three years (with weekly supervision sessions) before you get your R privilege that lets you have a home practice/open up your own private office (that means they want to make sure you’re still working, supervised, under someone).

Differential diagnosis of mental health disorders is not easy. It is a time consuming, slow, laborious skill to learn because it’s more than the DSM: it is quite literally thousands of hours of working with clients attempting to draw out from them the necessary and nuanced information to make an accurate clinical diagnosis of which the DSM plays but one small roll.

If one wants the capability to diagnose and to be taken seriously, they need to do the time and coursework necessary to get it. This of course saying nothing of the inaccuracy of psychiatric diagnosis in general and its questionable use in therapy. That’s another (post-modern, sociological view of disability) discussion for later (hopefully sometime this month).

Related and also problematic is the situation of Diagnosis Dilution (usually occurring when individuals self-diagnose themselves): there are clinical standards to determine if one has depression, bi-polar, anxiety disorders, etc. By self-diagnosing oneself, and providing improper diagnosis to others, the general public begins to view these diagnosis in a casual manner, with less and less understanding that they’re very real mental health conditions, that can have a real and pervasive impact on someone’s life.

Build your boundaries (learn from mistakes), know your scope, and don’t diagnose unless you’re trained and licensed to do so.

ON GOAL SETTING & ADVICE GIVING

I believe that one of the mistakes that those in the various and affiliated helping professions can find themselves making is falling into is the trap of giving advice (speaking of, this post isn’t advice to anyone: it’s just my beliefs. Take it, leave it, modify it…the choice is entirely yours).

I am of the very strong belief that the only ones who should ever be giving out advice professionally are consultants which is a very different role (and one I’ve often held as a business consultant) than the roles held in the helping professions.

Consulting is a very different practice than working in the helping professions. In consulting I am being paid to provide professional advice based upon very specialized knowledge I have, within the scope of my education, training, and experience. In the helping professions, we are paid to help our clients elicit the answers that exist within themselves, and to be a guiding light, and a reflection board for them, so that they can make their own decisions.

The Problems With Giving Advice

There are two main problems I see with giving advice (and you can read this in a plethora of text books, conference proceedings, and on more blogs than this one. This idea is not unique and it’s certainly not originally mine):

  1. The worker becomes responsible for the advice.
    This means that if the advice fails the client, the worker is responsible. This also means that If the advice helps the client, the client doesn’t get to claim victory over their work.
  2. The advice is coming from the helper and the helper’s perspective.
    We are not experts on our clients or our client’s lives. The client is the expert on themselves, not us. This means that we, as the helper, are saying what we think is best for the client, rather than listening to the client and helping them verbalize what they think is best for themselves.

Advice giving isn’t the only, or main problem though.

I have worked with a number of various helping professionals who will agree with what I wrote above in its entirety…and yet, when it comes time to write a client’s goals and service plan, will then let their pen fly across the paper: using their words, their thoughts, their beliefs of what their client’s goals are, instead of the client’s words, the client’s thoughts, the client’s beliefs, the client’s goals.

The exact same problems exist here/with this as they do in the section above.

When I studied Motivational Interviewing is when I learned what – for me – is the ideal in goal setting, and it looks a little like this: Instead of making goal suggestions, or asking a client “what are your goals?” I ask a client a scaling question:

“On a scale from 1-10, with 1 being the farthest away from being where you want to be, and 10 being you’re exactly where you want to be, and everything in life is near perfect, and unicorns are dancing around you as we speak, where are you right now?”

Then the client will respond, and say they say something like:

“Well, right now I’m at a 4.5”

And then I might say:

“Wow, a 4.5! Okay, how do you know you’re at a 4.5, and not a 4?”

And I will then, in the words of one of my many incredible teachers and mentors, Mr. Sobota: “shut up and stare at them.” while I reflectively listen.

When the client is done, I will generally use an affirmation, or a reflective statement based on what they said. And then I’ll say:

“So, on that same scale, if you were to take the leap from 4.5 to 5, what would be different? What would being at a 5 look like?”

I then shut up and stare at them again. When they’re finished, I then go:

“So what would you need to do, to get from a 4.5 to a 5?”

And here’s where it gets totally critical: you shut up and stare at them again. As soon as they start telling you what it will take for them to get from a 4.5 to a 5 you start writing as fast as you can, because what they’re telling you is their entire goal list and service plan…literally, they’re telling you everything they need to do to get to the next step closer to where they want to be, so take good and detailed notes. 

After this, at least for this session, it’s generally smooth sailing: you should have a lot of:

“So what I hear you saying is…[read back what you wrote down as reflective statements/affirmations]…so if I understood you correctly, you would like to work on [goal] and you believe that you can accomplish this goal by [action]…”

You can then take all of those (now confirmed/adjusted and then re-confirmed) notes, and transpose them to whatever agency goal/service plan forms you’re forced to work with.

Guess what’s missing from here? Any of my interests, any of my biases…any of me determining what I think my client wants…and since it all came from my client they are the one who bears responsibility if their plan doesn’t work (and then you can help the tweak their plan, if that’s the case, or work through roadblocks int he exact same way)…but they client is also the one who gets to claim victory when their plan DOES work! THEY did it! CHEERLEAD THE HECK OUT OF THEM!

What if my client is making the wrong choices? Selecting the wrong goals? What if what they’re choosing will get them sent back to jail or won’t help them reach recovery?

Generally speaking, it doesn’t matter a lick if you agree with your client’s goals or not. There are, of course, exceptions: if those goals are robbing a bank, or injuring themselves or someone else, or anything similar to any of these situations…then what you think becomes very important and safety is paramount (codes of ethics, and laws almost everywhere support this).

That said, even in a drug treatment program the client may not have a goal of entering into recovery…and that’s okay: the consequences are theirs, not yours. A client who may need to see a job coach as part of their probation may not want to engage in services. That’s okay too: you’re not the parole officer. You’re merely presenting the client with an opportunity to engage in work or not and informing them of what the consequences might be if they engage, or if they choose not to engage. What they choose to do with that opportunity (and the consequences: positive, negative, or neutral) are their’s to bear alone.

What our job is, as workers, as helpers, is to help our clients enumerate what their goals are, to help them elicit from within themselves the way in which they  believe they will best be able to reach those goals, and if the client’s goals aren’t safe, or may have devastating consequences it is our job to help them understand what those potential consequences might be, to work with them to ensure that they (and others are safe), and to help them see alternatives.

However, at the end of the day, our clients must be the ones to develop their goals, to develop their own service and care plans, and to make their own choices. Sometimes those choices are incredible and beautiful to behold. Sometimes those choices will land them back in jail, which can be terribly painful to watch…but that’s okay too: they have every right to make that choice, especially if they’ve worked with you to examine all of their potential options, and all of the potential consequences that can be foreseen, based upon their goals and interests.