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.